Generally speaking in the 911 EMS system I prefer fentanyl; it has a larger and safer therapeutic index, less side effects, and a more predictable clinical effect. The primary downside is that it has a short duration of action. In my opinion there is little detriment in the need for redosing though as the patient who is going to receive narcotics by EMS should be having a 1:1 ALS attendant during the duration of their EMS care.
In a more general sense I think about what we are treating and what drugs will most effectively treat their individual presentation.
If I have to reduce a opioid tolerant cancer patient and it takes 30 mg morphine equivalent to even touch pain I would far rather give that as 300 mcg of fentanyl than as morphine (or 4.5 mg of dilaudid for that matter). That being said I think even better and safer pain management can be achieved through multimodal drug therapies.
If I'm treating something like a known appy or sickle cell crisis (for example in an ED or transfer patient) I would prefer the longer duration of analgesia of morphine or dilaudid.
I also think that a lot of EMS patients, and patients in general, don't need narcotics. Good pain management can be achieved with non-narcotic medications for most patients, and many pain complaints actually have a better clinical response to medications that don't target narcotic receptors. 15 mg of IV toradol has been shown to largely not have the bleeding risk that many have feared and can be safe in many (certainly not all) surgical cases. Other good options may include IV tylenol, IV lidocaine, lidocaine patches, trigger point injections, digital blocks, hematoma blocks, infiltration of local anesthetics, compazine, reglan, phenergan, low dose ketamine, gabapentin, IV haldol, tessalon perles, benzocaine cough drops, pseudoephedrine (for ear aches), tea with honey, motrin, cochicine, indocin, decadron, ice and elevation, splinting, reduction, rest, decreasing environmental stimulus, ORT or IV fluids, an enema... and the list goes on and on.
