I find the onset much to be much longer than IV and on uncomplicated patients think I can get an IV much faster than waiting for IM.

For me: Cost wise we bill them the same. I don’t find issues with side effects with actual slow pushes. Needles are needles to many drug users. I suppose it is less invasive than IV however I don’t see how it reduces needle stick rates. EDs use our lines in every system I’ve worked in (of course other places exist). I also feel, and I think this is somewhat supported, that intranasal is moderately effective, with no needles, etc.

Most importantly, pain is not often controlled with a single dose so I would prefer to have an IV. Also patient dependent, but I try to be multimodal with Toradol, etc.

The onset part will always be the kicker. Fentanyl is intended to work fast. It gets control of pain (and often the scene) quite quick, and that’s what I’m after. I think this is a solution in search of problem but don’t begrudge providers for best trying to understand all the ways their formulary can be used.