Editor’s note: This article was originally published Sept. 17, 2019, and has been updated.
First responders, especially law enforcement officers, have become accustomed to hearing about the dangers of fentanyl exposure. We faced a similar trend during our initial encounters with clandestine methamphetamine lab enforcement and eradication. At that time, we had a limited understanding of the health risks associated the chemicals and toxins resulting from illicit methamphetamine production.
Now in the fentanyl age, we know better. Law enforcement, fire and rescue, and emergency medical personnel must balance safety with mobility and efficiency while working at scenes where the presence of fentanyl is known or suspected.
Fentanyl is a potent synthetic opioid that is very effective in relieving moderate to severe chronic pain. Like many opioid painkilling drugs, fentanyl finds its way into the wrong hands, and onto the wrong side of the law. That’s where we come in.
Fentanyl, a Schedule ll prescription narcotic analgesic, is produced in a variety of forms by the pharmaceutical industry. Medically prescribed fentanyl is available in lozenges, lollipops, oral and nasal sprays, injections, tablets, and transdermal patches.
Illicit fentanyl is usually produced in powder form. It can also be dropped onto blotter paper, placed into eyedroppers and nasal sprays, or made into pills that resemble other prescription opioids. Fentanyl is odorless, and because it is often mixed with other substances, it will not have a distinctive or unique appearance.
Illicit drug dealers mix fentanyl with other drugs, such as heroin, methamphetamine, cocaine, and MDMA. The American Medical Association notes the practice of mixing fentanyl and fentanyl analogs with other drugs, particularly heroin, is driving the drug overdose epidemic, which significantly worsened during the COVID pandemic. In 2020 and 2021, every state reported a spike or increase in overdoses.
When illicit fentanyl first hit the streets, media accounts focused on how even incredibly small amounts of the drug could cause illness or death. This in turn led many people, including first responders, to believe that overdose could occur through simple skin contact.
Thankfully, we now know better. Fentanyl must be absorbed into the body before the exposed person will suffer any harmful effects. Leading science organizations advise that incidental skin contact with dry fentanyl products is not likely to cause toxicity. The most concerning route of first responder fentanyl exposure is inhalation of airborne powder or aerosolized fentanyl, but those are less likely to occur than skin contact. Other forms of exposure include direct mucous membrane contact in the eyes, nose or mouth; ingestion (swallowing); and accidental needlestick. Controlling exposure to fentanyl, then, can be managed much the same way first responders control exposure to bodily fluids and other hazardous materials.
DO NOT use alcohol-based hand sanitizers to decontaminate as they do not remove opioids and may enhance absorption of fentanyl through the skin.
But what about all the anecdotal accounts of “passive” fentanyl exposure in first responders—situations in which EMS and law enforcement personnel collapsed, were administered naloxone and experienced downright scary symptoms? Some experts theorize the “nocebo effect” may be to blame. While not well understood, this phenomenon involves experiencing negative effects following the mere suggestion that they may occur. For example, patients told that a procedure can produce pain may be more likely to experience pain than a control group.
Whether the nocebo effect or something else is going on, passive fentanyl exposure symptoms usually differ significantly from the symptoms of fentanyl poisoning. Symptoms of fentanyl poisoning are much the same as poisoning by any other opioid and will be apparent by the triad of slowed breathing, decreased consciousness, and pinpoint pupils. Passive fentanyl exposure symptoms, on the other hand, can may include:
- Respiratory distress, respiratory depression, or respiratory arrest
- Nervous system depression
- Reduced level of consciousness
In cases where first responders reported symptoms due to passive exposure to fentanyl, all personnel recovered, and no deaths (to date) have been reported. Additionally, the specific routes of exposure were not identified.
There have not been any cases of fentanyl toxicity (poisoning or overdose) reported by first responders who have experienced passive exposure to fentanyl. Opioid toxicity relies on the drug entering the blood and brain from the environment. Toxicity cannot occur from simply being in proximity to the drug.
The first mitigation strategy is to avoid unprotected physical contact with fentanyl. Illicit fentanyl is difficult to identify visually and may be present in various physical forms that resemble other drugs. First responders who suspect any substance is or contains fentanyl should handle it as if it is fentanyl.
The presence of drug paraphernalia, tablet containers or wrappers, and powdery substances may be the first clues that fentanyl is present. If the call for service is a drug overdose, the reporting party may disclose which drug is involved.
Chemical reagent presumptive drug test kits can help to determine the presence of fentanyl and acetyl-fentanyl in substances found by first responders. Laboratory confirmatory tests are necessary for positive identification.
The National Institute for Occupational Safety and Health (NIOSH) recommends the use of nitrile gloves at any scene where the use or presence of fentanyl is suspected but no drugs are visible. Scenes where small amounts of illicit drugs in powder or liquid are visible require the addition of:
- Eye protection to prevent inadvertent eye exposures by touching with potentially contaminated hands or gloves
- Disposable respiratory protection (N100 or higher) to avoid inadvertent airborne particulate inhalation and touching the mouth with potentially contaminated gloves or hands
Environments with suspected large quantities of fentanyl require NIOSH-certified Chemical, Biological, Radiological, Nuclear (CBRN) Self-Contained Breathing Apparatus (SCBA) with a Level A protective suit. This highest level of PPE should be worn when the amount or concentration of the fentanyl is unknown, or if the location was used as a place for manufacturing, warehousing, or distributing fentanyl. Only a properly equipped and specialized hazmat team should perform the investigation, evidence collection, and decontamination at a large-scale fentanyl site.
Responders who come into contact with fentanyl on their skin should immediately wash the affected area with cool water and soap, taking care not to break the skin or scrub an open wound. DO NOT use alcohol-based hand sanitizers to decontaminate as they do not remove opioids and may enhance absorption of fentanyl through the skin.
Law enforcement, fire and rescue, and emergency medical personnel must balance safety with mobility and efficiency while working at scenes where the presence of fentanyl is known or suspected.
All contaminated clothing should be removed and laundered, being careful not to disturb any contaminated areas. All contaminated disposable PPE should be placed in durable polyethylene bags and disposed of properly.
Police canine handlers should be aware that dogs trained to perform detection activities should be excluded, or quickly removed, from fentanyl areas as they are also at risk for exposure. Fentanyl powder residues can remain on the dog and be carried away from the scene. Canine handlers should employ proper precautions and procedures to ensure the dog is not unnecessarily exposed to, or contaminated with, fentanyl.
Any responder who experiences harmful effects from a suspected fentanyl exposure should be immediately removed from the scene and provided medical assistance. If fentanyl is expected or known to be at a scene, EMS should be standing by.
If fentanyl exposure results in the symptoms of opioid poisoning, naloxone may be a temporary antidote. Naloxone may temporarily restore normal breathing and consciousness to a person experiencing a fentanyl overdose. It is important to note that in severe overdose cases, multiple doses of naloxone have been required to restore minimal physiological vital signs. All personnel who administer naloxone should be trained in its application, effects, and limitations. Where naloxone is administered, the patient should be transported to a hospital for medical treatment as soon as possible.
The dramatic rise in fentanyl-related deaths in the general population raises concern for first responders who come into contact with the drug. The key to fentanyl exposure prevention is understanding how exposure may occur and the ways to prevent it. The potential for injury to personnel who handle fentanyl, its analogs, and illicit substances that may contain fentanyl is easily mitigated with simple, well-known prevention techniques coupled with the use of readily available PPE. All first responders should be trained to recognize the symptoms of opioid/fentanyl toxicity, and to take appropriate steps to treat someone who may be suffering from it.
References and Additional Resources
- American Medical Association. (11/12/21) Issue brief: Nation’s drug-related overdose and death epidemic continues to worsen. Accessed 2/7/22 from https://www.ama-assn.org/system/files/issue-brief-increases-in-opioid-related-overdose.pdf.
- Centers for Disease Control, National Institute for Occupational Safety and Health. (2/11/20) Fentanyl: Emergency Responders at Risk. Accessed 2/7/22 from https://www.cdc.gov/niosh/topics/fentanyl/risk.html.
- Knopf T. (11/4/21) Did NC deputies overdose after an ‘exposure’ to fentanyl? Experts say that’s unlikely. North Carolina Health News. Accessed 2/922 from https://www.northcarolinahealthnews.org/2021/11/04/deputies-fentanyl-overdose-unlikely/.
- Nelson LS and Perrone H. (12/21/18) “Passive” fentanyl exposure: more myth than reality. STAT. Accessed 2/7/22 from https://www.statnews.com/2018/12/21/passive-fentanyl-exposure-myth-reality/.
- Northern New England Poison Center. Fentanyl and Carfentanil Exposures in First Responders. Accessed 2/7/22 from https://www.healthvermont.gov/sites/default/files/AAA.Fentanyl-Fact-Sheet_NNEPC_FINAL.pdf.
- Reuters Fact Check. (8/11/21) Fact Check-Overdose of fentanyl just by being in its presence is not possible, experts tell Reuters. Accessed 2/7/22 from https://www.reuters.com/article/factcheck-fentanyl-overdose/fact-check-overdose-of-fentanyl-just-by-being-in-its-presence-is-not-possible-experts-tell-reuters-idUSL1N2PI0PZ.
- Taxel S. (5/7/19) Fentanyl Facts and Fiction: A Safety Guide for First Responders. JEMS: Journal of Emergency Medical Services. Accessed 2/9/22 from https://www.jems.com/operations/fentanyl-facts-and-fiction-a-safety-guide-for-first-responders/.