CBRNeWORLD


Dr Christina Baxter, ceo of Emergency Response TIPS, US and Dr Michael Logan, of the research and scientific branch, Queensland Fire and Emergency Services, Australia


Synthetic Opioids in Operational Environments – Part II: Decontamination


epidemic. This resulted in over 60,000 deaths in 2016, which corresponds to more than 1,100 people dying per week, or 160 deaths per day, across the US. The death rate is still climbing. Sadly, responses to synthetic opioids are the new ‘white powder’ calls. This paper focusses on current knowledge and suitable decontamination methods that can be applied to responders, objects, and surfaces when dealing with synthetic opioids. Fentanyl and fentanyl analogues are


A


predominantly a respiratory hazard to emergency responders. While they are also a dermal hazard, the material penetrates the skin and moves into the blood stream very slowly, so is unlikely to be the source of a toxic dose for emergency responders. For example: in the case of fentanyl, for an average 165lb (75kg) person, the dose required for an analgesic effect is estimated to be 2.5micrograms, an anaesthetic effect occurs between 25 and 125micrograms, and the lethal dose is 2.5milligrams. While the effects of fentanyl via inhalation are seen almost immediately, the effects from dermal exposure take hours.


An appropriate decontamination approach Let’s quickly review our knowledge of fentanyl. For this article, we will focus on the solubility (hydrochloride salt, citrate salt, oxalate salt, or free base), pH of the solution, concentration of the threat material and chemical behaviour. The solubility of the different variants


of synthetic opioids is an important factor when considering decontamination.


s discussed in Part I of this series (CBRNe World, December 2017)1 the US is in the midst of an opioid


,


Water solubility: hydrochloride salt > citrate salt > oxalate salt > >> free base


Lipid solubility: free base >>> oxalate salt > citrate salt > hydrochloride salt


One way to increase the water solubility of lipid soluble materials is to add a surfactant (soap) to the solution. Regarding pH effects, measurements in cadaver skin demonstrated that the free base form of fentanyl is 218 times more permeable than the ionised (salt) forms with the maximum solubility reaching a plateau at pH9. Fentanyl also changes from its ionised form to the free base form at pH above neutral and it then becomes harder to destroy using oxidation. At pH3, 99.9% of the fentanyl would remain in its ionised (salt) form.2 Therefore, it is important to maintain fentanyl solution pH below neutral so the salt stays in its ionised form since the free base form is harder to destroy using oxidation and passes more rapidly through the skin. Higher concentrations of the threat


material have a better chance of getting operationally relevant doses across the skin barrier. Therefore, to minimise the amount


of material available for personnel exposure and to assist decontamination, the duration, concentration, and surface area of the threat must be minimised, the pH must be maintained at neutral or below, and the temperature should remain at ambient. There is much uncertainty about the


way chemicals destroy fentanyl and its analogues. Recent studies have shown peracetic acid is effective, as is the related product, Dahlgren Decon.3 However, bases were found to be ineffective, and there was much


uncertainty about the efficacy of bleach solutions, including calcium hypochlorite. A comprehensive project has recently started at the University of Queensland in Australia to understand the destruction of fentanyl and its analogues in operational settings, however, we can still make informed decisions about suitable decontamination approaches with what we know.


Evidence-based decontamination guidance Mucous membrane and skin exposure The single most important factor when dealing with synthetic opioids, is to protect the respiratory tract. This is closely followed by protecting mucous membranes, such as the eyes, nose, and mouth. The skin should also be protected and opportunities for contact with fentanyl minimised. From a decontamination


perspective, if the eyes and mucous membranes are suspected of having been contaminated, they should be flushed with copious amounts of saline or water to remove and minimise the dose. Immediate medical support should then be provided. Areas of direct skin contact with any


residue suspected of containing synthetic opioids should be washed immediately with copious amounts of water. As soon as feasible, skin surfaces should additionally be washed with soap and water, applying a skin-safe, low-pH soap to the skin surface using a sponge or wash cloth with minimal pressure. The body should be rinsed with clean water at low-pressure and all body surfaces should be wiped with a towel until they are dry. If an expedient decontamination


method is not available, an emergency


www.cbrneworld.com CBRNe Convergence, Orlando, USA, 6-8 November 2018 www.cbrneworld.com/convergence2018


February 2018 CBRNe WORLD


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