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Pharmacology 101: Fentanyl: What is the Occupational Exposure Risk for First Responders?
“Perhaps the greatest danger of first responder fear of exposure is delayed response to overdose victims.” —Herman PA, Brenner DS, Dandorf S, et al., J Med Toxicol. 2020
Fentanyl. Like many other pharmacologically active molecules, it is a tool that can have both therapeutic or toxic effects, depending on the circumstances of its use. We’ve published a series on fentanyl and naloxone pharmacology for EMS caregivers, which I hope has proven useful to readers. And given the widespread attention given to the concern for harmful occupational exposures in recent years, I thought additional commentary on this topic would be germane.
What do First Responders Believe?
In 2016, the DEA put information on its website containing statement such as “fentanyl can be absorbed through the skin or accidental inhalation of airborne powder can also occur,” and “just touching fentanyl or accidentally inhaling the substance during enforcement activity or field testing the substance can result in absorption through the skin,” and “the onset of adverse health effects, such as disorientation, coughing, sedation, respiratory distress or cardiac arrest is very rapid and profound, usually occurring within minutes of exposure.”1
The next year saw a spike in lay media reports of first responder occupational exposures. However, many of the symptoms described in these reports were apparently more consistent with panic or anxiety attacks rather than the respiratory depression associated with opioid overdoses.1–3
Thompson and colleagues published a survey in 2020 with over 5000 first responders including police, EMS, fire, and rescue. Approximately 15% of their survey respondents who reported occupational exposure believed they had been exposed to opioids, with the most commonly reported routes of exposure being skin and inhalation. The authors also noted that The National Institute for Occupational Safety and Health (NIOSH) released reports between 2018-2019 evaluating first responders’ symptoms following perceived occupational exposures, and concluded they were inconsistent with life-threatening signs of opioid toxicity.4
In addition to the Thompson survey, other data indicate that first responders including law enforcement are concerned about occupational exposure to fentanyl and information leading to misunderstandings regarding the risks of dermal exposure are still circulating.1,2,5 Hope Smiley-McDonald, Director of RTI International’s Center for Forensic Science Advancement and Application, was part of a team that conducted research on law enforcement perceptions. According to Smiley-McDonald, “In our first interview, an officer shared with us that just touching one grain of fentanyl, like a grain of sand, was enough to kill you. And the fear from that first interview was just profound.”
With regard to the media reports of first responder exposures, Smiley-McDonald said, “The media has really fallen short of doing their due diligence to follow up with the hospital when you hear of an officer that has been overdosed, and they've been taken to the hospital for care. There's no follow up about what was in the toxicology report.” This is also noted in a 2020 article published in the Journal of Medical Toxicology, in which Herman and colleagues stated, “Because the scientific literature does not contain confirmed first responder exposures, lay media reports remain the only 'evidence' of the phenomenon.”3
What Do Toxicology Experts Say?
In response to the reports in the lay media and growing concern from first responders, the American College of Medical Toxicology (ACMT) and the American Academy of Clinical Toxicology (AACT) released a joint position statement in 2017 titled Preventing Occupational Fentanyl and Fentanyl Analog Exposure to Emergency Responders, which opens with the statement, “Fentanyl and its analogs are potent opioid receptor agonists, but the risk of clinically significant exposure to emergency responders is extremely low. To date, we have not seen reports of emergency responders developing signs or symptoms consistent with opioid toxicity from incidental contact with opioids.”6
The ACMT/AACT joint statement further reinforces the fact that extant reports of first responder symptoms upon perceived fentanyl exposure were nonspecific, including “dizziness”, “feeling like body shutting down”, and “dying”—but “without objective signs of opioid toxicity such as respiratory depression.”6
Inhalation Exposure: What's the Risk?
The ACMT/AACT joint statement highlights data that show fentanyl’s low vapor pressure indicates that it is a low concern for standing product to evaporate into a gaseous phase, and additionally state that “At the highest airborne concentration encountered by [industrial fentanyl production] workers, an unprotected individual would require nearly 200 min of exposure to reach a dose of 100 mcg of fentanyl.”6 The joint statement makes a reference to a suspected use of weaponized aerosolized synthetic opioids in a 2002 hostage situation in Russia, but note that for first responders in America to encounter such a device seems unlikely.
This is the specific recommendation from ACMT/AACT for respiratory precautions: “In the unusual circumstance of significant airborne suspension of powdered opioids, a properly fitted N95 respirator or P100 mask is likely to provide reasonable respiratory protection.”6
How Dangerous is Dermal Exposure?
What about personal protective equipment (PPE)? While fentanyl may not be readily absorbed through the skin, Thompson and colleagues note that the landscape of drug use in America may be shifting to include an increasing amount of methamphetamines.4 Therefore, with the need to reduce exposures to other substances and biohazards, PPE remains an important component of protection for first responders.
According to the ACMT/AACT recommendations, “For routine handling of drug, nitrile gloves provide sufficient dermal protection. In exceptional circumstances where there are drug particles or droplets suspended in the air, an N95 respirator provides sufficient protection.”6
Take-Home Points
Lay media reports of occupational exposure to fentanyl often have described symptoms inconsistent with opioid overdose, and the scientific literature does not confirm any widespread phenomenon of first responder overdose due to occupational exposure to fentanyl. Herman and colleagues noted that “When a news story reports that a [first responder] was given naloxone and treated for opioid exposure, the story should clarify that receiving treatment and observation is not the same as requiring treatment and observation.”3
Fentanyl is not readily absorbed through skin. According to the 2018 ACMT/AACT position statement, “Incidental dermal absorption is unlikely to cause opioid toxicity,” and “…it is very 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.”6
PPE still important in mitigating even small risks. Because fentanyl is not the only substance that first responders may be exposed to, equipment including nitrile gloves and N95 respirators still play an important role in protection.6
Workers who may encounter fentanyl or fentanyl analogs should be trained to recognize the signs and symptoms of opioid intoxication, have naloxone readily available, and be trained to administer naloxone and provide active medical assistance.
EMS personnel are not the only first responders who may benefit from awareness of this topic—fire, police, and rescue are among other professions who share concerns regarding fentanyl. Additionally, EMS responders can provide education to other first responders with whom they work closely.
The complete statement and recommendations for general precautions and management of exposure from the ACMT/AACT can be found here—the document is succinct, clear, and relevant, and I recommend reading it in its entirety.
Up Next in Pharmacology 101
Stay tuned for more from Pharmacology 101: In our next article, we’ll discuss a case of a health care worker’s accidental dermal exposure to a significant amount of liquid fentanyl, and what happened afterward.
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. del Pozo B, Sightes E, Kang S, Goulka J, Ray B, Beletsky LA. Can touch this: training to correct police officer beliefs about overdose from incidental contact with fentanyl. Heal Justice. 2021;9(1):1-6. doi:10.1186/s40352-021-00163-5
2. Attaway PR, Smiley-McDonald HM, Davidson PJ, Kral AH. Perceived occupational risk of fentanyl exposure among law enforcement. Int J Drug Policy. 2021;95:103303. doi:10.1016/j.drugpo.2021.103303
3. 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
4. Thompson RA, Sanderson WT, Westneat S, et al. Perceptions of opioid and other illicit drug exposure reported among first responders in the southeast, 2017 to 2018. Heal Sci Reports. 2021;4(3). doi:10.1002/hsr2.335
5. 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
6. Moss MJ, Warrick BJ, Nelson LS, et al. ACMT and AACT Position Statement: Preventing Occupational Fentanyl and Fentanyl Analog Exposure to Emergency Responders. J Med Toxicol. 2017;13(4):347-351. doi:10.1007/s13181-017-0628-2
Daniel Hu, PharmD, BCCCP, has a doctor of pharmacy degree and is a medical science liaison with a background in critical care and emergency medicine pharmacy.
