Fentanyl or Morphine?

[Hamish]

Let's say you're treating a patient in severe pain (or so they say....)

You decide to administer an Opiate IV, but which one do you choose?

Please include your reasoning, I'm currently doing research on Opiates in the prehospital setting and why some clinicians have a preference for one or the other.

 

[Flying]

https://www.google.com/search?q=fentanyl+site:emtlife.com&oq=fentanyl+site:emtlife.com&aqs=chrome..69i57.401j0j9&sourceid=chrome&ie=UTF-8

https://www.google.com/search?q=morphine+site:emtlife.com&oq=morphine+site:emtlife.com&aqs=chrome..69i57.4512j0j7&sourceid=chrome&ie=UTF-8

https://www.google.com/search?q=fentanyl+vs+morphine+site:emtlife.com&oq=fentanyl+vs+morphine+site:emtlife.com&aqs=chrome..69i57.6737j0j7&sourceid=chrome&ie=UTF-8

https://www.google.com/search?ei=232PW7bjGe-MggfGjKewDQ&q=morphine+vs+fentanyl+site:emtlife.com&oq=morphine+vs+fentanyl+site:emtlife.com&gs_l=psy-ab.3...23835.27980..28230...2.0..0.76.1135.22......0....1..gws-wiz.VSHpeUoF4PA

https://scholar.google.com/scholar?hl=en&as_sdt=0,31&q=fentanyl+prehospital&btnG=

https://scholar.google.com/scholar?hl=en&as_sdt=0,31&q=morphine+prehospital&btnG=

 

[DesertMedic66]

If I had to pick between only those 2 I would go with Fentanyl.

Much less of a histamine release. Doesn’t drop a patients BP like Morphine. IME the majority of patients I have morphine to I had to follow up with zofran for nausea/vomiting but with Fentanyl I have only had 1-2 patients who became nauseated.

 

[Akulahawk]

If I had to choose between the two, I would also choose fentanyl over morphine for the same reason. While it's possible to premedicate with diphenhydramine prior to giving morphine, that's two medications that I'd have to give instead of one when I'm trying to relieve a patient's pain. Additionally there are some patients that will try to get you to slam the diphenhydramine. That's not going to happen... and I will dilute fentanyl so that I can more easily control the rate that the patient receives the dose. I've had a few disappointed patients because I won't give it the way they want it.

 

[akflightmedic]

State of Maine EMS does not even allow morphine anymore. Services carry fetanyl and thats it.

 

[hometownmedic5]

I only carry fent now, so the choic is easy. When I carried both, it was a bit more complex.

Fentanyl is great for high intensity pain, but has a very short duration of action, so if the source of the patients pain isnt going away(broken arm, burn, etc) and you have a long transport time(at the wrong time of day, my burn center is two hours away), you’re going to end up redosing fentanyl perhaps multiple times. Morphine has all sorts of attached complications previously mentioned here. It’s also much lower on the intensity scale, but has great stamina.

When I carried both and I was in a situation where we were going to be together for awhile, my go to maneuver was to hit you with a bonus of fentanyl to get you out of the woods, get a few other things done and when it was time to administer another dose, I would back the fent up with morphine instead of more fent. In consultation with my clinical director and medical director, we arrived at this as a more appropriate strategy than just giving repeat blouses of fent every 30 or 40 minutes. Different providers, different opinions.

 

[Peak]

Generally speaking in the 911 EMS system I prefer fentanyl; it has a larger and safer therapeutic index, less side effects, and a more predictable clinical effect. The primary downside is that it has a short duration of action. In my opinion there is little detriment in the need for redosing though as the patient who is going to receive narcotics by EMS should be having a 1:1 ALS attendant during the duration of their EMS care.

In a more general sense I think about what we are treating and what drugs will most effectively treat their individual presentation.

If I have to reduce a opioid tolerant cancer patient and it takes 30 mg morphine equivalent to even touch pain I would far rather give that as 300 mcg of fentanyl than as morphine (or 4.5 mg of dilaudid for that matter). That being said I think even better and safer pain management can be achieved through multimodal drug therapies.

If I'm treating something like a known appy or sickle cell crisis (for example in an ED or transfer patient) I would prefer the longer duration of analgesia of morphine or dilaudid.

I also think that a lot of EMS patients, and patients in general, don't need narcotics. Good pain management can be achieved with non-narcotic medications for most patients, and many pain complaints actually have a better clinical response to medications that don't target narcotic receptors. 15 mg of IV toradol has been shown to largely not have the bleeding risk that many have feared and can be safe in many (certainly not all) surgical cases. Other good options may include IV tylenol, IV lidocaine, lidocaine patches, trigger point injections, digital blocks, hematoma blocks, infiltration of local anesthetics, compazine, reglan, phenergan, low dose ketamine, gabapentin, IV haldol, tessalon perles, benzocaine cough drops, pseudoephedrine (for ear aches), tea with honey, motrin, cochicine, indocin, decadron, ice and elevation, splinting, reduction, rest, decreasing environmental stimulus, ORT or IV fluids, an enema... and the list goes on and on.