It is not clear what the legal ramifications are for the prosecution or defense of a drug-related case, but the recent decision of the Massachusetts state court to ban fentanyl and its analogs, such as carfentanil, from the courtroom reflects unfounded fear and misguided science.
There is little doubt that fentanyl, a highly potent opioid, and it analogs are extremely dangerous drugs when introduced into the body. Last year alone, the death rate from these synthetic opioids doubled from the prior year, accounting for well more than 20,000 fatalities, likely explaining the fall in life expectancy among certain demographic subgroups in the United States. So it is without doubt that these potent opioids can kill.
These cases share similarities: officers brush powder from their clothing, enter a vehicle with drug present, or find the drug on a suspect, and shortly thereafter develop vague symptoms such as lightheadedness, weakness or shortness of breath. Precincts have been evacuated, structural decontamination has been performed, and officers were justifiably sent to the emergency department for evaluation. These efforts are for naught. Stated plainly and simply, this is just not how fentanyl poisons.
To date, none of these reported law enforcement exposures has been confirmed to a medical standard, and the reported symptoms and responses to naloxone are not typical of opioid poisoning. Furthermore, there is a plausible explanation for these effects, as difficult as it is to hear. Police are susceptible to the same stress and worry that everyone suffers, perhaps with different thresholds or distinct etiologies. Note that in none of these reports has a dealer or user developed symptoms despite presumably much more significant and prolonged exposure.
To be clear, there are no disputes at all with law enforcement’s concern for officers’ well-being, nor for their desire for medical evaluation after an exposure. Law enforcement officers perform a tough job, and this added stressor does not make it any easier. All emergency physicians hope that there is never an officer who suffers harm related to occupational fentanyl exposure. Along with poison centers around the nation, we search continually to refine our understanding of the risks.
The focus on law enforcement in a discussion about legal proceedings emphasizes that the situations are essentially identical. The risk of exposure in a stopped vehicle or precinct evidence room is analogous to that in the courtroom — negligible. Fentanyl powder, even if not wrapped, will not poison through environmental exposure. It is not volatile, so there is none in the air we breathe. It is true that the powder can be disturbed by air currents, but powders do not stay airborne for long and quickly settle, vastly limiting inhalational exposure. Courtrooms are not particularly breezy, and the drug is certain to be securely contained.
Fentanyl can be absorbed through the skin, but this process is very slow and inefficient. The medicinal administration of fentanyl in patch form for long-term pain relief requires specific formulation to ensure it can traverse the layers of the skin. Even with this advanced chemical preparation it still takes hours for the drug to appear in the bloodstream. Likewise, touching confiscated product, while extremely unlikely to lead to symptoms, would not do so rapidly because the powdered fentanyl is absorbed even more slowly than the pharmaceutical form. This explains our passivity toward the aforementioned exposures with rapid onset effects and provides plenty of time for personal decontamination.
Several professional organizations and governmental agencies, along with individual medical experts such as medical toxicologists, have underscored the limited risk of occupational exposure to fentanyl and its analogs. Merely observing standard precautions by wearing gloves will prevent any dermal contact when handling the drug. If the skin is inadvertently contacted, prompt, but not panicked, washing with soap and water will completely remove all drug.
Left undisturbed, such as in a sealed package, the risk of harm is unequivocally absent.
Safety is of paramount importance at all times. Nobody should be harmed by needless exposure to a risky environmental toxin. Prohibition of drugs in the courthouse undoubtedly will prevent courtroom exposure, but this decision to do so should be made with the realistic understanding that exposure to protected product is completely non-threatening. The legal implications of the decision to ban evidence from the courtroom may not yet be defined, but should be juxtaposed to the essentially non-existent risk of unintentional fentanyl poisoning.
Lewis S. Nelson, M.D., is a professor and chair of the Department of Emergency Medicine and director of the Division of Medical Toxicology at Rutgers New Jersey Medical School. He is chief of service of the emergency department at University Hospital of Newark, New Jersey.