Fentanyl: A Deadly “Superdrug”…or is it? (It’s Less Dangerous Than You Think)

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There’s an ongoing hysterical and sensationalistic response to opioid-related deaths. Some police officers believe everyday situations may now require the use of Hazmat suits, first responders are worried they could overdose on fentanyl just by being in its presence, and Massachusetts has even banned courtroom exhibits containing fentanyl in most situations.

Fentanyl is undoubtedly potent, but this response is very unscientific and could be dangerous.

Recently there was a “mass casualty overdose” in northern California that caused one death and sent a dozen people to the hospital. As is now the norm, the authorities attributed the overdoses primarily to fentanyl. They also declared the scene a hazmat site and two officers began showing symptoms while responding to the situation.

Although mainstream sources in this case and countless others have described the symptoms suffered by first responders as being that of opioid toxicity, usually that’s not true. We don’t know what the officers in the California case experienced, but in other cases first responders have reported nonspecific symptoms like dizziness, rather than becoming unconscious, having respiratory depression, or showing anything else typical of an opioid overdose.

What the symptoms are consistent with is a psychogenic experience, such as from panic or the nocebo effect, where knowledge of potential negatives causes you to experience those negatives when you think you’ve taken the drug. Officers, EMS workers, and others are so worried about super deadly fentanyl that upon seeing it they begin to experience an innocuous but subjectively alarming change in their bodily state.

In essentially all of these cases, even though the first responders are taken to the hospital, toxicology results confirming fentanyl exposure haven’t been reported and there’s little reason to believe fentanyl is to blame.

It makes a lot of sense for first responders to think they’re being poisoned though. That’s what the media suggests and federal authorities like the DEA have outright said there’s a significant threat to law enforcement and others who come into contact with fentanyl during routine situations.

Warning: There is a significant threat to law enforcement personnel, and other first responders, who may come in contact with fentanyl and other fentanyl-related substances through routine law enforcement, emergency or life-saving activities. Since fentanyl can be ingested orally, inhaled through the nose or mouth, or absorbed through the skin or eyes, any substance suspected to contain fentanyl should be treated with extreme caution as exposure to a small amount can lead to significant health-related complications, respiratory depression, or death.

Accidental exposure can occur under a number of circumstances, including during the execution of search or arrest warrants, the purchase of fentanyl during undercover operations, the processing of drug evidence containing fentanyl or fentanyl-related substances, or the processing of non-drug evidence (e.g. drug proceeds, pill presses, scales, or drug paraphernalia) which may be contaminated with these substances.

Due to the high potency of fentanyl and fentanyl-related substances, exposure to small quantities can cause serious negative health effects, respiratory depression, and even death. – DEA (2018)

Many toxicologists have come out opposing the idea that accidental poisoning is a notable risk, but most people haven’t gotten that message. Perhaps that’s because it’s a bit less interesting when an article talks about the low level of risk instead of describing how first responders are risking their lives because fentanyl is so bad.

The incessant talk about how deadly this drug is needs to change.

It’s true fentanyl is killing thousands of users, but that fact has merely given the public a new drug to hate instead of making it clear that one of the biggest risks to users is that they don’t have a clean, reliable source for their substances. This situation is a perfect example of why prohibition is deadly, yet that’s not how it’s being framed. Instead, it seems common to just view these deaths as evidence that drugs are inherently terrible and need to be outlawed.

That mindset has contributed to an increase in the use of drug-induced homicide laws, for example, despite it being much more useful to focus on harm reduction and public health approaches, which could include decriminalization or legalization.

Fentanyl: A Lethal Superdrug…Or So They Say

With hazmat suits now being used just because fentanyl is present, it’s pretty clear the drug is misunderstood.

Fentanyl is simply an opioid used for pain and anesthesia whose nonmedical use has gone in and out since the 1970s. 100 μg is a common medical dose, while it’s estimated around 2 mg can be lethal. That’s a pretty good safety ratio (even better than a lot of commonly used drugs), but the drug is misleadingly characterized as inherently riskier than other opioids, when really the risk is higher because you don’t want an opioid that works at the microgram level to be hidden in illicit heroin or other drugs.

In recent years there’s been a huge rise in the illicit production of fentanyl, with it coming from China and Mexico, reportedly with significant involvement from the Sinaloa cartel and other organized crime groups.

Most of the time users are exposed to fentanyl without being aware. They purchase heroin, opioid pills, and sometimes non-opioids like cocaine or benzodiazepines and they end up receiving fentanyl on its own or mixed in with the intended drug. This is a big factor in the increase in overdoses and fatalities.

Given the way people are being harmed by fentanyl it may be more accurate to call this a poisoning epidemic, not an opioid epidemic. It’s not hard to safely use a known dose of an opioid, but it’s very difficult to be safe when you have no idea what you’ve been sold.

So here we are, with preliminary data from the CDC showing there were 72,000 drug deaths in 2017, in large part due to the drug supply becoming worse.

In the public’s mind, fentanyl is a very dangerous opioid and a barely visible amount of powder can be lethal. There’s some truth to this, but the correct implication of that fact is not that it’s especially dangerous when someone knows they’re using it, much less that fentanyl powder sitting on a table or even powder that’s blown into the air is likely to be deadly.

Common sense should make this obvious.

First responders are unintentionally exposed to less fentanyl than many drug users, sellers, and manufacturers, yet they  seem to be the only ones frequently reporting accidental poisonings. Given how much powder someone in the supply chain may be handling, there should be numerous reports of people accidentally dying from it getting in the air or on their skin. But there aren’t.

In their position statement on this issue, the American College of Medical Toxicology (ACMT) noted that at the highest airborne concentration of fentanyl in a manufacturing facility, it would take an unprotected person 200 minutes to inhale a 100 μg dose, which would still only be an effective, not a lethal dose (ACMT, 2017).

Though it’s possible to weaponize fentanils and use them as aerosols, such as what likely occurred during the 2002 Moscow theater hostage incident (Howard, 2018), accidental inhalation is essentially a non-concern in normal settings.

Fentanyl has a very low vapor pressure, meaning the transformation of powder into the gaseous form doesn’t readily happen on its own (ACMT, 2017). A small amount may be inhaled when the powder is physically agitated, like in cases where a fan blew powder around a residence or when a flash-bang grenade caused the drug to enter the air, but that amount is incredibly unlikely to be harmful.

The same applies to dermal exposure. If both of your palms were covered with fentanyl patches, which are specifically designed to facilitate transdermal delivery, it would take 14 min for you to get a 100 μg dose (ACMT, 2017). And that far overestimates the rate at which powder enters the body, since it has a much harder time passing through the skin compared to patches. So if someone notices they have some powder on their body they can just brush it away or wash it off and that’s the end of the story. They are not going to overdose. If putting some powder on your hand was an effective way to take opioids, drug users would probably be doing it.

Because the risks of exposure are low, the ACMT mostly recommends the use of nitrile gloves in routine situations.

More extensive personal protective equipment could impair the delivery of life-saving medical assistance from first responders either because it physically impairs mobility, like with a hazmat suit, or because getting the equipment and putting it on uses up the precious seconds or minutes that could make the difference between someone living or dying.

We don’t want this to turn into a replica of the late 1980s when some medical professionals were so scared of contracting HIV that people with the virus struggled to receive adequate care. Medical professionals and bystanders need to relax about the risks if we’re going to reduce harm as much as possible.

What We Really Need: Harm Reduction and Treatment

Instead of a crackdown approach and fear mongering, we need harm reduction and accurate information. Harm reduction measures like drug education, community naloxone availability and training (Kim, 2015), fentanyl test strips, needle exchange, and the creation of supervised consumption facilities (Meyers, 2014) could go a long way towards reducing fatalities, even though prohibition infringes on harm reduction.

Greater investment in evidence-based treatments, both for addiction itself and for the mental health conditions like depression that frequently accompany it, would also be helpful. The research is clear that one of the best treatments for opioid addiction is opioid agonist therapy, like with buprenorphine (Sigmon, 2016). Anecdotal reports also indicate alternative treatments like kratom may be very effective, though we do need more data on its long-term safety.

With buprenorphine, although the drug isn’t perfect, it can significantly reduce people’s use of illicit drugs, and at a time when the illicit market is this deadly, getting people out of that market should be a top priority. This kind of therapy could be further improved by allowing additional opioids to be prescribed, like in countries that offer oxycodone, hydrocodone, oxymorphone, or heroin.

Users and those around them should be educated about the risks of combining depressants, which is a common factor in opioid-related deaths, and they should know how to use naloxone, a very effective overdose reversal drug.

Having people be comfortable calling for medical help is more difficult when the justice system threatens to use drug-induced homicide laws and when people are worried about getting in trouble for drug possession. This is why Good Samaritan laws are important: they increase the likelihood of bystanders calling for help when someone overdoses, since otherwise they may just leave the overdose victim or try bad methods like ice water and slapping to try and wake them up. Though Good Samaritan laws are present throughout the country, people still fear getting the authorities involved, even more so since drug-induced homicide cases have gained popularity.

A large number of small-time dealers and sometimes just family members and friends have been prosecuted for manslaughter or murder just for playing a small, non-malicious role in someone’s accidental drug death. When something that severe is a risk, it’s understandable why people would hesitate to call for help.

There also needs to be proper treatment of pain. This crisis is widely described as having originated with the increase in opioid use for pain relief in the 1990s. As such, one of the early responses to the crisis was a cutback in prescribing (Kertesz, 2016). Some patients have been forcefully tapered without medical justification and a lot of doctors are now worried about treating chronic pain patients with opioids because it could be misinterpreted as drug dealing or endangerment.

There are definitely good reasons to limit long-term opioid use whenever possible, especially among current non-users, but every patient’s case needs to be evaluated on its own instead of being subject to a one-size-fits-all policy.

When people are in pain and they have their medication forcibly reduced or revoked they can be driven not only to illicit drug sources but to depression and suicide (Kertesz, 2016). Though legitimate patients who’ve switched to illicit drugs due to being cut off are not a major part of the illicit opioid using population, there’s still reason to believe some of those cases exist and each is a tragedy.

Even if someone is misusing their medication, the appropriate response is not to judge them and remove their access. Rather, they should be transferred to someone who can provide opioid agonist therapy or another kind of addiction treatment, depending on the individual’s goals. That response is far too uncommon right now, partly because society’s negative view of opioid prescribing has incentivized doctors to limit or avoid prescribing.


Some of my points here were inspired by statements from experts like Ryan Marino, David Juurlink, and Andrew Stolbach.

I think one of the most effective ways to change public policy is to change how individuals think about an issue, so you can make a difference just by discussing these facts with people you know. Of course it is true that many of them are not going to change their opinion, but once in a while changes do happen, which facilitates the slow movement towards a better societal approach to drugs.

References

ACMT. (2017). ACMT and AACT Position Statement: Preventing Occupational Fentanyl and Fentanyl Analog Exposure to Emergency Responders. Retrieved from https://www.acmt.net/_Library/Positions/Fentanyl_PPE_Emergency_Responders_.pdf

DEA. (2018). A Briefing Guide for First Responders. Retrieved from https://www.nvfc.org/wp-content/uploads/2018/03/Fentanyl-Briefing-Guide-for-First-Responders.pdf

Howard, J., & Hornsby-Myers, J. (2018). Fentanyls and the safety of first responders: Science and recommendations. American Journal of Industrial Medicine, 61(8), 633–639. https://doi.org/10.1002/ajim.22874

Kertesz, S. G. (2016). Turning the tide or riptide? The changing opioid epidemic. Substance Abuse, 38(1), 3–8. https://doi.org/10.1080/08897077.2016.1261070

Kim, H. K., & Nelson, L. S. (2015). Reducing the harm of opioid overdose with the safe use of naloxone: a pharmacologic review. Expert Opinion on Drug Safety, 14(7), 1137–1146. https://doi.org/10.1517/14740338.2015.1037274

Meyers, E., & Snyder, E. (2014). Harm Reduction at its Best: A case for Promoting Safe Injection Facilities. University of Ottawa Journal of Medicine, 4(2), 24–27. https://doi.org/10.18192/uojm.v4i2.1052

Sigmon, S. C., Ochalek, T. A., Meyer, A. C., Hruska, B., Heil, S. H., Badger, G. J., . . . Higgins, S. T. (2016). Interim Buprenorphine vs. Waiting List for Opioid Dependence. New England Journal of Medicine, 375(25), 2504–2505. https://doi.org/10.1056/nejmc1610047

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