Literature Review: Prehospital Analgesia Agents

     Rickard C, O'Meara P, McGrail M, et al. A randomized controlled trial of intranasal fentanyl vs. intravenous morphine for analgesia in the prehospital setting. Am J Emerg Med 25(8): 911—7, Oct 2007.

Abstract
     The objective of the study was to compare intranasal fentanyl (INF) with intravenous morphine (IVM) for prehospital analgesia. Methods—This was a randomized, controlled, open-label trial. Consecutive adult patients (n = 258) requiring analgesia were recruited. Patients received medication at five-minute or longer intervals: INF 180 mcg, two doses of 60 mcg, or IVM 2.5–5 mg, two doses of 2.5–5 mg. The endpoint was the difference in baseline/destination VRS (verbal rating score: 1–10). Results—Groups were equivalent for baseline VRS (mean: INF 8.3, IVM 8.1) and minutes to destination (mean: INF 27.2, IVM 30.6). Patients had a mean VRS reduction as follows: INF 4.22, IVM 3.57 (p = .08). Higher baseline VRS (p < .001), no methoxyflurane use (p < .01), and back pain (p = .02) predicted VRS reduction. Safety and acceptability were comparable. Conclusions—There was no significant difference in the effectiveness of INF and IVM for prehospital analgesia.

Comment
     Inadequacy of pain relief is a well-recognized weakness in EMS treatment. A number of previous studies have concluded that the majority of patients who could use prehospital analgesia do not receive adequate, or often even any, medication. Prehospital analgesia is safe, effective and given, often, hours before ED medication.

     One of the frequently cited barriers in prehospital opioid administration is that it requires an IV be started for rapid effect. This study from Australia introduces a new alternative: a method of administering a highly effective opioid without requiring an IV. Intranasal fentanyl has been successfully used in the emergency department and postoperatively and is being looked at for other indications. This has great promise for the prehospital treatment of pain.

Angelo Salvucci, Jr., MD, FACEP, is an emergency physician and medical director for the Santa Barbara County and Ventura County (CA) EMS Agencies, and chair of the California Commission on EMS.