"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."

"Inhalation is an exposure route of concern if drug particles are suspended in the air. Fentanyl has potentially high bioavailability (12–100%) by inhalation [14, 15]. It is highly suspected that a weaponized aerosolized containing carfentanil and remifentanil were used to subdue hostage-takers of a Moscow theater in 2002. One hundred twenty-five died as a result of this weaponized aerosolized exposure [16]. Although an optimized airborne dispersal device is unlikely to be encountered in a local event, we considered such a scenario for respiratory protection.

"Industrial producers of fentanyl use time-weighted average occupational exposure limits (OEL-TWA) for alfentanil (1 mcg/m3), fentanyl (0.1 mcg/m3), and sufentanil (0.032 mcg/m3) to limit exposure [17]. At the highest airborne concentration encountered by workers, an unprotected individual would require nearly 200 min of exposure to reach a dose of 100 mcg of fentanyl.

"The vapor pressure of fentanyl is very low (4.6 × 10-6 Pa) suggesting that evaporation of standing product into a gaseous phase is not a practical concern [18]."

"Race and citizenship patterns for fentanyl and fentanyl analogue offenders (Figure 13) differed compared to other drug offenders. Most notably, Black offenders constituted a greater proportion of fentanyl and fentanyl analogue offenders (40.5% and 58.9%, respectively) than other drug offenders (26.5%). Conversely, Hispanic offenders represented a smaller proportion of both fentanyl and fentanyl analogue offenders (33.9% and 9.1%, respectively), compared to other drug offenders (44.9%). U.S. citizens were more prominent in fentanyl (85.1%) and fentanyl analogue (96.1%) offenders compared to other drug offenders (78.3%).

"When focusing just on the comparison of fentanyl and fentanyl analogue offenders, Black offenders represented the largest group of both fentanyl (40.5%) and fentanyl analogue (58.9%) offenders. However, the representation of Hispanic offenders varied significantly, with Hispanics accounting for 33.9 percent of fentanyl offenders compared to 9.1 percent of fentanyl analogue offenders. This difference among the two groups in part reflects that fentanyl analogue offenders were somewhat more likely to be U.S. citizens (96.1%) compared to fentanyl offenders (85.1%)."

"Fentanyl was detected in 56.3% of 5,152 opioid overdose deaths in the 10 states during July–December 2016 (Figure). Among these 2,903 fentanyl-positive deaths, fentanyl was determined to be a cause of death by the medical examiner or coroner in nearly all (97.1%) of the deaths. Northeastern states (Maine, Massachusetts, New Hampshire, and Rhode Island) and Missouri** reported the highest percentages of opioid overdose deaths involving fentanyl (approximately 60%–90%), followed by Midwestern and Southern states (Ohio, West Virginia, and Wisconsin), where approximately 30%–55% of decedents tested positive for fentanyl. New Mexico and Oklahoma reported the lowest percentage of fentanyl-involved deaths (approximately 15%–25%). In contrast, states detecting any fentanyl analogs in >10% of opioid overdose deaths were spread across the Northeast (Maine, 28.6%, New Hampshire, 12.2%), Midwest (Ohio, 26.0%), and South (West Virginia, 20.1%) (Figure) (Table 1).

"Fentanyl analogs were present in 720 (14.0%) opioid overdose deaths, with the most common being carfentanil (389 deaths, 7.6%), furanylfentanyl (182, 3.5%), and acetylfentanyl (147, 2.9%) (Table 1). Fentanyl analogs contributed to death in 535 of the 573 (93.4%) decedents. Cause of death was not available for fentanyl analogs in 147 deaths.†† Five or more deaths involving carfentanil occurred in two states (Ohio and West Virginia), furanylfentanyl in five states (Maine, Massachusetts, Ohio, West Virginia, and Wisconsin), and acetylfentanyl in seven states (Maine, Massachusetts, New Hampshire, New Mexico, Ohio, West Virginia, and Wisconsin). U-47700 was present in 0.8% of deaths and found in five or more deaths only in Ohio, West Virginia, and Wisconsin (Table 1). Demographic characteristics of decedents were similar among overdose deaths involving fentanyl analogs and fentanyl (Table 2). Most were male (71.7% fentanyl and 72.2% fentanyl analogs), non-Hispanic white (81.3% fentanyl and 83.6% fentanyl analogs), and aged 25–44 years (58.4% fentanyl and 60.0% fentanyl analogs) (Table 2).

"Other illicit drugs co-occurred in 57.0% and 51.3% of deaths involving fentanyl and fentanyl analogs, respectively, with cocaine and confirmed or suspected heroin detected in a substantial percentage of deaths (Table 2). Nearly half (45.8%) of deaths involving fentanyl analogs tested positive for two or more analogs or fentanyl, or both. Specifically, 30.9%, 51.1%, and 97.3% of deaths involving carfentanil, furanylfentanyl, and acetylfentanyl, respectively, tested positive for fentanyl or additional fentanyl analogs. Forensic investigations found evidence of injection drug use in 46.8% and 42.1% of overdose deaths involving fentanyl and fentanyl analogs, respectively. Approximately one in five deaths involving fentanyl and fentanyl analogs had no evidence of injection drug use but did have evidence of other routes of administration. Among these deaths, snorting (52.4% fentanyl and 68.8% fentanyl analogs) and ingestion (38.2% fentanyl and 29.7% fentanyl analogs) were most common. Although rare, transdermal administration was found among deaths involving fentanyl (1.2%), likely indicating pharmaceutical fentanyl (Table 2). More than one third of deaths had no evidence of route of administration."

"These findings suggest interventions are needed to further support persons who inject drugs to use naloxone and call 911 when witnessing an overdose. Given the widespread fear of legal repercussions associated with overdose responses, guidance and education are needed to inform persons who inject drugs, police, and the public about policies that legalize the possession of naloxone and to limit arrest and prosecution for carrying naloxone with other injection paraphernalia [75,76]. States and localities should expand criminal legal protections for low-level drug related violations when witnesses call 911 for an overdose."

"Based on our findings, distributed fentanyl test strips would be reliable for the testing of samples identified as opioids and should be more widely distributed. There is growing evidence that fentanyl test strips may help prevent overdose when included with other evidence-based strategies (Peiper, 2019). Other informal techniques such as visual inspection of a substance have been applied by PWUD, but may not be effective in substances that contain traces of fentanyl (Peiper et al., 2019). Our study situated fentanyl test strips within sites that provide naloxone kits, drug use supplies such as syringes, supervised consumption of substances, and drug checking using both test strips and more sophisticated technologies. In contrast to the potential for behaviour change from drug checking results, analysis of several cohort studies within Vancouver during the period of increasing fentanyl contamination in late 2016 showed that a majority of PWUD did not change their drug use behaviours nor translate the knowledge of a changing drug supply to an increased risk of overdose (Brar et al., 2020; Moallef et al., 2019). These findings indicate the need for targeted education and harm reduction interventions for those at risk. Distribution of testing supplies provides an opportunity for further engagement. In BC, an expansion of this pilot program, including continuation at sites included in this evaluation, has occurred to distribute fentanyl test strips labelled with instructions for use. Notably, the described positive behaviour changes rely on an individual possessing knowledge around safer ways to use substances, including knowledge around using a small amount (“test dosing”) and using with others or not alone to avoid overdose and allow for naloxone administration. Furthermore, participants identified using at an OPS/SCS as a potential behaviour, which necessitates that these services exist. Our findings around behaviour change in response to a positive fentanyl result underscore the need for comprehensive harm reduction services and education."

"During 2015, drug overdoses accounted for 52,404 U.S. deaths, including 33,091 (63.1%) that involved an opioid. There has been progress in preventing methadone deaths, and death rates declined by 9.1%. However, rates of deaths involving other opioids, specifically heroin and synthetic opioids other than methadone (likely driven primarily by illicitly manufactured fentanyl) (2,3), increased sharply overall and across many states."

"With a total of 38 different opioids reported, the number of synthetic opioids has grown rapidly in Europe since the first substance was reported in 2009. In fact, most of these substances have been reported for the first time during the past two years, with 9 reported in 2016 and 13 during 2017. Although they play a small overall role in Europe’s drug market, many of the new opioids are highly potent substances that pose a risk of life-threatening poisoning because an overdose can cause respiratory depression (slowing down of breathing), which can lead to respiratory arrest (stopping breathing) and death. The public health importance of this risk is reflected in the fact that most deaths involving illicit opioid use are caused by respiratory depression (White and Irvine, 1999). Of particular concern are the new fentanils. These substances currently dominate this group, with a total of 28 reported since they first appeared in 2012.

"Reflecting their small share of the market as well as their high potency, new opioids accounted for only around 2% of the total number of seizures of new substances and about 0.2% of the total quantity reported to the EU Early Warning System during 2016. New opioids are found mainly in powders but also in tablets and, since 2014, liquids. For the most part, seizures are dominated by fentanils. There were around 1,600 seizures of new opioids reported by law enforcement during 2016, of which 70% were related to fentanils. These included 7.7 kg of powders (of which 60% contained fentanils), approximately 23,000 tablets (of which 13% contained fentanils) and 4.5 litres of liquids (of which fentanils accounted for 96% of the total). Some of these liquids are from seizures made by police and customs of nasal sprays, which appear to be growing in popularity as a way of using these substances."

"Alongside their legitimate uses as medicines and in research, the fentanils also have a long history of illicit use as replacements for heroin and other controlled opioids. Between 1979 and 1988, more than 10 fentanils that had been made in illicit laboratories were detected on the drug market in the United States (Henderson, 1991). The first was alpha-methylfentanyl, followed by substances such as 3-methylfentanyl and 4-fluorofentanyl. Typically, they were sold as heroin or ‘synthetic heroin’. Together, these substances were involved in more than 100 deaths, mostly in the state of California. Later, in the mid-2000s, illicitly manufactured fentanyl was sold as heroin or in mixtures with heroin, and was responsible for outbreaks of overdoses that involved hundreds of deaths in the eastern United States (Schumann et al., 2008). It appears that, with the exception of Estonia, where 3-methylfentanyl and fentanyl were responsible for an epidemic of fatal poisonings during this time, these substances caused limited problems elsewhere in Europe (Berens et al., 1996; de Boer et al., 2003; Fritschi and Klein, 1995; Kronstrand et al., 1997; Ojanperä et al., 2008; Poortman-van der Meer and Huizer, 1996).

"Over the past few years, there has been a large increase in the availability of fentanils in the United States, Canada and Europe (Gladden et al., 2016; US CDC, 2015). This has been driven by the opioid epidemics in North America, interest in selling these substances in Europe and broader changes in the illicit drug market."