Fentanyl & First Responders: An Asymmetric Threat

The United States is facing an epidemic of opioid abuse. This epidemic has fueled demand for all forms of opioids, including the deadly drug fentanyl. Fentanyl is extremely dangerous even in small quantities. Its street value, ease of manufacture and high potency have led to a situation where police and first responders are coming into more frequent contact with it. Here we will examine the possibility of fentanyl being deliberately used as a weapon of mass destruction (WMD) to cause a mass casualty incident (MCI).

Moscow Theater Siege

Moscow, Russia, Oct. 23, 2002: Approximately 50 Chechen terrorists stormed the Moscow Theater during a performance. Armed with machine guns, small arms and explosives, and wearing suicide vests, the terrorists quickly took control of the building and the approximately 700–800 civilians inside.

The Chechens demanded the Russian government withdraw all troops it had deployed in Chechnya to put down an ongoing insurrection. Chechnya had waged an unsuccessful war for independence from Russia that ended in defeat in 1996. The Russian military had ruthlessly crushed the insurgents and under President Vladimir Putin had again returned to the region in the wake of ongoing terrorist attacks inside Russia. The terrorists demanded a complete withdraw of all Russian military forces from the region or the hostages would be killed.

The Russian government faced with an insurmountable problem: The sheer number of terrorists and hostages along with the presence of explosives and machine guns in a relatively confined area ensured a bloodbath in the event that force was used to try to resolve the situation. There was no conventional scenario known where SWAT teams, Special Forces, anti-terrorist or hostage rescue teams could reasonably expect to neutralize the sheer number of terrorists before at least some of them were able to set off their explosives.

The crisis dragged on for over two days. Finally, early on Oct. 26, Russian security forces raided the building and incredibly killed all 50 terrorists. Soon-freed hostages were being brought out of the building—but many of the hostages were unconscious, and 130 of them ultimately died. What went wrong?

In an effort to kill the terrorists with as little collateral damage as possible, Russian officials injected a fentanyl-based gas (possibly carfentanyl) into the theater’s ventilation system. Their aim was to render the terrorists unconscious prior to security forces storming the building. This strategy worked, as no security troops were injured and all the terrorists were eliminated presumably while unconscious. Unfortunately, most if not all the hostages were also unconscious. It seems that little if any thought was given as to how to care for hundreds of deliberately overdosed civilians. The logistical/medical end of the operation was never fully planned out. The Russian government’s need for secrecy kept even medical professionals from being told the exact nature of the substance used. Consequently, dozens of innocent people died unnecessarily.

This event is proof of concept that anyone with a rudimentary understanding of chemistry could carry out the same type of attack. The questions for the fire service: What would we do if it happened here? How would we react? How are our people trained? How do we avoid the mistakes of the Russian government? 

Fentanyl basics

Fentanyl was first synthesized in 1959 by Belgian chemist Paul Jansen and later marketed as an intravenous analgesic drug, Sublimaze. The Centers for Disease Control and Prevention (CDC) offers this pharmaceutical definition of fentanyl: “Fentanyl is a member of the class of drugs known as fentanyls, rapid-acting opioid (synthetic opiate) drugs that alleviate pain without causing loss of consciousness (analgesic). Fentanyl depresses central nervous system (CNS) and respiratory function.” More information relating to fentanyl, fentanyl exposure, and response postures and recommendations are readily accessible at CDC.gov. 

Conventional pharmaceutical fentanyl is a manufactured synthetic opioid. It is used primarily as a pain reliever, but is commonly used for advanced cancer treatments as well. It is 50 to 100 times more potent than morphine—a staggering number due to the small amount that constitutes a lethal dose.

Because of its potency, ease of access, readily available supply and low-cost, fentanyl has become prolific in the illegal drug community. Unlike ricin, anthrax or other chemical or biological agents that are costly, time-consuming and require sophisticated manufacturing expertise to make, fentanyl is readily available in bulk. Anthrax particles must be between 1 and 20 microns to be considered weapons grade. By comparison, fentanyl citrate (medical grade fentanyl) is between 3 and 13 microns. Considerably close in size. At this size, fentanyl can be readily absorbed into the human body.

Fentanyl’s heroin-like effect makes it a better “high” for the user and thus more desirable. Fentanyl is commonly mixed or “cut” with heroin and/or cocaine as a combination product, increasing the effect of the drug on the human body. When absorbed or inhaled, depending on the concentration and dose, accidental exposure can and has been fatal.                 

With its ever-growing presence in the illegal drug market on the rise, the hazard for first responders becomes evident. First responders may encounter the drug in various forms, from bulk or personal-use quantities to full-blown manufacturing and packaging operation. Further, fentanyl can easily be manufactured almost anywhere and used as a WMD or anti-personnel agent in its current state without the need for a sophisticated lab setting. 

Logistical challenges

One of the challenges the Russians faced was the sheer number of victims needing medical attention. Approximately 800 critical care cases at once can overwhelm any medical system. Just transporting 800 people to hospitals can take hours, as the closest hospitals are overwhelmed and more distant facilities must be used. In the Moscow case, the authorities—despite being on scene for two days as the standoff dragged on—failed to take advantage of that time to set up critical care or triage areas or stage enough ambulances nearby. 

Emergency services and first responders must constantly anticipate the overwhelming challenges they will face if called to respond to any MCI. This is especially true—and magnified—when dealing with a hazmat situation. Even minor exposure to a substance like fentanyl can be deadly. Preplanning with local emergency management agencies to identify facilities, such as convention centers, gymnasiums or National Guard armories that can be rapidly converted to triage and treatment collection points, is a good place to start. 

Additionally, pre-positioning supplies and training for EMS providers in administering symptom-reversing drugs will save lives. Mutual-aid agreements with neighboring EMS providers and even the local public transportation authority can save critical time in mobilizing a rapid transportation element in the event of a worse-case scenario.                                          

Decontamination

The Interagency Board (IAB) published a report on fentanyl in August 2017. It stated the following relating to decontamination procedures: “Fentanyl and analogues are water soluble, so expedient decontamination (rinsing) of any contacted areas with water is advisable. Fentanyl in its hydrochloride form (the most common street form) is more soluble than the citrate form (medical grade). Both are more soluble than the free base. Consider adding soap to the wash water to account for the slightly soluble free base. Splashing should be kept to a minimum to avoid aerosolizing of the materials. Do not use bleach, alcohol-based solutions, or high pH soaps, as they all may enhance dermal absorption of synthetic opioids.”                  

The CDC and the National Institute for Occupational Safety and Health (NIOSH) recommend the following decontamination procedure, which is similar to the procedure currently employed by the Philadelphia Fire Department (PFD): “Wash hands with soap and water immediately after a potential exposure and after leaving a scene where fentanyl is known or suspected to be present to avoid potential exposure and to avoid cross contamination. Do not use hand sanitizers or bleach solutions to clean contaminated skin.”                 

The PFD HazMat Task Force (HMTF) 01 currently uses standardized tactics in the decontamination of potential fentanyl-contaminated individuals or objects. This consists of liquid soap and copious amounts of water. Although effective, it creates a large amount of runoff that must be collected and disposed. This comes at a cost and is staffing-intensive. 

The PFD HazMat unit is currently in the process of acquiring Dahlgren Decontamination solution, which reportedly neutralizes over 99.9 percent of bulk fentanyl hydrochloride within 5 minutes. The system is considerably smaller than traditional decontamination methods currently being deployed. This creates far fewer residual decontamination considerations.

Real life