The national opioid epidemic has triggered an irrational fear that is reminding clinicians of the initial reactions to HIV in the 1980s. Part of this is being driven by the new powerful synthetic opioids such as carfentanil — an elephant tranquilizer — making their way to the street in a variety of illicit substances.
“The problem is the internet stories that are not necessarily vetted for accuracy, and then they get passed along,” says Ryan A. Stanton, MD, emergency physician and medical director at University of Kentucky HealthCare Good Samaritan Hospital in Lexington. “People want to be afraid. There is so much fear mongering: ‘I’m going to walk by somebody who has opioids and I’m going to die.’ We had the same thing back in the 1980s with HIV. People thought you could get HIV from a hot tub or a toilet seat. We do this in the United States. We like to be super scared and dramatic about things, and that is where we are right now with this.”
New consensus guidelines1 representing a variety of federal agencies emphasize that “misinformation and inconsistent recommendations regarding fentanyl have resulted in confusion in the first responder community. You as a first responder — law enforcement, fire, rescue, and emergency medical services (EMS) personnel — are increasingly likely to encounter fentanyl in your daily activities. …. Inhalation of airborne powder is most likely to lead to harmful effects, but is less likely to occur than skin contact. Incidental skin contact may occur during daily activities but is not expected to lead to harmful effects if the contaminated skin is promptly washed off with water.”1
Hospital Employee Health asked Stanton for his reaction to the PPE guidelines and his perspective from one of the epicenters of the opioid epidemic.
“Looking at this list, it is pretty much common-sense stuff,” he says. “The challenge is that there is so much bad information, like people overdosing by touching [the skin of an OD patient]. It just doesn’t happen. It looks like what they are trying to do is clear up some of the bad information while putting in some [basic recommendations] everybody should already be doing.”
The guidelines recommend that responders wear gloves when the presence of fentanyl is suspected and avoid any actions that may cause opioid powder to become airborne. If opioids are airborne, a respirator should be worn, the guidelines state. Stanton says, from his experience, an N95 probably only is necessary for those entering an area where there is a clear risk of aerosolized opioid powder.
“Theoretically, if it is actually aerosolized there is not enough of a seal on a regular [surgical] mask to provide complete protection,” Stanton says. “Of course, it is going to provide some protection. But you need something that can actually filter out those particles that are in the air, whether it is an N95 in a hospital setting or even higher when you see folks dressed up to go into [opioid] labs. Those are the kind of people that are going to need full protection.”
That said, “there is not anyone I know who is going to avoid rendering care because they are concerned about the type of mask they have on,” he adds. “When I reach in to pull people out of an ambulance, all I am thinking is that there is somebody in front of me dying. That’s what frontline people do.”
Stanton has seen many patients in the throes of opioid overdose in a national epidemic that claimed some 60,000 lives last year in the U.S.2 He shared some clinical perspectives on the opioid epidemic in the following interview with HEH.
HEH: The recent guidance emphasized that skin contact with opioids poses much less risk than inhaling the drugs, though there seems to be some misconception about this.
Stanton: There have been some studies of the amount [of opioid] it would take to overdose through intact skin. You’re talking a huge amount — basically [the equivalent] of making a glove out of fentanyl patches and having it on your hand for 10 hours. Even then you would just get the equivalent of 100 micrograms, which is basically what we give most people for pain. The amount it would take to overdose by skin contact would be just astronomical.
HEH: The primary risk to healthcare workers is inhaling aerosolized particles of opioids?
Stanton: The reason people snort things is because the mucosa associated with the nasal pharynx is very vascular, so it’s a great way to transition things from the outside world into [the body]. It does concern us if there is aerosolization. Especially if you are walking into someplace that is working with this — that has some powder in the air. You do have the risk there, but for most people just having the basic PPE and the antidote [on hand is sufficient]. It’s basically not going to happen with plain old skin contact. For the frontline workers — especially police who may go into some place where [opioids] are being prepared — there is a risk of it being aerosolized. But if that was [frequently] the case we would expect for these dealers and those preparing it to be dead all over the place. They are working with large quantities of it and having no issues, but we fear we are going to get a grain of it on my hand and actually die from it. It doesn’t make sense. You don’t have drug dealers and distributors in hazmat suits.
HEH: It sounds like the message to healthcare workers and first responders is lower the fear factor and use common sense measures. What about reports of workers — including three nurses in Ohio — collapsing and needing to be administered the antidote?
Stanton: I think we are missing a lot of the rest of the story with these sorts of things and blame it on carfentanil or whatever fentanyl is out there. I think there is possibly more to the story. Until we can investigate and [analyze] the actual issues, we need to be careful what we blame it on. It causes unnecessary fear, but it also creates the potential that we may miss a real risk out there. We may miss it because we want to jump to the [conclusion] that you may have had a grain of fentanyl on your hand that caused you to become unconscious.
HEH: That’s an interesting perspective. There may be other factors we are not aware of?
Stanton: There is potentially something else going on — something else in the environment. Are there potentially other hazards that we are dealing with? So many people getting symptomatic is very unlikely to be from touching some version of fentanyl — especially in the hospital. I think the risk inside the hospital is super low. We are handling fentanyl all the time. It is not carfentanil, but we are dealing with it all the time. We give very powerful medications and you can overdose, but it is not that simple. I have patients come in all the time that have three, four, multiple fentanyl patches on their skin. They may be a littler altered and intoxicated, but they are not unconscious.
HEH: How does the naloxone antidote stop the overdose?
Stanton: The naloxone affects the opioid receptors. That is where you [rate] the potency of the opioid. Morphine, fentanyl, [etc.] all bind to a certain strength. The naloxone has a higher affinity to those receptors. It basically kicks off the opioid and then it binds and serves as a “cap.” It caps off those receptors. The opioid is still there in the system and your body will clear it out over time. The question is, if it is heroin or even fentanyl the length of time the naloxone can “hold” onto it is about the same time that it takes the body to get rid of drug itself. But if you were dealing with something like methadone, which until a few years ago was the No. 1 cause of overdose deaths, it takes a lot longer for the body to get rid of it. We have to keep dosing them with naloxone or give them a naloxone drip to keep them awake and stable. When people talk about [a drug being] naloxone resistant or “naloxone proof,” they are talking about drugs that are either going to last longer or they have a higher potency and a [binding] affinity that makes naloxone less likely to work.
HEH: What do you do in those type of cases?
Stanton: We don’t have to keep people awake in medicine. If you have taken something, we need to provide oxygen to the brain and the heart to keep you alive. I can intubate the patient and we can wait. The opioid itself does not kill anybody. It is the respiratory suppression that kills people. If someone comes into the hospital and I can’t wake them up because they have some elephant tranquilizer in them, I just intubate them. I put them on a ventilator and wait. Eventually, they are going to wake up. The problem that we have is the time from when they overdose to the time of the interventions to allow people to breathe. That’s why the risk of these [hospital] situations are so low — because rarely are these folks on their own and care can be rendered right away. Even if they overdose, we can provide oxygen to keep their brain or heart going so we don’t necessarily need to have the antidote, which is just to wake you up.
HEH: Regarding the tens of thousands of deaths being reported, did those people primarily die before these medical interventions could be delivered?
Stanton: Yes, or they were not administered in time. By the time they are found [or someone brings them to the ED] the damage is done. Their heart is stopped. They have brain damage from the lack of oxygen. There are people by themselves who overdose in their cars in a parking lot, with their foot on the brake and the car in drive. They lose consciousness and the car rolls into a light pole or a building. The majority of these people don’t want to die when they are using the drugs. They are trying to get the effect that meets that addiction requirement they have.
1. Federal Interagency Working Group. Fentanyl: Safety Recommendations for First Responders. Available at: http://bit.ly/2iValk4. Accessed Nov. 30, 2017.
2. CDC. O’Donnell JK, Halpin J, Mattson CL, et al. Deaths Involving Fentanyl, Fentanyl Analogs, and U-47700 — 10 States, July-December 2016. MMWR ePub: 27 October 2017. Available at: http://bit.ly/2idBfPT. Accessed Nov. 30, 2017.