In the 2025 ACC/AHA ACS Guidelines, opioids like morphine or fentanyl are reserved for severe, nitrate-resistant chest pain.

Pros:
• Pain relief
• Reduces sympathetic drive

Cons:
• May delay oral P2Y12 inhibitor absorption
• Risk of hypotension and respiratory depression
• No mortality benefit; may worsen outcomes if overused

Bottom line:
Use cautiously, only when truly needed—not routine. Pain shouldn’t mask ischemia.