Illicit fentanyl is extremely dangerous, but the hyperbole and misinformation that has become associated with it are also incredibly harmful. On Thursday March 11, 2022, multiple people experienced symptoms of overdose during a Fort Lauderdale, Florida-area, spring break party. At least six young people were treated and transported to hospitals. It has been reported that four of the victims were ingesting what they believed to be cocaine and then overdosed with two going “immediately into cardiac arrest.”
According to a Fort Lauderdale Fire Department Battalion Chief, the other two victims were exposed to the substance while trying to render aid to their classmates by performing CPR. He stated that they had not taken the drug themselves but absorbed enough to suffer overdoses while attempting to administer mouth to mouth resuscitation.1 A hazardous materials team was called to the scene and the substance was identified as cocaine contaminated with fentanyl.
Here are the facts. Fentanyl is a potent synthetic opioid that has become ubiquitous in the illicit drug supply across the country. It can cause overdoses at very low volumes, and it has been omnipresent in illicit opioids for years. Recently, it is being found as a contaminant or adulterant in other drugs such as cocaine, methamphetamine and street produced benzodiazepines with increasing frequency. This poses a substantial risk for people who are ingesting drugs especially when they are not knowingly using opioids.
JEMS Con 2022 Preview: Fentanyl Facts and Fiction: A Safety Guide for First Responders
EMS clinicians as well as all first responders must be aware of this because more and more patients are presenting with signs and symptoms of opioid toxicity including respiratory depression, apnea, hypoxia, somnolence, unconsciousness, diaphoresis, and miotic pupils without knowingly ingesting drugs that cause them. It is imperative that the clinical presentation is rapidly recognized and the appropriate interventions including oxygenation, ventilation, BLS airway management, and judicious administration of appropriately dosed naloxone are expediently deployed. In this case, it is clear that multiple victims experienced the ill effects of poisoned drugs and the medical personnel who responded to the scene provided lifesaving care. Beyond that, the reporting on the situation is muddled with hyperbole and misinformation.
The published statements that two of the victims absorbed enough fentanyl to overdose while performing CPR and mouth to mouth resuscitation are dubious and scientifically extremely unlikely. Additionally, the local ABC news affiliate, WPLG 10’s, statement that a hazardous materials team responded to “scour the house because any contact with fentanyl could make others sick as well” is patently false.2 The panic and factual distortion surrounding the risks of passive exposure to fentanyl are unfortunately widespread. They are frequently promogulated by public safety officials and then uncritically repeated throughout the local and national media. Statements and reporting like the ones in this situation have the potential to cause substantial harm.
They increase the stigma associated with illicit drug use and increase the fear and anxiety among both community members and professional rescuers. This stigma, fear, and anxiety can cause both lay rescuers and first responders to hesitate and potentially delay lifesaving intervention. They also cause the erroneous use of resources like the deployment of hazardous materials teams to scenes where there is suspected fentanyl, when standard precautions like wearing exam gloves and hand washing are more than sufficient to protect everyone. Finally, this misinformation has been weaponized and is being used to bring specious criminal charges against people due to perceived potential harms to first responders and law enforcement officers.3,4,5
While there are important details that have not been made publicly available about the two victims who are reported to have overdosed after performing CPR, the best available evidence should make the reader skeptical of the veracity of these claims. There is unanimous agreement among physicians and toxicologists, as well as clear evidence that toxicity and overdose from passive exposure to fentanyl is not possible.6 While preparations of fentanyl for transdermal and oral transmucosal administration exist, they are not what’s found in illicitly produced powders and pills. Illicit fentanyl has to be inhaled or injected to have any significant bioavailability. In a joint statement, the American College of Medical Toxicology (ACMT) and the American Academy of Clinical Toxicology (AACT) stated unequivocally that the risk of clinically significant exposure to fentanyl and its analogs to emergency responders is extremely low. Additionally, the report states that the transdermal absorption of fentanyl powder is extremely unlikely to occur.
It is further noted that inert fentanyl powder is not aerosolized, and it would be exceptionally rare for drug droplets or particles to be suspended in the air.7 There are two possibilities that one can surmise from the information that is available. The first is the two victims did not actually overdose, and they experienced symptoms of anxiety or another psychosomatic reaction. False reports of fentanyl exposure include: tachycardia, dizziness, syncope, dyspnea, and or nausea and vomiting. The second potential explanation is that they both did in fact knowingly ingest illicit drugs, experienced overdose, and then felt compelled to lie about it to avoid negative consequences.
Regardless of the exact circumstances in this case, it is the responsibility of those public safety officials who speak to the media, and the journalists who report their statements to ensure that they are not spreading misinformation and dangerous propaganda. There are very real dangers associated with illicit fentanyl and that cannot be understated. However, the panic, hysteria, and false information does nothing but obfuscate the real hazards and increase harm. People who use illicit drugs should test their drugs for fentanyl, never use alone, and make sure that naloxone is available. EMS clinicians must leave their biases at the door and treat patients using evidence-based treatment modalities with the appropriate PPE which in this case is exam gloves and common sense.
References
1. Dimichele, Angie. Fleshler, David, Kelley, Eileen, Perkins, Chris. Arrest made in Spring Break overdoses; victims include West Point football player. South Florida Sun Sentinel Website. Available at: https://www.sun-sentinel.com/local/broward/wilton-manors/fl-ne-wilton-manors-college-students-overdose-20220311-r4xyekm2orefbkrpq25avcvxqy-story.html. Accessed March 14, 2022.
2. Cocaine laced with fentanyl causes 6 overdoses in Wilton Manors. WPLG Local 10. https://www.youtube.com/watch?v=TTegtNkfcSw&t=127s. Accessed March 14, 2022.
3. Lekhtman, Alexander. Doubling Down on Fentanyl Myths, West Virginia Bill Would Punish “Exposing” Cops. Filter Magazine website. Available at: https://filtermag.org/west-virginia-fentanyl-exposure/. Accessed March 14, 2022.
4. Ellefson, Lindsey. Jail Time For An “Imaginary Crime”: It’s Almost Impossible To Overdose Just By Touching Fentanyl, But People Are Being Locked Up For It Anyway. Buzzfeed News. Available at: https://www.buzzfeednews.com/article/lindseyellefson/fentanyl-accidental-exposure-police. Accessed March 14, 2022.
5. Shackford, Scott. West Virginia Mulls New Criminal Penalties for Imaginary Threat of Police Fentanyl Exposure. Reason Magazine. Available at: https://reason.com/2022/01/25/west-virginia-mulls-new-criminal-penalties-for-imaginary-threat-of-police-fentanyl-exposure/. Accessed March 14, 2022.
6. Nelson, Lewis S. Perrone, Jeanmarie. ‘Passive’ fentanyl exposure: more myth than reality. STAT News website. Available at: https://www.statnews.com/2018/12/21/passive-fentanyl-exposure-myth-reality/. Accessed March 14, 2022.
7. Moss MJ, Warrick BJ, Nelson LS, et al. ACMT and AACT Position Statement: Preventing Occupational Fentanyl and Fentanyl Analog Exposure to Emergency Responders. J Med Toxicology. 2017;13(4):347–351. doi:10.1007/s13181-017-0628-2.
