Drug Exposure: Watching Out for First Responders

Opioid prescriptions have declined sharply over the last several years, but drug overdose continues to be a major cause of accidental death throughout the United States. Illicit opioids, especially synthetics like fentanyl, continue to be the primary causative agent, but stimulants like cocaine and methamphetamine are also becoming more prevalent. A first responder may encounter any number of toxic substances when they arrive on the scene of a suspected overdose, but only certain precautions ensure their safety from exposure.

In this session from PRIMA 2024, expert Pharmacist, Broker, and Risk Manager Alan Rook illustrated the typical assessment for first responders on the drug scene. From the PPE used to specific risk mitigation strategies, Alan effectively defined the potential dangers of an overdose while highlighting steps to help minimize personal risk from exposure.

Key objectives from this session include:

• A review of opioids and the opioid epidemic
• Understanding the dangers of fentanyl
• Risk assessments related to drug exposures
• Prevention strategies for first responders
• Safety procedure reviews
• Overdose treatments

What Are Opioids?

Prescription opioids are often used to treat chronic and acute pain. When used appropriately, they can be an important component of treatment, often prompting serious risks with continual use. Opioids work in the body’s nervous system to reduce the intensity of pain. Regularly prescribed following surgery or injury, opioids can be used to treat moderate-to-severe pain.

Common side effects of opioids:

• Respiratory depression
• Tolerance
• Physical dependence
• Increased sensitivity to pain
• Constipation
• Nausea, vomiting, and dry mouth
• Sleepiness
• Confusion
• Depression
• Itching
• Sweating

The Current Opioid Epidemic

The Center for Disease Control and Prevention (CDC) reports staggering statistics linked to opioid use.

• 645,000 deaths from an overdose involved opioids from 1999-2021.
• Drug overdose deaths in 2021 were six times higher than in 1999.
• Deaths caused by drug overdose increased more than 6% from 2020 to 2021.
• A total of 131,778,501 opioid prescriptions were dispensed in 2022.
• Over 75% of drug overdose deaths in 2021 were involved with an opioid.

Five Categories of Opioids

1. Natural opioids: morphine and codeine
2. Semi-synthetic opioids: oxycodone, hydrocodone, hydromorphone, oxymorphone
3. Methadone: synthetic opioids
4. Non-methadone synthetics: tramadol and fentanyl
5. Heroin: illicit (illegally made) opioid synthesized from morphine substances

The Fentanyl Crisis

Fentanyl hydrochloride was first introduced to the market in 1960. Originally synthesized by Belgian physician, Dr. Paul Janssen, this fast-acting substance was approved by the FDA to help treat pain through intramuscular injection. By the 1990s, a solid form of the drug was developed.

Fast forward to present day, this substance is rarely used as a solution. What was once a breakthrough during cancer treatment quickly became one of the most dangerous opioids. Today, fentanyl-related harm, overdose, and death in the United States are primarily linked to illegally made fentanyl.

Regularly sold through illegal drug markets, fentanyl has a reputation for its heroin-like effect. Often mixed with heroin and/or cocaine, fentanyl can influence a “euphoric effect.”

Currently, there are 42 known illicitly manufactured fentanyl analogs on the market. The drug is detected in counterfeit pills, powder, blotter paper, heroin, cocaine, crack cocaine, and crystal methamphetamine. It can be swallowed, snorted, injected, or absorbed in the mouth and skin.

Preventing First Responders to Exposure of Illicit Drugs

Responders likely encounter a mixture of illicit drugs while on the job. Common mixtures include a combination of illicit substances like cocaine, methamphetamines, cannabinoids, and cathinone, in addition to fentanyl and heroin. When a component of an illicit drug mixture is unfamiliar, emergency responders should follow safe operating procedures and use proper personal protective equipment (PPE).

Recommended protocols include:

• Wearing nitrile gloves when illicit drugs are present
• Wearing respiratory protection if powder illicit drugs are visible
• Avoiding risks related to airborne exposure of illicit drugs
• Avoiding contact of the eyes, nose, or mouth
• Hand washing with soap and water when working in contaminated areas

Potential Exposures for Emergency Responders

Illicit drugs appear in various forms. From powders to pills to liquids, emergency responders can easily come in contact with an opioid substance. Contact risks include:

• Breathing (inhalation)
• Eating (ingestion)
• Touching of the eyes, nose, or mouth with contaminated gloves or hands
• Dermal absorption (skin contact of liquid fentanyl)
• Being stuck by a needle (percutaneous)

Job Categories at Great Risk of Exposure to Illicit Drugs

Pre-Hospital Patient Care

Special Operations and Decontamination

Law Enforcement

• Investigators
• Evidence collectors
• Field officers

Conducting On-Scene Risk Assessments

First responders should receive special training in assessing risks related to drug exposure. Those on the scene should be knowledgeable in various detection protocols, including effective training procedures covering the following prompts:

• How to recognize the form of the drug and its quantity
• How to recognize situations that create risk of airborne exposure
• How to safely collect, handle, process, and store evidence that may be contaminated by illicit drugs
• How to recognize the signs and symptoms of poisoning from illicit drugs
• How to use PPE and recognizing when it is necessary
• Potential exposure routes of illicit drugs
• When and how to seek medical help

Naloxone

Today, many first responders trust the technology of Naloxone, a tool designed to provide temporary reversal of opioid overdoses, especially in emergency settings. Intended to block opioid receptors, Naloxone displaces the opioid drug and decreases the negative effects of an overdose.

One dose (a single spray or injection) should be given as soon as an overdose is observed or suspected. Emergency medical providers immediately administer the use upon request. Additional doses may be applied if the patient does not revive or relapses after the initial application.