I'm not sure why IV Fentanyl wasn't compared to Morphine, but the study is interesting none-the-less.
Prehosp Emerg Care. 2010 Oct-Dec;14(4):439-47. [Pubmed]
Effectiveness of morphine, fentanyl, and methoxyflurane in the prehospital setting.
Middleton PM, Simpson PM, Sinclair G, Dobbins TA, Math B, Bendall JC.
Abstract
Abstract Objective. To compare the effectiveness of intravenous (IV) morphine, intranasal (IN) fentanyl, and inhaled methoxyflurane when administered by paramedics to patients with moderate to severe pain. Methods. We conducted a retrospective comparative study of adult patients with moderate to severe pain treated by paramedics from the Ambulance Service of New South Wales who received IV morphine, IN fentanyl, or inhaled methoxyflurane either alone or in combination between January 1, 2004, and November 30, 2006. We used multivariate logistic regression to analyze data extracted from a clinical database containing routinely entered information from patient health care records. The primary outcome measure was effective analgesia, defined as a reduction in pain severity of >/=30% of initial pain score using an 11-point verbal numeric rating scale (VNRS-11). Results. The study population comprised 52,046 patients aged between 16 and 100 years with VNRS-11 scores of >/=5. All analgesic agents were effective in the majority of patients (81.8%, 80.0%, and 59.1% for morphine, fentanyl, and methoxyflurane, respectively). There was very strong evidence that methoxyflurane was inferior to both morphine and fentanyl (p < 0.0001). There was strong evidence that morphine was more effective than fentanyl (p = 0.002). There was no evidence that combination analgesia was better than either fentanyl or morphine alone. Conclusion. Inhaled methoxyflurane, IN fentanyl, and IV morphine are all effective analgesic agents in the out-of-hospital setting. Morphine and fentanyl are significantly more effective analgesic agents than methoxyflurane. Morphine appears to be more effective than IN fentanyl; however, the benefit of IV morphine may be offset to some degree by the ability to administer IN fentanyl without the need for IV access.
Pain management is one of those things commonly under done by paramedics. I believe common reasons for this lack of treatment include laziness, apathy, and disbelief. Paramedics don't want to do the added paperwork that goes with administering a controlled substance. They may not care too much about the pain that their patient is in, and are much more concerned about life-threatening conditions. Finally, the existence of drug seekers most-definitely decreases the amount of pain meds administered prehospitally. Whatever the reason, it isn't a good one. If your patient complains of pain, it should be treated. An ice pack or positioning may be enough for some, while heavy doses of potent narcotics may be required for others. We have the tools, now lets use them.
I have added the Wong-Baker 'faces' pain scale here to remind you of how to judge your pediatric patient's pain. The old one through ten severity scale is suffice for adults.
I agree that pain is often under-treated in the pre-hospital setting. In my experience pain relief is witheld for a variety of reasons: failure to accept the patient's subjective description of pain, reluctance to give narcotics to suspected drug-seekers, fear of side effects and adverse reactions, and lack of confidence in support from medical direction.
ReplyDeleteIntranasal fentanyl is a great step forward; it bridges the gap between inhaled analgesia and intravenous opioids. Hopefully this, combined with further education, will encourage paramedics to be more pro-active in treating pain.
As a side note, IV fentanyl was not compared in this study because it is not part of the protocols where the study was conducted.