Case Study: Massive Occupational Dermal Exposure to Liquid Fentanyl

Fentanyl continues to be a hot topic in the world of EMS, particularly in the context of occupational exposure risk for first responders – an area where there continues to be a significant misperception. 

Many first responders believe that even the smallest amount of fentanyl, whether inhaled or touched, can cause toxicity or fatality. Because of these concerns, I wanted to highlight a 2022 case report published in Prehospital and Disaster Medicine which details a confirmed, accidental occupational exposure to analytically confirmed pharmaceutical fentanyl. This case report is particularly interesting because the patient and the author are the same person.

The case 

Dr. Ryan Feldman, PharmD is an Emergency Medicine Clinical Pharmacy Specialist as well as a Clinical Toxicologist and Certified Poison Specialist, who experienced first-hand occupational exposure to liquid fentanyl while attempting to dispose of a container with 950 mcg of aqueous fentanyl (95 mL x 10 mcg/ml). The exposure occurred over a large skin surface area including his ungloved hand, wrist, and forearm. Notably, the exposure involved skin barrier compromise due to a healing laceration on his hand and an abrasion on his wrist. The total potential exposure was estimated to be up to 380 mcg of fentanyl.¹

Recalling the incident, Feldman’s first immediate thought was, Am I going to be okay? “Even though I have extensive training in pharmacokinetics and drug absorption, because of all the things I'd seen in the media – for half a second, I thought, Oh, wait, am I in trouble?”, he said. Realizing that sometimes in medicine, an accident can be an opportunity, his next step was to take a picture of his hand and arm before washing off the fentanyl liquid. The total exposure time was approximately 60 seconds.  

What was the clinical outcome? 

Despite a massive dermal exposure to liquid fentanyl for 60 seconds, Dr. Feldman experienced no adverse effects. He underwent a routine medical examination, which found his vitals remaining stable (HR 61 BPM, BP 129/92mmHg, RR 12, and oxygen saturation of 100% on room air). With no signs or symptoms of opioid toxicity, Dr. Feldman subsequently resumed working that day.¹  

Further discussion of dermal absorption of fentanyl 

I asked Dr. Feldman about the risk of toxicity after dermal exposure to fentanyl. His response: essentially none, assuming you walk to an area to decontaminate yourself promptly.

“Fentanyl doesn't just phase right through the skin,” he pointed out.  

Regarding absorption, Feldman also noted that in contrast to the liquid fentanyl covering his arm and hand, if he’d instead had his entire hand coated in powdered fentanyl, the rate of absorption would have been even slower.

“A powdered exposure, let's say a tablet that somebody had - if it gets on your skin, that powder now needs to dissolve into the liquid on your skin into the aqueous layer, and then dissolve through the skin.”  

Dr. Feldman said that proper PPE such as correct gloves, goggles, and respirators will provide significant protection because fentanyl is more likely to be absorbed via mucous membranes as opposed to skin. If a first responder is wearing proper PPE, the risk of occupational fentanyl toxicity is essentially negligible.  

“Now, could I dream up a scenario where someone had a hot boiling bath of fentanyl, and they jumped in it and somehow absorbed enough of it to experience toxicity because they had multiple cuts all over their body?” Feldman mused. “That's a very unique circumstance that I don't think anybody's going to be encountering in day-to-day life.”  

A more practical example of extreme exposure is provided in his case report, noting that using in vitro modeling to calculate a massive exposure to carfentanil (a substance 100 times more potent than fentanyl) “demonstrated the drug would need two minutes of exposure to the full palmar hand surface area of each hand to absorb a biologically relevant dose and up to 44 minutes to absorb a lethal dose.”¹ Simply put, it is difficult, or perhaps nearly impossible, to quickly achieve a toxic exposure to fentanyl via the skin.  

Why is this important for first responders? 

Surveys with first responders have demonstrated a high prevalence of concern for occupational fentanyl exposure and the belief that even limited exposure can lead to death. Additionally, in recent years the lay media has seen a spike in the reporting of first responders experiencing fentanyl toxicity due to occupational exposure – however, confirmation of fentanyl exposure is lacking, and the signs and symptoms reported have been inconsistent with opioid toxicity. Indeed, the scientific literature has noted that the symptoms in lay media cases have been more consistent with anxiety or panic attacks.^2–4

Feldman noted that there’s a type of feedback loop of confirmation bias.

“This is sort of what's going on with fentanyl,” he said. “Every time there's an unsubstantiated and unconfirmed exposure in the media, it sort of legitimizes a risk of potential exposure. But when you look at the symptoms that are developing [in lay media reports], they're not consistent at all with opioid overdose.” Feldman concurred that the symptoms represented in lay media reports are more consistent with the physical manifestations of a panic disorder.  

Take-home points for first responders 

Dr. Feldman explained his motivation for publishing his case report. “How can we start to realign the risk perception of occupational dermal fentanyl exposure? We can use real confirmed published cases of exposure. Look how quickly it can combat the misinformation around the idea that ‘just being near fentanyl can cause an exposure’. I think unfortunately, all the rampant media about risk is heightening people’s concerns about it, and then you're more likely to think you've been exposed as well.”  

Concluding his remarks, Dr. Feldman said, “I'm hoping that this information can help people feel safer at their jobs, because there are so many real risks that our first responders do an amazing job of navigating, and I don't think this should be one they need to worry about.” 

Dr. Feldman provides education through his various social media accounts: 

• Twitter: @EMPoisonPharmD and @LabPoison 

• IG: @Tox_talk  

• Facebook: The Poison Lab 

• www.thepoisonlab.com - podcast, medical games (shock/resuscitation), YouTube videos 

• https://wtfentanyl.com/ - information on occupational fentanyl exposure myths 

The views and opinions expressed in this article are those of the author and do not necessarily reflect those of people, institutions, or organizations they have been, currently are, or will be affiliated with. 

References 

1. Feldman R, Weston BW. Accidental Occupational Exposure to a Large Volume of Liquid Fentanyl on a Compromised Skin Barrier with No Resultant Effect. Prehosp Disaster Med. 2022;37(4):550-552. doi:10.1017/S1049023X22000905 

2. del Pozo B, Rich JD, Carroll JJ. Reports of accidental fentanyl overdose among police in the field: Toward correcting a harmful culture-bound syndrome. Int J Drug Policy. 2022;100:103520. doi:10.1016/j.drugpo.2021.103520 

3. Attaway PR, Smiley-McDonald HM, Davidson PJ, Kral AH. Perceived occupational risk of fentanyl exposure among law enforcement. Int J Drug Policy. 2021;95(xxxx):103303. doi:10.1016/j.drugpo.2021.103303 

4. Herman PA, Brenner DS, Dandorf S, et al. Media Reports of Unintentional Opioid Exposure of Public Safety First Responders in North America. J Med Toxicol. 2020;16(2):112-115. doi:10.1007/s13181-020-00762-y