ACMT Position Statement on Fentanyl “Exposure” Laws

ACMT Position Statement on Fentanyl “Exposure” Laws

Download Statement

November 1, 2024

Authors: Maryann Mazer-Amirshahi PharmD, MD, MPH, PhD, FACMT; Jerrold B. Leikin MDFACOEM,FACP, FACEP, FACMT, FAACT, FASAM; Andrew Stolbach MD, MPH, FACMT

The position of the American College of Medical Toxicology (ACMT), is as follows: 

On April 8, the governor of Florida signed  SB 718, legislation resulting in a second-degree felony for any adult who recklessly exposes a first responder to [fentanyl or fentanyl analog] and an overdose or serious bodily injury of the first responder results [1].

According to the text of this law [2], “expose” means, “to cause any of the following, including, but not limited to, ingestion, inhalation, needlestick injury, or absorption through skin or mucous membranes.”

As physicians who are experts in opioid overdose, opioid pharmacology, and opioid addiction, members of the  American College of Medical Toxicology share the sentiment that the ongoing opioid epidemic, driven by fentanyl and its analogs, is a public health emergency. We also agree that the safety of first responders is of paramount importance.

However, because there is essentially no risk of illness from incidental contact with fentanyl, we believe this type of  law is unnecessary, and potentially harmful.

Fentanyl and its analogs in street formulations are not absorbed through skin and are not volatile (they do not easily enter the air) [3,4].These characteristics explain why dermal contact and ambient air exposure do not result in entrance of fentanyl into the body. The clinical findings among emergency responders who become ill after incidental fentanyl contact are not consistent with those of opioid intoxication [5]. There has not been a confirmed case of incidental opioid exposure causing illness published in the scientific or medical literature [6].

We are concerned that this type of bill perpetuates misinformation about drug exposure and harms emergency responders by suggesting the presence of a danger that does not exist [7]. Fentanyl “exposure” bills will make it more difficult for emergency responders to do their jobs without making them more safe. We are concerned that perpetuating fear about incidental opioid exposure to emergency workers may delay care for those who overdose and need rapid medical assistance. We are also concerned that someone may delay seeking emergency care for a friend or family member out of misplaced fear of endangering an emergency responder. When someone experiences an opioid overdose and they are not breathing, every moment counts. A delay in treatment based on unjustified fears could result in severe medical outcomes such as permanent disability or death.

We wish to re-emphasize The American College of Medical Toxicology and American Academy of Clinical Toxicology recommendations in preventing occupational exposures of fentanyl and its analogues to first responders [3].

General Precautions and Management of Exposure 

● Workers who may encounter fentanyl or fentanyl analogs should be trained to recognize the symptoms and objective signs of opioid intoxication, have naloxone readily available, and be trained to administer naloxone. 

● For opioid intoxication to occur the drug must enter the blood and brain from the environment. Intoxication cannot occur from simply being in proximity to the drug. 

● Toxicity may occur in canines utilized to detect drugs. The risks are not equivalent to those in humans given the direct contact that dogs, and not humans, have with the local environment during a drug search. 

Dermal Precautions 

● For routine handling of these drugs, nitrile gloves provide sufficient protection.

●After incidental dermal exposure, the skin should immediately be washed with water, preferably with soap.

Mucous Membrane/Splash Exposure 

● Protection for eyes and face should be used during tasks where there exists the possibility of splash of liquid or powder to the face. 

● Avoid touching your mouth or nose with unwashed hands

Naloxone Administration and Airway Management 

● Naloxone should be administered to those with objective signs of hypoventilation from opioid intoxication. 

● If hypoventilation persists following the initial naloxone dose and personnel with advanced airway training are not available, repeat naloxone until reversal is seen or 10 mg is administered. Do not administer additional naloxone for failure to awaken, only for failure to breathe.

● Personnel with advanced airway training should provide airway support for patients who are in extremis or those who do not improve with naloxone. 

Long-term Sequelae of Exposure 

● In the absence of prolonged hypoxia, no persistent effects are expected following occupational fentanyl or fentanyl analog exposures. Those with small subclinical exposures will not experience long-term effects.

Furthermore, we recommend institution of an online training intervention for correcting false beliefs about the risk of fentanyl overdose under circumstances commonly encountered by first responders so that first responders not only feel safe, but to avoid treatment delays in the patients they serve .

Disclaimer

While individual practices may differ, this is the position of the American College of Medical Toxicology at the time written, after a review of the issue and pertinent literature. 

References

  1.  Florida Senate. (2024). Senate Bill 718: Exposures of First Responders to Fentanyl and Fentanyl Analogs. Retrieved from https://m.flsenate.gov/Bill/718/2024
  2. Florida Senate. (2024). Bill text: CS/CS/CS/SB 718. Retrieved from https://flsenate.gov/Session/Bill/2024/718/BillText/Filed/PDF
  3. Moss MJ, Warrick BJ, Nelson LS, McKay CA, Dubé PA, Gosselin S, Palmer RB, Stolbach AI. ACMT and AACT Position Statement: Preventing Occupational Fentanyl and Fentanyl Analog Exposure to Emergency Responders. J Med Toxicol. 2017 Dec;13(4):347-351. doi: 10.1007/s13181-017-0628-2. Epub 2017 Aug 25. PMID: 28842825; PMCID: PMC5711758.
  4. Poklis A. Fentanyl: a review for clinical and analytical toxicologists. J Toxicol Clin Toxicol. 1995;33(5):439-47. doi: 10.3109/15563659509013752. PMID: 7650768.
  5. Chiu SK, Hornsby-Myers JL, de Perio MA, Snawder JE, Wiegand DM, Trout D, Howard J. Health effects from unintentional occupational exposure to opioids among law enforcement officers: Two case investigations. Am J Ind Med. 2019 May;62(5):439-447. doi: 10.1002/ajim.22967. Epub 2019 Apr 23. PMID: 31016761; PMCID: PMC8905550.
  6. Herman PA, Brenner DS, Dandorf S, Kemp S, Kroll B, Trebach J, Hsieh YH, Stolbach AI. Media Reports of Unintentional Opioid Exposure of Public Safety First Responders in North America. J Med Toxicol. 2020 Apr;16(2):112-115. doi: 10.1007/s13181-020-00762-y. Epub 2020 Feb 24. PMID: 32096007; PMCID: PMC7099103.
  7. Del Pozo B, Rich JD, Carroll JJ. Reports of accidental fentanyl overdose among police in the field: Toward correcting a harmful culture-bound syndrome. Int J Drug Policy. 2022 Feb;100:103520. doi: 10.1016/j.drugpo.2021.103520. Epub 2021 Nov 14. PMID: 34785420; PMCID: PMC8810663.