The severity of the opioid epidemic is well-documented. In 2017, the Centers for Disease Control and Prevention (CDC) reported that drug overdose deaths in the United States more than tripled from 1999 to 2015.[1] From 2015 to 2016, opioid overdose deaths increased by more than 20 percent—rising from 52,898 in 2016 to 64,070 deaths in 2017.[2] Additionally, in 2016, U.S. life expectancy declined for the second year in a row caused in part by an increase in unintentional injuries, chiefly drug overdoses.[3],[4] The unintentional use of illicitly manufactured fentanyls (synthetic opioids) alone, or added to heroin, cocaine, or to counterfeit prescription tablets resembling oxycodone or hydrocodone, has been cited as an important driver of the recent increases in opioid overdose deaths.[5],[6] In March, the President announced a new opioid initiative to combat what he termed “worst drug crisis in American history,” declaring it to be a public health emergency,[7],[8] and proposing $10 billion in funding to combat the epidemic.[9]

First responders and other workers are potentially exposed to opioids as a result of their employment and may be at risk of acute opioid intoxication themselves. There have been many reports detailing symptoms first responders have developed when responding to drug overdose incidents in environments where multiple types of illicit drugs may be present.[10],[11],[12],[13] These reports have involved public sector police officers and fire-fighter emergency medical service providers as well as emergency medical service providers that are part of the public safety model but separate from police and fire departments. The National Institute for Occupational Safety and Health has been at the forefront of efforts to protect workers from opioid exposure. A new article published in the American Journal of Industrial Medicine, “Fentanyls and the Safety of First Responders: Science and Recommendations”, provides an in-depth review of opioid pharmacology, probable routes of exposure related to specific job tasks, signs and symptoms of acute opioid intoxication, management of intoxication, and recommended exposure prevention measures. We hope that this commentary assists first responders, police and fire department management, clinicians, and other interested parties in gaining a better understanding of the current scientific basis for existing exposure prevention recommendations as well as emphasizing that any set of recommendations to protect first responders must be based on sound scientific findings.

Based on the extent of the opioid use epidemic, other types of non-first responder workers may also be at risk of opioid exposure and should be aware of exposure prevention measures. These include sheriff deputies in city and county jails, correctional officers in state prisons, ambulance transport and hospital emergency room personnel, drug enforcement agency officers, law enforcement evidence collectors and laboratory analysts, site decontamination technicians. Other workers not normally thought to be at risk of opioid exposure, such as parks and recreation clean-up workers, and, possibly, even librarians (who are finding overdosed individuals),[14] should also be aware of appropriate exposure prevention measures. Training aimed at improving workers’ understanding about what routes of exposure and specific job tasks can put a worker at risk of the adverse health effects arising from multiple drug exposure, and the actions workers can take to protect themselves, including personal protective equipment (PPE), is critically important.

Exposure Prevention

A summary of the routes of opioid exposure for workers follows. More detailed information is provided in the journal article.

Inhalation

An important potential occupational route of exposure to opioids occurs by breathing air contaminated with airborne opioid particles. During response situations, powder-like fentanyls can become easily airborne by disturbing opioid-contaminated surfaces, brushing opioid powder from clothing, or other incidental activities that cause powder or liquid aerosolization. It is not known what level of airborne exposure would result in acute intoxication resulting in lethal respiratory depression in an occupational setting.

PPE: First responders entering an environment where airborne fentanyls are suspected or confirmed to be present, should wear a supplied-air respirator (SAR) or self-contained breathing apparatus (SCBA) to provide maximal protection. If airborne particles are not suspected or confirmed but small amounts of powder are visible, an N-100, P-100, or R-100 is recommended. Since no occupational exposure limit has been established for fentanyl, using the filter with the highest efficiency, and reducing face seal leakage as much as possible through proper fit testing and training, provides the most effective respiratory protection.[15]

Mucous Membranes

As important as inhalation is as a potential route of exposure, inadvertent contact of fentanyls with the mucous membranes of the eye, nose or mouth presents an equivalent hazard.

PPE: Given the potential risk of mucous membrane exposure, eye goggles, face shields, and mouth protection are part of all prudent prevention measures for exposed workers. Importantly, touching the eyes, nose or mouth after touching a contaminated individual, surface, or object should be avoided. Gloves should be changed regularly during an incident response as it would be difficult to spot a small amount of drug on a contaminated glove, skin, clothing, surface or object.

Dermal

Fentanyls have been known to be able to penetrate human skin. [16],[17],[18] Dermal exposure to fentanyls may be of more importance in chronic, low-level occupational exposure than in acute, high-level exposure incidents. In a pharmaceutical production facility where workers experience both inhalational and dermal chronic, low-level exposure to fentanyl, industrial hygiene and biomonitoring results strongly suggested that in most workers the dermal (as opposed to the inhalational) pathway is the primary route of exposure.[19] Symptoms of acute opioid intoxication resulting from incidental dermal contact with fentanyl therefore appears to be an unlikely occurrence.[20]

PPE: A prudent prevention measure to prevent transdermal exposure is to wear non-powder, nitrile gloves, 5 +/-2 millimeter thickness, to protect against transdermal exposure.¹⁵ If the skin becomes contaminated during a response incident, the skin should be washed promptly with soap and copious amounts of water.

Ingestion

Potential exposure to opioids may occur by ingestion if food or beverages become contaminated with opioids. Where fentanyls are suspected or confirmed to be present, it is prudent for responders not to eat, drink, or smoke. In addition, touching the mouth after touching contaminated objects of equipment can result in ingestion of opioids.

Percutaneous

Potential exposure to opioids may occur through the percutaneous route if contaminated needles or sharps penetrate intact skin. Multiple incidents of parenteral exposure through handling injectable anesthetics containing highly potent fentanyls and other tranquilizing agents used in veterinary medicine has been reported in the literature and in an online survey.[21]

Management of Acute Opioid Intoxication

Respiratory depression leading to shallow breathing or apnea is the most life-threatening toxic effect of acute opioid intoxication. Acute intoxication can also cause the gradual onset of central nervous system symptoms such as drowsiness, nausea and vomiting, and dizziness.[22] These signs and symptoms, occurring in a worker in an occupational setting where exposure to fentanyls is suspected or confirmed, should not be discounted and should be managed as an acute opioid intoxication.

Naloxone can rapidly counteract the respiratory depression, sedation, miosis, and analgesia caused by opioids.[23] The Surgeon General recently issued an advisory stating that for those “who come into contact with people at risk for opioid overdose, knowing how to use naloxone and keeping it within reach can save a life.” (see https://www.surgeongeneral.gov/priorities/opioid-overdose-prevention/naloxone-advisory.html) If available, naloxone should be administered when signs of acute intoxication are present although more study is needed to determine optimal out-of-hospital protocols.[24] Naloxone is unlikely to have any ameliorative effect if the signs and symptoms are not due to an opioid intoxication. However, its administration should not be withheld since complications attributed to naloxone are exceedingly rare.[25] Even in opioid-tolerant individuals who are taking opioids, low-doses of naloxone can restore breathing without causing opioid withdrawal symptoms.[26] If naloxone is not available, respiration can be supported by providing positive pressure ventilation by means of a bag-valve mask or, if one is not available, through rescue breaths using in standard cardio-pulmonary resuscitation techniques. The resuscitator must take steps to prevent becoming contaminated during resuscitation.

Recommendations

Although the probability of any particular response incident resulting in a life-threatening intoxication is not known at the present time, reports of ill effects in first responders at drug overdose incidents require that prudent prevention measures be taken to protect their health and safety.

Prevention measures designed to protect first responders and other workers from occupational exposure to fentanyls are available from a number of sources. These sources include: White House Safety Recommendations for First Responders; National Institute for Occupational Safety and Health; Drug Enforcement Administration; American College of Medical Toxicology and the American Academy of Clinical Toxicology; and the Interagency Board. Recommendations in these sources are available for: (1) safe work practices when fentanyls are suspected or confirmed to be present in an occupational setting; (2) training personnel in safe work practice and the appropriate use of medical countermeasures like naloxone; (3) the types of personal protective equipment needed to protect workers; and (4) decontamination methods.

Any source of recommended prevention measures is for general guidance only. Each response situation must be assessed individually to determine the risks to workers and how best to prevent exposure in specific circumstances. Furthermore, as new information about the risk of opioid exposure in occupational settings emerges, changes in recommended prevention measures for first responders may occur. Attention to these changes is critical to providing the most up-to-date worker protection recommendations. Check the websites listed above for the most current information.

Please let us know what types of information or materials would be helpful to you as you work to prevent fentanyl exposure for first responders.

John Howard, MD, is the Director of the National Institute for Occupational Safety and Health.

Jennifer Hornsby-Myers, MS, CIH, is a Senior Certified Industrial Hygienist in the NIOSH Emergency Preparedness and Response Office.

References

[1] Centers for Disease Control and Prevention. Annual Surveillance Report of Drug-Related Risks and Outcomes — United States, 2017. Surveillance Special Report 1. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. Published August 31, 2017. https://www.cdc.gov/drugoverdose/pdf/pubs/2017-cdc-drug-surveillance-report.pdf. Accessed March 9, 2018.

[2] Hedegaard H, Warner M, Minino AM. Drug overdose deaths in the United States, 1999-2016. National Center for Health Statistics (NCHS) Data Brief (No. 294), December, 2017. https://www.cdc.gov/nchs/data/databriefs/db294.pdf. Accessed March 9, 2018.

[3] Dowell D, Arias E, Kochanek K, Anderson R, Guy GP, Losby JL, Baldwin G. Contribution of opioid-involved poisoning to the change in life expectancy in the United States, 2000-2015. J Am Med Assoc. 2017;318(11):1065-1067.

[4] Kochanek KD, Murphy SL, Xu J, Arias E. Mortality in the United States, 2016. National Center for Health Statistics (NCHS) Data Brief 293. December 2017. https://www.cdc.gov/nchs/data/databriefs/db293.pdf. Accessed March 9, 2018.

[5] Drug Enforcement Administration (DEA). Counterfeit prescription containing fentanyls: a global threat. DEA Intelligence Brief. DEA-DCT-DIB-021-16. July 2016. https://www.dea.gov/docs/Counterfeit%20Prescription%20Pills.pdf. Accessed March 9, 2018.

[6] Dowell D, Noonan RK, Houry D. Underlying factors in drug overdose deaths. J Am Med Assoc. 2017;318(23):2295-2296.

[7] Hargan E. Determination that a public health emergency exists. October 26, 2017.

https://www.hhs.gov/sites/default/files/opioid%20PHE%20Declaration-no-sig.pdf. Accessed March 9, 2018.

[8] Johnson J, Wagner J. Trump declares the opioid crisis a public health emergency. Washington Post, October 26, 2017. https://www.washingtonpost.com/news/post-politics/wp/2017/10/26/trump-plans-to-declare-the-opioid-crisis-a-public-health-emergency/?utm_term=.d5fc5bb1ea04A. Accessed March 9, 2018.

[9] Budget of the United States for Fiscal Year 2019. Office of Management and Budget, Executive Office of the President. https://www.whitehouse.gov/wp-content/uploads/2018/02/budget-fy2019.pdf.

[10] Silva BM. War on opioids: first responders on front lines. TurnToTen. February 13, 2018. http://turnto10.com/features/health-landing-page/war-on-opioids-first-responders-on-the-front-lines. Accessed March 9, 2018.

[11] Zhang S. Fentanyl is so deadly that it is changing how first responders do their jobs. Atlantic Magazine. May 15, 2017. https://www.theatlantic.com/health/archive/2017/05/fentanyl-first-responders/526389/. Accessed March 9, 2018.

[12] Pinckard C. Ohio police officers accidentally contact fentanyl, overdoses. Cleveland.com. May 16, 2017. http://www.cleveland.com/metro/index.ssf/2017/05/ohio_police_officer_accidental.html. Accessed March 9, 2018.

[13] Rondinone N. Hartford SWAT officers exposed to heroin, fentanyl during drug raid. Hartford Courant. September 14, 2016. https://www.theatlantic.com/health/archive/2017/05/fentanyl-first-responders/526389/. Accessed March 9, 2018.

[14] Al-Hasani R, Bruchas MR. Molecular mechanisms of opioid receptor-dependent signaling and behavior. Anesthesiology. 2011;115(6): 1363–1381

[15] Drugs.com. Fentanyl Injection. September 30, 2016. https://www.drugs.com/fentanyl.html. Accessed April 9, 2018.

[16] Pastore MN, Kalia YN, Horstman M, Roberts MS. Transdermal patches: history, development and pharmacology. Br J Pharmacol. 2015;172:2179-2209.

[17] Nelson L, Schwaner R. Transdermal fentanyl: pharmacology and toxicology. J Med Toxicol. 2009;5(4):230-241.

[18] Van Nimmen NFJ, Poels KLC, Veulemans HAF. Identification of exposure pathways for opioid narcotic analgesics in pharmaceutical production workers. Ann Occup Hyg. 2006;50(7):665-677.

[19] Larsen RH, Nielsen F, Sørensen JA, Nielsen JB. Dermal penetration of fentanyl: inter- and intraindividual variations. Basic Clin Pharmacol. 2003;93(5):244-248.

[20] Salter J. Opioid dangers force police to abandon drug field tests. The Associated Press. February 21, 2018. https://www.denverpost.com/2018/02/21/police-drug-field-tests-opioids/. Accessed March 18, 2018.

[21] Brunton LL, Hilal-Dandan R, Knollman BC. Opioids, analgesia, and pain management In: Hardman J ed. Goodman & Gilman’s The pharmacologic basis of therapeutics. 13^th ed. New York: McGraw-Hill, 2017:355-386.

[22] Hoffman RS, Goldfrank LR. The poisoned patient with altered consciousness: controversies in the use of a ‘coma cocktail.’ J Am Med Assoc. 1995;274(7):562-569.

[23] Martin WR, Naloxone diagnosis and treatment. Ann Intern Med. 1976;85:765-768.

[24] Chou R, Korthuis PT, McCarty D, Coffin PO, Griffin JC, Davis-O’Reilly C, Grusing S, Daya M. Management of suspected opioid overdose with Naloxone in out-of-hospital settings. Ann Intern Med. 2017;167:867-875.

[25] Yealy DM, Paris PM, Kaplan RM, Heller MB, Marini SE. The safety of prehospital naloxone administration by paramedics. Ann Emerg Med. 1990;19:902-906.

[26] Swarm R, Abernathy AP, Anghelsecu D, Benedetti C, Blinderman CD, Boston B, Cleeland C, Coyle N, deLeon-Casasola OA, Eilers JG, Ferrell B, Janjan NA, Karver SB, Levey MH, Lynch M, Noryl N, Murphy BA, Nesbit SA, Oakes L, Obbens EA, Paice JA, Rabow MW, Syrjala KL, Urba S, Weinstein SM. Adult cancer pain: clinical practice guidelines in oncology. Journal of the National Comprehensive Cancer Network. 2010;8(9):1046-1086. http://www.jnccn.org/content/8/9/1046.full.pdf+html. Accessed April 9, 2018.