What You Need to Know

The following was adapted from the White House Fentanyl Safety Recommendations for First Responders in 2016.

Fentanyl can be present in a variety of different forms (e.g. powders, tablets, capsules, solutions, and rocks) and can be present in multiple different types of drugs (black tar heroin, methamphetamine, rock or powder cocaine, etc.).
Incidental skin contact may occur during daily activities, but is not expected to lead to harmful effects. Use universal precautions, including making sure contaminated skin is promptly washed off with water.
Personal Protective Equipment (PPE) (i.e. nitrile gloves) is effective in protecting you from skin exposure.
Significant quantities of airborne fentanyl particulates pose a slightly higher risk of exposure, so follow your department guidelines if the scene involves large amounts of suspected fentanyl (e.g. distribution/storage facility, pill milling operation, clandestine lab, gross contamination, spill or release).
Do not ingest any suspected fentanyl that you encounter at a scene via mucous membranes or the bloodstream directly (i.e. inhaling/snorting, smoking or injecting).
Do not touch your eyes, mouth, nose or any skin after touching any potentially contaminated surface.
Wash skin thoroughly after the incident before eating, drinking, smoking or using the restroom.

Signs of Fentanyl-related Opioid Toxicity (i.e. “Overdose”) and Proper Response Protocol:

Slow breathing or no breathing, drowsiness or unresponsiveness, and constricted or pinpoint pupils are the specific signs consistent with fentanyl intoxication.
Naloxone is an effective medication that rapidly reverses the effects of fentanyl.
If someone is exhibiting the above symptoms, administer naloxone according to your department protocols.
If naloxone is not available, rescue breathing can be a lifesaving measure until EMS arrives. Use standard basic life support safety precautions (e.g. pocket mask, gloves) to address the exposure risk.
If needed, initiate CPR until EMS arrives.
Other symptoms, such as dizziness, tachycardia (rapid heartbeat), rapid breathing, sweating and anxious feelings are not symptoms of opioid toxicity and the affected responder may be experiencing a response to fear of exposure. If a responder experiences these symptoms, they should also be evaluated by EMS or a mental health professional.

Background: Overdose & Fentanyl in San Francisco

California has one of the lowest rates of overdose deaths in the nation, with the number of opioid-related overdose deaths hovering around 2,000 over the last few years. However, the California Department of Public Health (CDPH) reports 234 fentanyl-related deaths in 2016 and 373 in 2017, marking a 59% increase over a one year period. While California is not experiencing the dramatic increases in overdose deaths compared with the Eastern part of the U.S., harm reduction programs and public health departments in various parts of the state continue to be proactive in addressing overdose risk by implementing evidence-based interventions like naloxone distribution and access to medication-assisted treatment (MAT).

San Francisco experiences approximately 100 opioid-related deaths per year (see Table 1). San Francisco has been experiencing an influx of IMF products into the drug supply since early 2015. While the presence of IMF in the San Francisco drug supply remains limited and inconsistent (as opposed to other regions of the country) we experienced a doubling of overdose deaths related to fentanyl in a one-year period; 22 deaths in 2016 compared with 11 deaths in 2015.

Table 1: Opioid Overdose Deaths, San Francisco CA 2016 (N=104)

Data provided by OCME to SFDPH’s Substance Use Research Unit (SURU) and analyzed by Chris Rowe and Dr. Phillip Coffin

San Francisco has a well-coordinated monitoring and response system in place to ensure up-to-date information and access to naloxone is widespread. The Department of Public Health (SFDPH), the Office of the Chief Medical Examiner (OCME) and the Drug Overdose Prevention and Education (DOPE) Project, San Francisco’s overdose prevention and naloxone distribution program operated by the Harm Reduction Coalition, work in tandem to prevent fatal overdose. OCME provides data to SFDPH and DOPE immediately when there are clusters of overdoses that appear to be fentanyl-related. SFDPH and DOPE then issue communications to harm reduction programs and other city departments and programs who provide services and care to PWUD.

According to data obtained from OCME and analyzed by SFDPH’s Substance Use Research Unit (SURU), we have some basic information about San Franciscans who have died from fentanyl-related overdose (see Table 2). Upon close review of the fentanyl-related deaths in San Francisco in 2016, we see that 14 of the 22 deaths had no evidence of injection, that 64% were discovered in a private residence or single room occupancy (SRO) hotel, and that 10 of the deaths also revealed the presence of methamphetamine, and 6 revealed the presence of cocaine. While this data does not tell us the whole story—for example, we do not know if the six individuals used fentanyl and cocaine separately and intentionally, or whether the cocaine contained fentanyl without their knowledge—it gives us a general picture of who is being affected by fentanyl-involved deaths in San Francisco.

This data shows us that, in addition to focusing on people experiencing homelessness and people who inject drugs, it is important to engage with individuals who are living in SROs and other congregate housing, and with individuals that are non-injectors, i.e. smoking or snorting fentanyl. Providing people who use multiple substances with information about fentanyl and overdose risk has always been a focus for SFDPH-funded programs like The DOPE Project and is crucial based on a review of this data.

Table 2: Fentanyl-Involved Deaths, San Francisco CA, 2016 (N=22)*

*There were no statistically significant differences between groups using Fisher’s exact of Kruskal-Wallis tests.