Fentanyl or Morphine? a qualitative investigation of solo responding paramedics´ decision-making in prehospital care

BACKGROUND: Solo responding unit (SRU) paramedics at Oslo University Hospital (OUH) can administer either morphine or fentanyl for prehospital pain management. Although both opioids are available, the choice between them is made by individual clinicians in time-critical situations, often with limited information, variable transport conditions, and minimal organisational feedback. Existing research has primarily focused on comparative efficacy and safety, while less attention has been paid to how paramedics reason in practice. This study explores the clinical, logistical, and organisational factors that influence SRU paramedics' opioid selection, how advantages and disadvantages of morphine and fentanyl are perceived, and how local norms and decision-making support shape practice. METHODS: This qualitative descriptive study employed three face-to-face focus groups with a total of 11 participants. The sessions were recorded, transcribed, and analysed thematically. The first author's dual role as an SRU paramedic was acknowledged and used reflexively to enhance the interpretation of the findings. RESULTS: The participants (1 female, 10 male, mean age 42 years, mean 19.6 years of ambulance experience from urban and rural regions within OUH) emphasised the role of personal experience and intuitive judgement in selecting between morphine and fentanyl. Fentanyl was favoured for rapid onset in acute traumatic pain or short transports, while morphine was selected for its longer duration in frail patients or lengthy transports. "Ambulance truths", informal, station-specific beliefs, filled gaps where formal guidance was lacking. Safety concerns existed for both drugs, although severe adverse events were rarely experienced by participants. CONCLUSION: SRU paramedics' opioid selection is shaped by an interplay of pharmacological reasoning, familiarity, organisational protocols, and cultural norms. The findings suggest that formalised training, streamlined documentation, and structured feedback mechanisms may support more consistent decision-making in prehospital analgesia.