Throughout AIHA’s history, the organization has risen to meet the needs of workers at risk. We are now called to respond to one of our greatest public health challenges: the opioid abuse epidemic.
The President’s Commission on Combating Drug Addiction and the Opioid Crisis has identified the need to act boldly to stop the opioid epidemic, as opioids are a prime contributor to the nation’s drug addiction and overdose crisis. The Centers for Disease Control and Prevention estimates that 142 Americans die every day from a drug overdose; in 2015, nearly two-thirds of drug overdoses were linked to opioids. Yes, opioid addiction is causing an unprecedented public health crisis that requires the collaboration and action of our leading national organizations dedicated to countering addiction; however, are there contributions that can be made by the industrial hygiene community? Are we considering the potential for our nation’s first responders—including law enforcement, emergency medical technicians, and crime lab analysts—to be exposed to opioids and potent synthetic analogues while on the job? HAZARDS OF OPIOIDS As a class of drugs, opioids are substances that produce morphinelike effects and are used medically to relieve pain. Opioids also produce euphoric effects. Opioids include opiates, an older term that refers to drugs derived from opium, including morphine. Other opioids are semisynthetic and synthetic drugs such as hydrocodone, oxycodone, and fentanyl. Fentanyl is 50 to 100 times more potent than morphine and hundreds of times more potent than heroin. Fentanyl is administered therapeutically by IV, by injection into the muscles, as a skin patch, as a solution that is sprayed under the tongue, and even as lollipops for children who are experiencing severe pain.
Illicit drugs such as cocaine, heroin, and methamphetamine are now adulterated with synthetic opioids, including fentanyl and fentanyl analogues. Illegal use of fentanyl includes swallowing, snorting, smoking, or injection. The human fatal dose of fentanyl is estimated at 2 to 3 milligrams—the equivalent of several grains of salt. Carfentanil, a fentanyl analogue used in large-animal veterinary medicine, has been discovered throughout the United States in the heroin supply, either alone or mixed with heroin or other fentanyl analogues. The potency of carfentanil is roughly 10,000 times greater than that of morphine and 100 times greater than that of fentanyl.
Fentanyl analogues were identified in illicit drugs as early as 1976, when α-methylfentanyl was mixed with China white heroin. Another illicit fentanyl analogue, 3-methylfentanyl, is 10 to 15 times more potent than fentanyl due to its increased binding affinity. OCCUPATIONAL EXPOSURES How does this information relate to the potential for occupational exposure? The web page on fentanyl in the NIOSH Emergency Response Safety and Health Database states, “Fentanyl can be absorbed into the body via inhalation, oral exposure or ingestion, or skin contact.” Therefore, the routes of occupational exposure include inhalation, through the mucous membranes of the nose and mouth, through contact with the eyes and skin, and via accidental ingestion, from hand-to-mouth contact or eating and drinking from objects contaminated with opioids.
The human fatal dose of fentanyl is estimated at 2 to 3 milligrams—the equivalent of several grains of salt.

AIHA Urges White House Commission to Protect Workers from Opioids Exposure In comments submitted Sept. 20 to the President’s Commission on Combating Drug Addiction and the Opioid Crisis, AIHA encouraged the commission to identify all workers, including volunteers, who may be exposed and the specific activities that place them at risk for exposure. Read AIHA's letter (PDF).
Police officers and EMTs may not routinely don personal protective equipment before entering environments for medical emergencies. Without PPE, they can be exposed to opioids when responding to requests for overdose-related emergency medical treatment. Police officers are also at risk for exposure when confiscating and processing evidence believed to contain illicit drugs or when investigating clandestine drug laboratories. The evidence is tested in crime laboratories, although testing is sometimes also conducted in the field by trained officers. Aviation safety inspectors, transportation safety inspectors, and postal inspectors may also be at risk for exposure when inspecting or handling packages of illicit drugs. Signs and symptoms of exposure include pinpoint pupils that may later become dilated; reduced level of consciousness; slow, shallow breathing; cessation of breathing; rigidity of the chest muscles, also called “wooden chest syndrome”; coma; and death.
Exposure events have occurred to law enforcement officers while executing search warrants, during traffic stops, and while conducting field testing. Emergency responders have required medical treatment following exposure to carfentanil, believed to be from contact with the interior of a vehicle and the arm of someone inside the vehicle who required emergency care. Reports of exposures to emergency room personnel that are believed to have occurred when handling clothing contaminated with opioid powders add to the growing list of occupations potentially at risk. These officers and health care professionals were successfully treated with Narcan (naloxone) nasal spray, the narcotic agonist used for emergency treatment of a known or suspected opioid overdose; however, we must do more to prevent these exposure events in the first place. LESSONS FROM PHARMA What can we learn from the pharmaceutical industry about controlling worker exposure to these potent opioids? Neither OSHA nor ACGIH has established occupational exposure limits for synthetic opioids; however, the pharmaceutical industry has established internal OELs for opiates, including synthetic opioids. NIOSH, on its web page devoted to fentanyl, lists the occupational exposure guideline adopted by Mallinckrodt Inc.: 0.7 µg/m3 as an eight-hour time-weighted average, and 2 µg/m3 as a 15-minute average. Validated sampling and analytical methods have been developed to measure exposures and to sample surface contamination.
It may not be reasonable, however, to expect that we can reliably quantify exposures for each task that places first responders at risk, since their job responsibilities are highly variable. It may be more reasonable, and more protective, to develop specific task-based exposure controls for first responders that are implemented whenever exposures are possible. This will require, however, that first responders are provided with PPE and Narcan; are trained in the hazards of synthetic opioids, the routes of occupational exposure, the signs and symptoms of an occupational exposure event, and the treatment methods; possess the skills to assess their risk of exposure and determine the level of PPE that should be worn; and know how to properly don, doff, and dispose of PPE.
Comparisons can be made between the analytical activities conducted in crime labs and similar activities in pharmaceutical quality-control laboratories, including storing, sampling, weighing, vortexing, and analyzing of opioids as well as routine cleaning and spill response. The pharmaceutical industry’s engineering controls, work practices, and PPE can serve as best practices for handling synthetic opioids in crime lab settings. In crime labs, quantitative exposure assessment, including surface sampling and comparison with the OELs established by the pharmaceutical industry, will support the verification and refinement of current controls that are used to protect these workers.
However, there are significant differences between confiscated evidence in crime labs and active pharmaceutical ingredients (such as fentanyl), and dosage forms in quality-control labs. Confiscated evidence in crime labs includes powders that are compressed into large “bricks,” compressed tablets (“pills”) meant to look like prescription tablets, liquids, gels, tars, crystals, and objects, such as syringes and pipes. Evidence can be large, unusually shaped, and packed into objects or other liquids to camouflage it from inspectors and sniffer dogs. Crime lab analysts must be prepared to handle these diverse forms of evidence and must often rely on their experience to determine their potential for exposure and adjust their work practices or PPE. In addition, the engineering and work practice controls that crime labs have successfully implemented for evidence not adulterated by synthetic opioids may no longer provide adequate containment and exposure control. By contrast, in a pharmaceutical quality-control lab, materials for testing are typically contained within small, sealed containers or finished dosage forms, such as syringes, vials, or compressed tablets. The high containment engineering controls and work practices required for controlling analysts’ exposure in pharmaceutical quality-control labs to synthetic opioids and other highly potent prescription drug agents have been rigorously tested and widely adopted.
Still, crime labs should consider some of the control approaches implemented by the pharmaceutical industry. For example, the pharmaceutical industry recognizes that standard laboratory fume hoods do not effectively control exposure to finely divided powders and other aerosols to the level required for synthetic opioids. The industry has adopted ventilated balance enclosures, biological safety cabinets, and glove box isolators to supplement laboratory fume hoods. These types of control devices, when used with well-defined work practices, permit analytical scale weighing activities that are traditionally performed on benchtops in crime labs. With a fatal dose of 2 to 3 milligrams and a 15-minute time-weighted exposure guide of 2 µg/m3, even careful weighing of milligram amounts requires rigorous exposure controls. The pharmaceutical industry tests the occupational containment of these control devices using air and surface sampling, in accordance with an industry standard, to ensure that, as used, workers are protected. In addition, the pharmaceutical industry’s methods for defining work practices; selecting, donning and doffing PPE; cleaning and decontaminating work surfaces and equipment; and responding to spills can serve as best practices for crime labs.
The Drug Enforcement Administration has published “Fentanyl—A Briefing Guide for First Responders,” which contains recommendations on best practices for first responders who may encounter, test, and transport exhibits that could contain fentanyl-related substances. The DEA does state, however, that the briefing guide provides interim guidance intended for educational and awareness purposes only, and should not to be treated as technical guidance. The guide stresses the importance of personal protective equipment and clothing, citing “A,” “B,” and “C” levels of protection, for responding to incidents and emergencies and for collecting and packaging evidence. Specific criteria and the associated procedures have not yet been developed. For example, even doffing PPE that has been worn to protect the wearer from highly toxic powders requires training and practice. PRIORITIES FOR WORKER PROTECTION AIHA believes that our members have the skills to recommend the specific task-based exposure controls that are needed.
AIHA’s approach to addressing the urgent needs for law enforcement, first responders, and crime lab analysts falls into four broad categories:
  1. Identification of the activities that can place these occupations at risk for exposure via inhalation, skin contact or accidental ingestion. For example, a detailed understanding of how law enforcement and EMTs respond to opioid-related medical emergencies; how evidence is collected, tested, and packaged in the field; how evidence is processed and transported; and how these activities currently vary among professions needs to be identified.
  2. Identification of the engineering controls, work practices, and PPE (gloves, protective clothing, and respiratory protection) that have been successfully adopted by the pharmaceutical and health care industries when handling opioids. Transferring knowledge from the professions and industries that have successfully handled synthetic opioids will significantly accelerate our ability to protect law enforcement, first responders, and crime lab analysts.
  3. Development of specific guidance and training to control opioid and opioid analogue exposure risks to these occupations during the performance of their responsibilities. This can include one-page brochures, wallet cards, and brief videos of training and demonstrations that can be shared via social media.
  4. Broad dissemination of the training and guidance, supported by AIHA members.

So, yes, there is an important role for AIHA in supporting our nation’s bold steps to curb the drug addiction and overdose crisis. The contributions we will make may save the lives of those on the front lines. DONNA S. HEIDEL, CIH, FAIHA, is industrial hygiene practice leader at Bureau Veritas North America Inc. and treasurer-elect of the AIHA Board of Directors. She can be reached via email.
RESOURCES Drug Enforcement Administration: Fentanyl—A Briefing Guide for First Responders (PDF, 2017).

How Can Our Profession Help?
BY DONNA S. HEIDEL
The Opioid Abuse
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Although the print version of The Synergist indicated The IAQ Investigator's Guide, 3rd edition, was already published, it isn't quite ready yet. We will be sure to let readers know when the Guide is available for purchase in the AIHA Marketplace.
 
My apologies for the error.
 
- Ed Rutkowski, Synergist editor
Disadvantages of being unacclimatized:
  • Readily show signs of heat stress when exposed to hot environments.
  • Difficulty replacing all of the water lost in sweat.
  • Failure to replace the water lost will slow or prevent acclimatization.
Benefits of acclimatization:
  • Increased sweating efficiency (earlier onset of sweating, greater sweat production, and reduced electrolyte loss in sweat).
  • Stabilization of the circulation.
  • Work is performed with lower core temperature and heart rate.
  • Increased skin blood flow at a given core temperature.
Acclimatization plan:
  • Gradually increase exposure time in hot environmental conditions over a period of 7 to 14 days.
  • For new workers, the schedule should be no more than 20% of the usual duration of work in the hot environment on day 1 and a no more than 20% increase on each additional day.
  • For workers who have had previous experience with the job, the acclimatization regimen should be no more than 50% of the usual duration of work in the hot environment on day 1, 60% on day 2, 80% on day 3, and 100% on day 4.
  • The time required for non–physically fit individuals to develop acclimatization is about 50% greater than for the physically fit.
Level of acclimatization:
  • Relative to the initial level of physical fitness and the total heat stress experienced by the individual.
Maintaining acclimatization:
  • Can be maintained for a few days of non-heat exposure.
  • Absence from work in the heat for a week or more results in a significant loss in the beneficial adaptations leading to an increase likelihood of acute dehydration, illness, or fatigue.
  • Can be regained in 2 to 3 days upon return to a hot job.
  • Appears to be better maintained by those who are physically fit.
  • Seasonal shifts in temperatures may result in difficulties.
  • Working in hot, humid environments provides adaptive benefits that also apply in hot, desert environments, and vice versa.
  • Air conditioning will not affect acclimatization.
Acclimatization in Workers