The use of mind-altering substances by humans is nothing new. Since the first person left a bowl of grain out in the rain, and then the sun and wild yeast did their thing, humans have had access to beer. Additional intoxicating substances followed through different methods of discovery. How people figured out that the milky substance contained in the un-ripened seed pod of the poppy flower is a powerful drug is beyond me. This drug is opium.
Opium use in America is also nothing new. In the 19th and early 20th centuries, a substance called laudanum was very popular. This product was a mixture of 10 percent opium and alcohol. Laudanum was available as an over-the-counter drug. It was basically the aspirin of its time and was recommended for pain relief for many common ailments and for serious diseases such as tuberculosis. The problem with laudanum is that it is highly addictive due to the opium content. As more and more people began to develop addictions, doctors began to discourage its use; government regulations restricting access to opioids soon followed.
Today, opium comes in many natural and synthetic forms. Modern pharmaceutical companies have created synthetic opioids (e.g., fentanyl, Dilaudid, Norco), which are much more powerful than their natural cousin. These medications were created to reduce pain and suffering for patients after injury or surgery and for those living with chronic pain. The problem is that humans tend to abuse these medications and can become addicted; take away the prescribed medications and some addicts will turn to street drugs out of desperation. Four in five new heroin users start out misusing prescription painkillers. Opioid abuse in the U.S. has become epidemic and many people are dying as a result.
I’m not going to get into the current debate on how fentanyl and related substances arrive on our streets; I am more concerned with their impact on first responders. We have seen numerous reports in the past several weeks of police, firefighters and emergency medical personnel being exposed to highly toxic opioids. These exposures have come through casual contact such as searching a car for drugs, brushing off a small amount of white powder (following a search in which the officer had used gloves and mask), touching a patient with a synthetic opioid on their person, or inhaling a drug after it was aerosolized from a flash/bang device. These recent events lead me to believe it might be time for a training refresher.
Risk from the Patient and the Material
A patient overdosing on opioids presents inherent risks to first responders. These drugs cause respiratory depression and we often find patients who aren’t breathing. Our first treatment options are to provide ventilation for the patient and administer Narcan (naloxone) if it is available. Naloxone will reverse the effects of the drug. Sometimes, when the patient becomes conscious, they are very agitated and can become violent. Also, they may have residue or greater amounts of the drug on their person. We need to be aware of these hazards and take appropriate precautions.
Hazardous Materials Refresher
First responders need to start approaching these incidents with a hazardous materials (hazmat) response mindset. I know it’s not practical for all responders to show up in Level A suits; that’s not what I’m talking about. We are taught from the beginning of our careers that hazmat calls are uniquely dangerous. Our first responsibility in these situations is to isolate the area and deny further entry of responders or civilians.
Many of the recent events where police officers and firefighters have been exposed to and become ill from fentanyl and other opiates have occurred through patient contact or contact with the drug by touching a contaminated object. If this happened at a hazmat call we would all say a policy or procedure had been violated. I’m not blaming the victim here but I am asking us to rethink our approach. We need to re-evaluate our mindset about responding to calls involving illicit drugs. We might need to start viewing them as hazmat calls.
Hazmat is defined as “A material or substance that poses a danger to life, property, or the environment if improperly stored, shipped or handled.” Based on the evidence I believe opioids fit this definition.
Routes of Exposure
There are four routes of exposure for a hazmat:
1. Absorption (through your skin)
2. Inhalation (through your lungs)
3. Ingestion (though your mouth)
4. Injection (by an object like a needle or through force such as liquid under pressure)
All four of these exposure routes are in play when it comes to illicit drugs. It is easy to understand that if you touched a drug with your finger, and then stuck your finger in your mouth, you would suffer an exposure to the drug. Or, if you were stuck by a hypodermic needle that was contaminated, you could be exposed to the drug. What about inhalation? Well, users often snort these materials through a straw, so exposure from breathing in the powder makes sense.
The most surprising exposure route, as noted by recent exposures to fentanyl, is absorption. The fact that just touching the material, or accidentally getting it on your skin, can cause you to become ill or intoxicated, and even overdose, is what is shocking to me. We need to take this issue seriously and protect ourselves from all routes of exposure.
How can we protect ourselves in a practical way when we encounter overdose calls daily? We need to have a “me first” attitude and use good decision-making, proper procedures and personal protective equipment (PPE).
I joined the fire service in the early 1980s—a time of discovery for bloodborne pathogens. As we encountered new communicable diseases, we realized we were potentially exposed when treating patients. We began training on and using the concepts of Universal Precautions.
Universal Precautions basically means “treat all blood and body fluids as if they were infectious.” We protected our hands with medical exam gloves, our eyes with protective eyewear, and our mouths and noses with medical masks. We didn’t wear masks for every call but we did use them when performing invasive procedures (e.g., intubating a patient’s airway). Many paramedics learned to wear a mask the hard way: by experiencing exposure to blood and other bodily fluids when performing these tasks.
We need to consider approaching drug overdoses, and drug investigations, with these principles in mind. What does this look like?
• If you suspect opioid use, ask safety-related questions about what substances may be present.
•Use hand protection (minimum and mandatory) at all potential overdose/drug investigation calls. To be sure you’re getting the maximum protection, use nitrile gloves rather than latex. One coroner’s office has indicated that latex gloves may allow absorption of synthetic opioids into the wearer’s skin.
• When encountering unknown substances, consider the use of N-95 masks, eye protection and paper covers for clothes and shoes.
• Handle patients and objects as if they were contaminated.
• Avoid (better yet, prohibit) cross-contamination. Only touch items with protected hands. Following the call, don’t touch anything until you have followed proper decontamination procedures
• If applicable under your EMS protocols, carry and be prepared to administer naloxone to patients and first responders who may become exposed.
If these steps sound burdensome, consider that they are common practices in settings such as dental offices.
For more guidance, access “Fentanyl: Safety Recommendations for First Responders,” recently released by the DEA.
Protect Yourself So You Can Protect Them
When we encounter new hazards in the workplace we need to evaluate the risk and develop new engineering and work practice controls to protect ourselves and our employees. The new threat of very powerful synthetic opioids, and the severe harm they cause, must be addressed in this manner. It’s difficult and maybe even impractical to avoid these hazards altogether; however, we need to try. If we can approach opioid overdose calls with a hazardous materials mindset, practice Universal Precautions, and slow down when there is discretionary time, we can reduce the risks and hopefully avoid any further injury.
It’s really about doing our jobs well, serving those we swore to protect—but still going home healthy at the end of the shift. Take care of yourselves and each other out there!