Fentanyl: Separating Fact from Fiction

There is so much sensationalism surrounding fentanyl that the preferred unit for measuring fentanyl seems to be in the number of people it could kill. Take this article from Arizona in February 2019. It states that “in Arizona in 2018, the DEA…seized 445 pounds of fentanyl…which is roughly enough to kill 75 million people.” Statistics like this are not only misleading, but add greatly to the stigma surrounding drug use.

This is not to say that fentanyl should not be taken seriously for those who are using drugs. We recently had a patient on the toxicology service who took what he thought was a Percocet, but actually contained fentanyl. The two friends that he used with woke up, but he did not. Finding the true number of fentanyl-related deaths and overdoses is made difficult by testing limitations at most hospitals, as fentanyl is not a drug that is detected on most commonly used urine drug screens. However, studies have shown that mortality from fentanyl and its derivatives has increased up to 300% among young adults since 2013 (Krieger 2018). The steep rise in opioid deaths correlates almost directly with the rise in contamination of heroin with fentanyl and its derivatives (CDC 2017). For this reason the Iowa Harm Reduction Coalition (IHRC) recommends checking drugs with fentanyl test strips before use. Fentanyl contamination is also not limited to opioids. It has been found in methamphetamine, cocaine as well as other drugs. Though the risks of contamination of other drug classes may also be overblown.

While the danger of fentanyl is certainly real for people who use drugs (PWUD), there is a myth that continues to be spread across the media that fentanyl poses a significant risk to police and other first responders. This dramatically overblown response ignores both the reality of the way fentanyl works and the fact that in almost every case, the symptoms described by those reportedly experiencing “unintentional overdoses” don’t match up with the actual human responses to an opioid overdose. Unfortunately, this myth does create the risk of real world harm: increasing stigmatization and fear of PWUD. The fear of exposure causes police to see PWUD as dangerous. Based solely on a story they heard from a friend or saw online, they may be hesitant to provide life-saving naloxone for someone who desperately needs it. The problem is that few, if any of these stories represent true opioid toxicity. These stories do highlight some fundamental principles that I always discuss with medical students and residents who I teach in my Toxicology course at the University of Iowa: the first being that exposure does not equal toxicity. For an exposure to lead to toxicity, enough of the drug needs to be absorbed and get into the person’s circulation in order for it to have an effect.

The most common routes of exposure in these sensational media articles are skin contact and accidental inhalation. Either some white powder brushed a first responder’s skin or was aerosolized by a fan or other means. While fentanyl is amenable to dermal absorption, it is not a quick process. Fentanyl patches that are used therapeutically take 3-13 hours to reach a therapeutic concentration (ACMT 2016). If you covered both of your palms with fentanyl patches, it would take around 14 minutes to receive 100 micrograms of fentanyl, which is a common dose for pain relief that physicians prescribe to an adult patient. While fentanyl has pretty good absorption through the lungs, the drug itself is very difficult to aerosolize in any significant amount that could lead to toxicity. Fentanyl derivatives have likely been aerosolized and weaponized in Russia, but this is a unique case and likely required specialized formulation and/or dispersal devices. The small risk of significant dermal or inhalational exposure would easily be mitigated with a regular pair of latex or nitrile gloves and a simple face mask, which are already standard PPE (personal protective equipment) for any first responder.

The second principle I teach to my toxicology students is that the symptoms that a patient is having must match the poison in order to establish a causal link. Fentanyl is an opioid and toxicity from all opioids results in the classic triad of small pupils, central nervous system depression (somnolence, nodding off), and respiratory depression. This last effect is why opioid toxicity is deadly: it stops the person from breathing. The cases that are reported in the media often describe dizziness, lightheadedness, numbness, palpitations (racing/heavy heartbeat) and a myriad of other symptoms that don’t fit with opioid toxicity. And while I can’t say I was there with the officers in these cases, their symptoms sound suspiciously like a panic attack. Symptoms of which often include lightheadedness, dizziness, palpitations, chest pain, and hyperventilation. These types of symptoms are justifiable for other reasons: law enforcement, EMS, and other first responders have stressful jobs, in which they may regularly experience anxiety and trauma. Given that they are continually hearing about the dramatic danger of an instant and potentially fatal overdose from incidental fentanyl exposure, a panic attack is an understandable response to encountering an individual who has overdosed and being tasked with the responsibility for saving their life. Naloxone, the antidote to opioid toxicity, unfortunately does not treat panic attacks or anxiety.

It is also important to remember that just because someone received naloxone does not mean that they needed naloxone. In the Emergency Department, naloxone is reserved for those patients who are showing signs of significant toxicity, as in respiratory depression. We do not administer naloxone to someone just because they are sleepy, since that’s not what kills them. The most egregious example of someone getting naloxone that doesn’t need it is the officer who self-administers naloxone. If you are overdosing on opioids, you will not be able to give yourself naloxone (see signs of opioid toxicity above). So if there is one thing to remember from this article, it’s this: if you can administer naloxone to yourself, you do not need naloxone. This is why if you’re going to use opioids, you should always use with someone else, with naloxone readily accessible.

The extremely low likelihood of significant absorption and the disconnect between the reported symptoms make it highly unlikely that any of these cases represent opioid toxicity. I am not aware of a single case of supposed fentanyl exposure that has been confirmed. There is a large group of physicians, harm reductionists, twitter personalities, and others who have been trying to dispel this myth for years. The American College of Medical Toxicologists and the American Academy of Clinical Toxicology released a joint position statement on fentanyl exposure. IHRC’s own Dan Runde also wrote an article about the myth of fentanyl exposure for first responders. And finally, some media outlets have started to listen to all of us fighting this myth.

By not using evidence-based approaches to fentanyl, we are putting those who use drugs at even greater risk. The delay it may take to receive naloxone from a first responder because they are worried about passive fentanyl exposure could mean all the difference for the person who overdosed. By perpetuating the myth that fentanyl poses a significant risk to first responders, the media has increased the danger and the stigma towards PWUD.

Written by:
Dr. Josh Radke
Emergency Medicine Physician
Associate Professor of Medical Toxicology
University of Iowa Hospitals and Clinics

References:

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2. Krieger, et al. High willingness to use rapid fentanyl test strips among young adults who use drugs. Harm Reduct J. 2018 Feb. 15:7
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