Editor's Note:
Due to the rapid spread of the opioid epidemic that spawned multiple safety concerns and unanswered questions, initial protocol and educational directives were very conservative, as reflected in this article. However, as research and actual experience evolved, these directives were updated to prioritize patient care balanced with fact-based scene safety precautions. See the following references for updates:
https://www.iaedjournal.org/scene-safety-in-an-opioid-epidemic
https://www.aedrjournal.org/potential-exposure-with-dr-mike-mcevoy
Every revision of the Medical Priority Dispatch System™ (MPDS®) is designed to incorporate the latest science in public health and emergency care for emergency medical dispatchers. Sometimes these changes reflect an undesirable trend in public health; such is the case for the dramatic rise in deaths from drug overdose—in particular opioid overdose.
And the EMD must be prepared with the proper set of lifesaving instructions when the callers and patients are in critical need.
MPDS version 13.1 contains revisions to Protocol 23: Overdose/Poisoning (Ingestion) to include a truly frightening addition to the synthetic drug world: fentanyl—and its chemical analog carfentanil. Fentanyl is anywhere from 50 to 100 times more potent than morphine, and carfentanil is up to 4,000 times more potent than heroin and 1,000 times more potent than fentanyl.1
It’s important to note that the revisions in MPDS v13.1 Protocol 23: Overdose/Poisoning (Ingestion) exist only in ProQA; they are not available in the printed cardset. The updates include additional Key Questions and enhanced PAIs for Narcan/Naloxone administration:
- The operator question “Ø Any mention of Fentanyl, Carfentanil, or U4 (Pink or Pinky)?” has been added to prompt specific suffix coding for those drugs.
- Key Question 9 asks “Is there any Narcan (naloxone) available?”
- If Narcan is available, Key Question 9a has the EMD tell the caller, “Good, I want you to give it to her/him now.” Regardless of whether Narcan has already been administered, the EMD may give instructions for administering the opioid antidote if the caller requests help.
- A new Determinant Code has been added: 23-D-1 “Arrest.” The remaining DELTA-level Determinant Codes have been renumbered.
Instructions an EMD provides also depend on the availability of Narcan and the patient’s condition (not breathing, started moving, still unconscious, waking up now) following administration, with the possibility of subsequent doses based on the patient’s medical response. ProQA also provides detailed PAIs for auto-injection, including how to manage pre-filled syringes (needle on, off, or attached) and directions guiding the injection: straight into her/his upper arm or thigh, right through any clothes. Be sure to push the plunger all the way down to give it all.
Both ProQA and the cardset provide instructions to give an additional dose if there is no improvement in her/his breathing (respiratory function) in 2 to 3 minutes or if symptoms return after the first dose.
New to MPDS v13.1 in ProQA are several additional problem suffixes, including suffixes that identify accidental and intentional overdoses of either fentanyl or carfentanil.
Carfentanil overdose and the delivery of DLS
“First do no harm” is a fundamental principle of the medical profession. Given known dangers of carfentanil exposure to unprotected bystanders, the IAED™ issued an official statement describing the recommended emergency dispatcher actions when instructing bystanders when this substance is present around the patient (released June 28, 2017, and available at emergencydispatch.org). It states the following:
The Emergency Dispatcher should be prepared to omit or discontinue all DLS instructions involving touching the patient if:
- The caller spontaneously provides information that suggests the presence of carfentanil (powder or liquid) on or in the immediate area of the patient.
Or
- The caller questions the safety of touching the patient when a known (or suspected) synthetic opioid is present.
The Emergency Dispatcher may discontinue treatment with a statement such as, “This could be a very dangerous situation. Do not touch the patient or disturb anything around them. Wait for the paramedics and tell me immediately if anything changes. If you feel unsafe, leave the area and take the phone with you if you can.”
As always, and as expressed by Protocol Rule, “If the complaint description involves hazardous materials (toxic substances) that pose a threat to bystanders or responders, go to Protocol 8.” It is not generally necessary in OVERDOSE cases, and should not be considered routine practice. However, it can be entirely appropriate if the caller provides information during Case Entry that suggests scene contamination is an imminent risk and the safety of the caller outweighs treating the patient.
In September 2017, the U.S. Drug Enforcement Agency (DEA) issued a public safety warning involving the extreme danger of even minimal contact with fentanyl and derivatives. Similar to the IAED advisory, the DEA cautioned against handling any substance suspected of containing the drug unless trained and outfitted to do so.
Even minor exposure to these drugs through skin contact or inhalation can send a healthy adult to the emergency room in respiratory distress. Personal protective equipment (PPE) such as nitrile gloves, an N-95 mask, eye protection, and coveralls are recommended for responders when treating known fentanyl-related overdoses.2
International concern
An analysis of opioid overdose deaths in 10 U.S. states participating in an Enhanced State Opioid Overdose Surveillance (ESOOS) found that illicitly manufactured fentanyl is a key factor driving opioid overdose deaths and that fentanyl analogs—similar in chemical structure, such as carfentanil—are increasingly contributing to significant public health implications. Estimates of U.S. drug overdose deaths exceeded 60,000 in 2016 and were partially driven by a fivefold increase in overdose deaths involving synthetic opioids fentanyl and carfentanil (excluding methadone), from 3,105 in 2013 to approximately 20,000 in 2016.3
Synthetic opioids are not isolated to substance abuse in the US.
In July 2017, the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) issued a warning regarding carfentanil due to increased confiscations and fatalities in several European Union member states. According to a report of the World Health Organization (WHO), deaths with confirmed exposure to carfentanil were reported by Belgium (1 case), Estonia (6), Finland (1), Lithuania (7), Norway (1), and Sweden (3), and the U.K. (28). The cases occurred between November 2016 and the first half of 2017.4
Carfentanil also has potential in biological warfare. In October 2002, Russian security forces subdued Chechen hostage takers at the Moscow Dubrovka theater with an unidentified, incapacitating chemical aerosol, which led to the deaths of 125 people. Carfentanil and remifentanil (another fentanyl derivative) were reported found in the clothing and urine of people in the theater.5
According to multiple sources, China banned production and supply of 116 psychoactive substances, including fentanyl, in 2015; a ban on carfentanil followed in 2017. While a ban can cut production temporarily, it doesn’t stop it for long. Production places and supply routes change. Production for the U.S. market has moved to Mexico. Although a ban cuts off production, the drugs themselves will still be found in the supply chain for some time. Production may go further underground or move to different locations and supply routes may change.
Fentanyl
Fentanyl is a prescription medication developed for medical patients experiencing severe pain due to cancer and extremely invasive surgeries. Although the original intent was administration by health practitioners, it evolved into an over-the-counter prescription available at any pharmacy or drugstore in the form of lozenges or a time-release gel patch. Street fentanyl can be exceptionally dangerous in relation to dosage (professional vs. amateur). As little as two milligrams of the white powder can cause a lethal reaction.
Fentanyl is a Schedule II narcotic under the United States Controlled Substances Act and approved by the Food and Drug Administration for limited use in pain relief.6 Fentanyl can be added to heroin or taken straight (injected, snorted/sniffed, smoked, taken orally by pill or tablet, or spiked onto blotter paper).
Carfentanil
Carfentanil is produced in large quantities in China and has been available as a high purity powder from websites that specialize in psychoactive products or so-called research chemicals and their marketing.7 Carfentanil is cut into heroin to increase its potency, and buyers generally don’t know what’s been mixed into the powder.
A fatal dose of fentanyl (two milligrams of powder) is the size of a U.S. penny. A fatal dose of carfentanil (0.02 milligrams of powder) is 100 times smaller, barely the size of Lincoln’s right ear on a penny’s head. Carfentanil can come in several forms, including spray, blotter paper, tablets, patch, and powder. In powder form, it can resemble cocaine or heroin.
Why is carfentanil so dangerous in such small amounts? It is the "elephant tranquilizer in the room." Carfentanil was manufactured to be a large-animal tranquilizer.
A 10-milligram dose of carfentanil is enough to sedate (immobilize) a wild female African elephant (weighing two and three tons); a captive female African elephant is administered a dose that is 25 percent less (7.5 milligrams).8 While this synthetic opioid was never designed for people or tested for use as a treatment, it’s easy to understand why a 0.02-milligram dose of carfentanil can kill a person weighing 200 pounds, which is a twentieth to a thirtieth the weight of a two- or three-ton wild or captive female African elephant.
Within minutes, carfentanil immobilizes an elephant (elephant is down). Within seconds, carfentanil can stop a person’s breathing and stop the person’s heart.
In December 2017, the World Health Organization (WHO) endorsed a recommendation from the Expert Committee on Drug Dependence (ECDD) to include carfentanil into Schedules I and IV of the 1961 U.N. Single Convention on Narcotic Drugs.9 Schedule I substances are subject to strict drug control measures. Schedule IV imposes the strongest possible regulations on substances by prohibiting production and supply of substances except under license for specific purposes, such as medical treatment and research. In the case of carfentanil, there is no indication for human use.10
The 1961 convention has since been amended three times and carfentanil retains Schedules I and IV status.
Naloxone
Respiratory depression and subsequent respiratory arrest are the most serious adverse effects of any opioid overdose. The typical clinical picture in acute intoxication is the same as in opioid overdoses in general (i.e., a reduced state of consciousness, respiratory depression, and small pupils). Among the milder adverse effects of opioids, including fentanyl derivatives, are disturbances of the digestive tract, such as constipation and nausea. However, even at dosages of less than one milligram, fentanyl and its derivatives are substances with a powerful depressive effect on the central nervous system. The onset of these symptoms usually occurs within minutes of exposure.
Naloxone is used for the full or partial reversal of central nervous system and respiratory depression caused by opioids. The U.S. Food and Drug Administration approved a handheld naloxone intramuscular or subcutaneous auto-injector in 2014 and an intranasal formulation in 2015.
Administering naloxone can reverse an overdose of fentanyl, carfentanil, and other opioids, although when administering an antidote, the strength of the opioid needs to be taken into account. Multiple doses of naloxone may be required.
Sources
1 “Drug Profile: Heroin, Fentanyl, and Carfentanil.” Holistic Recovery Centers. 2017; Feb. 6. https://holisticrecoverycenters.com/heroin-fentanyl-carfentanil/ (accessed April 18, 2018).
2 “Fentanyl: A Briefing guide for First Responders.” U.S. Department of Justice, Drug Enforcement Administration. 2017; June 17. https://asprtracie.hhs.gov/technical-resources/resource/4449/fentanyl-a-briefing-guide-for-first-responders (accessed April 18, 2018).
3 O’Donnell JK, Halpin J, Mattson CL, Goldberger BA, Gladden RM. “Deaths Involving Fentanyl, Fentanyl Analogs, and U-47700—10 States, July–December 2016.” Centers for Disease Control and Prevention. 2017; Nov. 3. https://www.cdc.gov/mmwr/volumes/66/wr/mm6643e1.htm. (accessed April 16, 2018).
4 ”Carfentanil: A Critical Review Report.” World Health Organization. Expert Committee on Drug Dependence. 2017; Nov 6-10. http://www.who.int/medicines/access/controlled-substances/Critical_Review_Carfentanil.pdf (accessed April 16, 2018).
5 See note 4.
6 “Fentanyl FAQs.” United States Drug Enforcement Administration. https://www.dea.gov/factsheets/fentany (accessed April 18, 2018).
7 See note 4.
8 Mikota SK, Plumb DC. “Elephant Formulary.” Elephant Care International. 2003–2017. http://elephantcare.org/resources/formulary/drug-index/carfentanil/ (accessed April 13, 2018).
9 See note 3.
10 “WHO recommends the most stringent level of international control for synthetic opioid carfentanil.” World Health Organization. 2017; Dec. 13. http://www.who.int/medicines/news/2017/WHO-recommends-most-stringent-level-int-control/en/ (accessed April 16, 2018).
