In 2021, more than 107,000 Americans died as the result of a drug overdose, up 15 percent from 2020.
Of those, more than 71,000 were related to the synthetic opioid fentanyl. That’s nearly 200 each day. In the time it takes you to read this blog, another person will die. In fact, fentanyl is now the leading cause of death for Americans aged 18-45, surpassing homicide, car accidents, and disease.
To support first responders in addressing this crisis, industry experts Caleb Holt, product development center manager, Texas A&M Engineering Extension Service; Dr. Christina Baxter, owner, Emergency Response TIPS; Jason Tracy, program manager, DetectAChem; Evan Durnal, program manager, MRIGlobal; Michael Cashman, senior law enforcement instructor, Network Environmental Services; and, Paul Siebert, program director, Texas A&M Engineering Extension Service, partnered for a discussion regarding this emerging and pressing threat. This conversation was recorded and shared as a series of four podcasts called “Let’s Talk Fentanyl” and can be found at MRIGlobal.org, with the key takeaways summarized below.
What is Fentanyl and How Did We Get Here?
In the late 1990s and for the next 15 years, pain clinics across the country served as distributors for opioids, with oxycontin being among the most popular. A significant increase in the number of overdose deaths attributed to this drug followed, resulting in a crackdown on manufacturers, these distributors, and users. Crack and heroin quickly filled some of this void, but also left users – and illicit manufacturers – looking for a powerful and profitable alternative. Enter fentanyl.
Fentanyl is a synthetic opioid, which targets the opioid receptors in the brain, reducing pain and elevating pleasure and relaxation. There are approximately 1,400 known fentanyl analogs, 500 of which are of interest to today’s market, and 30-40 of which are the most common. Based on the precursors used to make them, each has a different toxicity, with some being much more potent than others. Unfortunately, because of its powerful opioid properties, both pharmaceutically and illicitly manufactured fentanyl can be diverted for abuse.
When pharmaceutically manufactured fentanyl is used as prescribed, it can be a fast-acting opioid that has been described as a “wonder drug” by some. It can be beneficial for patients in addressing pain or those who are terminally ill, providing quick pain relief. This includes cancer patients, anyone recovering from surgery, moms recovering from childbirth, and athletes with a lingering sports injury. It is these same populations of non-traditional drug users who become addicted. In fact, many first encounters with fentanyl are when it’s prescribed for a medical issue. Between three and 10 percent of people become addicted after their first use. Every time they refill a prescription, users are significantly more likely to become addicted, especially for those dealing with significant pain.
For illicit manufacturers, fentanyl offers numerous benefits. Foremost, it can be produced much more inexpensively than many illicit drugs. At approximately 1/25th the cost of heroin, but with a similar or greater high for users, it can deliver a much greater return on their investment. Additionally, because fentanyl is synthetically produced, its production timeline is not as lengthy as a drug like heroin, which is dependent on the cultivation and processing of poppies.
For users, fentanyl doesn’t have the same stigma associated with it as a drug like heroin. Because it can be prescribed by a doctor, continued use is often perceived as nothing more than a prescription refill, even if secured illicitly. It is also less expensive than many other drugs, while still offering the high sought by users. As a result, when fentanyl first became popular in the early 2010’s, it displaced a significant portion of the heroin market. It is also sometimes used to cut various drugs and increase its potency, reduce its cost, or be disguised as a highly potent version of that drug. Unfortunately, it is also much more toxic. An overdose death can occur when users believe they are purchasing an illicit drug or a counterfeit prescription drug and don’t know it has been cut with fentanyl.
Fentanyl is so deadly because of its toxicity. When assessing the toxicity of various drugs, oral morphine is used as the baseline because it has been studied extensively. Tylenol is 1/360th as toxic; Advil is 1/222nd as toxic; heroin is 4-5 times more toxic; fentanyl is 50-100 times more toxic. The large animal tranquilizer carfentanil (used for elephants, horses, and others), which is the most potent known fentanyl analog, is 10,000-100,000 times more toxic. Unfortunately, it too is used by people, often with deadly results.
Street or slang names for fentanyl include Apace, China Girl, China Town, China White, Dance Fever, Goodfellas, Great Bear, He-Man, Murder 8, Poison, Tango & Cash, and Chinese Food.
How is Fentanyl Consumed?
Clandestinely produced fentanyl is primarily manufactured in Mexico, India, or China and then imported to its country of use for further processing. In North America, it is often cut with baby formula and then pilled or further processed for consumption. This processing can result in a highly inconsistent product, as the amount of fentanyl in each dose can vary widely and pose a significant danger to users.
While pills or intravenous needle injections are most common, consumption methods can now include blotter paper (like LSD), eye drops, and nasal spray. Fentanyl is also known to have been produced to look like aspirin or even Pez candies. When injected, the user’s high is almost immediate. If inhaled, it may take 2-3 minutes. Following consumption, a pill can take an hour or more for the user to feel results. These are all particularly dangerous not only for how inconsistent and toxic they can be, but also because they may not be recognized as such.
When in powdered form, fentanyl poses the greatest threat to first responders. It can easily become aerosolized and then ingested through contact with the eye or nasal membrane, resulting in similar effects to those a user might experience.
What Are On Scene Risks and Best Practices?
EMS, fire, and police are usually the first to arrive on scene following an emergency call, often walking into a situation with any number of unknowns. When doing so, the first of these responders should assess the situation for anything that may put them at risk, then promptly communicate and address those issues. A variety of detection equipment is on the market and useful in these cases, with research available to help inform your department’s understanding of its options.
With fentanyl specifically, a scene with needles or pills is often okay to work, as those are contained. Powdered product at the scene presents an elevated set of risks. Powdered fentanyl resembles baby powder or powdered sugar. Even if the product is not obvious, responders should also look for blenders, bulk baby formula (and no babies), and baggies, all of which could be an indication of a production facility and the presence of powdered fentanyl.
Having powdered fentanyl on site also prompts additional risks due to objects that would normally be considered harmless like the air conditioner, a ceiling fan, cross ventilation due to open doors, or even product being flushed down the toilet. Each can aerosolize fentanyl and create a hazard for first responders.
If it is believed that powdered fentanyl may be involved, first responders should do their best to leave the room or building where it may be and alert the proper expertise from their department or otherwise. Often, fire and police departments have the equipment and capability to deal with the identification and processing of such hazards.
A color-coded stop chart can be useful in assessing a scene and providing helpful reminders about PPE and best practices.
- Green is often a case of an overdose with a needle or pills, both of which are contained. In these cases, first responders should wear their gloves and standard gear, including at least an N95 face mask. In all situations involving fentanyl, it’s important for first responders to wear glasses so they don’t inadvertently get product in their eyes.
- Yellow is a case with a large amount of material that is contained. This situation should prompt engagement with additional expertise, who should be wearing long sleeves and a full-face respirator like a P100, which must be fit tested. Everyone on site should shower after leaving the scene.
- Red is a situation where milling and pilling production is taking place on site, so exposure is a more significant risk. In addition to the steps described above, expert responders should also wear a self-contained breathing apparatus (SCBA) and particulate tight gear.
If it is critical that an individual needs care and exposure to fentanyl is a risk, first responders should either gently cover the product or spray it with a water mist, limiting its ability to become aerosolized. They should then relocate the person from the area, providing care away from where the drug could become disturbed.
If the patient has powdered product on them, approach and treat from the head down to avoid the shirt area, where the powder likely is. The shirt and other clothing should be cut away to help reduce exposure, rather than pulled off the person.
While meth users will be alert and their eyes wide open, indications of fentanyl use can include pinpoint pupils, difficulty breathing (10-12 breaths/minute), or they can’t be awoken from a deep sleep. By being aware of these characteristics, responders can offer appropriate treatment.
Should a first responder get fentanyl on their skin, soap and water is the best solution. Other options like bleach or hand sanitizer can actually increase absorption of the product into the skin.
What Are We Looking At?
When seeing a quantity of fentanyl on scene, it can be difficult to know how much is there. Before collection by the proper experts, you can approximate an estimate:
- Kilogram – the size of a brick
- Gram – a packet of salt
- Milligram – two grains and is enough to kill you if exposed
- Microgram – if you were to pour salt into your hand rub it off, it still leaves a film, though you can’t see it – this is a microgram. Two micrograms are enough to feel the effects of an opioid.
- Nanogram – use a paper towel to then clean your hand. Though you can’t see the film, if you were to lick your hand, you can still taste the salt – this is a nanogram. While you won’t feel the effects of an opioid exposure at this level, it can be detected in your bloodstream.
Because fentanyl exposure can be harmful, it’s critical to follow a few simple steps to ensure your safety while on scene. In the past, sampling for marijuana, cocaine, and other drugs involved opening a baggie or stabbing a bale of suspected product to take a sample. First responders can’t do that anymore, because if the product inside is fentanyl, it could become aerosolized and get into your nose or eyes. It’s suggested to now treat it like a loaded weapon, as it could hurt or kill you. This is even the case with pills, which can be difficult to test because of their outer coating. DEA recommends collecting and submitting the product to the lab.
Further, any field testing that must take place on scene should dictate proper PPE and on-site handling procedures by trained experts. If you don’t have to test it, save it, and send it to the lab instead. Any packaging should be wiped down and marked as suspected fentanyl before packing it for the next person in the chain of investigation. For transport, it should be double-bagged, stored in a crush proof container, and then kept in the trunk of your car or other storage away from you and other passengers. Anything to minimize exposure is key.
Even when taking the proper precautions, exposure can happen. If it does occur, promptly use soap and water to thoroughly wash your hands any areas that have been exposed. Should you be working undercover and unable to wear proper PPE, limit exposure by turning off your vehicle’s air conditioning and putting the product in a disposable coffee cup with a lid. Use another coffee cup to keep soap and water to quickly wash exposed areas, especially if dealing with powdered product. Your cover team should also be alerted to have Narcan on scene with them should exposure occur.
While there are always new products on the market and challenges to be faced, there is optimism because people are talking about the issue and many departments are collaborating to address it in their communities. This is critical, because since you started reading, another life has been lost.
Getting started with MRIGlobal
Contact MRIGlobal to further understand the risks and best practices associated with opioids, or visit CBRNETechIndex.com for independent, unbiased, and reliable information on the right equipment for your use.
As a not-for-profit contract research organization, we have proven ourselves as an objective partner driven to make our clients’ products more successful. We specialize in defense, human health, pharmaceutical sciences, in-vitro diagnostics, agriculture, and global health.
To learn more about the work we’ve done or how we can help you, contact us today. If you are part of an agency, business, or academic institution seeking assistance with a project, use our Project Quote Tool to get started.
Sign up for our newsletter
Sign up for the MRIGlobal newsletter! It’s the best way to get the latest updates in the world of applied scientific engineering research delivered directly to your inbox.