Recently I had to do an article critique for my English Composition class. From recent conversations with colleagues, I chose this article.
Do emergency responders really need specific gloves to protect them from fentanyl exposure?
Producers of 'Fentanyl resistant gloves,' would say yes. In a recent article for the Occupational Health & Safety Magazine, we find the statement: “Just as there are gloves designed for cut protection or chemical resistance, there are gloves tested and proven to provide protection against fentanyl and gastric acid.” My critique of this article will be investigating the absorption routes, rates, and dangers of standard nitrile gloves juxtaposed with the recommended “fentanyl resistant gloves.”
Clip of the article:
On August 1st, 2018, the Occupational Health & Safety Magazine published: “Fentanyl Risks Put Focus on Hand Protection” the article begins by accurately extrapolating a twenty one percent increase in opioid related deaths from 2015 to 2016. With its growing prevalence, the article infers that emergency first responders are at a serious risk for inadvertent exposure. There is a solid foundational observation that I do not believe anyone can disagree with. The data referenced in this article shows a clear increase in opioid related overdoses amongst the general population. In the latter portion of the article is where it lists certain aspects of a glove that need to be taken into consideration when purchasing for your agency or program.
My skepticism rises at the amount of danger posed to first responders by transient dermal exposure. The position that agencies need to buy specific gloves to protect their employees from dermal fentanyl exposure, appears to be lacking scientific validation.
Just how well is fentanyl absorbed through the skin?
To answer this question, we need to look at the pharmacokinetics of transdermal absorption. The skin is the largest organ in the body and helps create a barrier to keep water in and toxins out. The outer-most layer is called the epidermis and contains a membrane called the stratum corneum. This layer is only made up of twenty percent water and acts as the primary barrier for toxic absorption. Being predominately a lipophilic membrane, a compound that is lipophobic will meet difficulty absorbing through this layer, and into the dermis. Because of the epidermis absorption delay, the stratum corneum acts as a secondary reservoir when patients are given therapy via transdermal patches. The delay between the transdermal application of a drug to its minimum effective concentration (MEC) is dependent on many factors, such as: body temperature, molecular mass, lipophilic properties, and membrane thickness.
Fentanyl is lipophilic and certainly ideal for transdermal application (Margetts and Sawyer, 2007), however even patches designed to expedite fentanyl absorption into the circulation, do not reach peak plasma concentrations for up to twenty-four hours (p.174). It would be extremely unlikely that a first responder would become instantaneously ill by merely “touching” fentanyl.
In order for a fentanyl patch to release at a rate of 100 micrograms per hour, the actual patch would need to be dosed at 16.8 milligrams. There are 1000 micrograms in a milligram. You can see the astronomical amount of dermal fentanyl that needs to be applied just to reach a therapeutic dose.
So why then do we see very intelligent people show signs of an overdose after believing they’ve been exposed? There is always the potential that this substance was inhaled, which fentanyl resistant gloves would be of no assistance. But the interesting finding amongst most of these reports, is the symptoms are atypical from an opioid toxicity. Dilated pupils, tachycardia, and diaphoresis all fit within the psychogenic or panic syndrome. Largely the incidental perceived fentanyl exposures could likely be linked to a phenomenon known as the “nocebo effect” (Stromberg, 2012).
It is also of note that there is a current position statement from the American College of Medical Toxicology (ACMT) and American Academy of Clinical Toxicology (AACT) from December of 2017 (which they have not seen the need to change) that states:
"Fentanyl and its analogs are potent opioid receptor agonists, but the risk of clinically significant exposure to emergency responders is extremely low. To date, we have not seen reports of emergency responders developing signs or symptoms consistent with opioid toxicity from incidental contact with opioids. Incidental dermal absorption is unlikely to cause opioid toxicity. For routine handling of drug, nitrile gloves provide sufficient dermal protection."
I conclude this critique by requesting you provide scientific evidence that industry standard nitrile gloves are not suitable to prevent absorption of fentanyl fast enough to cause deleterious side effects. I have no doubt that the product is well intentioned, but the hysteria of rapid dermal absorption from fentanyl is supported amongst no scientific evidence.
Margetts, L., Sawyer, R., (2007). Transdermal drug delivery: principles and opioid therapy. British Journal of Anesthesia, 7, 174. doi:10.1093/bjaceaccp/mkm033
Stromberg, J. (2012, July 23). What is the nocebo effect?, Retrieved from Smithsonian Website: https://www.smithsonianmag.com/science-nature/what-is-the-nocebo-effect-5451823/