DEPARTMENTS
LETTERS
The opinions expressed in letters to the editor are those of the authors and do not necessarily reflect the views of AIHA® or The Synergist®. Letters are published at the discretion of the editor and may be edited for clarity. Send letters to The Synergist.
Opioids Revisited
HIERARCHY OF CONTROLS I was happy to see Donna Heidel’s November 2017 cover story (“The Opioid Abuse Epidemic”). The story asked the right question—“How can our profession help?”—but came up with an incomplete answer. The article focused on the potential exposures to emergency and law enforcement dealing with opioid victims, which poses a real risk to those workers. As industrial hygienists, though, we are taught to use the hierarchy of controls to address problems.  The more fundamental questions we need to ask are “Why are so many people in so much pain that they need such potent pain killers?” and “How many of these people are in pain because of work-related injuries?” Asking these questions could lead IHs to address the root cause of this epidemic and propose solutions, such as ergonomic programs that can prevent back pain in the workplace. Scott Schneider, CIH, FAIHA Heidel responds: The hierarchy of controls is certainly applicable to analytical activities conducted on evidence by crime lab analysts. The pharmaceutical industry’s engineering controls, work practices, and PPE, as mentioned in the article, 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. Recommending exposure controls, using a hierarchical approach, for first responders requires a deeper understanding by the industrial hygiene community about the activities and work practices that can place these professions at risk for exposure. 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. Moving up the hierarchy of controls for first responders requires detailed understanding of work practices. AIHA has begun to learn more about first responders' job tasks and practices through roundtable discussions with these professionals. The larger questions about “why are so many people in so much pain that they need such potent pain killers” and “how many of these people are in pain because of work-related injuries” are being studied by the President's Commission on Combating Drug Addiction and the Opioid Crisis. AIHA has had web meetings with the Commission to learn more about how our profession can support solving this crisis. The Commission encourages members of the public wishing to submit written comments for the Commission’s consideration to do so via emailDonna Heidel, CIH, FAIHA EXPOSED POPULATIONS Recent articles in The Synergist appropriately discuss the hazards of opioids exposures to first responders, law enforcement, crime labs, and other related professionals (“The Opioid Abuse Epidemic” and “Occupational Exposures to Fentanyl,” November 2017; and “Protection in an Uncontrolled Environment,” December 2017). But the industrial hygiene profession should not lose sight of the fact that a number of other public- and private-sector workers, as well as community residents, are among the exposed populations. These individuals include inspectors whose work follows that of first responders, such as Certified Industrial Hygienists, who perform residue assessments of properties; the workers who perform site cleanup, including residences and commercial properties; and the unsuspecting residents or future tenants who occupy a home that was involved in a fentanyl law enforcement activity but was never assessed, cleaned up, or verified as “safe” for occupation. As a CIH, I perform many clandestine drug residue assessments and oversee the cleanup activities until verified through sampling after the mitigative activity is appropriately completed. What I have clearly seen is that residues from opioids (including fentanyl and carfentanil) are commonly prevalent on surfaces following significant use, handling, or illegal storage and distribution—so much so that the residences and projects that I am currently working on exhibit potentially toxic residue conditions within the premises if not identified and mitigated. The lethal dose to carfentanil (a commonly used opioid derivative) is only 20 micrograms and is similar in size to only a few grains of sand. We have commonly found these residue levels within residences where illicit opioid use and handling have been performed. Michael A. Polkabla, CIH, REA
The industrial hygiene profession should not lose sight of the fact that a number of other public- and private-sector workers, as well as community residents, are among the exposed populations.
FOCUS ON IMPAIRMENT Several recent articles in The Synergist and other health and safety publications address the hazards of opioids and the role of the industrial hygiene community in protecting first responders from occupational exposure. Donna Heidel does a very good job in offering several areas for AIHA involvement in the opioid epidemic. Below are three supplemental points. Impairment. Emphasis is currently placed on lethal doses (in the range of multiple micrograms for potent fentanyl analogs, such as carfentanil; multiple milligrams for morphine and heroin) and potential for overdose by first responders. Going forward, it may be important to place additional emphasis on concentrations, especially airborne or surface concentrations, that result in impairment of the first responder rather than a lethal overdose. Exposure at levels appreciably less than fatal doses can still result in unclear thinking, delayed response time, and increased likelihood of a trip or fall. In the case of an illicit drug operation, if those involved in the illicit operation are present, impairment is likely to increase the chance of injury or a fatality. Even when the illicit operators are not present, serious injury can result from a fall or from poor judgment handling weapons that were left behind.  A “level of concern” for the first responder should be based on impairment of capabilities. This level of concern in turn should determine appropriate levels of personal protective equipment. PPE selection should also consider recent Drug Enforcement Agency data regarding overdose deaths and analyses of opioid products in that area of the country as well as the environment of the response (for example, is the environment an enclosed space, does it require a medical response, or is it a clandestine mixing/cutting opioid operation). Carfentanil. Carfentanil has been added to some street drugs in recent years. It was first discovered in seizures of illicit drugs in Eastern Europe in 2012. By 2016, carfentanil seizures had occurred in many other countries in Europe and North America. In the United States, CDC statistics for ten states that analyze for specific fentanyl analogs show that 17.3 percent of total opioid fatalities in Ohio during the last six months of 2016 tested positive for carfentanil. In a 2012 study published in Addiction Biology of fifteen naïve (non-user) volunteers, carfentanil was administered intravenously at a mean dose of 0.049 ug/kg. Dizziness was reported in 60 percent of the volunteers. For an 80-kilogram adult, this is equivalent to an IV dose of approximately 4 micrograms carfentanil. If carfentanil is similarly potent by inhalation, many first responders may be at risk of an impaired response when carfentanil is present. This is particularly a concern when the response is in an enclosed space such as a car or illicit opioid operation and if carfentanil is present in a solid formulation such as a powder. Relapse concern. Studies show relapse rates among opioid substance abusers at approximately 90 percent after two years following inpatient treatment. Responders and healthcare professionals are not immune to opioid substance abuse. They are certainly part of the 1.9 million Americans who have substance use disorders related to prescription opioid pain medicines as reported by the National Institute on Drug Abuse in 2014. Recovering opioid abusers, as with recovering alcoholics, can show an increase in relapse rates after low levels of exposure to the substance of concern. Although there are privacy considerations, individuals with prior opioid substance abuse issues should be informed that some response work may subject them to unexpected opioid exposure that may increase the likelihood of a relapse. Peter B. Harnett, MS, MPH, CIH, CSP  Mary E. Greenhalgh, MPH, CIH
RESOURCES (provided by Peter Harnett and Mary Greenhalgh) Addiction Biology: “Differential Response to IV Carfentanil in Chronic Cocaine Users and Healthy Controls” (January 2012).  Irish Medical Journal: “Lapse and Relapse Following Inpatient Treatment of Opiate Dependence” (June 2010). Morbidity and Mortality Weekly Report: “Deaths Involving Fentanyl, Fentanyl Analogs, and U-47700 — 10 States, July–December 2016(November 2017). NIH/NIDA, “What Science Tells Us About Opioid Abuse and Addiction” (January 2016).