Morphine and Fentanyl

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TrueNorthMedic

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I've been told by people that I work with and by my instructors in school that morphine is more useful for abdominal pain and non traumatic back pain and that fentanyl is better for pain related to trauma. Has any body found this to be the case? Or does it really matter?
There is nothing specific in our protocols and in my service we do a mixture of long transport times (in which case I may want to use morphine for the longer duration) and very short transport times (when the shorter onset time of fentanyl may be useful).
I'm a new paramedic and I would prefer to use my pain medications based on what is best for my patient. I was just wondering what others experiences are. Thanks!
 
Fentanyl is our go-to IV analgesic in the ICU (both on surgical ICU and medical ICU), whether it is a drip or push. Occasionally we'll use morphine pushes for pain. Morphine drips are generally only used for CMO patients.

The only studies I'm really aware of are for angina patients, not other types of pain (though that doesn't mean they're not out there). Anecdotally, however, I'd say that Fentanyl is generally pretty effective when dosed correctly for almost any type of pain. Plus, it doesn't cause as much hypotension as morphine.

Do you guys carry Toradol?
 
One of the services I run with P/T is no longer stocking Morphine. Fent is the go to for prehospital pain management now for them in all situations, including cardiac related chest pain. MONA is now FONA.
 
Thanks, those studies are pretty clear that Morphine and Fentanyl are equally effective for different types of pain. Our medical director doesn't care which one we use and we can use them fairly liberally without online med control.

We do carry Toradol and both our PCP's and ACP's can give it (only ACP's can give opioids), but for some reason our medical director wants us to call for orders before we use it. Because of that, I can't see myself using the Toradol very much, unless Morphine or Fent are contraindicated for some reason, or I'm not getting effective pain relief with them. And we also use low dose Ketamine for analgesia without orders so..... there's that.

I have used Fent for cardiac chest pain a couple of times and found it works well. I have found you don't need as much Fent to control cardiac chest pain as I would use for other types of pain. Anecdotal though.
 
TrueNorthMedic said:
And we also use low dose Ketamine for analgesia without orders so..... there's that.
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My state just put Ketamine into their protocols. IM. For psych only. So I'm jealous of you.
 
We dont even stock Ms anymore. Our analgesia protocol is, on paper, robust and well thought out. In practice, I have Fent and Toradol IV, PO APAP and Ibuprofen. We didn’t get the IV Tylenol or Ibuprofen because the infusion time was too long to be useful in EMS, so we went with a PO formulary because....reasons.

I like(d) Morphine for pain that isnt going to go away easily or soon. Burns, fractures, other trauma. The duration of action is preferable, as long as the hemodynamic effects aren’t going to compromise the patient. I prefer Fentanyl for the initial medication due to its rapid onset of action and peak level of effect, which I would frequently back up with the longer acting, lower intensity Morphine. Now, its all fent. I didn’t agree with this change, but nobody asked me.

So far, no ketamine for analgesia, but it’s still in flux. We can still give the induction dose in our chem restraint protocol for behavioral sedation because my state EMS officers can’t do math, but we can’t be trusted to give it at a lower dose for pain. :smh:
 
I look at narcotic choice as a function of what I'm trying to achieve and how long it will last.

I find fentanyl to be a much safer drug in that if I give a little too much it effects respiratory drive less, especially in kids and little old ladies. When given with a benzo or barbiturate I find fentanyl to be less sedating than other IV narcotics. When I'm in the field I prefer to give fentanyl because I'm one to one with the patient and can redose when needed, but we also have generous protocols and our medical director trusts us to dose appropriately without needing to call in. If I had an extended transport and could only dose once or twice without calling in I would probably prefer to give morphine.

@TrueNorthMedic What is your protocol on giving toradol? I know that studies have showing the increased bleeding risk to be minimal a but it is impossible to get the medical directors of our 911 EMS agencies to adopt it. And how are you giving ketamine, we stick ours on a syringe pump and give it over 10 minutes but most buses don't have syringe pumps...
 
I use morphine primarily on transfers where it's already working for the patient. In the same vein (heh) if the patient says they've had a previous similar episode and morphine worked, I'll start with that. Occasionally I might use it after fentanyl on a really long transport to keep someone therapeutic. Or Ketamine. Or fent. Or who knows, I have no real hard and fast rules.
 
OP, your instructor’s claims are completely untrue.

Both drugs are equally effective analgesics at equipotent doses. Fentanyl is an objectively better drug in the majority of scenarios, however, due to its cleaner pharmacodynamic profile and faster / more reliable onset and duration. There are good reasons why morphine has been slowly but steadily falling out of favor for a couple decades now.

The only time I would use morphine in transport is if, like Tigger said, someone was already getting it regularly and it was working really well for them. Even then I’d probably just keep them on their baseline regimen but use fentanyl for breakthrough pain. Or if I’m all out of fentanyl and hydromorphone, which has happened.
 
The only time I've ever thought about different analgesia for different types of pain is with labor epidurals, but the principle may apply here. The difference, I think may lie in somatic v. visceral pain, if there is a difference at all. Fentanyl is good for anything if you give enough and it reaches a therapeutic onset almost immediately as opposed to morphine, which you really have to wait for.

Somatic pain is soft tissue/musculoskeletal and visceral is more internal organ distrubution, i.e heart, lung, bowel, gall bladder, uterus etc. The quality of each kind is well known and may suggest preferences for different drugs. But as a rule, for me it's fentanyl to get the patient comfortable and morphine (or something like it) to keep the patient comfortable.
 
Good point about somatic vs visceral pain.

I’m thinking some people might think morphine works better for abdominal (more likely to be visceral) pain because MS tends to make people sleepier.
 
Peak said:
What is your protocol on giving toradol? I know that studies have showing the increased bleeding risk to be minimal a but it is impossible to get the medical directors of our 911 EMS agencies to adopt it. And how are you giving ketamine, we stick ours on a syringe pump and give it over 10 minutes but most buses don't have syringe pumps...
Click to expand...

Here's our Toradol protocol:
To be used for moderate to severe pain.
Indications: Isolated hip or extremity trauma, renal colic, acute hx of musculoskeletal back strain, cancer related pain.
Contraindications: Pregnant pt, allergy or hypersensitivity to ASA or NSAID's, Ibuprofen or NSAID use within last 6 hrs, current active bleeding, GI bleed in the last 6 months, TIA or CVA in last 24 hrs, known renal impairment, asthma with no prior use of ASA or NSAID's.
Pt must be between the ages of 16 and 65, normotensive with unaltered LOC.
15-30mg IM or IV with online med control orders only.

We give our Ketamine slow IV push, usually over 2 minutes. 0.1-0.3 mg/kg.

The somatic vs visceral pain is exactly what I was getting at in my original post, I just wasn't able to say it as well as E tank.

Up until now I've only been using Morphine for my abdominal pain pts (which I seem to get a lot of). It works good, but as was already mentioned, you have to wait a bit for it to have good effect. I'll be trying Fentanyl next time I have the chance.

Thanks everyone for your replies!
 
I favor hydromorphone to morphine. Fentanyl for short, Dilaudid for long.
 
E tank said:
Yes...morphine is kind of an antique.
Click to expand...

I mostly still see it in two cases:

1. Cardiac patients. I don't think there's legitimate reason, it's just what the cardiologists are used to.
2. ED patients, seemingly on the theory that it's less prone to abuse than Dilaudid.
 
Brandon O said:
I mostly still see it in two cases:

1. Cardiac patients. I don't think there's legitimate reason, it's just what the cardiologists are used to.
2. ED patients, seemingly on the theory that it's less prone to abuse than Dilaudid.
Click to expand...

It's as hard/easy to get as Dilaudid in the ER...a snob would say it's just an unsophisticated choice in both the CCL and ER.
 
I like fentanyl + ketamine a lot for almost everything. FONA for angina.
 
My guess is that the morphine is for abdominal pain, and fentanyl is for trauma is more likely the result of a sort of "game of telephone". Rules of thing passed down from medic to medic... Likely starting from the fact that morphine can cause a drop in BP, not something you want in trauma, so fentanyl is preferred in trauma.

Just a guess. Otherwise they are pretty nearly interchangeable in effectiveness. However very few people are allergic to fentanyl compared to morphine
 
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