Author: PoliceOne Digital Edition
By Greg Friese, MS, NRP
Accounts of police officers or paramedics who are alleged to have been overcome by fentanyl after caring for a patient might be causing responders to worry about their own safety.
A group of expert panelists at the 2017 EMS World Expo – including a Drug Enforcement Administration chemist and special agent – shared six strategies to protect public safety personnel during an opioid-related response.
1. Assess the scene for exposure risks and crime evidence.
Use dispatch information to assess the risk for fentanyl exposure through inhalation or contamination to skin or clothing. Use the scene size-up to make decisions about PPE usage and additional resources.
Every overdose incident is a potential crime scene. If EMTs, paramedics and firefighters arrive before law enforcement and notice evidence of drug use or paraphernalia, they should follow local protocols to request police response.
2. Pre-plan and train for fentanyl recognition and exposure.
Because fentanyl derivatives are known to more strongly bind with opioid receptors, responders are reporting an increasing need to stock more naloxone.
The InterAgency Board – a voluntary collaborative panel of emergency preparedness and response practitioners – has recommended PPE use to prevent exposure to synthetic opioids after a detailed examination of available evidence.
3. Respiratory PPE is the best protection against aerosolized fentanyl.
The DEA is seeing fentanyl cut into every drug, including heroin and cocaine, and assumes all drug samples it is testing include fentanyl. When powdered fentanyl or other drug powders are known or suspected of being aerosolized, respiratory PPE is important since inhalation is the easiest route for accidental fentanyl exposure and mucosal absorption is 30 times faster than transdermal absorption. Wearing a mask is the best initial protection.
4. Use additional PPE for fentanyl overdose responses.
In addition to a mask, the panel recommended nitrile, single-use examination gloves and safety glasses for most responses. When there are larger amounts of hazardous material or fire risk, the InterAgency board has additional recommendations for higher levels of protection.
It’s especially important to use simulation training to be proficient in opioid patient assessment and care with a mask, gloves and eye protection.
5. Wash fentanyl-contaminated skin with soap and water.
Responders should always wear gloves, but if their skin is exposed to fentanyl, they should first wipe the visible contamination from their skin. Next, wash skin thoroughly with soap and water, including a second water rinse.
Don’t use any alcohol-based sanitizers on fentanyl-contaminated skin. Alcohol increases the rate of transdermal transfer by 100 times.
6. Recognize other threats, dangers.
IV drug users regularly engage in other high-risk behaviors, so responders should keep the threat of hepatitis or HIV/AIDS in mind. Every organization must have an exposure control plan and be committed to training personnel in how to avoid exposures, reporting exposures to blood and other potentially infectious materials, and providing testing and follow-up care when indicated by state and federal law and regulation.
Emergency responders are also at risk of compassion fatigue from the growing number of responses for opioid overdose, especially for patients who have overdosed multiple times. Recognizing the potential for compassion fatigue, which leads to burnout, and providing training on the science of addiction is important for every public safety organization.
Personal protective equipment needs for responders
To protect emergency responders from exposure to fentanyl, experts recommend the following:
- Dust mask to protect against aerosolized fentanyl inhalation. Nitrile, single-use examination gloves to protect against skin exposure and transdermal transmission. Safety glasses for additional protection from mucosal membrane absorption. Immediate washing with soap and water of any exposed or contaminated skin. Remove and clean any uniform clothing that might have been contaminated by fentanyl, blood or other potentially infectious material during patient assessment and care.
In addition, education about potential routes of exposure, enforcing policies and procedures, and distributing medical intelligence about the opioid epidemic are all important to giving responders peace of mind when responding on opioid-related overdose calls.
Why the opioid crisis is becoming a fentanyl crisis
Fentanyl, because it is a synthetic, factory-made drug, is of increasing concern to the DEA and public safety leaders. Fentanyl is mostly manufactured in China and directly shipped in small qualities to buyers who find and purchase it from internet sellers.
Fentanyl is cheaper and stronger than illicit opioid pills or heroin. One kilogram of fentanyl costs about $8,000 compared to $80,000 per kg for heroin.
Fentanyl derivatives and analogs come in different strengths and formulations to avoid federal regulation. U4770, a fentanyl mimic, attaches to the same receptors as other opioids, but attaches more strongly. U4990, another fentanyl mimic, came out of China in mid-2017 in response to new regulations banning U4770 production. A small change in the drug’s molecular structure makes it legal even though it has never been tested on humans.
The stronger binding of fentanyl derivatives to opioid receptors may require higher doses of naloxone to reverse the overdose and restore adequate respirations.
About the Author Greg Friese, MS, NRP, is Editor-in-Chief of EMS1.com. He is an educator, author, paramedic, and marathon runner.