On the fictional cop show Blue Bloods, in the appropriately titled episode 鈥淧ain Killers,鈥 detective Maria Baez picks up a tray containing drug paraphernalia and a white powder and is soon , fighting for her life, as a healthcare worker proclaims, 鈥淔entanyl is a synthetic opioid, 50 to 100 times stronger than morphine. The slightest exposure can trigger an overdose.鈥 As reported by Lindsey Ellefson , the night the episode premiered, over eight million people watched it.
The belief that simply coming into contact with fentanyl can kill you is widespread within law enforcement. But is it true?
Where fentanyl comes from
In , Dr. Paul Janssen, the founder of the Belgian company Janssen Pharmaceuticals (which would later be bought by Johnson & Johnson), synthesized a new opioid: fentanyl.
Opioids act on specific receptors in our body, which results in pain relief. Opium has been used by humanity for millennia: it is the milky fluid from the opium poppy. In , a specific opioid from this latex was extracted. Named morphine, it would be adopted for pain relief and as a general anesthetic . But what Janssen wanted was to create in the laboratory the most potent and fast-acting pain reliever. He succeeded by synthesizing fentanyl, which would be approved for use in Europe in and in the United States in . To this day, fentanyl is synthetic opioid in medicine.
When fentanyl binds to certain opioid receptors in our body, the effect is euphoria, drowsiness, relaxation, and pain and anxiety relief. This has led to its abuse by some healthcare workers, especially anesthesiologists and surgeons who have easy access to it. But in 2013, fentanyl became the fountainhead of , which had begun in 1999 with a rise in prescription opioid overdose deaths and continued in 2010 with a second wave caused by heroin overdoses.
Deaths from fentanyl were not new in 2013. Heroin and cocaine had been adulterated with fentanyl before, causing . Clandestine labs were shut down, and the Drug Enforcement Administration (DEA) in the United States limited access to certain fentanyl precursors. Around 2013, however, the dam burst. Fentanyl-laced heroin and cocaine became more and more available, as well as counterfeit opioid pills made to resemble Xanax and OxyContin but containing the much more potent fentanyl.
A on the illicit manufacturing of the drug changed the production landscape but not the outcome: chemical precursors used in the synthesis of fentanyl and of other legal pharmaceuticals are now made in China and shipped to Mexico, where powerful drug cartels recruit chemistry students and graduates from local universities to finish the synthesis of fentanyl, before moving the product across the border. (As an aside, a points out that most cases of fentanyl misuse in North America and Eastern Europe implicate illicitly manufactured fentanyl, whereas a substantial percentage of abused fentanyl in Western Europe and Australia comes from legal fentanyl made for medical use being diverted.)
Accidental deaths from fentanyl often arise because the person did not know they were consuming the powerful opioid. Early studies showed fentanyl to be more potent than morphine and more potent than heroin, meaning that a much lower dose of fentanyl is needed to create the same response. Fentanyl represents a danger not just to recreational drug users, whose supply may have been surreptitiously laced with the synthetic opioid, but also to teenagers with anxiety and/or depression. Sixteen-year-old Cooper Davis from Shawnee, Kansas took half of a pill said to contain oxycodone, a pill he got from a drug dealer he found through Snapchat, and died from accidentally overdosing on its fentanyl. His mother pushed back against the use of this word, overdose. 鈥淐urious teenagers [with anxiety and depression] decide to self-medicate and not bother their parents,鈥 she told the authors of . 鈥淭here is a stigma when we say 鈥榦verdose,鈥 and the public thinks, not my family, not my kid. People aren鈥檛 listening if we call it an overdose. Let鈥檚 call it poisoning.鈥
These tragedies are now more common, with deaths from accidental overdoses or poisonings . And it鈥檚 not just from fentanyl. Minor players include similar molecules which were developed over the decades to create better anesthetic agents but were put aside due to undesirable side effects. A molecule like carfentanyl, which looks like fentanyl but has a specific chemical group added to it, was synthesized to be used in large animals as an anesthetic. It is 100 times as potent as fentanyl and has made its way into the heroin supply in the United States. To this long list of fentanyl analogs, we can add synthetic opioids not based on the fentanyl backbone, with unremarkable names like U-47700 and AH-7921.
Given the clear hazard posed by potent opioids like fentanyl, it鈥檚 no wonder that many first responders are afraid to be anywhere near them. This fear, though, is misplaced and can have dire consequences for the people in need of medical attention.
Touching a raw nerve
It started in Montreal. In April 2013, police conducted seven raids around Montreal and seized drug-making equipment and synthetic drugs, including a fentanyl derivative called desmethyl fentanyl. The clandestine labs making these drugs contained many chemicals, and that four police officers became ill from handling some of these drugs. One was hospitalized with heart problems, while three other cops, who were wearing masks and gloves, developed rashes on their arms. The link between touching fentanyl and getting sick .
But what really cemented the fear that merely touching fentanyl or one of its analogs causes instant harm was . A man who had just been released from jail on bond was driving and was pulled over by a police officer, who was joined by Chris Green, a local off-duty cop who happened to be nearby. The two officers found drugs in the car and the man admitted that the powder in his vehicle might include fentanyl. Green noticed some powder on his shirt and brushed it off with his naked hand.
An hour or so later, Green was sweaty, barely coherent, and not feeling well. He was taken to the hospital, where he was treated for an overdose. The man he had arrested was charged with drug trafficking and possession, yes, but also with assault on a peace officer because he had exposed Green to fentanyl. The attorney general for Ohio released a statement to the press during sentencing which would echo for years to come: 鈥淔entanyl is so dangerous,鈥 he said, 鈥渢hat even the slightest exposure can be deadly.鈥 The news media was quick to repeat this memorable quote.
The belief that simply touching fentanyl will cause physical harm is . It is reinforced by media coverage, which often repeats this presumption with no pushback. Cops who survive their encounter with unknown white powders will tell journalists that 鈥溾 or 鈥溾
So, are there any reported cases of harm caused by touching fentanyl?
鈥淣o.鈥 The man who gave me this unambiguous answer is Dr. Ryan Marino. He is a medical toxicologist and an associate professor at Case Western Reserve School of Medicine in Cleveland, Ohio. He is also one of a handful of experts frequently pushing back against opioid myths through . His stance on this issue is backed up by (ACMT), which deems the risk to emergency responders as 鈥渆xtremely low,鈥 and is echoed in , in which rescue specialist Simon Taxel reminds us that this position is unanimously agreed upon by physicians and toxicologists. 鈥淚f there was a real hazard,鈥 Taxel writes, 鈥渋t would stand to reason that the people who produce fentanyl, distribute it, or use it would suffer similar exposures. This is simply not happening.鈥 Same with carfentanyl, the extremely potent synthetic opioid. 鈥淚t鈥檚 more potent,鈥 told Dr. Joshua Radke, an ER doctor, to , 鈥渂ut it鈥檚 not magically more dangerous.鈥
You may be skeptical if you know that fentanyl patches exist, in which the opioid is allowed to seep through the skin and provide relief to patients dealing with chronic pain. But these transdermal patches were the fruit of significant investments to devise a technology that would allow fentanyl to be absorbed through the skin. Even with this patented delivery system, a patient will start to benefit from the fentanyl only . The effect is far from instantaneous. In fact, you can witness showing that a heroin powder tests positive for fentanyl and then holding it in his left hand for an extended period of time. 鈥淚鈥檓 experiencing no signs of toxicity, no overdose symptoms, nothing whatsoever,鈥 he calmly states. 鈥淚 don鈥檛 know what else to do.鈥
But what about the danger of accidentally inhaling fentanyl while conducting a drug bust? Reassuringly, the drug and its analogs are not easily airborne, with the ACMT referring to this hypothetical situation as 鈥渆xceptional circumstances.鈥 There would need to be large quantities aerosolized and breathed in to get a meaningful amount in the bloodstream. The closest thing might have been , in which Chechen terrorists occupied a theatre. The Russian Federation responded by pumping in a gas that killed 129 of the more than 800 hostages, as well as at least 33 terrorists. The Russian government did not initially reveal the composition of the gas. An of the clothing worn by two British survivors and the urine from a third revealed the presence of carfentanyl and remifentanil. Even if those were indeed the gases used to subdue the terrorists, it is clear that this situation bears little resemblance to first responders arriving at the scene of a fentanyl overdose, or even to police officers raiding a fentanyl laboratory.
First responders who believe they are overdosing on fentanyl from simply touching it in fact exhibit the exact opposite of the symptoms we would expect. While fentanyl makes you euphoric and slows down your breathing, cops start breathing faster, sweat a lot, and become anxious. 鈥淚 don鈥檛 want to discredit anyone or say they鈥檙e faking,鈥 says Dr. Marino. 鈥淚 do think people are having a true medical emergency when this happens. The symptoms seem most consistent with a panic attack or anxiety or a fear reaction.鈥 Some will claim they had to administer naloxone (trade name Narcan), which can reverse an opioid overdose, in order to save their life. But if you are conscious enough to self-administer naloxone, you鈥檙e not overdosing on opioids. You would have lost consciousness and barely been breathing.
This panic over accidentally touching fentanyl is causing actual harm. 鈥淚 have seen this play out,鈥 Dr. Marino tells me, 鈥淧eople are scared to resuscitate an overdosing person, because they鈥檙e worried about getting close to them.鈥 Police departments spend unnecessary money on hazmat suits and special 鈥渇entanyl-resistant gloves.鈥 Regular disposable nitrile gloves have been tested and are ; in fact, the human skin is already a pretty good barrier. But because of this dread, people are being charged with imaginary crimes for exposing a cop鈥檚 bare skin to fentanyl, and a coalition of attorneys general to classify fentanyl, one of the most frequently used drugs in medicine, as a 鈥渨eapon of mass destruction.鈥 Fear spreads while science crawls.
If someone looks like they are overdosing on an opioid like fentanyl, the best thing to do after calling emergency medical services is to administer naloxone, which competitively binds to the same receptors as opioids do without activating them. Naloxone nasal spray is and . Naloxone can take a few minutes to kick in and more than one dose may be needed. Also, its effect wears off , making medical attention necessary regardless. Naloxone will not cause harm, even in someone who is not actually overdosing on an opioid, except in one situation: if the person has been using opioids daily for a long time and is dependent on them, receiving naloxone will cause drug withdrawal symptoms. 鈥淏ut it鈥檚 definitely better than the alternative being death,鈥 Dr. Marino told me.
And if you are a first responder and your partner has a panic attack after accidentally touching a white powder at the scene, having them seek medical attention may be necessary, but simply calming them down can work wonders. 鈥淚 think there was one in Jacksonville a couple of months ago,鈥 Dr. Marino said, 鈥渨here he had his partner sit down and slow his breathing down. That would be productive rather than just giving Narcan over and over again and adding to the panic.鈥
Blue Bloods may have fueled the fear over accidental fentanyl poisoning, but another cop show took a different approach. On an episode of Will Trent, a law enforcement officer starts panicking . The show鈥檚 protagonist, Will Trent, replies, unphased: 鈥淧retty sure that鈥檚 laundry detergent. Just wash your hands. Either way, you鈥檒l be fine.鈥 We need more scientifically accurate representations like this one.
Take-home message:
- There are no verified cases of poisoning from a casual fentanyl exposure
- First responders who accidentally touch what they believe to be fentanyl and start hyperventilating exhibit symptoms that are the exact opposite of what fentanyl poisoning would look like. Their symptoms are more consistent with a panic attack
- The myth that simply touching fentanyl can kill you causes harm: it delays first responders from helping people who are overdosing, it drives cops to buy unnecessary and expensive protective equipment, and it leads to people receiving harsher sentences for the imaginary crime of exposing a cop to fentanyl
