Authors: Peter B. Harnett, MS, MPH, CIH, CSP and Mary E. Greenhalgh, MPH, CIH of COEH
Background
Several recent health and safety publications include articles addressing proper first responder actions for illicit opioid operations as well as safety considerations when the first responder arrives to assist an overdose victim or enters an enclosed environment where potent narcotics are present. (The term “opioid” is used here to capture opiate derivatives such as morphine and heroin as well as synthetic and semi-synthetic narcotics including fentanyl and fentanyl analogs.) In the above scenarios, the first responder and/or team should have Narcan™ (naloxone) on hand as an antidote and have prior detailed training in its administration. The first responder should also have on appropriate personal protective equipment (PPE) that may include dermal and respiratory protection. Proper PPE determinations are difficult to make. NIOSH is one of the Federal agencies that continues to develop guidance on PPE decision-making for opioid first responders.
Many of these articles correctly point out that fentanyl is approximately 50 to 100 times more potent than morphine and that carfentanil is approximately 10,000 times more potent than morphine with regard to analgesic (relief of pain) capability. The potencies and relative potencies will differ based on routes of exposure. For example, inhalation and to a lesser extent dermal represent the most likely routes of exposure for a first responder. There is limited information on potency of fentanyl analogs by inhalation and even less information on inhalation or dermal potency for carfentanil.
Below, additional information is provided on two items that are important additions to the opioid first responder discussion.
- Emphasis on Impairment Rather than Lethal Dose
Many of these communications emphasize lethal doses (multiple microgram quantity range for fentanyl analogs and milligram quantity range for morphine), but it is more important to address airborne or surface concentrations that result in an impaired response since it will be more common that the first responder is exposed at levels appreciably less than fatal doses. Exposure of a first responder at levels at or below known therapeutic levels 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, any of these occurrences are likely to increase the chance of a fatality. Even when the illicit operators are not present, serious injury can result from a fall or poor judgment handling weapons that were left behind.
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- Carfentanil, Increasing Concern for the First Responder
Carfentanil is being added to 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. Based on statistics from July to December 2016 for ten states that analyze for specific fentanyl analogs, 7.6% of the ~5,200 opioid fatalities tested positive for carfentanil with Ohio reporting 17.3%. (CDC, November 2017).[1] In a recent study (Minkowski et al, 2012)[2] with fifteen naïve (non-user) volunteers, carfentanil was administered intravenously (iv) at 0.019 mg/kg. Dizziness was reported in 60% of the volunteers. For an 80-kilogram adult, this is equivalent to 1.5 micrograms carfentanil dose (iv). If carfentanil is similarly potent by inhalation, many first responders may be at significant risk whenever carfentanil is present. This is particularly a concern if the response is in an enclosed space such as a car or illicit opioid operation and carfentanil is present in a solid formulation such as a powder.
[1] Deaths Involving Fentanyl, Fentanyl Analogs, and U-47700 — 10 States, July–December 2016, CDC, November 2017. https://www.cdc.gov/mmwr/volumes/66/wr/mm6643e1.htm
[2] Minkowski, C. P., Epstein, D., Frost, J. J., & Gorelick, D. A. (2012). Differential response to IV carfentanil in chronic cocaine users and healthy controls. Addiction Biology, 17(1), 149-155.