Oral fentanyl AKA lollipop

[52bravo]

like to know some thing about lollipop, from you guys.

first how do thay like heat, do thay melt in the s... heat of Iraq?

2nd the dosis the TCCC say 400 mcg, some of you tells my that you use 800 mcg, the paper by dr's Russ S. Kotwal Kevin C. O’Connor, and John B. Holcomb (and et al)A Novel Pain Management Strategy for Combat Casualty Care uses 1600 mcg.
so what to use to give the same effect of 10-20 mg morphine IV/IM in real life? i have look it up in the book it say 800 mcg.

3th not a easy one, how long do it have a effect?, the book say ½ time is 7h, but what in reallife, the paper look at the effect after 5h, and there where still good effect there


A Novel Pain Management Strategy for Combat
Casualty Care
Russ S. Kotwal, MD, MPH
Kevin C. O’Connor, DO
Troy R. Johnson, MD
Dan S. Mosely, MD
David E. Meyer, MS, PT
John B. Holcomb, MD


Study objective: Pain control in trauma patients should be an integral part of the
continuum of care, beginning at the scene with out-of-hospital trauma management,
sustained through the evacuation process, and optimized during hospitalization. This
study evaluates the effectiveness of a novel application of a pain control medication,
currently indicated for the management of chronic and breakthrough cancer pain, in the
reduction of acute pain for wounded Special Operations soldiers in an austere combat
environment.
Methods: Doses (1,600 mg) of oral transmucosal fentanyl citrate were administered by
medical personnel during missions executed in support of Operation Iraqi Freedom from
March 3, 2003, to May 3, 2003. Hemodynamically stable casualties presenting with
isolated, uncomplicated orthopedic injuries or extremity wounds who would not have
otherwise required an intravenous catheter were eligible for treatment and evaluation.
Pretreatment, 15-minute posttreatment, and 5-hour posttreatment pain intensities were
quantified by the verbal 0-to-10 numeric rating scale.
Results: A total of 22 patients, aged 21 to 37 years, met the study criterion. The mean
difference in verbal pain scores (5.77; 95% confidence interval [CI] 5.18 to 6.37) was
found to be statistically significant between the mean pain rating at 0 minutes and the
rating at 15 minutes. However, the mean difference (0.39; 95% CI 0.18 to 0.96) was not
statistically significant between 15 minutes and 5 hours, indicating the sustained action
of the intervention without the need for redosing. One patient experienced an episode of
hypoventilation that resolved readily with administration of naloxone. Other
documented adverse effects were minor and included pruritus (22.7%), nausea (13.6%),
emesis (9.1%), and lightheadedness (9.1%).
Conclusion: Oral transmucosal fentanyl citrate can provide an alternative means of
delivering effective, rapid-onset, and noninvasive pain management in an out-ofhospital,
combat, or austere environment.
[Ann Emerg Med. 2004;44:121-127.]

[Air.177]

Perhaps some of the answers you seek may be found Here (http://www.professionalsoldiers.com/forums/showthread.php?t=3000&highlight=fentanyl)

[52bravo]

no look for first hand experience whit it use. i now all about IV use off fentanyl but i have never use oral fenanyl befor.

[haztacmedic]

The Russians can tell you about how not to deploy Fentanyl Gas.....

[TF Kilo]

Dr. Kotwal was my Battalion Surgeon.

Pretty much, if I recall correctly, he came up with the idea of using these. They had been out for cancer patient pain management, but hadn't been widely used in any prehospital setting, let alone combat medicine.

400mg has a kick.

The method of deployment was relatively simple. Once the patient is stabilized, then they can have a lollypop. Quite literally.

obvious counterindications: maxofacial trauma, basically if they physically can't suck on a candy lollypop then you don't need to give them one of these. Must be concious and relatively lucid.

15 minutes sucking on it, 15 off... decrease by 1 minute down to 5 minutes.. Basically any wound that patient has, they will know about but sure as hell won't care about it.

With the 400mg dosage, we found that it was way too much for a straight shot, hence the titration effect with the staggered administration.

[52bravo]

Tx TK Kilo

[ccrn]

My unit didnt allow medics to carry morphine in the field for some reason. Ive been told by medics in other units they experienced the same thing.

After three of our soldiers lived 45 minutes after suffering mulitple traumatic amuptations I asked the battalion PA if he would add fentanyl lollipops to the their formulary. They did.

I dont know from personal experience as I am not a medic but I do know ours carried the fentanyl for the duration of the tour and did use it often so Im thinking they must have withstood the heat reasonably well.

Id like to add a part of an AAR from a PA with a Ranger unit post engangement:

Improve
*Issue:Pain control of severely injured patients.
Discussion:The Fentanyl lollipop (400mcg) has been effective for severe sprains and blunt force truama fractures but has not provided adequate relief for severe injuries such as gunshot wounds/compartment syndromes. The time to action is delayed and most patients required IV morphine to control their pain.
Recommendation:Maintain Fentanyl as an option for mild/moderate pain but have a low threshold for utilization of Morphine. Consider 800mcg Fentanyl lozenges.

The AAR also recommended training for compartement syndromes and focusing first aid more on dressings and bleeding control and less on IV fluids-
HTH

[82ndtrooper]

1600mg doses ? :eek: I've had plenty of Demerol, Stadal, and Morphine for various injuries. Dislocated shoulders that required concious sedation for relocation of the anterior dislocation, and for abortive treatment of acute migraine headaches that are what I like to call "out of abortive range" with common houshold pain relievers and triptans.

I understand that composition of the opiod and other elements to the medication are measured differently, but is 1600mg equivalent to say 100mg of Demerol, or 10mg of Morphine, 4mg of Stadol ?

I've had these administered both intramuscular and intravenious. Obviously the intravenienus dosage are pushed in smaller dosage than an intramuscular, but the effect is almost instantantious when the nurse pulls the syringe from the catheter. (Like you just got hit with a twelve pack of beer all in one dance)

What is the anesthetic effect of this drug ? It seems like a whopper of a dosage if it's purely an synthetic opiod with phenagan for nausea.

[Surgicalcric]

1600mg doses...

It is 1600 mcg (micrograms) not 1600mg (milligrams)

1000mcg = 1mg

HTH,

Crip

[52bravo]

82ndtrooper:

tx, good points but i am look for ones who use the lollipops. i use IV morfin ect on PTs almost every day. have not use lollipop on other than ped's. and old cancer pt's.

[ccrn]

What is the anesthetic effect of this drug ?

Combined with a benzo like midazolam (versed) its works well for light to moderate conscience sedation. We use it all the time for procedures at the bedside or in interventional radiology.

I know that EMS will use similar meds for reductions, extrications etc but Crip would have to expend on that as its not my area of expertise (yet).

52bravo, sorry I cant give you more info on the fentanyl lozenges. I searched and found some info online so you should be able to do the same (Im sure you have) the most meaningful to me being the AAR I posted above. Perhaps your guys could start a study of their own?

[Surgicalcric]

...I know that EMS will use similar meds for reductions, extrications etc but Crip would have to expend on that as its not my area of expertise (yet).

We werent using Fentanyl Lollipops or lozenges in EMS when I came here to the SFQC; I do not believe that has changed. We did use Morphine (with Promethazine) the majority of the time for mod-severe pain mgmt with the occassional use of Nitrous Oxide (self-administered). MS was given during extrication if and only if it was a simple extrication and the injuries were simple in nature, ie: extremity fx's. If the patient c/o back/neck, abd, or pelvic pain or had LOC, werent A&Ox3, or had other Neuro deficits Morphone was contraindicated until they were out of the vehicle/wreckage and a thorough secondary eval had been performed.

Reductions were never performed in EMS either.

HTH,

Crip

[ccrn]

Reductions were never performed in EMS either.

HTH,

Crip


Ok then I might have something confused then.

I seem to recall a discussion with some flight nurses regarding conscience sedation for reductions in the flield but then again, I've fallen on my head more than once-

[Surgicalcric]

...I seem to recall a discussion with some flight nurses regarding conscience sedation for reductions in the field but then again, I've fallen on my head more than once-

Reductions of dislocations/fractures ARE NOT taught in the NREMT-P curriculum. What is taught is traction/realignment to maintain/reestablish distal perfusion and as such is a limb-sparing procedure. Setting and final reduction is saved for the ER/Ortho MD. I dont know of any EMS service (not that they arent out there) whose SOP's allow for CS by definition but more just mild sedation. Now there are those I have witnessed who will give liberal amounts of XXXX but if they were ever caught "it would be that ass."

Also SOP's for flight medics/RN's are usually a bit more liberal than they are for the run-of-the-mill EMS service. I know they were when I was flying.

Hope this clears up my inability to state my point earlier.

Crip

[ccrn]

Hope this clears up my inability to state my point earlier.

Crip

NP, the lack of clarity was my fault.

I think probably I use the term reduction a bit too liberally. I didnt mean to insinuate that EMT-Ps will perform CS but rather RNs (not that they couldnt).

Thanks for squaring me away-

[Doczilla]

I understand that composition of the opiod and other elements to the medication are measured differently, but is 1600mg equivalent to say 100mg of Demerol, or 10mg of Morphine, 4mg of Stadol ?

What is the anesthetic effect of this drug ? It seems like a whopper of a dosage if it's purely an synthetic opiod with phenagan for nausea.

Equianalgesic dosing is roughly:
100mcg of IV Fentanyl = 10mg of IV morphine = 75mg of IV demerol

Fentanyl provides analgesia in the same manner of all opiods, but can be used in higher doses to produce coma.

The 1600mcg fentanyl lollipop is roughly equivalent to carrying 160mg of morphine. To be honest it may not be as effectively absorbed by mouth as it is when given IV, so the effective dosage the patient gets may be less. It comes in dosages ranging from 400mcg to 1600mcg.

That said, the patient doesn't get it all in one dose. It's designed to be titrated as needed, and has a much shorter duration of action than morphine. The 1600mcg lollipop means that the patient will be able to get repeat doses for some significant period of time without breaking out more ampules of medicine. This is key in the austere environment, where the medic can carry this one little lollipop that will sustain the patient's pain control needs over a long period of time, as evacuation may be prolonged.

Fentanyl is a terrific prehospital drug to use for pain control. In most EMS settings and even in many military ones (downtown Baghdad), the lollipop is too much drug for a short transport time, and most of it would be wasted (these things aren't cheap). IV fentanyl is a very good choice here. It can be used like anything else for acute pain control. I often add it to my RSI regimen, and it can be used as a continuous infusion in the ICU for patients on the ventilator.

As Crip said, reductions aren't frequently done in the prehospital setting. A paramedic may use procedural sedation for cardioversion or transcutaneous pacing. For intubation, the doses of meds are higher, and it's technically not "procedural sedation" since you don't usually care if they keep breathing or not.

'zilla

[52bravo]

some good points doczilla

i here in Denmark it is meant to replaces the 10 mg morphine IM. and it is not meant to replaces IV pain medicine.

it work fast in ped's, but you say it dont fast in adults? your ref. to bagdad.

on the dosis:Normally 25% of the drug is absorbed via the buccal mucosa directly into the bloodstream while the remaining 75% is swallowed and then slowly absorbed in the gastrointestinal tract. Two-thirds of the swallowed (or 50% of the total dose) is metabolized by the liver and becomes unavailable for any pain relief function. This is why the drug is far less potent if consumed orally compared to transmucosally.

[ernesto]

manufacturer told me Fentanyl Lollipops will be good for about 9 month under conditions like in Iraq and Afghanistan. This is an off the record info though.
And no they dont melt in the sandbox.

approximately:
600 mcg Fentanyl transmucodermal : 60 mcg Fentanyl iv : 6 mg Morphine iv : 18 mg Morphine oral

Id carry 600 or 800 mcg lozenges


ernesto

[The Reaper]

ernesto, have you followed the instructions in your registration message before posting?

TR