a reply to: peter vlar
That's fair, and in a battlefield situation where there's not time to start an IV, I'd agree that pushing anything gets less practical. I'd argue that
sufentanil still may not be the answer, because I'm guessing that most people in that situation don't have the tolerance for it. And, if you don't
have time to start an IV, then dealing with respiratory arrest is probably also not practical. Why not intranasal fentanyl or ketamine for those
injuries? (There may be a good reason, I have no experience being there so I just don't know. There are a few things we would do in the hospital
setting to control pain even without IV access before we'd use IM morphine, so I'm just curious.)
I appreciate that there are patients with real pain, and I'm firmly against the idea that anyone asking for pain medication is a junkie. Of course I
believe in sickle cell pain, and cancer pain, and chronic pain from injuries - to name a few. So I apologize if you thought I was saying that no one
should need or use high dose narcotics. The hoops that both patients and providers have to jump through are cumbersome, and there is much scrutiny on
both sides when doses get that high.
Also, thank you for your service.
The new push is for multimodal pain control, which I admit I'm skeptical of in patients with pain like yours. Some patients just require opioids, and
I see no way to ever get completely around that. The problem is with the overuse, misuse, and diversion. Many patients need regimens of scheduled and
PRN narcotics, but not everyone with a broken finger needs oxycodone for 6 weeks. And of course, the more of it that's available, the more of it that
gets into the wrong hands. While certainly not everyone is drug seeking and abusing, many people are. We see plenty of people overdose on their own
narcotics, black market narcotics, their grandparents' narcotics, their pets' narcotics, and more. We have patients who try to chew up fentanyl
patches to get high, patients who can't be discharged on long-term antibiotics for fear that they will inject opioids into their central lines,
patients who cause severe injuries to themselves to justify the need for narcotics. It's a struggle for everyone, and there is no simple answer.
My issue isn't with narcotics, I just have trouble understanding why this particular one is necessary. We have long-acting oral narcotics,
short-acting oral narcotics, sublingual narcotics, IV narcotics, IM narcotics, narcotic patches, intranasal narcotics, ON-Q pumps, ketamine infusions,
and a whole host of multimodal options to add to all of that. I don't see what role sublingual sufentanil is filling that isn't already covered,
except offering a much higher dose in a much smaller package. The risks seem to outweigh the benefits, and I would guess that the people who
would/will suffer will outnumber those who benefit. No one's going to surgery without IV access in a hospital, I doubt EMS would assume the risk of
administering 30mcg of oral sufentail pre-hospital, and I don't see this being used in the emergency department. It appears that they are planning to
slap a warning on it restricting it to supervised inpatient use, so inpatient treatment of refractory pain is about all I can come up with.
But hey, nobody asked me so the FDA will do what it's going to do. It'll be interesting for sure to see how it's used if it makes it to market. It
would shock me if it even makes it to most hospital's formularies, so the whole exercise may be mostly meaningless.