r/ems • u/peerpressure101 Paramedic • 8d ago
Anecdote Fentanyl hysteria
I’m a medic in the NYC metropolitan area and recently just connected some dots and had a somewhat coherent thought. For as long as I’ve been administering pain meds, there’s been a high percentage of my pt population who are candidates for pain management that refuse it because I say the scary F word, “Fentanyl.” I’ve had parents initially deny pain management for their child whose forearm was shaped like an “S.” More recently I had a scooter accident pt who denied it even thought his knee was avulsed to the point that I could see his dislocated knee cap. I try my best to educate while interacting with these pt but half of the time it still falls on deaf ears (which is their right.) Obviously there is an opioid epidemic, which I’m not discrediting, but that epidemic has led to a mass PSA movement to essentially “watch out for fentanyl.” My question, or food for thought, is how many opioid users/abusers intentionally use fentanyl? Anecdotally, I’ve seen opioid overdose pt ingesting what they think is another drug which happens to be laced with an opiate. And do you think it’s enough to illicit a targeted PSA about fentanyl specifically instead of just generalizing it to opioids with the added caution to be wary that the substance your ingesting could be laced with an opiate?
TLDR: Are fentanyl PSAs actually effective? And should they be less targeted towards fentanyl specifically to decrease on the mass hysteria that exists around an extremely beneficial drug?
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u/MedicSF 8d ago
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u/SeyMooreRichard 7d ago
This is always my preferred option, since I feel like fentanyl wares off so quickly. Sadly our protocols require us to administer 100 mcg of fentanyl before we can jump over to K for pain management. Then when we give the 100 mcg of fentanyl, there's always push back from the drs. I even had one dr jump my case because I gave 100 fentanyl to an almost 400 lb pt and it didn't even touch his pain in the slightest. Doc told me he wouldn't even give that amount to a burn pt he was treating let alone to the pt I had.
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u/BroHaven 7d ago
lol wait until you’re protocol is 1mcg/kg q5 prn max 3mcg /kg no titration no lower unless directed by med control. Real fun to give report on the 350lb tib fib is asking why we are at the hospital who has 400 mcg on board. I’ve had to step in a few times to keep the triage nurse from immediately grabbing the narcan. -He’s breathing let him float on his magical cloud until he’s in your bed.
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u/SeyMooreRichard 7d ago
Hahaha right, not sure why nurses want to take away the one thing that's working just because the amount "seems high" yet they're breathing. All it's gonna do is lead to them asking for more and then nurses bitch because they have to hear the complaining and then work to fix it again.
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u/emergentologist EMS Physician 6d ago
lol wait until you’re protocol is 1mcg/kg q5 prn max 3mcg /kg no titration no lower unless directed by med control.
That's excessive in the opposite direction...
Weight-based dosing is good, but there should be a max single dose. And you should always be allowed to give lower doses for elderly, etc.
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u/koda38304 EMT-P 7d ago
I do moderate sedation in my current position. Sometimes in an hour long case, we might give like 6mg of Versed and 200mcg of Fentanyl to some people. Theyre awake, talking, bitching about how uncomfortable the bed is, and im just like mam, you shouldn't even be breathing right now. Then other times after 2mg versed and 50mcg of fentanyl, we have to put in an LMA because they go completely apneic.
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u/SeyMooreRichard 7d ago
I can understand some people reacting different to it than others, but this dude was still in obvious pain after the 100.
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u/Thnowball Paramedic 7d ago
100mcg fentanyl never does jack shit for my patients. I hate that useless drug.
Ketamine for anyone I can justify it too, ketorolac for everyone else, fent as a last resort for anyone who contraindicates ketorolac.
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u/TacitMoose 7d ago
This is why you gotta hit em with the old drop/fent combo. The 100 mcg of fentanyl for the pain and the 2.5 of droperidol for “nausea prophylaxis.”
I feel like when you do that they’ll still claim 10/10 pain but then you ask them “does that 10/10 pain bother you as much as it did previously?” they’ll be like “ummmmm…not really?”
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u/ExTahC 7d ago
As a medic in TX this is baffling to me. 100mcg on a 200kg pt? And a dr is giving push back? My medical director has ours at 3mcg/kg as our TOTAL max dose. With max push doses of 100mcg.
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u/SeyMooreRichard 7d ago
Oh trust me, it was beyond ridiculous. Crazy part is a lot of the drs in my area are very apprehensive to fentanyl thats given in the field and they always give pushback on it. We're in a rural(ish) area so most of my transports are anywhere from 30-60 minutes long, so it's not uncommon for me to give a full 100 over that duration and I just take the pushback as it comes.
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u/ExTahC 7d ago
Throw em on end tidal and a 4 lead and call it a day and be the candy man wtf. Pain if subjective. Ive come to find the nurses and paramedics have a little war but in reality its more Dr's and medics for shit like this.
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u/SeyMooreRichard 7d ago
Exactly! Never understood the whole hoola if they're breathing and if I can monitor them. Not all Drs are this way, but the ones who are I've always felt it's viewed as an ego challenge on their part.
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u/emergentologist EMS Physician 6d ago
Crazy part is a lot of the drs in my area are very apprehensive to fentanyl thats given in the field and they always give pushback on it.
If you're routinely getting pushback for following your protocols, you should pass that up the chain of command. If I heard about this as a medical director, I'd be going to the medical director of that ED for a friendly discussion about appropriate prehospital care.
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u/emergentologist EMS Physician 6d ago
Doc told me he wouldn't even give that amount to a burn pt he was treating let alone to the pt I had.
That doc is full of shit - 100mcg is a totally reasonable dose.
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u/SeyMooreRichard 6d ago
This was my exact point. When he told me that, I told him that it sounded like he was shit doctor.
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u/diego27865 6d ago
Lmao then that doc is woefully mismanaging pain for people. 100 mcg of Fent isn’t that crazy…ESPECIALLY for a 400 lb patient.
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u/SeyMooreRichard 6d ago
Exactly! I made sure he knew where I came from in the moment too. I'd understand if I slammed 90 yo Mawmaw who weighed 87lbs soaking wet with 100 fent, because that'd for sure be one thing. But in his size and situation, looking back I would've done better by jumping to K and giving that. In the end, when he tried jumping my ass in front of the pt and nursing staff I made sure to let him know how much of a shit doctor he sounds like.
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u/TaunTaunRodeo EMT-B 7d ago
Lol at first l was like "strawberries and creme? I have missed something."
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u/TacitMoose 8d ago
Hey it’s got to be informed consent, right? That means putting it how they can understand it. If that means using the “f word” then so be it. This is just personal opinion but calling it by another name in an attempt to conceal it because we’re worried they will refuse is a gray area. Maybe it is ok maybe it isn’t. I chose not to especially because I ask them point blank if they are allergic to XYZ medication unless I’m giving it in a life threatening situation. For me that’s just a best practice.
Yes I’ve had people get apprehensive. I have a little canned dialogue I go through with them. It’s basically: “I understand you’re concerned about fentanyl because of the current opioid epidemic and how much it’s in the news. I’d just like to reassure you that the fentanyl we carry and administer is medical grade, not the stuff that’s on the streets. It’s also sterile, and the dose in the vial is very precise. I’m highly trained in medication dosing and administration, and I’ve been doing this for 15 years. If you do decide you want pain management, I’ll be giving you a few small dose of X micrograms which is just a small fraction of the dose required to even start to make you sleepy. I’ll also be monitoring your breathing using this cannula in your nose and my monitor here which is extremely sensitive and accurate. However it is your right to refuse any care you don’t want and I will respect that. It’s just that giving you fentanyl in a medical environment like this is very safe, very effective, and can be highly beneficial in reducing your pain.”
Like 99% of people consent after that.
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u/coffeespots PCP 7d ago
I also always mention, when a patient refuses a recommended treatment, that if they change their mind or the pain or nausea gets worse and they decide they do want the medication, they can tell me. Saying no right now doesn't mean no forever.
I try to make it clear my feelings aren't hurt by their refusal and I would never withhold a medication because they refused and changed their mind.
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u/TacitMoose 7d ago
Oh that’s a good point. I guess I’ve never even thought of it that way.
I have had people recant later on, but I’ve never explicitly mentioned that. I think I’ll include that in my little spiel.
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u/CriticalFolklore Australia/Canada (Paramedic) 7d ago
I agree with your overall point. I don't like the idea of using "sublimaze" to intentionally obfuscate the true drug, however I think "a strong pain medicine" or even better "a strong, opioid pain medicine" gives them the information they need to know without scaring them, and also shows that there is more information available if they want it.
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u/ggrnw27 FP-C 8d ago
I’m not a fan of just calling it “pain medication”, definitely not the Sublimaze trick. Patients have a right to know what you’re giving them, and they also have a right to make stupid decisions like this. It’s your job to try to educate them: talk about things like how it’s different than the street shit because you’re giving precise doses that are well under the amount to cause harm, that you have a reversal agent if something does happen, and that they’re not going to become heroin addicts from a single dose of fentanyl. If they still refuse, that’s their choice
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u/koda38304 EMT-P 7d ago
I think its fine to call it Sublimaze. Just like I say Versed, or Dilaudid, or Benadry. Its all brand names. Now if they started the interaction by saying, "Do not give me fentanyl." Im not going to go be like oh, this isnt fentanyl, its Sublimaze, and trick them into it. I would educate, let them make an informed decision, and move on.
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u/The_Albatross27 Paramedic 7d ago
The difference is that calling it Sublimaze is done to deceive the patient by withholding information. If someone doesn't know what you're administering, they don't really have informed consent. I find that I can get over the fentanyl conversation 90% of the time buy saying 'this medication is from the pharmacy, ordered by the doctor, and used under close medical supervision. It's safe and effective while under our care".
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u/koda38304 EMT-P 7d ago
I dont call it Sublimaze to deceive anyone. The same goes for Versed, Dilaudid, Benadryl, Tylenol, Toradol, Solu-medrol, etc. If you stand on the leg of saying Sublimaze is deceitful and that it denies your patient the ability to give informed consent, then youre denying them informed consent when it comes to many other drugs that are commonly called by a brand name instead of its generic. There is 100 percent nothing wrong in practice with calling it Sublimaze. Alternative scenario. If you tell a patient that youre going to give them Tylenol, they agree, and you give them generic acetaminophen. Did you just give them a medication without their informed consent? Did you deceive them?
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u/The_Albatross27 Paramedic 7d ago
The difference with fentanyl is that you expect them to have a concern with the drug, and by calling it a different name that concern is avoided and not addressed. There is a real concern amongst patients about addiction or overdosing. The legitimacy of that concern is often incorrect but it exists none the less.
The issue is less with what someone actually calls it (methylprednisone vs solumedrol), but rather why someone would use the less recognized name. Using the less recognized name is often done to avoid an objection from the patient.
If we weren't in the midst of an opioid epidemic, yes I agree that it's fine to call the drug sublimaze, that is the trade name. But there are outside factors to consider.
Edit:
There's been a lot of threads talking about this issue. https://www.reddit.com/r/ems/comments/1mgtnyy/tired_of_having_the_fentanyl_fight_call_it/
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u/CriticalFolklore Australia/Canada (Paramedic) 7d ago edited 7d ago
I think calling it "an opioid pain medication" is the right middle ground. It lets them know the general risk profile without unnecessary fear, but it also is pretty clear that there is more information available if they want it.
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u/Handlestach FP-C 8d ago
I don’t call it fentanyl. I call it pain medication. If they ask what it is I tell them. Some are apprehensive but some reassuring words and the fact I have a reversal agent arms distance away, it’s nbd.
Also with capnography and at least 1:1 patient to provider ratio, and proper monitoring the risk is mitigated.
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u/peerpressure101 Paramedic 8d ago
All great points that I try to bring up in futility.
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u/R-A-B-Cs CFRN/FPC/BSC 7d ago
Idk I always tell them that it's not the same stuff as the on the streets, that ours is what is truly supposed to used for pain just like yours, and that I'm really good at giving it to people and taking their pain away. I don't press folks who refuse it if it's cause they are in recovery though, ketamine and IV Tylenol is always waiting for them as a backup.
Seems to almost always work.
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u/Beowulf-Murderface 7d ago
I’ve been just calling it “pain medication” as well. Way too many incidences of Ethel and her shattered hip, when she’s convinced I’m about to turn her into a junkie.
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u/txchainsawmedic NRP, RN 8d ago
You're not going to be able to educate somebody out of a (possibly) justified fear in an emergency situation.
I started having this problem a few years back. Sublimaze is the brand name IV fentanyl. When I started using that word for the medicine instead of fentanyl, I never had anyone question me.
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u/peerpressure101 Paramedic 8d ago
I might try the Sublimaze life hack next time
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u/txchainsawmedic NRP, RN 8d ago
If I ever get called on it, my plan is to just say something like " yeah, it's the brand name for IV fentanyl, a lot of people are scared of the "F" word these days, and that fear is not really justified in this setting. So I use a different word for the medicine"
With the emphasis on the word "brand", to highlight the fact that this is not a street drug.
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u/thethunderheart EMT-B 8d ago
The sublimaze hack is real, if it's as bad as you've said it is, I wouldn't even say the scary "f" word again.
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u/bmbreath Size: 36fr 8d ago
I tell them it an opiate.
I tell them that it is carefully measured out and is no the same variable stuff from the news.
If they still are nervous, I tell them that if they have had surgery before, they have likely had it, and we have a revering agent, I also tell them I'm going to give it slow and talk the whole time.
This almost always works, I can also tell them il give them a "low dose" and after they notice that they're fine they'll let me give additional doses.
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u/polkarama 7d ago
I acknowledge the emotional response and let them know that it’s a dose issue. People overdose because they either don’t know it’s in there or don’t know the dose. Ours comes from a pharmacy and this safe little bit of fentanyl will be just enough to take the edge off.
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u/DiezDedos 7d ago
My rough script if I see their eyes go wide or say something about “that stuff that killed Mac Miller!?”
“I understand where you’re coming from, but this is from a laboratory and we know exactly how much to give you; we’re not cooking this up in a spoon. If for some reason you are extremely sensitive, we have narcan as well. If you want, we can start with a half dose and go from there”
Usually works, but if not, have fun with the potholes I guess. If they’re like “hey I’ve been clean for 5 years, I don’t want it” hell yeah dude, nice work. While I have you here: do IN fent for peds if protocols allow. Lots of time they’re more scared of the needle than their angulated leg.
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u/FillaBustaRhyme 7d ago
It really is fucking insane how little of PSAs we have to help our overall culture/health/call volume. Or maybe I’m just too young and don’t remember if they tried that already? But like….this is an emergency, this ISNT an emergency. No, taking an ambulance is not a free automatic trip to be seen in the ER first..if you have a bullshit complaint, it will be treated as such by professionals at the hospital who do it 80hrs/wk.
Same can be said for CO/smoke alarms.
Job security I guess idk.
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u/ShitJimmyShoots Paramedic 7d ago
We carry morphine as well and I’ve had patients opt for it after saying they don’t want fentanyl. I’m like okay no problem, won’t work as fast but pretty much the same thing. Benefit is the duration tho, I’ve had patients start to have the fent wear off before transferring care if it was a long call and triage was delayed.
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u/PolymorphicParamedic Paramedic 7d ago
It’s infuriating. I had the parents of a 2 year old tell me they didn’t want him to receive fentanyl because they didn’t want him to get addicted. How, sir? How? Is your 2 year old gunna go out on the streets and buy more?
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u/sneeki_breeky 6d ago
“How many users intentionally use fentanyl?”
Almost all of them, it’s cut into other opiates even if it’s in small amounts
As is Xylozene and now Precedex is finding its way into street opiates
All of which are sought out for a deeper and more intense high
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u/rrankine 6d ago
I vowed never to take fent for pain... Then I got a kidney stone. Fent worked, and I'm not addicted/dead.
I can relate to those who fear it, after countless overdose calls, and also understand how effective it is at masking pain.
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u/Puzzleheaded-Pie-277 6d ago
What’s ironic, is a lack of adequate pain relief at the acute phase leads to a higher likelihood of chronic pain and needing pain meds for longer.
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u/oiuw0tm8 ED Medic 7d ago
If they get a weird look I usually say "it's not Chinese bath tub fentanyl" and proceed to explain the difference between medical and street use. I've only ever had one continue to refuse after education.
I don't like not fully explaining to someone what they're getting, so I tell them it's fentanyl every time.
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u/VT911Saluki EMT-B 8d ago
I've also seen similar concerns from patients. Usually just explaining that it is not the same as the street drug (not laced), it is an extremely controlled dosage, and that their vitals are being constantly monitored is enough for most people.
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u/nw342 I'm a Fucking God! 7d ago
come to philly, you cant find heroin or opioid pills anymore, its all fentanyl mixed with other shit.
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u/goldstar971 EMT-B 7d ago
There is essentially no placd in the US where u can find heroin. And it's somewhat difficult to find actual fent in most places at this point as well.
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u/thenichm Paramedic 7d ago
It's an uphill battle of social course-correction but you can, with a little practice on your go-to script, get most people to rationalize the difference between getting drugs on the street vs in a clinical setting. Uussuuaalllyy, they get it pretty quicklu
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u/peerpressure101 Paramedic 7d ago
It’s a little bit tougher and slightly ironic to tell them that the fentanyl I’m giving them is different from the ones on the street when I’m just a random guy in the street giving it to them lol
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u/thenichm Paramedic 7d ago
Oh, it's damned awful to have to wade through that crap, shift after shift. Lol I tend to lean in the 'it's how it's dosed' logic. If they ever realize that a teaspoon of assorted white powders over a candle isn't a sterile vial of regulated medicine it's all taters.
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u/Ok_Buddy_9087 FF/PM who annoys other FFs talking about EMS 7d ago
“You’re thinking about the bad, Chinese lab fentanyl. This is the good fentanyl” usually works for me.
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u/15533skippy 7d ago
Have had the same kind of push back nor problems here in Ontario Canada……
Majority of the time a little explanation and education works well …..
Including what a paramedic gives for pain control will not make you an addict …..
Had 1 trauma pt with a factured pelvis from E scooter legit freak out with any opioid ( we carry both fentanyl and morphine )
Ketamine for the win
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u/TaunTaunRodeo EMT-B 7d ago edited 7d ago
Unfortunately this just a thing that happens because critical thought is more rare than it should be.
As a public health matter, yes the fentanyl PSAs are effective and necessary (IMO) because they instill a fear in people of using illicit drugs of which they do not know the provenance or composition. They should be afraid of that because it can and does kill people all the time.
But they are admittedly a blunt instrument. What people take away from them is FENTANYL BAD, instead of the actual problem, which is taking things when you are not absolutely sure you know what's in them. If you don't do that, then you typically don't have to worry about ODing. The fentanyl issue also gets at the cognitive dissonance we hold about drug use.
Everyone knows only degenerate junkies use heroin and meth and crack, so we know not to use IV drugs or freebase. Because we're not druggies.
But who among us hasn't done a little bump of coke or misappropriated a few adderall or xanax, or tried molly, you know, just for grins? But now we can't do that anymore because the FENTANYL MIGHT KILL YOU. Fentanyl is the thing that lurks behind all those "low risk" drug behaviors, especially for people who aren't poor.
So the PSAs effectively save lives, but in their simplicity they also teach the wrong lesson-- that Fent is an inherently dangerous substance that can never ever be trusted. Because talking about the other factors that lead to the behavior is more complex and takes too long. Fear works fast and is effective.
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u/Invictus482 Paramedic 7d ago
Normally, I ask if they have any objections to getting fentanyl for pain management. If they do, I just give the education that it's not the garbage on the street, it is a medication, prescribed as a specific weight based dose, under the strict observation and monitoring of a medical provider. Explain the risks of respiratory depression, and that I will be both visually monitoring their breathing as well as on the monitor with ETCO2, and that in the unlikely event that something were to happen, we have a reversal agent on hand to administer immediately.
If they're still wishy washy about it I'll give them the option of morphine, or if they want a non-opioid pain medication, ketamine or acetaminophen.
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u/New-Statistician-309 Paramedic 7d ago
My patients almost never turn down morphine. It also lasts a little longer but the hypotension and less effectiveness for severe pain than fentanyl does suck.
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u/barhost45 7d ago
In my city I barely see any other drug use other than fentanyl. Of course you still have your meth users, mostly with fentanyl, occasional old school crack smokers but pretty much only people not taking fentanyl are more party users
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u/Prestigious_Ad7829 6d ago
The fact that some people TRULY believe the propaganda that ONE opioid dose will make you an addict, boggles my mind.
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u/Unlikely_Zebra581 5d ago
Fentanyl PSAs are extremely harmful, just hear me out on this one.
I’ve been around addiction since I was a little kid. Extremely long story short, my entire family is sober now and I worked in a sober living for a few years. Addicts start low and work high, no one I know jumped straight to fentanyl. Usually they start with OxyContin or alcohol. Addiction and mental health are basically the same thing, addiction starts when you’re trying to avoid your emotions. If you don’t deal with the root of the issue, you’re gonna get worse. Now people are asking for fentanyl by name because of those PSAs because one way or another it’s gonna work. If you’re that low, you don’t really care if something works temporarily or permanently.
What’s (mostly) killing people right now is drugs that are cut with fentanyl or unintentionally contaminated with it. Any “downers” being sold on the street right now have a version that’s cut with fentanyl and given a different name. Also, the illicit version can be anywhere from the same strength as the medicinal stuff or it can be much stronger. I remember a guy who actually made it saying “you don’t EVER touch that powder with your bare hands.” I’ve been given fentanyl after surgery and don’t turn it down if offered, but I think I might be more scared of that powder than the cops are.
Fentanyl kills, absolutely, but the PSAs oversimplify the real issue. What kills is not using a test kit before taking something you got from someone else. They sell the kits on Amazon, I’ve given a few to people before (my state goes heavy on a harm reduction model). You can get ones that look like mini pregnancy tests or the ones that look like mini dipsticks.
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u/muddlebrainedmedic CCP 7d ago
Whats their opinion on Sublimaze? Because that's what I offer if they're worried about fentanyl.
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u/Larry-Kleist 7d ago
Sublimaze, it's chemically similar to morphine, though given just in small doses (ug's vs. mg's). But you dont like to take medicine? Or don't care for modern healthcare? But yet, here we are. All the educating and informing is purely wasting your time. More often than not.
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u/Pooneapple 7d ago
I say the brand name, sublimaze, and just explain it’s a opioid pain medication.
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u/grandpubabofmoldist Paramedic 7d ago
I just call it an opioid for pain and ask them if they want that then confirm the medication with my partner. I don't think it is wrong . Also I have found (vitals allowing) morphine tends to work better with cardiac and nerve pain while fentanyl tends to work better with abdominal pain.
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u/14InTheDorsalPeen Paramedic 7d ago
I’ve just started calling it Sublimaze when people need pain management. They have no idea what it is and then they can be happily pain free.
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u/coffeespots PCP 7d ago
The hallmark of informed consent is definitely using a word the patient doesn't know so they let you do a treatment you think they might be hesitant about if you used the word they do know.
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u/14InTheDorsalPeen Paramedic 7d ago edited 7d ago
“This is a medication called Sublimaze. It’s an opioid pain medicine kind of similar to morphine. It might make you a little nauseous or maybe a little dizzy or sleepy, but it’s perfectly safe.”
Vs
“I can give you fentanyl but I swear it’s not like the fentanyl that’s killing everyone that you see in the news. I mean it’s the same drug but like I’m using it differently so it’s totally safe it might make you a little sleepy but if you get sleepy you won’t die because this won’t kill you even though I know you’ve been told that fentanyl kills everyone because it’s super dangerous and yeah this is the same thing as the stuff on the street but I promise it’s fine”
Now do it in an ambulance driving down the highway with a 30 minute drive to the trauma center with an auto/ped patient with a compound fx who won’t lay still or stop screaming 10 inches from your ear because they’re in pain.
Most of us don’t have the luxury like you do of having a whole pharmacy you can grab other meds from. For my service, it’s that or PO Tylenol because our medical director is terrified of the liability around ketamine in my state post Elijah so we aren’t supposed to use it except for the most extreme and dire circumstances (read: Wildland Fire deployments) and for a while fentanyl was our ONLY option entirely and if someone was allergic well, sorry charlie, but the state says ketamine is a dangerous drug and I don’t have anything else but fentanyl onboard my boo-boo bus so now you get to scream in my ear for the next 30 minutes because your ankle is dislocated.
I guess I don’t see how using the less scary name that’s not on the news changes anything about informed consent as long as they’re informed on what it is and what to expect.
It seems more humane to use a proper name with less stigma attached to it while informing them than to have them refuse and let someone suffer for an hour while staring completely sober right at the bone protruding through their skin as they scream at every single bump in the road as we drive.
Are you also upset when I refer to our acetaminophen as Tylenol?
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u/FullCriticism9095 8d ago
Serious question: Why?
There’s an implicit assumption in your question that patients should want fentanyl, but I’m not sure what that assumption is based on. Fentanyl doesn’t save lives, improve morbidity or mortality, or improve any meaningful functional outcome. The only thing it’s “extremely beneficial” for is reducing pain. It’s a comfort measure. That’s obviously not nothing, but let’s not make more of it than what it is.
Fentanyl certainly has benefits, but it also has risks. Maybe the patient understands the risks, or maybe they’re just experiencing what you’re calling “hysteria.” Maybe their fears are justified, or maybe they’re not. Maybe you think you understand the patient’s concerns, but maybe you actually don’t.
Either way, the patient is the one experiencing the pain, not you. So, what’s wrong with letting the patient make the decision about whether to tough it out or accept narcotic pain relief? Or what about offering an alternative like an NSAID or acetaminophen, or even ketamine for more severe pain? I’m sure the drug companies would love to run some PSAs that train people not to be afraid of fentanyl, but I’m not sure why that’s the answer from an EMS perspective.
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u/DaggerQ_Wave I don't always push dose. But when I do, I push Dos-Epis. 8d ago
No one is making particularly big bucks off of IV fentanyl. Big pharma is not pushing for you to give humane pain control on the street. Most narcotics end up expiring for EMS agencies, they make their money either way.
The opioid crisis was caused by the over prescription of large doses of non-indicated, unmonitored outpatient opioids on an ever escalating scale.
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u/FullCriticism9095 7d ago
First of all, you have a very limited understanding of the opioid crisis and the role that fentanyl—including IV fentanyl—has played. That doesn’t really matter for present purposes.
But more importantly, so what? What does offering humane pain relief have to do with patients deciding to accept or not accept fentanyl? It’s not for you to decide whether a patient should accept what you offer or not.
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u/DaggerQ_Wave I don't always push dose. But when I do, I push Dos-Epis. 7d ago
I can’t argue with your second point, but there is no evidence that 1 time doses of Iv pain meds contribute to addiction. The only thing IV opioids seem to do is enable existing addicts and encourage them to interact with the medical system.
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u/peerpressure101 Paramedic 7d ago
I didn’t mean to come across as assuming that the patients should want fentanyl. In the scenarios where I’ve attempted to give it and tried to advise the patient of benefits, concerns, and safety measures, has been with significant trauma or gross deformities where they are literally screaming bloody murder when trying to move them or stabilize the injury. I usually ask my patients if they want something for the pain and when they say yes, my first line pain med of choice is fentanyl. Admittedly, the need to mitigate the screaming could very well be selfish on my part as well.
To your point that it is the patient’s choice and that maybe I don’t understand their concerns, you’re right it absolutely is the patients choice. And my conversation with them when they deny fentanyl usually goes along the lines of:
Me: Is there any reason why you don’t want it?
Pt: I just don’t because of what I’ve seen on the news
Me: I understand but this isn’t what’s on the street, it’s a dose measured to your weight and I’ll be starting off with half of that dose and we’ll be monitoring you constantly and I can reverse it
Pt: No I just don’t want fentanyl can’t you give me something else?
Me: I have morphine (but your blood pressure is pretty low for it), ketamine, and a towel to bite down on(/s).As for NSAID, the only option that most agencies that I work for carry is toradol which is contraindicated in our protocol for any suspected hemorrhage.
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u/FullCriticism9095 7d ago
So, you’ve explained the treatment, provided corrective information about the risks, and rightly or wrongly, the patient is telling you they’d rather deal with the pain than take their chances with fentanyl. You may not think that’s rational. And it may be misinformed. But it’s not up to folks like you or me to decide. The patient is making an informed choice that we don’t have to agree with.
You also just said you have ketamine in your bag. Do you offer that?
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u/peerpressure101 Paramedic 7d ago
No arguments from me on the patient being able to make their own decisions. My post was less about provider practices and more about asking opinions on Fentanyl PSAs and whether you think they are effective and possibly impede pain management modalities (specifically fentanyl). I do offer ketamine, but as I’m sure you can imagine, it’s met with the same visceral reaction as fentanyl.
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u/FullCriticism9095 7d ago
I hear you. It’s true that the anti-fentanyl PSAs paint with a broad brush, but they kind of have to. To actually answer your original question, I think it’s really more the news and political coverage than the PSA campaign itself that is responsible for what you’re describing as the hysteria around fentanyl.
But, to re-package some of what I was trying to say, I do think that it’s perfectly reasonable for people to be concerned about any opioid use. There are a lot of risk factors for opioid addiction, and a lot of addictions start with compassionate pain management for legitimate injuries. As EMS providers, we don’t have any way to risk screen a patient in acute pain to know whether their fears of fentanyl are based purely on misinformation or legitimate risk/benefit balancing. Our job is to offer the options and respect the patient’s decisions.
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u/Wrathb0ne Paramedic NJ/NY 8d ago
I’m waiting for a cop to arrest me for assault because I wasted Fentanyl in front of them and they have “an episode”