Recognition of an exposure hazard is vital to protecting emergency response personnel. General safety precautions, such as use of disposable gloves and a uniform that covers the skin, may afford protection against incidental contact, but these will not be effective against larger exposures.

Law enforcement and other public safety workers may have to contend with a variety of potential exposure scenarios that present varying levels of risk to responders. Those with high potential exposures include special operation squads raiding active clandestine labs and “pill mills,” or investigative personnel collecting evidence. Moderate risk may be associated with routine law enforcement or emergency medical actions where visible suspect powder material is present. Low risk may be related to law enforcement or medical response scenarios where illicit drug activity is suspected but no visible powders are present.

Fentanyl and its derivatives, as well as laced illicit drugs, typically are encountered in powder form, which presents both inhalation and dermal exposure risks. Due to the high bioavailability of these opioid particles, the greatest exposure risk is attributable to inhalation or mucous membrane exposures. Fentanyl, for example, exhibits a 30-fold greater absorption rate across mucous membranes when compared to intact skin. Despite this, dermal contact poses a serious secondary exposure risk that must be protected against, especially if the skin is moist.

For these reasons, emergency response personnel must be trained to anticipate and recognize situations where an exposure to opioids may exist and then assess the level of associated risk. Several guidelines have been developed to aid in the recognition, assessment and control of fentanyl and other synthetic opioid exposures. These include the resources listed below from the American College of Medical Toxicology and American Academy of Clinical Toxicology, the InterAgency Board for Equipment Standardization and Interoperability, NIOSH, and the U.S. Drug Enforcement Administration. Each guideline provides a slightly different approach on how to assess the level of risk and control exposures, but the basic approach and controls are all similar. The first step to recognizing a hazard is to establish clear indicators that emergency response personnel can use in the field. The primary indicator of an opioid overdose is respiratory depression or arrest. The more objective signs of an overdose include slowed breathing (hypoventilation), cessation of breathing (apnea), lack of oxygen (hypoxia) with cyanosis (blue discoloration) of the lips and skin, and possibly a depressed level of consciousness. Secondary signs, such as pinpoint pupils, clammy skin, and drowsiness, may also be associated with opioid use or overdose. More generalized signs of dizziness, nausea, or anxiety are not reliable indicators of an overdose.

The presence of drug paraphernalia and powders in the vicinity can also lead to an assumption of possible illicit drug use. Distribution and production facilities are likely to have chemical synthesis equipment, weighing scales, pill presses, and packaging materials present, along with larger amounts of powders and liquids. Since the advent of the opioid crisis, several groups have developed guidelines to assist with performing related risk assessments and identifying appropriate exposure controls to protect workers, including the use of PPE. Both NIOSH and the InterAgency Board for Equipment Standardization and Interoperability have established risk levels based on the exposure scenario and the level of exposure. These risk levels are then used to recommend effective PPE and controls.

The IAB has published recommendations for selecting and using PPE to protect emergency responders potentially exposed to fentanyl and other synthetic opioids. IAB’s guidelines expand the levels of exposure risk to include:

• high (chemicals, production lab)
  
• minimal
  
• moderate (small volume)
  
• moderate (large volume)
  
• high (particulates, milling operations)
  

A matrix establishes levels of PPE based on exposure risk and any of six operational response functions from EMS patient care to decontamination operations. Subsequently, a table defines the skin, eye, face, and respiratory protection associated with each PPE risk level.

As an example, evidence collection at a production facility would warrant a level IV, high risk and high-volume PPE hazard, requiring nitrile gloves, a uniform, sleeve covers, chemical goggles, and a NIOSH-approved P100 respirator. In contrast, an EMS technician responding to a drug overdose with no visible opioid present would fall under a level I, low risk PPE hazard, requiring only nitrile gloves and a uniform.

In a similar manner, NIOSH recommends PPE protection under four job classifications (pre-hospital patient care, law enforcement regular duties, investigations and evidence collection, and special operations and decontamination) and three exposure levels (minimal, moderate, and high). A law enforcement officer searching a suspect with no indication of drug use or presence (minimal exposure risk) would wear nitrile gloves for protection. In contrast, a crime scene investigator at a site with small amounts of visible opioids (moderate exposure risk) would use thicker nitrile gloves, wrist and arm protection (protective sleeves), goggles, and a NIOSH-approved P100 respirator or equivalent. The levels of protection for each scenario are similar to those recommended by the IAB. Minimizing exposures in emergency responders requires a focused and structured effort that aims to prepare personnel to anticipate, recognize, and assess risks, and equips them with the tools and procedures to protect themselves. This approach involves:

• training responders on the proper care, use, decontamination and storage of PPE
  
• training responders to recognize and assess hazardous scenarios
  
• providing levels of PPE protection for the anticipated levels of exposure
  
• training responders to select appropriate levels of PPE
  
• training responders on the proper donning and doffing of PPE to control exposures
  
• establishing standard operating procedures for exposure control and chemical hygiene
• training responders to recognize the signs and symptoms of opioid intoxication
• training responders on how to wash opioids from the skin, eyes, nose, and mouth
  
• providing naloxone injectors to reverse the lethal effects of opioids
  
• training responders on the administration of naloxone to affected patients or responders

Since many of the exposure scenarios are uncontrolled situations, it is often difficult to use engineering controls, such as ventilation to capture aerosolized powders. Consequently, protecting responders depends heavily on PPE.

For moderate exposure risks, a NIOSH-approved N95 or P100 respirator is typically recommended. Higher levels of respiratory protection, such as a powered-air purifying respirator (PAPR) or self-contained breathing apparatus (SCBA), may be warranted under more severe exposure conditions.

Both eye and face protection are recommended when the possibility of facial contact exists. This is because fentanyl and related opioids cross mucous membranes at a higher rate than through the skin. Similar to inhalation, exposure through the eyes, nose, or mouth could lead to more acute and severe toxicity.

Uniforms and disposable nitrile gloves have been shown to provide adequate dermal protection against incidental exposures. Larger exposures may require double gloving or use of thicker nitrile gloves, as well as a water-resistant coverall or encapsulated suit.

It must be noted that incidental dermal exposures need to be immediately washed away with copious amounts of water, plus a mild soap or detergent, if available. Alcohol-based hand sanitizers and hypochlorite bleach solutions should be avoided, as they may not effectively dissolve or remove opioids from the skin. Alcohol-based products may increase dermal absorption. Synthetic opioids, such as fentanyl, pose a significant hazard to emergency responders. This is further complicated by the fact that emergency responders work in an uncontrolled environment. The keys to protecting these workers are to anticipate exposures, recognize and evaluate risks early on, provide adequate PPE, and have well-established hygiene and control procedures that trained workers can implement.