By Gary Evans, Medical Writer

Three Ohio hospital nurses recently had to be revived with an opioid antidote after caring for a drugged patient, underscoring a new occupational threat to healthcare workers and the lack of federal guidelines to protect them.

The incident, which the three healthcare workers survived, drives home the growing occupational risk of the national opioid epidemic. Though few details were released, the life-threatening effect of the drug involved suggests exposure to carfentanil. It is estimated that carfentanil — a drug approved for tranquilizing elephants — is 100 times more potent than fentanyl, a similar synthetic opioid.1 Both narcotics are much stronger than heroin, and are sold on the street or added to other drugs to boost potency and, presumably, profits.

“It is not known which type it was, but based on their symptoms it appears it was carfentanil,” says Michelle Mahon, RN, a union representative for the nurses, who work at Affinity Medical Center in Massillon, OH. “One of the frightening things about this is that carfentanil is so strong that just a small grain of it can be very potent. This is something that could happen anywhere these toxins are present. We are looking at this as a canary in a coal mine.”

Asked for details on the incident, Susan Koosh, vice president of marketing and community relations at Affinity Medical Center, issued the following statement to Hospital Employee Health: “While we cannot provide specific details about patients or employees in regard to the incident, I can share that we have effective policies and procedures in place for handling hazardous drugs and any accidental exposure.”

Those policies and procedures either were not in place or not followed on Aug. 8, 2017, when three nurses at the hospital succumbed to the effects of the powerful narcotic and had to be administered naloxone. This antidote blocks the opioid receptors in the brain and restores proper breathing function. The nurses apparently were involved in care and/or room cleaning for a patient admitted for an overdose of the narcotics. Room cleaning raises the possibility of aerosolization of the drug, but it had not been reported whether the narcotic was inhaled.

“It is very difficult to pin down in hindsight the exact mechanism of exposure,” says Mahon, a union official with National Nurses United. “There are many potential points of exposures from the time the patient arrived through the cleanup of the room.”

National Guidance Lacking

Citing the lack of national guidelines for nurses and other healthcare workers, the union is developing personal protective equipment (PPE) recommendations to prevent exposures to hospitalized patients.

“Our focus [now] is really to examine all of the potential ways nurses could be exposed,” Mahon says. “Those include body fluid precautions as well as other environmental precautions. We are currently assessing the best available evidence regarding opiate overdose and occupational exposures. We will be releasing a safety protocol and recommendations for nurses, as well as other healthcare workers who face opioid exposure, as soon as possible.”

The National Institute for Occupational Safety and Health (NIOSH) updated its occupational exposure guidelines for fentanyl on Aug. 24, 2017, but the measures are primarily for first responders and public safety exposures.

“What NIOSH has put out is mostly for first responders — prehospital,” says Christina Spring, MA, associate director for communication at the agency. “[We] are aware of the reports of the issue and trying to determine next steps. At this point, NIOSH hasn’t put out guidance for hospitals workers.”

Illicitly manufactured fentanyl can be in powder, tablet, or liquid form, NIOSH notes on its website. (For more information on preventing fentanyl exposure, visit: http://bit.ly/2wIDLae.)

“Potential exposure routes of greatest concern include inhalation, mucous membrane contact, ingestion, and percutaneous exposure (e.g., needlestick),” according to NIOSH. “Any of these exposure routes can potentially result in a variety of symptoms that can include the rapid onset of life-threatening respiratory depression. Skin contact is also a potential exposure route, but is not likely to lead to overdose unless large volumes of highly concentrated powder are encountered over an extended period of time. Brief skin contact with fentanyl or its analogues is not expected to lead to toxic effects if any visible contamination is promptly removed. There are no established federal or consensus occupational exposure limits for fentanyl or its analogues.”

For example, in a “moderate” risk situation of an emergency medical worker responding to a suspected fentanyl overdose, NIOSH recommendations include the following PPE:

  • A filtering facepiece respirator such as a P100 FFR.
  • Face and eye protection (i.e., goggles).
  • Powder-free nitrile gloves.
  • Wrist/arm protection such as long sleeves, sleeve covers, or gowns.
  • Wash hands with soap and water immediately after a potential exposure and after leaving a scene where fentanyl is known or suspected to be present to avoid potential exposure and to avoid cross-contamination.
  • Do not use hand sanitizers or bleach solutions to clean contaminated skin.

“We have seen first responders have to be treated for contact exposures,” Mahon says. “We know that law enforcement and EMS have been affected by the increase in the synthetic opioids, including fentanyl and carfentanil. We are stepping up because no one has made recommendations for nurses and other healthcare workers who are providing life-saving care for patients once they reach the hospital.”

The Fourth Wave Looms

The threat of exposure to healthcare workers to debilitating narcotics is the latest manifestation of a national opioid epidemic that has included medical staff diverting drugs for personal use, admitted patients injecting their IV lines with street drugs, and the recent arrest of a nurse charged with attempting to smuggle a fentanyl patch to an inmate.2 In addition, 18 police officers in Pittsburgh recently had to be taken to a hospital for treatment after being exposed to opioids when a table laden with the narcotics was overturned in a drug raid.3

“Carfentanil has already been attributed to several deaths, even among opioid-tolerant patients,” according to a paper by emergency physicians.1 “Exposures present with symptoms typical of opioid overdose, including decreased alertness, respiratory depression, and pinpoint pupils. Symptom onset is very rapid after exposure. Importantly, patients may require unusually large or repeated doses of naloxone. Even with reversal of acute symptoms with naloxone, recurrence of symptoms may occur and warrants prolonged observation in a hospital setting. Failure to treat in a timely manner can result in respiratory arrest, hypoxia, or death.”

Although there are regions of particular risk, it is becoming apparent that some aspect of the epidemic may appear anywhere in the country.

“Here in the Midwest, if you look at where this opioid epidemic is hitting the hardest, certainly Affinity Medical Center is right in the epicenter — in Stark County, Ohio — of this crisis,” Mahon says. “It is certainly not the only one. We have been hearing reports of nurses, and the evidence bears out that there are more and more [opioid] patients coming in, having to be treated in the field and by first responders such as emergency department nurses and personnel. Even inpatients can pose a potential risk of exposure if they have this history. The risk is there, and organizationally we follow the precautionary principle and believe the highest standards need to be in place — assuming the worst in every case to protect healthcare workers. That’s where we are coming from on this.”

The CDC recently reported, in commemorating Aug. 31, 2017, as International Overdose Awareness Day, that the opioid epidemic has hit the United States in three distinct waves.4

Approximately 300,000 people — roughly the population of Pittsburgh — died of opioid overdose from 1999-2015, when 33,000 died in one year alone. The estimated overdose deaths in 1999 were 8,050.

“The first wave of deaths began in 1999 and included deaths involving prescription opioids,” according to the CDC. “It was followed by a second wave, beginning in 2010, and characterized by deaths involving heroin. A third wave started in 2013, with deaths involving synthetic opioids, particularly illicitly manufactured fentanyl [IMF].”

Drug products containing IMF now come in various guises, including counterfeit prescription pills, mixed with cocaine, or sold as powders to persons using heroin with and without their knowledge that they are ingesting IMF, the CDC warns.

“Rapid increases in fentanyl drug product rates in the Northeast, Midwest, and South coincided with increases in synthetic opioid death rates with and without heroin starting in 2013,” the CDC noted. “Overdoses involving both heroin and synthetic opioids primarily drove increases in heroin deaths in the Northeast and Midwest during 2013-2015. Targeting timely response efforts requires rapid surveillance of illicit opioid products and deaths.”

‘The Real Face of America’

While NIOSH is considering the issue, there does not appear to be any active national surveillance system for these exposures and subsequent effects in healthcare workers.

“What we’re seeing is very concerning,” Mahon says. “It’s not getting reported, and we certainly know it is affecting our patients at very high rates.”

NIOSH recommends a filtered respirator for possible fentanyl exposures, but Mahon says the nursing union can find little data to guide PPE for carfentanil, a large-animal veterinary drug that is not indicated for humans.

“We really have a big job ahead of us in that regard,” she says. “We are doing our due diligence to put out protocols, polices, and protection guidelines that reflect the best evidence. What has been noted — particularly with these stronger [opioid] doses — is that it is taking more naloxone to reverse the impact than it does for heroin or fentanyl. Very large doses have been needed to reverse the effect of the carfentanil.”

The National Institute of Drug Abuse estimates that 90 Americans die every day of an opioid overdose. How did we get here? The following is the institute’s explanation, posted on a National Institutes of Health webpage, current as of June 2017:

“In the late 1990s, pharmaceutical companies reassured the medical community that patients would not become addicted to prescription opioid pain relievers, and healthcare providers began to prescribe them at greater rates. This subsequently led to widespread diversion and misuse of these medications before it became clear that these medications could, indeed, be highly addictive.” (For more information, visit: http://bit.ly/2iIWiNS.)

To summarize the impact in one harrowing sentence, the drug institute estimates that 80% of people who use heroin in the United States first misused prescription opioids.

“This crisis is affecting every single state,” Mahon says. “There is a lot of focus in areas where things are particularly bad, like Appalachia and Ohio, but there is no state that is immune. This needs to be addressed in a national, systemic way. One of the things that we know is that social and economic problems tend to present themselves on the frontlines in our hospitals at the bedside. Nurses are typically the first ones to encounter that. We see the real face of America every day.”

REFERENCES

  1. Dingle HE, Williams SR, Slovis C. Carfentanil Exposure Treatment & Precautionary Measures for EMS Providers. JEMS Dec. 16, 2016. Available at: http://bit.ly/2wnWtRX.
  2. Benton, B. Nurse caught leaving fentanyl patch stuck to a door at Grundy County Courthouse. Times Free Press, July 26, 2017. Available at: http://bit.ly/2vJriyE.
  3. Bradbury S, Goldstein A. 18 police officers exposed to fentanyl during West End raid; all unharmed. Pittsburgh Post-Gazette, Aug. 9, 2017. Available at: http://bit.ly/2vFr8cg.
  4. CDC. Trends in Deaths Involving Heroin and Synthetic Opioids Excluding Methadone, and Law Enforcement Drug Product Reports, by Census Region — United States, 2006–2015. MMWR 2017;66(34):897-908.