Dr Christina Baxter, CEO of Emergency Response TIPS, and Dr Michael Logan, of the research and scientific branch, Queensland Fire and Emergency Services, Australia on Synthetic Opioids in Operational Environments – Part III: Protection
The drugs don’t work T
he first two papers in this series on responding to incidents involving synthetic opioids focused on
detection and decontamination. This paper covers the selection of appropriate personal protective equipment (PPE). All three documents may be used together to formulate operational guidelines specific to your community. Is your agency using an evidence-
based approach to select the personal protective equipment for your team when responding to incidents involving synthetic opioids? Does this approach include both scientific evidence about the hazard and operational information regarding the risk? The opening section of this paper outlines the scientific evidence currently available for synthetic opioids, including fentanyl and fentanyl analogues pertinent to respiratory and skin exposure. The second part applies the risk associated with a variety of operational objectives along with the scientific evidence to recommend the appropriate protective posture for a variety of situations. First, it is important to understand
that synthetic opioids are inhalation, ingestion and dermal absorption hazards. Inhalation is the predominant hazard, but ingestion and dermal absorption contribute towards the total dose and therefore must be minimised or eliminated. Unfortunately, unlike many other hazards that we deal with in the operational environment, there are no published exposure standards or clean-up guidance telling us how much is safe. In the case of synthetic opioids, data is available from the pharmaceutical industry dating back to the invention of fentanyl by Dr Paul Janssen in 1959.1
The industry has
published occupational exposure limits (OELs) for fentanyl with the eight hour time weighted average (OEL-TWA) ranging from 0.1 to 0.7μg/m3 and a 15 minute short term exposure limit (OEL- STEL) of 2μg/m3
.2,3 In the case of fentanyl, for an average CBRNe Convergence, Orlando, USA, 6-8 November 2018
www.cbrneworld.com/convergence2018 36 CBRNe WORLD February 2018
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165lb (75kg) person, the dose required for an analgesic effect is estimated to be 2.5µg, an anaesthetic effect ranges between 25 and 125μg, and the lethal dose is 2.5mg. While the analgesic effect is not lethal, it can cause symptoms (drowsiness, nausea, confusion, euphoria) that will reduce the emergency responder’s ability to function properly. The anaesthetic effect can lead to respiratory depression and arrest if not properly monitored. Therefore, while the lethal dose is considered to be 2.5mg, it is imperative that the emergency responders never receive a dose of even 2.5µg so that they can continue to operate effectively.
Risk analysis for respiratory protection To perform the risk analysis for a variety of scenarios in which an emergency responder might be exposed, several assumptions have to be made. These relate to: variations in product purity for different operational scenarios; variations in time for task execution; no other risk control measures being applied; a maximum airborne value of 7310ng/m3
as measured in a pharmaceutical production facility4; the
protection levels provided by different respiratory products; and, that standard breathing rates apply across a variety of operational tasks.5 First, let’s determine the appropriate
class of respiratory protection to provide the necessary level of safety using the assigned protection factor (APF). In the US, APFs can be found in OSHA 29 CFR 1910.14(d)(3)(i)(A). The table below
provides a subset of APFs of interest to the emergency response community. To determine the appropriate level of
protection, we must first estimate the maximum concentration of threat material we expect to encounter for a given operational scenario. In the case of the pharmaceutical company4
where the
average maximum airborne concentration of fentanyl was measured at 7310ng/m3
, the required respiratory
protection factor was 73, therefore a full- face piece PAPR or SCBA was needed. We would consider this similar to a moderate or high risk operational environment. The next question is whether or not a half-mask APR would be suitable for situations where the risk was considered to be minimal (eg traffic stops). Using the protection factors and the OEL of 0.1μg/m3
allowable would be 1μg/m3
, the maximum concentration of fentanyl
in the air. Taking a midsize car with an average internal volume of 2.69m3
, the
maximum amount of fentanyl in the air would only be 2.69µg. Even at a dilution factor of 1% fentanyl in the cut product, that still only allows for 269μg of cut product suspended in the air. This simple situation demonstrates the need to adopt respiratory protection even in minimal risk situations where there is uncontained product. However, caution should be used when employing half- mask respirators in the operational environment when the threat of opioid suspension in the air is viable. Finally, the considerations for
filtration efficiency must be addressed for those situations where half-face air
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