Letter to the Editor
We read with interest the recent article by Dan Runde, MD, with commentary from Joshua Radke, MD, entitled “First Responders Worried about Fentanyl OD? Minimize Fear by Quashing that Myth.” (EMN 2018;40:1; http://bit.ly/2RwLakd.) This article does not completely address situations in which first responders could sustain clinically important exposures to fentanyl and related opioids. The potential for occupational exposure to fentanyl as a threat to first responders is acknowledged in position statements from the CDC, NIOSH, ACMT, and AACT (CDC. August 24, 2017; http://bit.ly/2ocqMYe; Clin Toxicol [Phila] 2018;56:297; http://bit.ly/2DfwvFv.) The DEA has also stated that inhaled fentanyl in the field poses a serious danger and should be treated with extreme caution. (http://bit.ly/2DcKr2S.)
Exposure to aerosolized fentanyl dust constitutes an important risk for inhalation exposure by first responders. It is true that the vapor pressure of fentanyl is low, but this applies to liquid fentanyl and not aerosolized solid phase particles containing fentanyl. In illicit manufacturing, it would be difficult to state confidently that an unregulated setting such as home manufacturing would be free of aerosolized fentanyl. Such aerosolized fentanyl poses a potential inhalation threat to first responders. Once inhaled, systemic absorption and adverse clinical effects are biologically plausible. Consequently, first responders should be warned regarding the proper use of personal protective equipment, including respiratory protection, as recommended by the CDC.
Maricel Dela Cruz, DO, MPH, &
Michael I. Greenberg, MD, MPH
Dr. Runde responds: While the specter of accidental fentanyl exposure raised by Drs. Dela Cruz and Greenberg is no doubt well intentioned, it unfortunately places misguided theoretical fears over the very real lives at stake in the midst of our current opioid crisis. Evidence of harm to first responders caused by accidental exposure is virtually nonexistent while at least 130 Americans die every day from opioid overdoses. (CDC. Dec 19, 2018; http://bit.ly/2FUU2gk.) When responding to opioid overdoses, minutes mean the difference between life and death. The statement cited by the authors from the ACMT and AACT (the only source that appears to take into account the actual pharmacology and physics related to fentanyl), states, “Fentanyl and its analogs are potent opioid receptor agonists, but the risk of clinically significant exposure to emergency responders is extremely low. To date, we have not seen reports of emergency responders developing signs or symptoms consistent with opioid toxicity from incidental contact with opioids.”
Absent extraordinary circumstances unlikely to ever be encountered by our first responders, such as the Moscow theater hostage crisis where the Russian military may have weaponized aerosolized fentanyl in a closed space (http://bit.ly/2AXPuCW), a pair of nitrile gloves is all they should need in the vast majority of cases. In rare situations (i.e., visibly aerosolized powder or an enclosed space with rapid air flow), an N-95 face mask would provide more than enough protection. Further delays to don Level A or B PPE (spacesuits and full body suits with air tanks) or calling a HAZMAT team are driven by fear, not an objective assessment of the exceedingly low risk of accidental overdose. Delaying response to overdose victims is the real threat.