Introduction
Overdose deaths involving opioids in the USA have skyrocketed 41.5% since 2010 [1],
with a provisional count of over 47,105 deaths from August 2018 to August 2019 [2].
Synthetic opioids, particularly fentanyl, have driven deaths in recent years due to
their high potency and low overdose threshold. Indeed, death statistics in Missouri
suggest over 75% of fatal opioid overdoses involved fentanyl in 2018 [3].
In Missouri, emergency medical services (EMS) personnel and law enforcement officers
(LEOs) are called to respond to the increasing numbers of opioid overdoses. Emergency
responders report frequent occupational safety concerns related to illicit drug use
[4]. One common fear is needle stick injury and the subsequent potential risk of contracting
infectious diseases [5]. Additionally, emergency responders express concern for their
own safety during overdose reversals, including purported instances of aggression
and combativeness on the part of the survivor [6, 7].
With the relatively recent surge in fentanyl-related overdoses, a new occupational
safety concern has emerged among emergency responders: the fear of overdosing from
touching fentanyl [8]. In 2017 alone, over 150 media reports describing first responder
exposures to opioids surfaced [9]. Reports of overdose due to fentanyl contact among
first responders [10–13] have been repeatedly refuted by medical experts [14–16].
Yet, mixed messages from the US government agencies [17] and their prominence in media
outlets have catalyzed the spread of misinformation about the risks of accidental
fentanyl contact. The high level of concern about this theoretical threat has been
especially stark in the context of the COVID-19 pandemic, particularly in the USA,
when police have reportedly expressed comparatively little anxiety about contracting
the potentially deadly virus [18].
There has been an increase in products marketed to address the fear of fentanyl, including
fentanyl exposure prevention kits [19, 20], gloves marketed to protect against fentanyl
[21], other fentanyl-resistant gear and screening devices [22], and fentanyl clean-ups
[23]. Additionally, legislators in the USA have proposed the Providing Officers with
Electronic Resources (POWER) Act that would fund state and local enforcement agencies
to purchase fentanyl screening devices to protect officers from incidental exposure
[24]. However, because these screening procedures require the use of class B hazmat
suits [25] and other equipment prior to responding to the overdose, these precautions
could potentially delay the time-sensitive, lifesaving administration of naloxone
and rescue breathing.
Concerns about fentanyl exposure continue to spread despite a clear consensus from
medical experts that overdose from incidental skin contact is a medical impossibility
[14, 15]. Indeed, this claim has been officially debunked by the American College
of Medical Toxicology and the American Academy of Clinical Toxicology [16] and the
National Occupational Safety and Health with the CDC [26]. A drug policy advocate
has also disproven this myth by holding fentanyl powder in his hand without consequence
and widely circulating the internet footage [15]. Researchers who study reported overdoses
from fentanyl exposure among emergency responders have explained that cases documented
thus far can best be attributed to the “nocebo effect”—a phenomenon in which individuals
believe they have encountered a toxic substance and therefore experience the expected
symptoms of exposure [27]. This is consistent with our broader understanding of occupational
wellness and mental health—or lack thereof—among first responders [28]. When individuals
are already operating under acute stress and with few mental health reserves, fear
of overdose from touching fentanyl could serve as an additional stressor.
To our knowledge, only one study has examined emergency responders’ perceptions of
risk associated with brief exposure to fentanyl. In their study of 247 first responders
in New York, Persaud and Jennings found 80% of responders believed “briefly touching
fentanyl could be deadly.” Based on these findings, the authors concluded trainings
should incorporate accurate information about fentanyl risk and overdose response.
To date, no studies have explored the extent to which these beliefs are modifiable
through training and education.
As part of a broader effort to improve community access to naloxone, the authors of
the current study developed comprehensive training for emergency responders on recognizing
and responding to an overdose, basic tenets of addiction, and the roles of treatment
and harm reduction strategies. Because unfounded fears about incidental contact with
fentanyl could result in delays in responding to overdoses, we incorporated medically
accurate information regarding fentanyl exposure into this existing overdose education
and response training program. In addition to increasing knowledge and improving attitudes
towards overdose recognition and response scenarios [29, 30], we aimed to decrease
participants’ endorsement of the pre- and post-training survey statement “I can overdose
from touching fentanyl.”
Methods
Participants
Between January and August 2019, project staff conducted eight LEO trainings and three
EMS trainings for a total of 11 trainings reaching 200 participants. All trainings
were conducted in the Eastern Region of Missouri, which consistently demonstrates
the highest drug overdose rates in the state [3]. Though all trainings were tailored
for professional emergency responders, other professionals were allowed to attend,
though their survey data was omitted (n = 17). For this study, 113 participants identified
as an LEO or Security Officer “LEO group” and 27 participants identified as an EMS,
EMT, or Fire Department Worker “EMS group”, for a total of 140 participants.
Demographics
Demographic data were collected on the age, race, ethnicity, and gender of each participant
(see Table 1).
Table 1
Demographics
Overall (N = 140)
LEO group (n = 113)
EMS group (n = 27)
Mean age (SD)
40.96 (11.27)
40.6 (11.0)
42.3 (12.5)
Men
110 (79.7%)
98 (86.7%)
12 (44.4%)
Hispanic/Latino(a)
5 (3.6%)
4 (3.5%)
1 (3.7%)
Race
White
115 (82.1%)
89 (78.8%)
26 (96.3%)
Black
15 (10.7%)
15 (13.3%)
0
Multiracial or other1
4 (2.9%)
3 (2.7%)
1 (3.7%)
Refused
6 (4.3%)
6 (5.3%)
0
1Other races includes Asian, American Indian/Alaskan Native, or Native Hawaiian/Pacific
Islander
Procedure
LEO and EMS training content included information about the nature of addiction as
a chronic brain disease, harm reduction principles, concerns about “enabling” drug
use (i.e., naloxone-related risk compensation [29]), the role of addiction treatment
medications, and Missouri’s naloxone and Good Samaritan laws, in addition to accurate
information regarding the medical impossibility of overdosing from incidental skin
exposure to fentanyl. The training portion addressing fentanyl misconceptions took
approximately 10 min to present and discuss. In LEO trainings, the fentanyl information
was taught by an emergency medicine physician. For EMS trainings, it was covered by
the Project Manager.
Participants were consented prior to the start of each training. They were then given
a paper survey including items tapping their knowledge and attitudes about a range
of topics related to opioid overdose recognition and response, including but not limited
to their belief that it is possible to overdose from touching fentanyl (for the purposes
of this study, only this item related to fentanyl contact was analyzed and reported).
Participants completed the same survey immediately following the training. The surveys
were later manually entered into REDCap by a research assistant. The University of
Missouri–St. Louis IRB approved this research study.
Measure of belief in fentanyl exposure risk
Before and after the training session, participants indicated their agreement with
the following original item by checking either “True” or “False”: “I can overdose
from touching fentanyl.”
Statistical analyses
We used SPSS to conduct a Fisher’s exact test to assess differences in pre- and post-training
item responses across the LEO and EMS groups. We then applied McNemar’s test, appropriate
for paired, categorical data, to assess changes in the pre- and post-training proportions
of responses in the overall sample and by professional groups (LEO vs. EMS) to determine
the effectiveness of brief training on reducing the false belief that one can overdose
from touching fentanyl.
Results
Baseline differences by profession
On the pre-training survey, only 20.9% of all participants correctly answered “False”
to the statement “I can overdose from touching fentanyl.” There were differences in
responses across the professional groups, with 16.8% of LEOs and 37.0% of EMS participants
answering “False” (Fisher’s exact test; p = .033).
Effect of brief training
Post-training, 83.6% of all participants correctly responded “False” to the statement
(a difference of 62.7% from pre-training; McNemar’s test; p < .001). Within group
pre-post comparisons also reached significance for both groups, with 81.4% of the
LEO group (McNemar’s test; p < .001) and 92.6% of the EMS group answering “False”
post-training (McNemar’s test; p < .001). This reflected an improvement of 64.6% and
55.6% among LEO and EMS participants, respectively (see Fig. 1). The proportion of
correct post-training responses did not significantly differ across professional groups
(Fisher’s exact test; p = .301).
Fig. 1
Percent correctly responding “False” to the item “I can overdose from touching fentanyl”
at pre-training and post-training
Discussion
With this study, we determined that a brief, 10-min presentation and discussion of
accurate information regarding the lack of risk associated with incidental fentanyl
exposure reduces emergency responders’ endorsement of the belief they could overdose
from such contact and that such endorsements varied between LEO and EMS professional
groups. Indeed, our results suggest LEOs are more likely than EMS personnel to believe
they can overdose from touching fentanyl, though this difference goes away following
the corrective, informational presentation. The pre-training difference is likely
due to EMS personnel having more formal medical training, more experience responding
to opioid overdoses than LEOs, and less interaction with police and the US Drug Enforcement
Administration (DEA) colleagues who have been the driving force behind misinformation
about risks of fentanyl contact [17, 31]. Overall, it is promising that both professional
groups responded well to the brief informational presentation, with over 80% of LEOs
and over 90% of EMS personnel demonstrating a factually accurate understanding about
the lack of overdose risk from incidental fentanyl exposure in the post-training survey.
In the context of COVID-19 and the emerging threats faced by first responders, it
is imperative they have accurate, up-to-date information regarding their own occupational
safety. Low levels of knowledge about fentanyl, particularly among police, may reflect
the relative paucity of training on occupational safety topics outside of weapons
and acts of violence, as research on training pertaining to needle stick injuries
has demonstrated [32].
Limitations and future directions
Despite its novelty and important implications, our study is not without its limitations,
including the lack of generalizability of these findings beyond predominantly White
and male emergency responders in the Midwest, as well as the relatively small sample
size and simple study design, prevented us from conducting more advanced analyses,
assessing confounding variables, or drawing causal inferences. Additionally, we do
not have information to link responders’ beliefs with their tangible behaviors in
the field or the protocols of their agencies. For example, an individual police officer
may understand incidental contact with fentanyl is innocuous but still be bound by
departmental policy to don excessive protective gear or call for responder backup
before attempting to save the life of the individual who has overdosed. Future research
should explore associations between departmental protocols, individual responders’
concerns about fentanyl exposure, and responders’ behaviors on the scene. Also, our
2 h training (described in the “Methods” section) included a number of additional
modules not directly related to fentanyl contact. As the information addressing fentanyl
misconceptions was concise and required only 10 min to teach and discuss, future studies
should investigate whether a brief fentanyl-focused training is sufficient to alleviate
fears about fentanyl exposure.
Conclusions
To our knowledge, this study is the first to demonstrate the effectiveness of a training
intervention in correcting emergency responders’ potentially dangerous misconception
that they can overdose from touching fentanyl, a misconception that could result in
unnecessary delays when responding to an actual overdose, which requires urgent administration
of naloxone and rescue breathing. With brain hypoxia and fatal overdose potentially
occurring within minutes of one experiencing respiratory depression from potent opioid
consumption [33], such delays in responding could result in the serious brain injury
or death of the overdose victim. Emergency responder training programs about overdose
recognition and response should include medically accurate information about the lack
of danger of accidental skin contact with fentanyl to ensure responders act as quickly
as possible when called to the scene of a life-threatening overdose.