The United States is suffering from an opioid epidemic. An alarming number of illicit drug users are overdosing by wittingly or unwittingly using fentanyl or its analogues. This influx of overdoses is requiring responses by public safety personnel to render medical care to those drug users. The media is regularly reporting exposures to emergency response personnel by fentanyl during these response functions. Public safety personnel, such as firefighters, EMS responders, and police officers must implement a comprehensive risk assessment to reduce exposures to fentanyl.
History of Fentanyl
In the early 1960s, a Belgian chemist named Paul Janssen synthesized a drug he named fentanyl. Janssen’s company, Janssen Pharmaceutica initially introduced the drug into the medicinal market as an anesthesia to be used during surgery; however, it was later marketed for pain management. Janssen went on to develop analogues of fentanyl. Analogues are versions of the original drug with small chemical changes that may offer stronger or weaker effects. In the 1970s Janssen developed highly potent analogues of fentanyl, including carfentanil and sufentanil. Subsequently in the 1990s, Janssen Pharmaceutica developed a transdermal patch that allowed for the administration of fentanyl through the skin (Stanley, 2014).
According to the United States Drug Enforcement Agency (2017), fentanyl is 50-100 times more potent than morphine and carfentanil is 100 times stronger than fentanyl. The developments of many of the analogues of fentanyl are attributed to increasing patient tolerances to opioids and opiates. The medical community needed something stronger than morphine and meperidine and the fentanyl analogues solved this problem (Stanley, 2014).
In 2013, the DEA started to see a rising number of overdoses related to illicit opioid use. These overdoses were a result of “counterfeit pharmaceutical products containing fentanyl, fentanyl-related substances, and other synthetic opioids” (DEA, 2017, p. 3). The number of opioid related deaths has risen 72.2% over the last few years. According to Herman et al. (2020), “In 2018, more than 48,000 Americans died from opioid overdose, with synthetic opioids such as fentanyl contributing to more than half” (p. 112). While some of the illicit fentanyl use comes from legally produced fentanyl diverted into the illicit drug market, illicitly produced fentanyl is causing the rise in opioid deaths (DEA, 2017).
Fentanyl and its analogues are the most potent opioids available and have a short duration of action which can create an intense euphoric feeling. These characteristics make the drugs enticing to drug users. Profit margins can be much higher for criminal organizations, which encourages drug dealers to sell these products. Many drug dealers use fentanyl to cut heroin, which makes their product more attractive because of its potency. Drug users are unwittingly injecting this mix, causing an overdose (DEA, 2017).
The news media is routinely reporting fentanyl exposures by unsuspecting public safety personnel (Herman et al., 2020). Police officers can be exposed to fentanyl when searching suspects or vehicles and emergency medical services (EMS) workers may receive exposures while treating overdose victims. These reported exposures are increasing the level of anxiety for public safety personnel and creating additional concern for their health and safety.
Like any other exposure hazard, performing a fentanyl risk assessment can assist response personnel to identify the actual health concerns, reduce worker anxiety, and provide recommended work practices. A comprehensive understanding of the hazards and risks of fentanyl can decrease the potential exposure to public safety workers. This process can also help management to formulate policies, procedures, and guidelines for their workers to follow when responding to incidents involving fentanyl or its analogues.
Identification of Fentanyl
Fentanyl, in its purest form, is a white, crystalline solid. Through the clandestine manufacturing process, contaminates may enter the process and change the characteristics of fentanyl, like color or texture. Law enforcement agencies also discovered many cases where dyes and other chemicals are mixed with fentanyl and pressed into pills that are made to resemble oxycodone pills. The DEA has also discovered bricks of white powdered fentanyl (DEA, 2017).
Liquids may contain fentanyl mixed into a solvent, like water or alcohol. Liquid fentanyl citrate is the compound used in the injectable and transdermal formulas (Stanley, 2014). These forms may present as clear, colored, or opaque liquids.
The use of visual means is usually insufficient to identify fentanyl; looking at the drug may not provide enough indication as to its composition. Other forms of identification, including field screening methods and laboratory analysis may be required to identify fentanyl. Sometimes public safety personnel must use intelligence gathering to direct their suspicions that fentanyl may be present. This may include information from family members that an overdose victim took fentanyl or from a confidential human source during law enforcement operations.
Signs and Symptoms of Exposure
“Workers who may encounter fentanyl or fentanyl analogs should be trained to recognize the symptoms and objective signs of opioid intoxication…” (ACMT, 2017, para. 18). Emergency response personnel educated in the signs and symptoms of exposure can act quickly to provide care to affected coworkers. Signs and symptoms of opioid exposure include, but are not limited to, pinpoint or constricted pupils, slow or absent breathing, and disorientation (DEA, 2017).
Routes of Exposure
Fentanyl can enter the body through inhalation, injection, ingestion, and skin absorption (CDC, 2016). Public safety personnel must understand these pathways so they can prevent inadvertent exposure. These routes of exposure influence the selection of appropriate control options.
Inhalation. Inhalation of fentanyl powder is the most common route of exposure for public safety personnel. “Fentanyl has potentially high bioavailability by inhalation” (ACMT, 2017, para. 9). A very small amount of fentanyl inhaled can cause adverse health effects. EMS personnel may suspend fentanyl into the air during patient treatment, whereas police officers can aerosolize fentanyl powder when opening unknown packages or searching vehicles. During inhalation, fentanyl particles can come in contact with mucous membranes and absorb into the body. Mucous membranes offer 30 times more absorption of fentanyl than does the skin (ACMT, 2017).
Injection. Needles, broken glassware, and other sharps contaminated with fentanyl pose an injection hazard to public safety personnel. EMS and law enforcement personnel may need to handle needles used by drug users that contain fentanyl or one of its analogues. In addition to a biohazardous concern, inadvertent injection of a fentanyl analogue, even at very small levels, can cause serious health effects.
Ingestion. Hand to mouth ingestion of fentanyl is a possible route of exposure for emergency response personnel. A law enforcement officer may need to collect fentanyl drug evidence using chemical resistant gloves. If he or she touches their face or smokes a cigarette, fentanyl may transfer from the hands to the face or mouth. This could cause fentanyl to enter the mucous membranes of the mouth or the digestive tract.
Absorption. Much confusion exists about the true absorption hazard of fentanyl. The media has sensationalized the perceived risk of fentanyl skin absorption (Herman et al., 2020). This may stem from a confusion of the transdermal patch and powdered forms of fentanyl.
The transdermal patch used to administer fentanyl is an engineered medical device designed to provide a metered dose of fentanyl to the patient. “The skin acts as both a barrier and a reservoir for the transdermally administered drug. This causes the drug to be absorbed slowly and released in a sustained manner…” (Varvel, Shafer, Hwang, Coen, & Stanski, 1989, p 928). The process which permits the flow of drug into the body is very slow. It takes between three and 13 hours for transdermally administered fentanyl to achieve therapeutic levels in the blood. Further, it takes 35 hours to reach peak concentration (ACMT, 2017). This shows that, while fentanyl can be absorbed through the skin, it does not happen quickly.
It is even more difficult to receive a significant dermal exposure to the powder form of fentanyl. Unlike a transdermal delivery system that uses an adhesive patch to adhere to the skin, powdered fentanyl sits on the skin and requires dissolution as the pathway through the skin. The skin must also have sufficient exposed surface area and moisture content to facilitate skin migration (ACMT, 2017). One study conducted by Van Nimmen, Poels, & Veulemans (2006) in a pharmaceutical fentanyl manufacturing operation showed a correlation of workers that received a dermal exposure to the skin and fentanyl metabolite presence in the urine. This study suggests that fentanyl does absorb through the skin, however the test subjects were working with large amounts of pharmaceutical grade fentanyl in the manufacture setting. Even though researchers detected metabolites in the worker’s urine, the workers did not exhibit any signs and symptoms of exposure. This further supports the poor skin absorbency of fentanyl. According to the American College of Medical Toxicology (2017), “…it is unlikely that small, unintentional skin exposures to tablets or powder would cause significant opioid toxicity, and if toxicity were to occur, it would not develop rapidly, allowing time for removal” (para. 14).
A number of factors can significantly impact the level of risk assumed when responding to incidents involving fentanyl. Elements that increase risk include large quantities of the drug, high purity of the drug, high-potency analogues, uncontained drugs, windy conditions, hot conditions, and other hazards present at the scene. These risks may influence determining which control options are adequate.
Public safety personnel can effectively control fentanyl exposure by using a risk management model. The hierarchy of controls is a mitigation method used to manage exposure to hazards. The hierarchy includes elimination, substitution, engineering controls, administrative controls, and personal protective equipment.
Elimination. The best and preferred method to control hazards is by eliminating the hazard. In industry, safety professionals eliminate hazards during the development of a process or work flow. However, during emergency response operations, eliminating hazards can be difficult. Conditions are often uncontrolled and personnel assume a certain level of risk in order to eliminate risk to future operations. For example, during the processing of a crime scene involving fentanyl, response personnel can don personal protective equipment, make entry into the location, and remove the fentanyl from the site. In doing so, personnel performing subsequent operations may need less or no personal protective equipment.
Substitution. Substitution is the replacement of a dangerous material for a less dangerous material. In the circumstances described in this paper, substitution is not an appropriate method to control fentanyl hazards.
Engineering Controls. An acceptable method to mitigate fentanyl hazards is by employing certain engineering controls. Performing field testing operations within a glove box apparatus ensures containment of fentanyl within the box. Safety personnel use mechanical ventilation to evacuate contamination from spaces. Care should be taken when using ventilation to remove fentanyl as it may spread contamination and increase exposure to other emergency response personnel.
Administrative Controls. Due to the very nature of emergency response operations, personnel often use administrative controls to manage risk. The use of caution tape, or other barriers, helps to communicate hazardous locations to personnel. Providing a site safety briefing informs personnel about the hazards present and methods implemented to control exposures. Providing training to personnel raises their awareness of the hazard, which in turn helps them to recognize the risks of fentanyl. Organizations should establish policies, procedures and guidance documents for their personnel to follow. Enhancing communications, like marking evidence as “possible fentanyl,” helps to convey hazards to personnel required to handle the evidence. Implementing good work practices, like limiting contact with the hazard and taking steps to reduce aerosolizing fentanyl can significantly improve health and safety. Using good hygiene
practices, like handwashing can reduce the hand-to-mouth route of exposure. Personnel must take care when using alcohol-based hand sanitizers. These products do not degrade fentanyl, rather they dissolve the fentanyl and may actually increase skin absorption (ACMT, 2017).
Personal Protective Equipment. A thorough risk assessment will determine the need for and level of personal protective equipment. Personnel should evaluate each situation for the risk of exposure and select the personal protective equipment with the purpose of reducing the exposure to the hazard. Generally, fentanyl presents as a particulate hazard. The likely scenario that public safety personnel may face involves powdered or solid forms of fentanyl. As such, responders must consider particulate personal protective equipment.
Regulatory agencies have not developed occupational exposure limits (OELs) for fentanyl. However, the pharmaceutical industry established OELs to provide exposure control for workers. The pharmaceutical industry established an OEL for fentanyl at 0.0001 mg/m-3 (Van Nimmen, et al., 2006). Particulate respirators, either filtering facepieces or half-face respirators, rated as P100 meet stringent criteria established by the National Institute for Occupational Safety and Health (NIOSH). These respirators have a minimum efficiency of 99.97%. Filtering facepieces rated as N95 are only 95% efficient. Considering the low OEL of fentanyl, the improved efficiency of the P100 respirator is appropriate for protecting workers.
While the skin absorption hazard is not considered a significant route of exposure, it is prudent to wear protective clothing to reduce contamination to work uniforms. Personnel may consider the use of a particulate suit. Personnel should consider chemical protective clothing when encountering liquids, as these may permeate particulate suits.
Safety goggles provide full eye protection. Safety glasses have void spaces that may allow fentanyl to enter. Since fentanyl can enter the mucous membranes of the eyes, safety goggles are preferred. Additionally, if responders select a full-face respirator safety goggles are not necessary.
Nitrile exam gloves provide adequate protection against solid fentanyl (CDC, 2016). Nitrile exam gloves may provide protection from liquids containing fentanyl; however, responders must check chemical compatibilities to ensure the gloves will provide adequate protection. Other gloves, like butyl rubber are also an option; however, they are more expensive and are not generally readily available.
Organizations must also establish proper decontamination procedures. Simple, routine options may involve proper doffing techniques and personal hygiene. More complex operations may include using water and a surfactant or other decontamination solution used to degrade fentanyl.
If discretionary time is available prior to performing operations, response personnel and managers must perform proper operational planning. Teams should be well prepared to perform required tasks, including educating them on proper control methods. Managers should ensure that personnel are properly trained, equipped, and available to respond to incidents involving fentanyl.
Good Work Practices
Like with other hazardous materials, response personnel should avoid contact with fentanyl whenever possible. If handling is required, personnel must limit the likelihood of aerosolizing fentanyl. Personnel should also use personal protective equipment when it is reasonable and foreseeable that exposure may occur. The outcome of a good risk assessment will dictate personal protective equipment requirements.
The DEA advises against field testing of suspected fentanyl drug evidence (DEA, 2017). Organizations must determine if this option is right for them. Law enforcement managers should contact prosecutors to discuss the impact of not field-testing evidence. If managers determine that field testing is necessary, they should establish proper procedures to ensure personnel are protected from exposure to fentanyl.
Naloxone is a post-exposure medication used to reverse the health effects of opioid symptoms. The availability and use of naloxone are not a substitute for proper planning, good procedures, and personal protective equipment use. Naloxone may have limited use against high potency fentanyl analogues. Exposure may require resuscitation methods and large doses of naloxone beyond the capability of public safety responders. Naloxone should be a part of, but not a sole pillar of, a response program to incidents involving fentanyl.
The risks that public safety responders face is ever changing. The influx of fentanyl in the illicit drug market since 2013 provides increased concern for exposure to fentanyl and its analogues (DEA, 2017). Arming responders with knowledge, skills, equipment, supplies, policies, procedures, and guidelines can help to prepare them to face this hazard, in light of many reported public safety exposures.
EMS workers are asked to care for drug users who overdose on these dangerous drugs (CDC, 2017). They must be prepared to protect themselves from these drugs while they perform their jobs. More and more police departments are arming their officers with naloxone to use for drug overdose victims. Additionally, their jobs require them to investigate crime, process crime scenes, and handle evidence that may contain fentanyl. Firefighters may respond to fires involving the clandestine manufacture of illicit fentanyl. They must be properly protected to reduce exposure to this dangerous drug and any precursor materials.
The importance of performing a thorough risk assessment cannot be understated. Organizations need to provide responders with the resources they need to maintain their health and safety. Workers must be able to identify the threat of fentanyl, know the signs and symptoms of exposure to opioids, understand the routes of exposure from fentanyl, know how to control fentanyl exposure, consider appropriate response considerations, and know what countermeasures are available.
American College of Medical Toxicology (ACMT). (2017, July 12). ACMT and AACT position statement: Preventing occupational fentanyl and fentanyl analog exposure to emergency responders. Retrieved from http://www.acmt.net/_Library/Fentanyl_Position/ Fentanyl_PPE_Emergency_Responders_.pdf
Centers for Disease Control and Prevention (CDC). (2016, November 28). Fentanyl: Preventing occupational exposure to emergency responders. Retrieved from https://www.cdc.gov/ niosh/topics/fentanyl/default.html
Herman, P. A., Brenner, D. S., Dandorf, S., Kemp, S., Kroll, B., Trebach, J.,… Stolbach, A. I.
(2020). Media reports of unintentional opioid exposure of public safety fire responders in North America. Journal of Medical Toxicology, 16, 112-115. Retrieved from https://doi.org/10.1007/s13181-020-00762-y
Stanley, T. H., (2014, December). The fentanyl story. The Journal of Pain, 15(12), 1215-1226. Retrieved from http://www.jpain.org/article/S1526-5900(14)00905-5/pdf
US Drug Enforcement Agency (DEA). (2017). Fentanyl: A briefing guide for first responder. Retrieved from https://www.dea.gov/druginfo/ Fentanyl_BriefingGuideforFirstResponders_June2017.pdf
Van Nimmen, N. F. J., Poels, K. L. C., & Veulemans, H. A. F. (2006, October 1). Identification of exposure pathways for opioid narcotic analgesics in pharmaceutical production workers. The Annals of Occupational Hygiene, 50(7), 665-677. Retrieved from https://doi.org/10.1093/ annhyg/mel028
Varel, J. R., Shafer, S. L., Hwang, S. S., Coen, P. A., & Stanki, D. R. (1989). Absorption characteristics of transdermally administered fentanyl. Anesthesiology, 70 (6), 928-934. Retrieved from http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1953534
Ryan Miller is a part-time faculty member for Occupational Safety and Health in the College of Safety and Emergency Services at Columbia Southern University. He is a Forensic Operations Specialist for the Federal Bureau of Investigation, specializing in health and safety matters during high hazard and complex crime scene processing. He is a Principal Member of both the National Fire Protection Association’s Technical Committee for Hazardous Materials Response Personal and Technical Committee for Emergency Responders Operational Health. Mr. Miller has earned is Master of Science degree from Murray State University and is a Certified Safety Professional (CSP) through the Board of Certified Safety Professionals.
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