Overview

As discussed in our 2021 article on opioid abuse, the rate of opioid use has been on the rise for decades. In recent years, the US has seen an explosion of illicit fentanyl availability, use, and overdoses, which has led to increased media coverage of the drug¹. While many of your patients will not have heard of many of the drugs you carry, most have at least heard of fentanyl, and some may have developed fears or misconceptions about its dangers.

Fentanyl is a synthetic opioid, meaning that unlike heroin or morphine (opiates), which are derived from the poppy plant, fentanyl is created from chemicals in a lab. Fentanyl is packaged in a variety of ways, from transdermal patches to lollipops to vials for injection (the form most commonly carried by EMS)². Illicit fentanyl is commonly found in powder or pill form but could be found in liquid form or mixed with other illegal drugs like methamphetamine³.

Prehospital Uses of Fentanyl

Fentanyl is, at least anecdotally, one of the more commonly used drugs in an ambulance. Fentanyl is typically the first-line drug of choice for prehospital pain management because it is quick-acting and has relatively few adverse side effects when compared to morphine (which is often used as the standard for comparison of opioids). Fentanyl is used to treat orthopedic pain such as fractured bones, manage abdominal and chest pain, and even as sedation after intubation or before painful procedures like cardioversion or pacing.

Patient Fears

Some patients may be fearful of receiving fentanyl, even in a clinical setting, due to the dangers of overdose they have heard about on the news or social media. While this fear may cause some patients to decline pain management altogether, EMS providers can help assuage patient fears by explaining that receiving a controlled dose of fentanyl or other opioids in a clinical setting is generally considered safe and that the antidote (naloxone) is available in case of an overdose. Anecdotally, offering patients a smaller-than-normal dose has also been successful in putting their minds at ease while still managing their pain. Some services may provide alternatives to fentanyl for pain management, such as ketorolac (Toradol), ketamine, or a different opioid like morphine or hydromorphone (Dilaudid).

Managing Overdose Patient

With rates of opioid use and abuse on the rise, EMS providers have found themselves on the front lines of the opioid crisis, responding to increasing numbers of opioid overdose calls. Hallmark opioid overdose symptoms include drowsiness/loss of consciousness, respiratory depression, and constricted pupils. If not corrected, opioid overdoses can lead to respiratory arrest and death.

When responding to opioid overdoses, rely on the first few principles you learned as an EMS provider: Scene Safety and ABCs.

Overdoses can occur anywhere, and often, the scene is chaotic. Creating a safe scene in which to work is the priority. Bystanders may be distraught from watching a friend or family member overdose, so assign a crew member or police officer to manage any bystanders nearby so you can focus on patient care. Since fentanyl is often injected or smoked, keep an eye out for drug paraphernalia, especially needles, which could lead to unintentional blood-borne pathogen exposure. If you cannot adequately assess the area around the patient, you need to quickly move them to ensure your and your crew's safety (for example, you might move to a sidewalk if the patient is found lying in a grassy park area).

The primary killer in an opioid overdose is respiratory depression. Quickly assessing the airway and administering rescue breaths addresses the life threat, allowing you time to administer other treatments like naloxone. Breaths can be administered via BVM or pocket mask, and using airway adjuncts like an NPA will help optimize ventilation without resorting to more invasive means like supraglottic airways or endotracheal intubation. Next, naloxone can be administered intranasally, intramuscularly, or intravenously. While the onset of naloxone is considered “immediate,” it may take two or more minutes before the patient begins to respond (usually, this looks like taking spontaneous breaths)⁴. The lag time between administration and spontaneous breathing is why it’s important to provide supplemental ventilation to opioid overdose patients: you’ll remember from your CPR class that brain cells begin to die after just four minutes without oxygen, so providing supplemental breaths to overdose patients is critical in preventing further harm.

Once the initial respiratory emergency has been addressed and naloxone has begun to take effect, it’s essential to check for other potential causes for the patient’s altered mentation. For example, you might find someone unconscious in bed with syringes on their nightstand and think you have a textbook opioid overdose, only to learn later that they are a diabetic and were hypoglycemic. It’s also important to remember that illicit drugs are not quality-controlled in the same way that pharmaceuticals are, so something sold as fentanyl might contain other drugs like xylazine, which is also a CNS depressant but isn’t reversed by naloxone⁵.

After opioid overdose reversal by EMS, some controversy remains as to whether the patient must be transported to the hospital. Because the half-life of naloxone is shorter than the half-life of many opioids, including fentanyl, there is a concern for rebound opioid toxicity (more simply, re-overdosing once the naloxone wears off)^2,6; therefore, it is essential always to follow local protocols when treating, transporting, and educating these patients on opioid overdose. 

Risk to Responders

EMS providers, firefighters, and police officers may come into contact with fentanyl or other illicit drugs as part of their regular work duties. While the risk of accidental exposure causing an overdose is low, the CDC recommends that first responders take precautions, such as wearing gloves, when responding to potential overdose calls to ensure provider safety^3,7. In addition to the possible risk of exposure to drugs and blood-borne pathogens, these scenes pose a risk for general safety and patient escalation. Therefore, situational awareness and working as a unified front with all on scene, including law enforcement, are crucial to provider safety.