Five Questions With: Ryan Marino, MD, on Fentanyl Panic

On March 16 the Vermont-based site VTDigger became the latest news platform to share a breathless story about a police officer overdosing via a brief incidental exposure to drugs. In this case Sgt. Brett Flansburg “collected a small quantity of heroin in a plastic baggie” during a traffic stop.¹ Apparently fine as the possessing motorist was cuffed and taken into custody, Flansburg “began to feel ill” as he drove back to his barracks. Once there, the news source reported, “he collapsed in the parking lot and was found unresponsive.” Fellow troopers administered three doses of naloxone to revive him; Flansburg was then treated and released at a hospital. The suspect—seen to actually swallow a baggie of drugs—did not need medical care.

The article—based on a release from the Vermont State Police—did not report Flansburg inhaling or ingesting the substance he collected; it suggested only dermal contact through the baggie. But it quoted the director of the Vermont State Police saying, “Now there is a new threat that we’re seeing up close: the risk of exposure to powerful drugs that can kill in even tiny amounts. This is so troubling and disconcerting, and it places members of law enforcement at unnecessary risk of possibly losing their lives.”

It sure does—if they snort or eat them. Touching them or just being in the vicinity, not so much.

Yet alarmist stories about dermal and other unlikely exposures proliferate despite the fact that opioids like heroin and fentanyl, powerful though they may be, do not absorb through the skin or easily aerosolize for accidental inhaling. What happened to Flansburg was likely a panic attack. But while such realities are well-known in the medical community, they can be tough to get across to anxious cops, click-starved journalists, and the public at large. 

Across social media a few committed clinicians are doing their best to push back with better facts for the overcredulous. Ryan Marino (@ryanmarino) is often among them. An emergency physician and toxicology fellow at the University of Pittsburgh, Marino challenged VTDigger’s claims on Twitter, as he has in many similar cases, and helped prompt a strong clarification a few days later.²

Marino spoke with EMS World about his efforts to help tamp down the hysteria and create better understanding about the real risks of fentanyl and other opioids.

EMS World: How did your interest in the current opioid misinformation begin, any why is it important to counter some of the bad info that gets disseminated? 

Marino: I honestly don’t remember how it began, but I’ve actually seen it play out. There was a patient in the hospital for other issues who used opioids and had an overdose, and when I showed up staff was actually attempting to place towels under the door instead of going in and resuscitating the patient. That was definitely shocking and frightening to me. 

And it’s not uncommon. I take a lot of calls from outside facilities, and I have heard this so many times. It’s important—opioids are killing a lot of Americans; it’s a big issue. We have first responders out there on the front lines who are the biggest asset to the community in resuscitating these people and preventing their deaths. And I think making their jobs easier, so they don’t have to worry about going near these patients and can be able to do their jobs, is why this matters.

With fentanyl in particular, why do you think there’s so much bad information out there?

It’s hard to say; this is speculation on my part. But I think the news media has definitely latched on to the fact that these more potent opioids are driving the number of deaths, and so they’ve kind of taken on popular boogeyman characteristics. It makes it much easier to blame fentanyl than anything else. And then the even more potent fentanyl analogs like carfentanil come around, and it can definitely scare you. If you’re hearing that people are dying and then seeing reports of other people getting sick just being near it, that can kind of spiral out of control. And once this narrative becomes accepted in the public domain, it’s hard to take it back.

Part of the problem may be that the CDC statement on fentanyl’s occupational risk to first responders is perhaps a bit unclear. You said on Twitter at one point that it hedged too much. Can you elaborate on that? How could it have been better?

A body like the CDC wants to cover all its bases. There was this kind of nebulous incident that happened in Moscow a number of years ago where some sort of fentanyl was potentially used [to kill terrorists].³ No one knows what really happened, but that parlayed into concern about it as a potential weapon. So there are some sources that will say that it’s possible it could be weaponized. I think that’s kind of been extrapolated over to first responder/occupational contact types of exposures, which wouldn’t be the same kind of situation. So that’s where the CDC is coming from: If someone were to get sick and they’d said it was totally impossible, that would be a big issue. Nothing is totally impossible. But the fact that it hasn’t happened in 40-plus years makes me think it’s pretty unlikely at this point. 

When you see misinformation being spread, who are the typical culprits? Is it police departments, local news? Are they open to being corrected?

It seems in most cases something will happen, usually to a law enforcement officer, and they put out a press release saying this public servant was taken to the hospital and speculating on what the cause could be. Then that’s printed as fact by some news source without talking to anyone about whether it’s likely or not.

I think there are enough of these stories out there now that probably everyone’s heard them. And for people like the police who do this kind of work, they may even know someone who’s suffered these symptoms. It’s hard to say no, that person you know did not really get sick from fentanyl, when that’s what someone saw or believes was the case. Some people are open to learning more, but some are just very defensive. They may want to believe what they’ve been told, or they trust whoever their source was more than me, some random stranger on the Internet. 

One of the crazy things to me is that with all these stories, none of them ever update with the toxicological testing! I know for a fact from other sources that some of them have ended up being negative, but that’s never released by law enforcement or the news. 

With so much bad medical information circulating—from antivaccine nonsense to Gwyneth and her jade eggs—how can we in EMS and emergency medicine do a better job spreading good facts and helping people be better informed?

We have two jobs: to stay safe and to take care of our patients. So for our part, basic precautions: Scene safety and environmental PPE are the main things I would recommend in these scenarios no matter what. If I’m touching someone at some unknown scene, I don’t want to end up with an infection—it could be measles! I worry about that more than fentanyl! But I think just kind of staying true to the message and making sure what we’re doing is in the best interests of both the people we work with and the people we serve, to try to get the best information out there.

The other issue I see with this kind of fentanyl panic is that it probably comes from the societal stigma about drugs and drug users. You see words like dirty used, and so touching these people and getting sick seems to me like a natural extension of these fears. But it also leads to more and more stigma. I mean, people are scared now to go grocery shopping or to public pools if they think someone there uses drugs! That really harms all the work we’re trying to do to solve the overdose crisis and help people with addiction. If they’re going to be stigmatized by society, that hurts their chances of long-term success.

References

1.  Galloway A. Vermont state trooper revived with Narcan after traffic stop. VTDigger, 2019 Mar 16; https://vtdigger.org/2019/03/16/vermont-state-trooper-recovers-drug-overdose/.

2. Meyn C. Fact-check: Vermont’s police chief said cops risk death from opioid exposure. He’s wrong. VTDigger, 2019 Mar 20; https://vtdigger.org/2019/03/20/fact-check-vermonts-police-chief-said-cops-risk-death-opioid-exposure-hes-wrong/.

3. To end the 2002 Dubrovka Theater siege, Russian authorities used a lethal gas that killed all the hostage-takers but also more than 200 hostages. It remains unknown what the gas was, but some experts believe it was a fentanyl derivative. No one else has been able to successfully aerosolize such compounds.