The workers at risk of exposure to opioids include emergency medical services personnel, law enforcement officers and detectives, firefighters, and hazardous materials responders. These emergency responders are especially at risk of exposure to the more potent and lethal synthetic opioids, such as fentanyl and its derivatives. The keys to protecting these workers are to anticipate exposures, recognize and evaluate risks early on, provide adequate personal protective equipment, and have well-established hygiene and control procedures that trained workers can implement. The level of control and PPE depend on the route of exposure (for example, inhalation versus dermal contact) and the amount of exposure. Having an antidote, such as naloxone, readily available is also essential in the event of a significant exposure. THE SYNTHETIC OPIOID CRISIS Opioids are an important class of drugs prescribed to patients to help manage chronic pain due to surgery, cancer treatment, and many other medical conditions. When legally prescribed and taken as directed, opioids are very effective at pain management. Unfortunately, they are highly addictive and subject to abuse; consequently, the U.S. Drug Enforcement Agency (DEA) regulates many opioids as Schedule II Controlled Substances. Abuse of or overexposure to these drugs can cause respiratory arrest and death.
In the last several years, one synthetic opioid, fentanyl, has received a tremendous amount of attention in the media. Illicit use of fentanyl and several of its derivatives is increasing; according to the Centers for Disease Control and Prevention, there was a six-fold increase in the total number of deaths due to overdoses from 2001 to 2014, and overdose deaths involving synthetic opioids, including fentanyl, increased by 80 percent from 2013 to 2014.
Fentanyl is approximately 100 times more potent than morphine and 50 times more potent than heroin. (Morphine and heroin are naturally occurring opioids.) As little as 2–3 mg of fentanyl has been known to be lethal. Carfentanil, a synthetic opioid whose chemical structure is similar to fentanyl’s, is up to 10,000 times more potent than morphine. Drug dealers sometimes lace heroin and other drugs with these cheap synthetic opioids, subjecting unsuspecting addicts to overdoses. Respiratory arrest or apnea (cessation of breathing) is the primary health effect associated with overdose fatalities.
An unfortunate consequence is the exposure risk these extremely hazardous synthetic opioids pose to law enforcement and first responders, as well as prison and emergency medical personnel who may have to deal with what is now a public health epidemic. ANTICIPATING EXPOSURES TO EMERGENCY RESPONDERS Synthetic opioids come in a variety of physical forms, including pills, powders, liquids, nasal sprays, dermal patches, and on blotter paper. Different levels of risk are associated with the route of exposure and amount. For example, powders are a concern, because they can easily become aerosolized and inhaled, especially when opening a container to check its contents. The particle size of synthetic opioid powders typically ranges from 0.2 to 2 µm, and the powders are easily aerosolized. Liquids can also be of concern due to the potential for absorption via the skin, eyes, and mucous membranes, or vaporization upon heating, such as in a fire.
Common exposure scenarios for emergency responders include the following:
Contact with drug users. Law enforcement officers and EMS personnel can be exposed to drug users carrying small amounts of synthetic opioids. Exposure can occur when responding to a drug overdose or death, or when searching a suspect. The product may not be readily visible under these circumstances, but the risk of exposure is typically lower when the drug is contained and in smaller amounts.
Collection of evidence and on-site testing. Exposures can also occur when officers or agents collect suspected opioids as evidence or test them on site (for example, using colorimetric indicators). The practice of opening containers or baggies is likely to release the powder into the air. Many law enforcement agencies now have policies that discourage this practice in an uncontrolled environment.
Distribution and production. Drug raids and investigations of locations used to produce or distribute opioids are more likely to result in higher exposures, as larger amounts of powders and liquids can be present. According to a May 15, 2017 report in The Atlantic, flashbang grenades—nonlethal weapons intended to stun adversaries—can aerosolize large amounts of liquid or powder opioids, which has resulted in significant exposures and observed adverse health effects in law enforcement personnel.
Fires. Structural fires pose an additional risk, on top of the common thermal and physical hazards. Both inhalation and dermal contact with opioids may exist depending on the nature of the fire and firefighting activities. Synthetic opioids are water-soluble and thus pose less of a hazard if saturated with copious amounts of water. However, dermal contact with heavily contaminated water could pose a hazard for dermal absorption.
Editor’s note: The cover article of our November issue by Donna S. Heidel presented an overview of the opioid abuse epidemic and the ways industrial hygienists and other OEHS professionals can respond to this public health crisis. For this month’s special issue on emergency response, Mark Tartaglia and Robert N. Phalen examine occupational exposures to opioids and discuss controls, including personal protective equipment.
Photo: Fentanyl response team, hazmat cleanup. Courtesy U.S. Drug Enforcement Agency.
Fentanyl exhibits a 30-fold greater absorption rate across mucous membranes when compared to intact skin.
Photo courtesy DuPont.
RECOGNIZING AND EVALUATING RISK 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. INDICATORS OF EXPOSURE 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. LEVELS OF RISK 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. EXPOSURE CONTROLS 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

PERSONAL PROTECTIVE EQUIPMENT
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.
Respiratory protection. 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.
Eye and mucus membrane protection. 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.
Dermal protection. 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. PROTECTION IN AN UNCONTROLLED ENVIRONMENT 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. MARK TARTAGLIA, MSPH, CIH, is the senior CIH consultant supporting the DuPont Protection Solutions business. He can be reached at (240) 401-5465 or via email. ROBERT N. PHALEN, PHD, CIH, is an associate professor of Industrial Hygiene at University of Houston-Clear Lake in Houston, Texas. He can be reached at (281) 283-3753 or via email.
RESOURCES American College of Medical Toxicology: “ACMT and AACT Position Statement: Preventing Occupational Fentanyl and Fentanyl Analog Exposure to Emergency Responders” (PDF, July 2017).
U.S. Drug Enforcement Agency: “Fentanyl: A Briefing Guide for First Responders” (PDF, June 2017).

Emergency Responders and Opioids Exposures
BY MARK TARTAGLIA AND ROBERT N. PHALEN
Protection in an
Uncontrolled
Environment
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