title: Safety and efficacy of oral transmucosal fentanyl citrate for prehospital pain control on the battlefield.
abstract: BACKGROUND
  Acute pain, resulting from trauma and other causes, is a common condition that imposes a need for prehospital analgesia on and off the battlefield. The narcotic most frequently used for prehospital analgesia on the battlefield during the past century has been morphine. Intramuscular morphine has a delayed onset of pain relief that is suboptimal and difficult to titrate. Although intravenously administered morphine can readily provide rapid and effective prehospital analgesia, oral transmucosal fentanyl citrate (OTFC) is a safe alternative that does not require intravenous access. This study evaluates the safety and efficacy of OTFC in the prehospital battlefield environment.
  
  
  METHODS
  Data collected during combat deployments (Afghanistan and Iraq) from March 15, 2003, to March 31, 2010, were analyzed. Patients were US Army Special Operations Command casualties. Patients receiving OTFC for acute pain were evaluated. Pretreatment and posttreatment pain intensities were quantified by the verbal numeric rating scale (NRS) from 0 to 10. OTFC adverse effects and injuries treated were also evaluated.
  
  
  RESULTS
  A total of 286 patients were administered OTFC, of whom 197 had NRS pain evaluations conducted before and approximately 15 minutes to 30 minutes following treatment. The difference between NRS pain scores at 0 minutes (NRS, 8.0 [1.4]) and 15 minutes to 30 minutes (NRS, 3.2 [2.1]) was significant (p < 0.001). Only 18.3% (36 of 197) of patients were also administered other types of analgesics. Nausea was the most common adverse effect as reported by 12.7% (25 of 197) of patients. The only major adverse effect occurred in the patient who received the largest opioid dose, 3,200-µg OTFC and 20-mg morphine. This patient exhibited hypoventilation and saturation of less than 90% requiring low-dose naloxone.
  
  
  CONCLUSIONS
  OTFC is a rapid and noninvasive pain management strategy that provides safe and effective analgesia in the prehospital battlefield setting. OTFC has considerable implications for use in civilian prehospital and austere environments.
  
  
  METHODS
  Therapeutic study, level IV.
authors.affiliation: US Army Austere and Wilderness Medicine Fellowship, Madigan Army Medical Center, Fort Bragg, North Carolina, USA.
authors.forename: Ian S
authors.initials: IS
authors.lastname: Wedmore
authors.forename: Russ S
authors.initials: RS
authors.lastname: Kotwal
authors.forename: John G
authors.initials: JG
authors.lastname: McManus
authors.forename: Andre
authors.initials: A
authors.lastname: Pennardt
authors.forename: Timothy S
authors.initials: TS
authors.lastname: Talbot
authors.forename: Marcie
authors.initials: M
authors.lastname: Fowler
authors.forename: Laura
authors.initials: L
authors.lastname: McGhee
mesh_terms: D058956:Administration, Mucosal; D000284:Administration, Oral; D000346:Afghanistan; D000701:Analgesics, Opioid / Q000008:administration & dosage* / Q000009:adverse effects; D000704:Analysis of Variance; D015331:Cohort Studies; D004632:Emergency Medical Services / Q000379:methods*; D005260:Female; D005283:Fentanyl / Q000008:administration & dosage* / Q000009:adverse effects; D006801:Humans; D007493:Iraq; D008297:Male; D054527:Mass Casualty Incidents; D009061:Mouth Mucosa / Q000187:drug effects; D010146:Pain / Q000188:drug therapy* / Q000209:etiology / Q000503:physiopathology; D059408:Pain Management / Q000379:methods; D010147:Pain Measurement / Q000187:drug effects*; D061214:Patient Safety; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D018709:Statistics, Nonparametric; D016896:Treatment Outcome; D014857:Warfare; D014947:Wounds and Injuries / Q000150:complications / Q000175:diagnosis
chemical_list: D000701:Analgesics, Opioid; D005283:Fentanyl