Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Newer and Better Medications

When a drug manufacturer comes up with a new medication, or just a me too medication, many of us rush to give this drug to our patients.

Should we?

Does newer mean better?

I think that fentanyl is clearly better than morphine for the prehospital treatment of pain. Fentanyl (1960)[1] is newer than morphine (1805).[2] Fentanyl is also a much more recent addition to my protocols. Morphine was in the protocols when I moved to Pennsylvania, but fentanyl was only added to the paramedic scope of practice about a decade ago. It took a few more years for anyone to write a protocol to actually use fentanyl. One of the local university hospital helicopter services used fentanyl, but fentanyl was only allowed in already intubated patients because of the mythology surrounding fentanyl.

Is my preference for fentanyl because of its novelty?

No. Fentanyl appears to have less of a cardiovascular depressant effect than morphine, which is mostly due to the morphine causing release of histamine, which causes vasodilation (and other effects).

Fentanyl wears off much more quickly than morphine, so there should be perceived need to give naloxone to reverse any possible respiratory depression in the ED (Emergency Department) because an amount of medication was adequate to manage pain while bouncing down the road in a truck is too much for sitting on a much thicker mattress in a hospital that does not bounce.

Are any of the newer anti-psychotic medications any better than droperidol?

No, we just have less experience using the newer drugs, so we assume that ignorance of side effects means that there are no side effects. There is no reason to believe that the newer anti-psychotics are any less likely to produce torsades.[3]

Why do so many people choose to use the newer anti-psycotics?

They believe that there is less likelihood of torsades with these drugs, because we are more ignorant of the side effects of these drugs.

Ignorance is bliss – right up until reality interrupts that blissful ignorance.

Newer does not equal better any more than more equals better.

Footnotes:

[1] Fentanyl
Wikipedia
Article

Fentanyl was first synthesized by Paul Janssen in 1960[9]

Footnote [9] is to the following –

The history and development of the fentanyl series.
Stanley TH.
J Pain Symptom Manage. 1992 Apr;7(3 Suppl):S3-7.
PMID: 1517629 [PubMed – indexed for MEDLINE]

[2] Morphine
Wikipedia
Article

first isolated in 1804 by Friedrich Sertürner, first distributed by him in 1817, and first commercially sold by Merck in 1827, which at the time was a single small chemists’ shop. It was more widely used after the invention of the hypodermic needle in 1857.

[3] Droperidol, QT prolongation, and sudden death – what is the evidence – Part I
Rogue Medic
Thu, 01 Dec 2011
Article

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