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November 1, 2017
What EMS providers need to know to protect themselves from fentanyl exposure
The opioid crisis is better understood as a fentanyl crisis with real dangers to emergency responders, according to an expert-panel presentation convened in Las Vegas at EMS World Expo 2017.
The panel discussion, sponsored by Bound Tree Medical, included a Drug Enforcement Administration chemist and an EMS medical director, and focused on the risks to fentanyl exposure and contamination to EMTs, paramedics, firefighters and police officers.
The top concern of the panelists was the availability of and proper use of personal protective equipment to protect emergency responders from exposure to fentanyl. Their top PPE recommendations were:
James DiSarno, senior forensic chemist, DEA, provided important historical context to the opioid epidemic. DiSarno explained that the epidemic is a result of pain management practices and flawed promotion of opioid pills as non-addictive. He recalled the growth of pain clinics for the increasing number of patients seeking pain management.
"These people were in pain," DiSarno said. "But then what happened is these people got addicted."
Those patients, now addicted to opioids, sought out illegal pills, heroin and fentanyl as the DEA put pain management clinics out of business. Drug dealers took advantage of this population of addicts by lowering the price of heroin.
"People who were never intending to use heroin turned to heroin because they were addicted," DiSarno said.
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 fentanyl from internet sellers.
A kilogram of fentanyl is more powerful than heroin and a tenth of the cost. One kilogram of fentanyl costs about $8,000 compared to $80,000 per kg for heroin.
Memorable quotes on protecting emergency responders from opioid exposures
Here are memorable quotes from the panelists on the opioid epidemic and protecting emergency responders from the risks of opioid exposures.
"65,000 deaths last year were attributed to drug overdoses – more than gun violence and auto accidents in a year. The opioid epidemic has impacted every community in the country. It does not discriminate."
"The fentanyl epidemic has changed how the DEA has done business. It is a total game changer in the forensic world and for law enforcement."
"Mostly our laboratory is seeing fentanyl, drugs that mimic fentanyl, fentanyl derivatives and fentanyl analogs and fentanyl mixed with almost every drug out there."
"We consider carfentanil to be a weapon of mass destruction. That's how dangerous it is."
"Opioid addiction is a disease. As each disease process presents itself, we need to look at new ways to combat the disease."
"What we all miss is plain old, boring heroin. The clinical presentations are becoming more and more complicated."
"It's easy to get caught up in the media hype. The media wants to sell this as a heroin crisis. It's not. I would submit that we are dealing with a fentanyl crisis."
"We can't sleep walk to preparedness. We have to be smart. We have to be strategic."
"The risk (of fentanyl exposure) is something you have to take into consideration and you have to balance that with the likelihood that a delayed response could be fatal to the (overdosed) individual."
"A toxicologist recommended (to me) you treat these drugs like they are blood. If you see a big pile of something that looks like white powder, don't go splashing around in it."
Top takeaways on fentanyl dangers to emergency responders
The expert panel was convened in the wake of increasing reports of emergency responders, including police officers, paramedics, and correctional officers being sickened after assessing and treating opioid overdose patients. In addition, the panel sought to bring the best available guidance from the InterAgency Board, CDC, NIOSH and DEA on how to safely handle patients, avoid fentanyl exposure and manage a crime scene that may also be a hazmat incident.
1. Opioid crisis is really a fentanyl crisis
Fentanyl is cheaper and stronger than illicit opioid pills or heroin. Fentanyl derivatives and analogs come in different strengths and formulations to avoid federal regulation. DiSarno described how there are many types of fentanyl and that U4770, a fentanyl mimic, attaches to the same receptors as other opioids, but attaches more strongly.
U4990, another fentanyl mimic, came out of China a couple of months ago 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.
Cushman explained that it's important to assess patients for the classic opioid toxidrome signs and symptoms of respiratory depression, reduced level of consciousness and pinpoint pupils, but because of how fentanyl is synthesized, responders might not see the classic toxidrome. The stronger binding of fentanyl derivatives to opioid receptors may require higher doses of naloxone to reverse the overdose and restore adequate respirations.
2. 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 requesting 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.
Evidence of drugs, drug manufacturing equipment and drug administration supplies should not be touched or moved. Call local law enforcement. Moving any actual or potential evidence can compromise the investigation's chain of custody.
3. 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 on the ambulance and in the emergency department. Cushman also reminded attendees about the importance of BVM proficiency to ventilate any apneic patient.
The InterAgency Board has recommended PPE for to prevent exposure to synthetic opioids after a detailed examination of available evidence. Maniscalco encouraged all public safety leaders to review the IAB matrix as part of a comprehensive update of policies and procedures.
4. Respiratory PPE is 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, as well as other drug powders, is known or suspected of being aerosolized, respiratory PPE is important since inhalation is the easiest route for accidental fentanyl exposure.
Cushman is much more concerned about fentanyl inhalation because mucousal absorption is 30 times faster than transdermal absorption. Wearing a mask is the best initial protection. DiSarno highly recommended a "dust mask" as the most important PPE and protection against aerosolized fentanyl.
5. 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. Cushman encouraged attendees to practice skills like intubation and ventilation while wearing a dust mask, N100 mask or additional PPE they may be using based on the potential threat and their level of training.
6. Wash fentanyl-contaminated skin with soap and water
Responders should always wear gloves, but if they have a fentanyl skin exposure, 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. Use water, not an alcohol-based hand cleaner for cleaning an unknown substance off of your skin.
7. Recognize other threats, dangers
Swayze reminded attendees that IV drug users regularly engage in other high-risk behaviors. The long-term threat of hepatitis or HIV/AIDS to emergency responders has to be kept in mind because of life-changing consequences of those diseases.
Every organization has to 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.
Media-hyped 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. Education about potential routes of exposure, enforcing policies and procedures, making PPE available and distributing medical intelligence about the opioid epidemic are all important to giving responders peace of mind while performing their lifesaving duties.
Chris Cebollero, Inside EMS podcast host and event moderator, asked each of the panelists for their final recommendations to EMTs, paramedics, firefighters and police officers.
"We are not going to arrest or seize our way out of this. We have to start with youth and have conversations at an early age to talk about the issues and cycle (of addiction). Safety and prevention is really the key."
"Illicit tablet makers have gotten so good, the DEA labs can't visually tell the difference between a fake oxycodone tablet and a real tablet. Fake tablets are being produced by hundreds of thousands per day."
"Follow an all-hazards approach – scene safety, PPE and ABCs before N (naloxone)."
"Download the 14-page (InterAgency Board) document. It will guide you through the policies and training, which we cross walked with NIOSH and DEA procedures for personal protection. Be smart, be clinical, be professional – we'll get through this."
"Take care of yourselves and colleagues. We can't tackle this issue just by administering more and more Narcan. Reach out to drug and alcohol addiction folks, police brothers and sisters to work together to reduce supply and reduce demand."
Learn more about opioid safety