There is uncertainty surrounding law enforcement officers’ exposure to and health effects from opioids encountered while at work protecting the public. Over the past several years, the media have reported instances of opioid exposures and health effects among first responders and other public service workers across the U.S.[i],[ii],[iii],[iv] These reports provide incomplete or uncorroborated information about incidents involving work‐related exposures to drugs among responders. An article from NIOSH researchers entitled “Health effects from unintentional occupational exposure to opioids among law enforcement officers: Two case investigations” published in the American Journal of Industrial Medicine seeks to characterize the risk associated with unintentional occupational exposure to drugs. The article summarizes two NIOSH Health Hazard Evaluations (HHEs), discusses prevention of occupational exposure to fentanyl and its analogues, and emphasizes the need to protect responders while research continues. A summary of the article follows.
The following two HHEs were conducted by NIOSH at the request of law enforcement agencies to evaluate incidents involving drugs where officers experienced health effects. [v],[vi],[vii] The objectives of the HHEs were to evaluate the potential exposure to drugs among law enforcement officers and the reported health effects, and to provide recommendations on preventing occupational exposures to drugs among law enforcement officers. We are highlighting these examples of incidents from New Hampshire in 2017 and Virginia in 2018 because they show different situations. Other evaluations of incidents involving first responders with unintentional occupational exposures to drugs, with similar implications for prevention, are available on the NIOSH website.
Health Hazard Evaluation 1
A police officer (Officer 1) performed a traffic stop and vehicle search. Officer 1 found materials consistent with illicit drugs, including the contents of an unlabeled rubber container. When Officer 1 opened the rubber container outside of the vehicle, a gust of wind blew powder from inside the rubber container onto Officer 1, who reported that the powder was “all over me and my uniform.” Officer 1 was wearing a short‐sleeved uniform and no gloves. Officer 1 attempted to brush the powder off and used hand sanitizer to clean the hands and arms.
Within 5 minutes of opening the container, Officer 1 became disoriented and lightheaded, and had “blurry vision.” A second officer called for an ambulance, which arrived approximately 10 minutes after symptom onset. Emergency medical service (EMS) providers assisted with decontamination by washing Officer 1’s exposed skin with water. EMS providers noted that Officer 1 was alert and had elevated blood pressure, heart rate, and respiratory rate upon their arrival. EMS providers noted that Officer 1’s pupils were 4 mm (normal range is 2–4mm in diameter depending on ambient light) and reactive. During transport to the emergency department, Officer 1 noted intermittent symptoms of “trouble thinking and staying awake.” Officer 1 reported “mild blurry vision” in the emergency department, which resolved after several hours. Physical examination in the emergency department noted that Officer 1 was alert and there were “no constricted pupils.” No laboratory tests were done on Officer 1. Symptoms resolved and the emergency department physician’s discharge assessment was “chemical exposure.” The forensic laboratory identified fentanyl and methamphetamine in the powder remaining in the rubber container.
Health Hazard Evaluation 2
Four police officers (Officers 2–5) developed symptoms while responding to a 911 call about an unconscious person with a possible drug overdose in a hotel room. Three of the four officers (Officers 2–4) responded to the hotel room. Upon entry, they saw drug paraphernalia and powders scattered in plain view. Two people were in the hotel room, including the overdose victim mentioned in the 911 call who was in the hotel room’s bathroom. Officers noted hearing the toilet flush multiple times. The officers observed the overdose victim to be intoxicated. Officers 2–4 detained the two people and secured the hotel room while awaiting the processing of a search warrant. Officers 2–4 were wearing short-sleeved uniforms. Officers 2 and 3 wore gloves upon entry into the hotel room and Officer 4 put on gloves shortly after entering the hotel room.
Officers 2–4 took turns leaving the hotel room to retrieve and put on half‐facepiece respirators with P‐100 filters after observing what appeared to be drugs in powder form. Officer 3 returned to police headquarters to process a search warrant to further search the hotel room; this involved handling a camera that Officer 3 had used to take photographs in the hotel room. At police headquarters, Officer 3 was assisted by Officer 5. Officer 5 handled the camera and other items that had been in the hotel room; those items had no visible signs of contamination. At police headquarters, Officers 3 and 5 both developed lightheadedness and dizziness. Officer 3 also reported feeling “groggy” and complained of numbness in both hands and tongue, while Officer 5 reported weakness, headache, blurry vision, increased sweating, a feeling of warmth, and “feeling drunk” as well. Officers 2 and 4, who remained in the hotel room, developed symptoms at the scene or soon after leaving the scene. Of note, Officer 2’s initial symptoms, which included blurry vision, feeling of warmth, weakness, dizziness, lightheadedness, and feeling “drunk,” progressed such that Officer 2 was assisted outside the hotel room before slumping against the wall and subsequently to the ground. Officer 4 administered one dose of intranasal naloxone to Officer 2 with rapid improvement in symptoms.
Before transport to the emergency department, Officers 2–5 underwent decontamination procedures consisting of removing clothing and equipment, showering or being washed with water, and putting on fresh garments. In the emergency department, Officers 2–5 had normal body temperatures, normal to elevated blood pressures, and normal to elevated heart rates. Officers 2–4 had normal to elevated respiratory rates during their monitoring period; Officer 5 had a respiratory rate ranging from 9 to 20 breaths per minute in the emergency department. On physical examination, Officers 2–5 were alert and oriented; none had documented constricted pupils. Electrocardiograms did not reveal any electrocardiographic abnormalities. Officers 3–5 had blood tests which ruled out several medical conditions including volume depletion and hypoglycemia; Officer 2 did not have blood tests. Urine samples from Officers 2–5 tested negative in a screen for seven drugs. Officers 2–5 were discharged from the emergency department after several hours of observation and improvement of symptoms. After the incident, forensic laboratory testing of evidence samples confirmed that opioids, cocaine, methamphetamine, and cathinones (“bath salts”) were present in the hotel room.
Health Effects Issues
In these two incidents, the five officers experienced a variety of health effects so they could not continue performing their essential law enforcement job duties. The health effects experienced by the officers were not consistent with severe (life-threatening or late‐stage) opioid toxicity. Signs and symptoms of severe or late‐stage opioid toxicity include profound lethargy or other indications of central nervous system depression; shallow, slow, or absent breathing; constricted pupils or miosis; slow heart rate; and low body temperature.[v],[viii],[ix] Low‐dose exposure to opioids may result in milder symptoms. Officer 2’s improvement after receiving naloxone suggests that opioids were a substantial component of the mixed exposure. Low‐level exposure to combinations of opioids and other drugs, particularly stimulants such as cocaine or amphetamines, might be consistent with the health effects experienced by the officers in these two incidents. Exposure to a combination of opioids and stimulants might produce health effects not characteristic of a pure opioid or a pure stimulant exposure. In addition to a drug’s pharmacological characteristics, other factors such as perceived risk might contribute to the observed health effects. The possible relationships between perceived risk, the types of exposures, and the clinical status of the officers were not assessed.
Potential routes of occupational exposure to drugs include inhalation, mucous membrane (e.g., eyes, nose, and mouth) absorption, ingestion, absorption through the skin, or a combination. Brief skin contact with powdered fentanyl or its analogues is not expected to lead to toxic effects if visible contamination is promptly removed. [i],[ii],[x],[xi],[xii],[xiii] In these two investigations, all these routes of exposure were possible. Touching the face with contaminated gloves or bare hands can lead to mucous membrane exposure, highlighting the need for training (e.g., properly performed glove changes and avoidance of touching the face). Hand sanitizer that contains alcohol may increase absorption of fentanyl powder and should be avoided. [i,iv,xiv]
Quantifying the risk associated with potential exposure to drugs present in incidents involving emergency responders is difficult for a number of reasons. Both incidents described above involved multiple types of drugs identified through forensic testing conducted after the response. Forensic testing is typically conducted for law enforcement purposes, and may not accurately represent the actual amounts of substances present at the scene. For example, not all of the substances present at the scene may be sent to the forensic laboratory for analysis.
Law enforcement officers and other responders might perform different work activities at every response. Responders might not know which parts of any specific scene are contaminated with a potentially toxic agent. For example, the officers in HHE 2 arrived at the hotel room, they heard the toilet being flushed multiple times. In some situations, persons using illicit substances might hide or dispose of them before interacting with police, for example, by dumping them into the toilet and flushing repeatedly. This process likely contaminates bathroom floors and surfaces. Bathrooms, which usually are small spaces with limited ventilation, might also allow materials to remain airborne longer and be more concentrated. In addition, the rapidly changing environment and public safety concerns during such responses might impede exposure assessment.
The officers’ negative urine drug screens in HHE 2 do not rule out the possibility of exposure to drugs. Tests to detect synthetic opioids in the blood (or serum) and urine have limitations. [v],[xiv],[xv] For example, routine urine toxicology tests currently used are designed to screen for opiates. Screening tests for opiates will not detect synthetic opioids such as fentanyl. [vii]
Prevention for First Responders
In these incidents, health effects did not allow any of the officers to continue conducting their essential law enforcement job duties. Some officers experienced debilitating health effects. While the potential for risk associated with unintentional occupational exposure to drugs among responders is clear from these investigations, completely characterizing that risk and the relationship of specific exposures to observed health effects faces challenges. While these data gaps are being addressed through additional investigations, steps to prevent exposures and work‐related health effects should be taken by all organizations employing responders or other public service workers who face similar risks.
Steps for prevention fall into two main categories:
(1) creation and implementation of guidance of appropriate controls and
(2) education and training.
Both are important to help protect first responders from exposure to hazardous agents and for first response work to be performed in a manner that minimizes the potential for health effects from illicit drug exposure.
NIOSH and others have issued guidance on how to protect emergency responders from exposures to fentanyl and its analogues. [xii,xiv,xv,xvi] These guidance documents are important tools for identifying how to prevent exposure through:
- on‐scene risk assessment,
- work practices to minimize exposure, and
- personal protective equipment (PPE) selection based on the anticipated level of exposure.
Education and training are needed to prevent unintentional law enforcement officer exposure to illicit drugs. It is also important to provide information on actual versus perceived risk in specific exposure situations. For example, officers may experience less anxiety if they understand that brief dermal exposure with suspected fentanyl products in powder form can be remedied by washing the affected skin with soap and water, [xvi] as opposed to believing that any dermal contact will result in a life‐threatening opioid overdose.
In the context of the current opioid epidemic, it is increasingly likely that fentanyl will be present in a scene where other hazardous drugs are found. At the time of any given response, law enforcement officers will generally not know the identity of all the substances at the scene. We believe the principles outlined in the current guidance focusing on fentanyl are applicable in the absence of guidance specific for many other opioid and stimulant drugs to which first responders might be exposed.
NIOSH guidance encompasses scene assessment, work practices, PPE, and training, all of which help prevent occupational exposures in responders. Additionally, making naloxone available and providing responders with training on when and how to use it are important to keeping first responders safe. [xiv,xvii]
We want your help. What is the most effective way to provide education and training to first responders on preventing accidental opioid exposure in the workplace? Please click here to provide input in the comment section below the blog post on the NIOSH website.
[i] Bureau of Justice Statistics. Full‐time employees in law enforcement agencies, 1997–2016 (NCJ 251762). https://www.bjs.gov/content/pub/pdf/ftelea9716.pdf. Accessed 3 October 2018.
[ii] Burgess JL, Barnhart S, Checkoway H. Investigating clandestine drug laboratories: adverse medical effects in law enforcement personnel. Am J Ind Med. 1996;30:488‐494.
[iii] Silva BM War on opioids: first responders on front lines. https://turnto10.com/features/health‐landing‐page/war‐on‐opioids‐firstresponders‐on‐the‐front‐lines. Accessed 9 March 2018.
[iv] WSAZ News Staff. 29 Treated for fentanyl exposure at Ross Co. prison, substance identified as heroin/fentanyl combination. http://www.wsaz.com/content/news/Ross‐Correctional‐Institution‐onlockdown‐491990671.html. Accessed 9 September 2018.
[v] Drug Enforcement Administration. Schedules of controlled substances:temporary placement of 4‐fluoroisobutyryl fentanyl into Schedule I. Temporary scheduling order. Fed Regist. 2017;82:20544‐20548.
[vi] NIOSH. Health hazard evaluation report: Evaluation of a New Hampshire law enforcement officer’s unintentional occupational exposure to illicit drugs. By Chiu S, Hornsby‐Myers J, Trout D. Cincinnati, OH: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, NIOSH HETA No. 2018‐0132‐3322. https://www.cdc.gov/niosh/hhe/reports/pdfs/2018‐0132‐3322.pdf. Accessed 3 October 2018.
[vii] NIOSH. Health hazard evaluation report: Evaluation of law enforcement officers’ potential occupational exposure to illicit drugs —Virginia. By Chiu S, Hornsby‐Myers J, Trout D. Cincinnati, OH: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, NIOSH HETA No. 2018‐0113‐3325. https://www.cdc.gov/niosh/hhe/pdf/2018‐0113‐3325.pdf. Accessed 3 October 2018.
[viii] Boyer EW. Management of opioid analgesic overdose. N Engl J Med. 2012;367:146‐155.
[ix] Ropper AH, Samuels MA, Klein JP, eds. Adams and Victor’s Principles of Neurology. 10th ed. New York: The McGraw‐Hill Companies; 2014.
[x] NIOSH. Health hazard evaluation report: evaluation of police officers’ exposures to chemicals while working inside a drug vault—Kentucky. By Fent KW, Durgam S, West C, Gibbins J, and Smith J. Cincinnati, OH: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, NIOSH HETA No. 2010‐0017‐3133. https://www.cdc.gov/niosh/hhe/reports/pdfs/2010‐0017‐3133.pdf. Accessed 3 October 2018.
[xi] Lynch MJ, Suyama J, Guyette FX. Scene safety and force protection in the era of ultra‐potent opioids. Prehosp Emerg Care. 2018;22:157‐162.
[xii] Interagency Board. Recommendations on selection and use of personal protective equipment and decontamination products for first responders against exposure hazards to synthetic opioids, including fentanyl and fentanyl analogues. Arlington, VA: Interagency Board. https://www.interagencyboard.org/content/first‐responderppe‐and‐decontamination‐recommendations‐fentanyl‐august‐2017. Accessed 3 October 2018.
[xiii] Moss MJ, Warrick BJ, Nelson LS, et al. ACMT and AACT position statement: preventing occupational fentanyl and fentanyl analog exposure to emergency responders. Clin Toxicol. 2017;56:391‐400.
[xiv] Suzuki J, El‐Haddad S. A review: fentanyl and non‐pharmaceutical fentanyls. Drug Alcohol Depend. 2017;171:107‐116.
[xv] Armenian P, Vo KT, Barr‐Walker J, Lynch KL. Fentanyl, fentanyl analogs and novel synthetic opioids: a comprehensive review. Neuropharmacology. 2017;134(Part A):121‐132.
[xvi] White House Office of National Drug Control Policy. Fentanyl safety recommendations for first Responders. https://www.whitehouse.gov/ondcp/key‐issues/fentanyl. Accessed 3 October 2018.
[xvii] Howard J, Hornsby‐Myers J. Fentanyls and the safety of first responders: science and recommendations. Am J Ind Med. 2018;61:633‐639.