Fentanyl Fear and Facts

In the video Chad Sabora tests the substance first—he says it’s heroin cut with fentanyl, and the camera zooms in on a test strip that confirms the fentanyl’s presence.¹ He’s already touched it, but to underscore his point he then taps a small line of the powder into his bare palm, where he holds it while addressing the camera. He does not experience symptoms. He does not overdose. 

In that 2018 video Sabora, a former prosecutor and recovering heroin addict who now leads the Missouri Network for Opiate Reform and Recovery, tried to douse some of the burgeoning hysteria about fentanyl and its risks of incidental exposure. As powerful as it may be, he reminds viewers, you cannot overdose just by touching or being near it. And yet in perusing the news and social media today, it’s hard to say he—or any of the other physicians and experts who similarly struggle to set this record straight—was very successful. Misinformation and unfounded fear still abound. 

“For whatever reason, it seems like this notion just will not go away,” says Ryan Marino, MD, a medical toxicologist, emergency physician and addiction medicine specialist, and assistant professor at the Case Western Reserve University School of Medicine in Ohio who has become prominent on social media for his efforts to combat fentanyl misinformation. “It’s kind of like Whac-A-Mole or a cockroach infestation: No matter how many times we try to address this myth, another story always comes up.” 

“It’s unfortunate how this myth seems to have taken hold, and now people really think they’re at risk of accidentally getting poisoned from fentanyl,” agrees Andrew Stolbach, MD, MPH, an associate professor of emergency medicine who leads the toxicology training curriculum at The Johns Hopkins Hospital in Baltimore. “It’s not to anybody’s benefit for us to be unnecessarily scared about that—it’s really unlikely.”

Effective Defenses

It’s hard to blame people without medical education for being credulous about breathless media accounts of overdoses, especially when their sources seem authoritative. “Authoritative” sources bear some responsibility for today’s fentanyl misinformation. 

A 2016 DEA warning, now retracted, stated directly, “fentanyl can be absorbed through the skin or through accidental inhalation of airborne powder.”² The next year the Justice Department released a video featuring DEA boss Chuck Rosenberg warning, “[Fentanyl] is extremely dangerous to users and those who simply come into contact with it. If you’re a first responder, that could be you.³

“It can be absorbed into the bloodstream through your skin…or even by accidentally breathing tiny amounts of airborne powder,” Rosenberg said. 

In fact, intact skin is an effective barrier against fentanyl, and in powder form it is extremely hard to aerosolize. 

A 2019 video still available as part of NIOSH’s “Illicit Drug Tool-Kit for First Responders” tells of a Virginia police officer who entered a motel room where white powder was visible, had no apparent direct contact with it, then made it back to headquarters before developing symptoms that required naloxone.⁴ Local media reported a second officer back at the station reported symptoms after just handling a camera from the scene.⁵ Officers at the scene became affected despite respirators.

Such avenues of intoxication are unlikely, to put it mildly. First, as Sabora showed, the existence of fentanyl patches notwithstanding, it doesn’t work transdermally. 

“The reality is that the development of those patches was extremely challenging,” says Stephen Murray, a paramedic and community implementation specialist at Boston Medical Center who develops and researches postoverdose teams. “It took them a decade to figure out how to effectively deliver fentanyl through the skin. And the reason it works is because it actually doesn’t deliver it that effectively—you only get about 20% of the dose per hour. That’s an effective way to manage people’s pain long-term, but it doesn’t really create the same level of  acute overdose risk that injecting or sniffing poses.” 

Second, fentanyl, and opioids in general, don’t get airborne easily. The passive stirring up of ultrafine particles in a normal response situation isn’t something to stress about. 

“Fentanyl has a very low vapor pressure, and so people can snort it, but it doesn’t just get into the air,” says Marino. “Because of that low vapor pressure, even in facilities where they’re making liquid formulations of fentanyl, which you might think would evaporate into the air much quicker, it just doesn’t happen. It doesn’t get into the air in any significant amount that could cause an exposure or overdose without it being very much intentional.”

A More Interesting Story

Still, the experts have their hands full battling alarmist, unscientific, and unnuanced educational efforts and media coverage. The mainstream news outlets that have uncritically regurgitated unlikely exposure stories without talking to docs are too numerous to count.

But in many quarters of public safety, the dangers of just being around fentanyl are nearly an article of faith. One recent study found 80% of New York first responders believed touching fentanyl even briefly could be deadly.⁶ Other authors found a similar rate among Indiana police.⁷ 

When they hear overdose accounts from sources like police and government, media tend to believe them, often without further investigation. A team led by Johns Hopkins’ Paul Herman, MD, that explored the origins of fentanyl misinformation found more than 200 media accounts of accidental first responder opioid exposure from January 2012 to March 2018, but not one with a “plausible route of exposure, clinical manifestations consistent with exposure, and laboratory testing that confirmed exposure.”² The scientific literature, similarly, confirmed no such exposures. 

“I think we should hold the media to certain standards in this, and in some cases the reporting hasn’t met that standard,” says Stolbach, a coauthor of the Herman paper. “Reports may take at face value that somebody was treated for ‘fentanyl poisoning’ when with a bit of digging, they’ll realize bringing somebody to the hospital for suspected exposure is not the same thing as confirming somebody got poisoned. 

“A lot of reporters get it right, but when people get it wrong, I think it’s an easier story. It’s a lazier story. And it always spreads because it’s a more interesting story.” 

Inside the House

Dubitable exposures to fentanyl aren’t limited to law enforcement. Perhaps more alarmingly, a pair of recent accounts have come from inside the house of EMS. 

In January the emergency department at Massachusetts’ Falmouth Hospital was closed and decontaminated after “several staff members and first responders were passively exposed to fentanyl,” MassLive.com reported.⁸ Falmouth Fire Rescue personnel responded to help police evaluate a man sitting outside the hospital on a bench. Taken inside he became combative, allegedly exposing responders to an unknown substance. A paramedic was among those who reported feeling lightheaded afterward, and at least three people received naloxone. The ED diverted patients for hours while a hazmat team decontaminated. The fire department said the substance on the man contained fentanyl and unspecified other chemicals. 

While the fire department continues to assert those affected were felled by inhalation, MassLive, after an initial public upbraiding, also talked to medical experts who said exposure in such a manner wasn’t plausible. 

In Tennessee an alleged drug user named Tommy Starnes is charged with two counts of felony reckless endangerment after a deputy and an EMS provider believed they experienced symptoms after treating him for a potential overdose of fentanyl-laced heroin.⁹

The EMS provider started having symptoms while driving Starnes to the hospital, the sheriff’s department said in a press release.¹⁰ A deputy took the wheel, and by arrival at the ED, he too was having “overdose symptoms.” Questioned by BuzzFeed, Sheriff Wesley Holt would not describe the symptoms, and both Holt and Starnes’ public defender said they were unaware of the body of evidence showing such exposure all but impossible.⁹ Both responders were treated and released. 

San Diego Backlash

Police, though, seem the most common reporters of symptoms after passive fentanyl exposures. A high-profile case in 2021 was typical of that in many ways—but also showed how things may be changing.  

Last August the San Diego County Sheriff’s Department released a video purporting to show Deputy David Faiivae succumbing to fentanyl intoxication after performing a field test on powder during a July arrest.¹¹ In the video—which combines deputies’ body-worn camera footage with somber first-person narratives—Corp. Scott Crane describes the drug as “superdangerous” and warns Faiivae, his trainee, about getting too close to it.  “A couple seconds later,” recounts Crane, “[Faiivae] took some steps back and collapsed.” Given four doses of naloxone, Faiivae survived. 

Pushback was fast and vigorous, with critics noting you can’t overdose from dermal contact or just coming near fentanyl, and hundreds signed an online petition calling for the video’s retraction. The local San Diego Union-Tribune, which didn’t initially question the department’s account, became more skeptical. It subsequently reported Sheriff Bill Gore had merely assumed the collapse was fentanyl-driven and diagnosed it himself without physician input.¹² No toxicology report was done.

Gore later released the full unedited body-cam footage from both Faiivae and Crane, but it didn’t resolve many concerns. “I am puzzled by the fact that the sheriff has not yet retracted his previous statements about this being an overdose,” Leo Beletsky, JD, MPH, an associate adjunct professor of medicine at UC San Diego, told local station KGTV after the full release. “This is not an overdose.”¹³ 

“When you see someone drop down from standing in open air without any sort of clear exposure, that doesn’t make any sense chemically or physiologically,” says Marino. “The person who was with him wasn’t affected when he was also in proximity to the drug. And the symptoms didn’t fit with an opioid overdose—he was breathing the whole time. Fentanyl suppresses respiratory drive, so you can’t overdose without having significant respiratory depression.”

The original video was removed by Vimeo. It was still available from the department as of late February but not by late March.¹¹ It remained on the department’s YouTube channel as of early April.¹⁴ 

An important point to this pushback is that no one is suggesting these officers or any purported fentanyl victims are lying or trying to perpetrate a fraud. More likely is that elevated anxiety around what they’re convinced is a deadly-at-a-distance threat progresses into physical symptoms—basically, a panic attack.

This is a recognized phenomenon, the nocebo effect: Individuals believe they’ve encountered a toxic substance and thus experience its expected symptoms. 

“If you work on the streets, you know it’s scary out there—there’s violence toward providers, there’s violence toward law enforcement,” says Murray. “We’re all taught to be mindful of our situation and cautious about walking into things. And law enforcement, even more so than EMS, has to treat each encounter as a potential threat. So I think there’s maybe just a level of hypervigilance where they perceive there’s a threat happening, and it causes a reaction.

“We don’t see EMS providers dropping left and right from fentanyl exposures, and we respond to thousands of overdoses a year in this country.”

The Costs of Misinformation

Is there a downside to overcaution? Naloxone doesn’t harm you, drugs should be handled carefully, and if potential users are scared away from fentanyl, all the better, no? 

Yet there are costs. Starnes faces jail time for a “crime” that’s all but impossible. There’s also an Ohio man, Justin Buckel, presently incarcerated for something similar: “assaulting” a police officer who brushed Buckel’s fentanyl off his shirt, then claimed symptoms an hour later.⁹ There may be others. “These are real consequences for the people being charged with these crimes,” notes Murray. “It’s not some abstract thing—jail time is serious.”

The Falmouth ED closure certainly came with costs. Tennessee agencies spent thousands to decontaminate Starnes’ ambulance.⁹ And perhaps most perniciously, unwarranted fears of exposure may lead emergency responders and lay citizens alike to be reluctant to help true overdose victims, for whom time is vital. 

“If there’s any hesitation responding, even if it’s putting on PPE that’s unnecessary, those extra seconds can really mean a lot,” says Marino. “I’ve seen bystanders not want to respond at all because they’re worried they can overdose.” 

“If it was just ‘better safe than sorry,’ I’m all for that,” adds Stolbach. “But in this case there can be a real cost in terms of the patient. Every second matters if they’re not breathing.” 

Corrective Messaging

For good information on this issue, start with the American College of Medical Toxicology (ACMT) and American Academy of Clinical Toxicology (AACT). They released a statement in 2017 that was comprehensive and forthright, saying:

To date we have not seen reports of emergency responders developing signs or symptoms consistent with opioid toxicity from incidental contact with opioids. Incidental dermal absorption is unlikely to cause opioid toxicity. For routine handling of [the] drug, nitrile gloves provide sufficient dermal protection. In exceptional circumstances where there are drug particles or droplets suspended in the air, an N95 respirator provides sufficient protection.¹⁵ 

The statement adds that naloxone should only be given for “objective signs of hypoventilation or a depressed level of consciousness, and not for vague concerns such as dizziness or anxiety.” 

Marino has developed a fact sheet for first responders (search #wtfentanyl on Twitter), and at least two recent papers describe formal efforts to provide accurate education and reduce providers’ fears. 

The Indiana study mentioned above, published last year in Health & Justice, delivered brief online training with “corrective messaging” about overdose risk from fentanyl contact to 204 officers. Before the training 80% believed touching or inhaling it posed a significant risk; the training reduced that to 39%.⁷ 

A project in Missouri published the previous year incorporated accurate information about exposure risk into existing overdose and response training for 140 EMS and police personnel. Before the training 17% of police and 37% of EMS providers knew they couldn’t overdose from touching fentanyl; afterward those numbers improved to 81% of police and 93% of EMS.¹⁶ 

There’s also a pretty decent argument from common sense.

“If people got high from opioids just touching your skin,” notes Stolbach, “why would anybody ever bother to inject them? And if people got high just from being in the same room as an opioid, why don’t the dealers—who are cutting it and moving it and handling it and packaging it—get sick?”

Open to Correction

We can’t all deliver formal education to those who need it. But on calls and in interactions, especially with our health care and public safety colleagues (and, when you get the chance, the media), we can at least share good information and help squelch needless panic. 

“It can be hard to contradict someone, especially when it’s law enforcement telling you something their training has told them, but we have to do what’s best for the public and our patients,” says Marino. “Certainly no one is an expert in everything, and in medicine information changes all the time. So all of us need to be open to correction and better understanding of the scientific data.”

“With law enforcement in particular, we should be making them more at ease,” says Murray. “There are real threats they need to worry about, and this is not one of them.”  

References

1. Chad Sabora Facebook page. Accessed March 22, 2022. www.facebook.com/505686240/videos/10156508237216241/

2. Herman PA, Brenner DS, Dandorf S, et al. Media Reports of Unintentional Opioid Exposure of Public Safety First Responders in North America. J Med Toxicol. 2020; 16(2). doi: 10.1007/s13181-020-00762-y

3. Rosenberg C. DEA Officer Safety Alert—Fentanyl: A Real Threat to Law Enforcement. Department of Justice. Published June 6, 2017. Accessed March 22, 2022. www.justice.gov/opa/video/roll-call-video-warns-about-dangers-fentanyl-exposure

4. Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health. Video #1: Illicit Drugs, Including Fentanyl—Preventing Occupational Exposure to Emergency Responders. Illicit Drug Tool-Kit for First Responders. Updated April 5, 2019. Accessed March 22, 2022. www.cdc.gov/niosh/topics/fentanyl/toolkit.html

5. Epps K. Long sentences suggested for couple whose drugs caused four Fredericksburg officers to overdose. Fredericksburg Free-Lance Star. December 28, 2018. Accessed March 22, 2022. https://fredericksburg.com/news/crime_courts/long-sentences-suggested-for-couple-whose-drugs-caused-four-fredericksburg-officers-to-overdose/article_544c6214-0fdf-5f5c-ab82-5876f7a7bbb1.html

6. Persaud E, Jennings CR. Pilot Study on Risk Perceptions and Knowledge of Fentanyl Exposure Among New York State First Responders. Disaster Med Public Health Prep. 2020; 14(4): 437–41. doi: 10.1017/dmp.2019.95. Epub 2019 Oct 1

7. del Poza B, Sightes E, Kang S, Goulka J, Ray B, Beletsky L. Can touch this: training to correct police officer beliefs about overdose from incidental contact with fentanyl. Health Justice. 2021; 9(34). Published November 24, 2021

8. Matthews T. A Cape Cod ER was shut down, Narcan given to staff after opioid exposure, but experts say airborne overdose is ‘impossible’. MassLive. Published January 1, 2022. Accessed February 25, 2022. www.masslive.com/capecod/2022/01/a-cape-cod-er-was-shut-down-narcan-given-to-staff-after-opioid-exposure-but-experts-say-airborne-overdose-is-impossible.html

9. Ellefson L. Jail Time For an “Imaginary Crime”: It’s Almost Impossible to Overdose Just by Touching Fentanyl, but People Are Being Locked Up for It Anyway. BuzzFeed News. Published January 5, 2022. Accessed March 22, 2022. www.buzzfeednews.com/article/lindseyellefson/fentanyl-accidental-exposure-police

10. Duncan C. Press release. Greene County TN Sheriff’s Department Facebook page. Posted September 17, 2021. Accessed February 25, 2022. www.facebook.com/GreeneCountyTNSO

11. San Diego County Sheriff’s Department. The Dangers of Fentanyl—Public Safety Video. www.sdsheriff.gov/Home/Components/News/News/562/514. Published August 5, 2021. Accessed March 22, 2022.

12. Kucher K, Figueroa T. Sheriff ‘shocked’ by pushback from medical experts over fentanyl video. San Diego Union-Tribune. August 9, 2021. Accessed February 25, 2022. www.sandiegouniontribune.com/news/public-safety/story/2021-08-09/sheriff-shocked-by-pushback-from-medical-experts-over-fentanyl-video

13. Hernandez S. Medical experts questioning body cam video of fentanyl incident. KGTV 10 News San Diego. Published August 14, 2021. Accessed February 24, 2022.

14. San Diego County Sheriff’s Department. The Dangers of Fentanyl—San Diego County Sheriff's Department. YouTube. Accessed March 22, 2022. www.youtube.com/watch?v=zJ7TaLQDRR8&t=2s  

15. American College of Medical Toxicology, American Academy of Clinical Toxicology. ACMT and AACT Position Statement: Preventing Occupational Fentanyl and Fentanyl Analog Exposure to Emergency Responders. American College of Medical Toxicology. Published July 12, 2017. Accessed March 22, 2022. www.acmt.net/cgi/page.cgi/_zine.html/The_ACMT_Connection/ACMT_Statement_on_Fentanyl_Exposure

16. Winograd RP, Phillips S, Wood CA, et al. Training to reduce emergency responders’ perceived overdose risk from contact with fentanyl: early evidence of success. Harm Reduct J. 2020; 17: 58. Accessed March 22, 2022. https://harmreductionjournal.biomedcentral.com/articles/10.1186/s12954-020-00402-2

John Erich is the senior editor of EMS World.