Incidental Fentanyl Exposure

[NPO]

Everyone has seen the video by now. A cop is acting funny, another officer fumbles with some narcan and administers it. All supposedly after a drug arrest.

By now Facebook is a flood with people who are "educating" people about how incidental overdose from fentanyl is very unlikely, and that the mass hysteria is media driven. However, even the CDC says that it's very possible to overdose from skin contact with fentanyl.

So I ask you, what evidence is there? We know transdermal fentanyl is a thing, although I suspect it's quite slow. What about mucus membranes? The CDC says extremely small amounts can cause an overdose. Who are we to believe?

EMS providers say it's all over blown. Law Enforcement is donning Class A suits for warrant searches. Where is the disconnect?

What about fentanyl analogs and such, like carfentinil? Is the fentanyl that LE encounters different than what us as EMS providers are accustomed to?

I don't understand why one industry things it's an over reaction, and why the CDC and LE think it's such a big deal. Also, what is the real threat for incidental exposure, if any?

 

[ThadeusJ]

Its the carfentanil that you want to worry about since its 100 times more potent that fentanyl and 5000 times more potent than heroin and 10,000 times more potent than morphine. Four grains can kill you, so accidental exposure isn't that hard. We have had several firefighters experience exposure as well as a few police officers. Better safe than sorry and don't try to play the odds (IMHO).

 

[DrParasite]

EMS providers say it's all over blown. Law Enforcement is donning Class A suits for warrant searches. Where is the disconnect?

I can't imagine LEO in level A suits for a simple warrant search....... Level C sure, Level B, maybe if you suspect airborne threats, but unless there is a reason, Level A simply isn't practical.

However, even the CDC says that it's very possible to overdose from skin contact with fentanyl.

Sure it's possible, but how likely is it to happen? Many things are possible, however the chances are still slim. That being said, you still need to utilize PPE where appropriate.

We have had several firefighters experience exposure as well as a few police officers. Better safe than sorry and don't try to play the odds (IMHO).

Would you be willing to share how they were exposed? what were the circumstances around it? and what type of PPE were they wearing (or not wearing) when they were exposed?

 

[Carlos Danger]

You will never develop toxicity from dermal exposure to normal concentrations of pharmaceutical fentanyl. Fentanyl patches are very concentrated and especially formulated to be absorbed through the dermis, and still it takes hours of wearing one to develop therapeutic serum concentrations. You can put all you want of normal fentanyl on your skin and it’ll evaporate before it gets absorbed to any significant degree.

The problem is that the stuff you run into on the streets isn’t pharmaceutical grade. It is probably formulated to be as concentrated as possible, I still think toxic serum levels would be hard to achieve through dermal exposure, but it would certainly be reasonable to take precautions against. Respiratory exposure should probably be a bigger concern.

Carfentanil is another story. It’s dangers to first responders have likely been exaggerated, but it is so ultra-potent that I definitely wouldn’t mess with it without respiratory and dermal protection.

The confusion, I think, comes from the fact that people are afraid of what they don’t understand. And no doubt there has been some sensationalism involved.

 

[chriscemt]

And no doubt there has been some sensationalism involved.

In FB videos? Never!

I think a lot of the misinformation comes from no proper distinction being made between fentanyl and carfentanil, and of course, any of the homemade "fentanyl" being made.

 

[jwk]

Its the carfentanil that you want to worry about since its 100 times more potent that fentanyl and 5000 times more potent than heroin and 10,000 times more potent than morphine. Four grains can kill you, so accidental exposure isn't that hard. We have had several firefighters experience exposure as well as a few police officers. Better safe than sorry and don't try to play the odds (IMHO).

Not sure what you're calling a "grain" but a grain is an actual unit of weight and equals 65mg. A 325mg aspirin tablet is 5 grains.

 

[medichopeful]

Its the carfentanil that you want to worry about since its 100 times more potent that fentanyl and 5000 times more potent than heroin and 10,000 times more potent than morphine. Four grains can kill you, so accidental exposure isn't that hard. We have had several firefighters experience exposure as well as a few police officers. Better safe than sorry and don't try to play the odds (IMHO).

If that's the case, why are the manufacturers not overdosing left and right?

You can be exposed to something and not be affected by it. You can also be exposed to something and not instantly OD.

Is it possible to OD/feel the effects of these substances if they land on the skin? Probably, but it would take a LONG time, and a fair amount of it.

If you inhale some of these substances, I can see it being an issue, but only if there is a ton of the stuff (or if it was intentionally weaponized).

I'd be most concerned with exposure to mucous membranes or open wounds, but that seems pretty low down on the list of possibilities. And again, I feel there would need to be a fair amount of the stuff to truly cause an issue.

Keep in mind this statement from the AACT and ACMT:

"To date, we have not seen reports of emergency responders developing signs or symptoms consistent with opioid toxicity from incidental contact with opioids."

I suggest that you (and everyone) look over this position statement/article. It dispels a lot of the myths surrounding these opioids.

https://www.acmt.net/_Library/Fentanyl_Position/Fentanyl_PPE_Emergency_Responders_.pdf

 

[medichopeful]

Not sure what you're calling a "grain" but a grain is an actual unit of weight and equals 65mg. A 325mg aspirin tablet is 5 grains.

Perhaps they meant "granule"?

 

[NPO]

Not sure what you're calling a "grain" but a grain is an actual unit of weight and equals 65mg. A 325mg aspirin tablet is 5 grains.

Ha! I remember being taught in medic school that the nirto dose was 0.4mg or 1/150 of a grain, but no one knew why.

 

[medichopeful]

Everyone has seen the video by now. A cop is acting funny, another officer fumbles with some narcan and administers it. All supposedly after a drug arrest.

That whole things was ridiculous and painful to watch. I don't blame the individual officers, however. They were just doing what they were trained to do, with the information they had been given.

By now Facebook is a flood with people who are "educating" people about how incidental overdose from fentanyl is very unlikely, and that the mass hysteria is media driven. However, even the CDC says that it's very possible to overdose from skin contact with fentanyl.

My understanding is that it is possible to OD from skin contact with Fentanyl, but you would need to be in prolonged contact with it (hours and hours). However, I don't really see that happening in the field.

So I ask you, what evidence is there? We know transdermal fentanyl is a thing, although I suspect it's quite slow. What about mucus membranes? The CDC says extremely small amounts can cause an overdose.

I'm not really sure that this is what the CDC is saying, but I could be wrong. Can you post a link to this?

Who are we to believe?

I'm going with the scientists on this one. And from everything I've seen, the scientists are saying that this is WAY overblown.

Is the fentanyl that LE encounters different than what us as EMS providers are accustomed to?

Nah, we've just developed a tolerance to it because we carry it!

I don't understand why one industry things it's an over reaction, and why the CDC and LE think it's such a big deal. Also, what is the real threat for incidental exposure, if any?

Like I stated above, I don't really think that the CDC is saying it's a big deal. They are saying to be careful, but reasonably so.

I think the big issue is priorities. One of the primary jobs of LE is to combat drug use, so they can use this misinformation to their advantage ("Look how dangerous these drugs are!"). EMS, on the other hand, is more focused on patient care and evidence-based practice ("Look, these drugs are dangerous when misused, but the evidence states that these stories are fake news"). Different priorities, different agendas, different knowledge bases. Education can go a long way towards easing stress.

Here is some extra information on this subject:
https://www.acmt.net/_Library/Fentanyl_Position/Fentanyl_PPE_Emergency_Responders_.pdf
https://www.whitehouse.gov/sites/wh...fety Recommendations for First Respond....pdf


Edited to add links.

 

[Peak]

Certainly there can be an exposure risk, meds like 3-methylfentanyl or carfentanil are incredibly potent. I would be most concerned as others have discussed of a powder being inhaled.

I think running into a lab situation would be very rare, most drugs are manufactured overseas and are only cut down here. If you were in a lab then the agents used to manufacture may have very low partial pressures and easily be inhaled and become incapacitating. I would probably worry more about some of the other byproducts of manufacture more though.

My concern for lethality would be pretty low, if we look back to moscow theater crisis a gas that was shown to contain carfentanil and remifentanil were suspended (most likely in halothane) which incapacitated both the hostages and terrorists without killing them, most of the deaths were from placing the hostages on their
backs where they then self occluded their airways. If you are part of a team (whether treating medical victims, conducting a search, or performing rescue) you are unlikely to be alone and basic airway management would prevent long term problems.

Most of these fentanyl or derivatives are used to cut heroin, its not just carried around in the raw chemical form. I don't think that risk is out there for most EMS or ED staff and would be easily mitigated with a class B suit and respirator for all but the most extreme cases, and I have yet to hear of a case that occurred and was actually confirmed with laboratory testing.

 

[NPO]

My apologies. I need to take a few steps back and make a couple corrections. I kept saying CDC, however my "data" was actually from a DEA publication. Too many acronym agencies.

Also, when I specifically stated Level A suits I was recalling a photo, however looking back, they are wearing Level B suits. The photo is attached. But there was this pulled from the publication:

Due to the high risk potential associated
with these substances, only law
enforcement personnel employing the
proper PPE (from Personal PPE to Level “A”
PPE) as referenced under General Safety
Recommendations should consider
handling any substance suspected to
contain fentanyl or a fentanyl-related
substance.

Here is a link to the said document:
https://www.google.com/url?sa=t&sou...FjAAegQIBhAB&usg=AOvVaw3jI3WHQ9mZ7QC4rxdNA0wp

 

[E tank]

Who are they going to shoot?

 

[medichopeful]

My apologies. I need to take a few steps back and make a couple corrections. I kept saying CDC, however my "data" was actually from a DEA publication. Too many acronym agencies.

Agreed, way too many acronyms.

The DEA publishing that information makes sense, as they are an enforcement agency. They are focused on law, not science. What better way to help their mission than to scare people about the substances they are trying to fight and eliminate? It really makes perfect sense, and is a good strategy and plan. From a non-biased perspective, I would have to give them credit for that strategy. It's anti-drug propaganda.

From the perspective of someone who prefers the truth, I don't like their strategy one bit.

Also, when I specifically stated Level A suits I was recalling a photo, however looking back, they are wearing Level B suits

Either way, still overkill!

A picture like the one you posted is going to get a lot more publicity and discussion than a picture of the same officers without the suits. They're going to use that to their advantage.

It's sort of like the EMS ads that say "Learn to be a hero!" or "Learn to save a life!" Overdramatic, but catchy.

I'm not anti-LE, in fact I'm very pro-LE and have many friends in LE. I am, however, pro-science and anti-misinformation.

 

[ThadeusJ]

Not sure what you're calling a "grain" but a grain is an actual unit of weight and equals 65mg. A 325mg aspirin tablet is 5 grains.

My information from a pharmacist was four grains (recognizing that he was referring to weight). Performing a quick Google search, I found on a several sites:
"Although never tested in humans, the lethal dose of carfentanil may be in the order of 20mcg (micrograms), perhaps the size of one grain of salt." and "The drug is 100 times more powerful than fentanyl, meaning a dose of 0.02 mg is enough to kill a human. That amount is smaller than a grain of salt."

Given your definition that a grain is 65 mg, then carfentanil is significantly less than that. My apologies.

 

[medichopeful]

My information from a pharmacist was four grains (recognizing that he was referring to weight). Performing a quick Google search, I found on a several sites:
"Although never tested in humans, the lethal dose of carfentanil may be in the order of 20mcg (micrograms), perhaps the size of one grain of salt." and "The drug is 100 times more powerful than fentanyl, meaning a dose of 0.02 mg is enough to kill a human. That amount is smaller than a grain of salt."

I could definitely see that being true.

However, it would need to have a reliable entry into the body (for example, injected or straight onto a mucous membrane/open cut). I just don't see this being a common occurrence in the field, and groups of incredibly smart people are saying the same thing.

Nobody is denying that these substances are dangerous (they most certainly are). What we are saying, however, is that in the way EMS/police/fire are going to come into contact with them, the danger is way overblown.

 

[jwk]

My information from a pharmacist was four grains (recognizing that he was referring to weight). Performing a quick Google search, I found on a several sites:
"Although never tested in humans, the lethal dose of carfentanil may be in the order of 20mcg (micrograms), perhaps the size of one grain of salt." and "The drug is 100 times more powerful than fentanyl, meaning a dose of 0.02 mg is enough to kill a human. That amount is smaller than a grain of salt."

Given your definition that a grain is 65 mg, then carfentanil is significantly less than that. My apologies.

I only know this because I'm old. This was from the old apothecary units of measure. As NPO noted, 1/150 of a grain was 0.4mg, which was the routine pre-op dose for atropine, which just about everyone in anesthesia used to give to dry up oral secretions (the less spit the better).

 

[E tank]

I only know this because I'm old. This was from the old apothecary units of measure. As NPO noted, 1/150 of a grain was 0.4mg, which was the routine pre-op dose for atropine, which just about everyone in anesthesia used to give to dry up oral secretions (the less spit the better).

Sub-lingual NTG too...odd way of giving the order over the radio too...NTG, grains one to one-fifty, SL

 

[MSDeltaFlt]

Everyone has seen the video by now. A cop is acting funny, another officer fumbles with some narcan and administers it. All supposedly after a drug arrest.

Da-da-da-da-da-da-da-da...