Experts Skeptical After Fentanyl Scare Closes Mass. ED

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On Jan. 6 Falmouth Hospital’s emergency department diverted all incoming patients to other area hospitals for several hours as a hazmat team decontaminated the area after several staff members and first responders were passively exposed to fentanyl and administered Narcan due to reported symptoms.

Several healthcare workers and medical experts who spoke to MassLive, however, say this response was not in line with medical evidence and is part of a long history of misconceptions surrounding the opioid, namely the possible risk of overdose when exposed passively.

On that Thursday in early January Falmouth Fire Rescue announced the department responded to the Falmouth Hospital campus to assist the Falmouth Police Department with an evaluation of a man sitting on a bench outside the hospital.

The man was transported to the hospital’s emergency department but became “combative” during the transfer and as a result, several first responders and hospital staff were exposed to a substance on the man, according to the fire department’s news release.

After the exposure, two police officers, two security officers, two hospital staff members and a paramedic began to experience symptoms of lightheadedness, Falmouth Fire Rescue Chief Tim Smith told WHDH. In coordination, the hospital and fire department decided to isolate the man in a treatment room and put in a request for the state hazmat team to respond to the hospital.

The emergency department diverted patients to other area hospitals for at least five hours while the hazmat team decontaminated the emergency department, ambulances and tended to personnel.

According to the fire department, the hazmat team later identified that the substance on the man contained fentanyl, among other chemicals. The department did not disclose what other chemicals were found in the substance.

“It was on his person, may have been in a bag, and when they were removing some of his clothing it got released,” Falmouth Fire Chief Tim Smith told WHDH.

At least three of the individuals exposed to the substance were treated with Narcan, or naloxone, a nasal spray used for the treatment of a known or suspected opioid overdose emergency. The prescription is administered when an individual is showing signs of breathing problems or not responding, according to the medicine’s website.

The fire department believes the individuals were exposed to fentanyl through inhalation.

“Even though everyone has masks on and gloves, it was potent enough to affect them when they were breathing it in,” Smith told WHDH.

Several news outlets, including MassLive and the Cape Cod Times, reported on the incident as it was described by the Falmouth Fire department. Following the publishing of the story several experts reached out to MassLive to dispute the possibility of a fentanyl overdose from passive exposure.

Dr. Ryan Marino, a medical toxicologist and addiction medicine specialist at University Hospitals in Ohio and assistant professor at Case Western Reserve University School of Medicine, said it would not have been possible for the individuals exposed during the hospital’s incident to overdose.

“I’m not saying these people didn’t have these symptoms, didn’t have something really happen,” he said in a phone call with MassLive. “It’s just that it was not a fentanyl overdose and it would not be possible for it to have been a fentanyl overdose.”

Fentanyl, in powder form, does not cross the skin barrier, he explained.

“There are transdermal fentanyl patches available on the market, which I think is where a lot of the confusion comes from,” Marino said.

MassLive made several attempts over the past two weeks to contact both Falmouth Fire Rescue and Cape Cod Healthcare Inc. asking for comment on the incident but did not receive any response. Cape Cod Healthcare Inc. runs Falmouth Hospital.

Those transdermal fentanyl patches include chemicals that are soluble, allowing for the fentanyl to cut across the skin barrier. For context, a 75 microgram fentanyl patch would take up to 13 hours to reach therapeutic concentrations in the bloodstream, he said.

Furthermore, fentanyl has a very low vapor pressure, making it difficult to get in the air, Marino said.

“Fentanyl does not just get into the air on its own, you would really have to be kind of working hard to do so, to inhale any fentanyl,” he said.

In 2017, the American College of Medical Toxicology and American Academy of Clinical Toxicology put out a position statement regarding emergency responders’ exposure to fentanyl in both its occupational form, or clinical use, and analog form, or synthetic use.

“Fentanyl and its analogs are potent opioid receptor agonists, but the risk of clinically significant exposure to emergency responders is extremely low,” the statement reads. “To date, we have not seen reports of emergency responders developing signs or symptoms consistent with opioid toxicity from incidental contact with opioids.”

The statement explains that emergency responders outfitted with proper personal protective equipment, including nitrile gloves and N95 masks, will be sufficiently protected against incidental absorption.

“In the unlikely event of poisoning, naloxone should be administered to those with objective signs of hypoventilation or a depressed level of consciousness, and not for vague concerns such as dizziness or anxiety,” the statement continues.

Marino said the symptoms described by the individuals who were administered Narcan at the Falmouth hospital are more in line with that of an anxiety attack.

“I think that these people thought that they were experiencing a fentanyl overdose and that’s why Narcan was administered,” Marino said. “It sounds like everyone involved really felt that this was really happening, which kind of underscores the importance of correcting this narrative.”

The ACMT and AACT statement addresses the passive airborne transmission of fentanyl outright, stating, “evaporation of standing product into a gaseous phase is not a practical concern.”

Becca Nash, an EMT-Basic with the Boylston Fire Department, agreed with Marino and said protocol calls for responders to only administer Narcan when an individual is showing signs of their breathing slowing.

“It’s extremely potent,” Nash said, speaking on fentanyl. “And dangerous, but only if you’re purposefully ingesting it. If it’s in the air and you get some on your skin, that’s not really how it’s absorbed, not enough to overdose you.”

First responders’ concerns over passive exposure to fentanyl have grown over the years due to more synthetic opioids hitting the streets, but training to recognize the objective symptoms of opioid intoxication, proper PPE outfitting and naloxone training, can assist workers when responding to medical calls and crime scene, according to the ACMT.

Colby Fiske, a paramedic who works in Worcester County, said basic precaution provides for very limited exposure to opioids when responding to calls as a first responder.

Narcan, he said, is only administered when an individual’s breathing is depressed.

“We don’t administer Narcan based on mental status,” Fiske said. “We don’t administer Narcan as a prophylactic agent for a narcotic exposure. We administer purely on ‘are they breathing or are they not breathing?’”

Marino said part of the issue is reports of the fentanyl scares are made and then not corrected.

“I think the main issue is that there are so many of these reports that come out and no one usually bothers to do the correction afterward,” he said. “Or nobody’s paying attention at that point. And when it comes out that this wasn’t a fentanyl overdose, this is impossible, these people didn’t have fentanyl in their system, that either doesn’t make it to print or people just aren’t paying attention anymore.”

This cycle, Marino said, contributes to anxiety surrounding the drug.

“When you’re seeing some sort of story on the news every week that people were brought down by just being near fentanyl, you’re going to believe that that’s true and can happen to you as well,” he said.