The opioid isn't easily absorbed through the skin, no matter what viral headlines say.
Ty Wright for The Washington Post via Getty Images
Christopher Moraff has worked with fentanyl and related highly potent synthetic opioids at least once or twice a week for the past year. To collect data, Moraff, a journalist and independent researcher, gathers samples of street heroin and cocaine in Philadelphia—then tests them for the presence of fentanyls. Eighty percent of his heroin samples are positive. He does not wear protective gear.
If public fears about these substances are correct, Moraff is taking an extraordinary risk. Massachusetts recently banned courtroom exhibits containing fentanyls in most cases based on concerns that they might waft out of their packaging and start killing bystanders. Some police officers have started to wear masks, gloves, and hazmat suits during busts, following anecdotal reports that skin or aerosol exposure to fentanyls had made cops and nurses ill—even requiring the use of the opioid antidote, naloxone.
But toxicologists and physicians who actually work with overdose victims and directly with fentanyl say these worries are misguided. It would be difficult to get even mildly high—let alone overdose—by touching street fentanyl or being near people who use it. (One possible explanation for the reported symptoms is the nocebo effect, or the phenomenon where even thinking a substance is harmful can lead to exposed people experiencing negative side effects.) But if first responders avoid or delay treating overdose victims because they fear such exposure, more deaths may result.
Jeremy Faust, an instructor at Harvard Medical School and emergency room physician at Brigham and Women’s Hospital has treated many fentanyl victims in the ER. He says, “It’s just not a substance that is easily absorbed through the skin,” noting that pharmaceutical companies spent many years and millions of dollars in order to develop technology for a patch to deliver the drug via the skin.
“I have definitely had it on my hands and I have touched people that have used it,” Moraff says. Recently, just out of curiosity, he tested his own urine after he’d spent time testing drug samples that were positive for fentanyl. Unsurprisingly to him, the urine test was negative.
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Basically, if fentanyl could kill via skin exposure or just being near it, users wouldn’t need to inject or ingest it to get high—and we would also be seeing many, many more dead dealers because they handle much larger quantities more frequently.
“I’m immersed in the drug culture here and [constantly] talking to users and dealers,” Moraff says, adding that he’s never heard of a case of dealer or worker dying from accidental exposure, even in “millhouses” where large quantities are processed. Faust, who co-wrote an op-ed in the New York Times about fentanyl myths, says that despite talking to many experts and hearing from many readers, no one has ever reported a skin exposure case with documented toxicology—that is, urine or blood testing.
Getting fatally exposed from particles floating in the air where fentanyl is being or has been used seems even less likely. Only one government has ever been known to have successfully aerosolized a fentanyl as a weapon—meaning, it takes work to do so—and no one else seems to know the technology that was used to achieve this.
In 2002, the Russian government used a form of aerosolized fentanyl to take down several dozen Chechen terrorists who were holding 850 people hostage in a theatre. It is not clear how the fentanyl was aerosolized, but because authorities didn’t tell doctors what had caused the victims to collapse, naloxone wasn’t administered and nearly 200 people died.
Without deliberately aerosolizing the drug, then, unless you’re actually manufacturing the pure stuff or somehow manage to accidentally snort or breathe in a big burst of pure powder, risk from air or skin contact with fentanyl is minimal.
The myth that these exposures can harm, however, may already be costing lives. “I can’t think of a situation in which time is more relevant and fleeting than an opioid overdose,” Faust says, explaining that time spent putting on unnecessary protective gear could be the difference between whether someone dies, is brain-damaged, or simply gets up and walks away.
Other myths about the danger of fentanyls may be doing harm, too. Some media, for example, have claimed that these drugs do not respond to naloxone—even though there is no evidence that this is true. While larger doses of naloxone may be needed to reverse overdoses that contain fentanyls, a compound that is completely immune to it has not been discovered.
“The amount of naloxone you need to reverse even carfentanil, which is an order of magnitude or more times stronger than fentanyl, is not even that much greater,” Faust notes. He cites a case report of a veterinarian who got squirted in the eye with carfentanil, which is used to tranquilize large animals like elephants. “The reversal dose was a lot higher than a typical OD, but it wasn’t like they had to call in extra or needed a wheelbarrow full,” he adds.
Some have also claimed that fentanyl’s potency means that it may be resistant to treatment with medications for opioid use disorder like buprenorphine and methadone. However, this, too, is not accurate: A recent study of overdose prevention using these medications in recently released prisoners who were exposed to a market flooded with fentanyl found that they still reduced relapse and death rates.
The media seeks novelty relentlessly—every drug epidemic always has to be the most severe, every new drug on the scene has to be the most addictive and deadly ever. This has led to some hilarious contradictions in newspaper archives, where journalists first claim that heroin, then crack, then meth, then heroin again is just the worst. It also leads to cynicism when, in fact, we do currently have the worst overdose epidemic in history because, of course, that’s what we heard last time.
But without exaggeration, street fentanyls are truly the deadliest opioids we have seen. We don’t need to claim that they kill if you just touch or walk by them or that they resist all treatment for this to be true.
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