VANCOUVER—As first responders increasingly come into contact with opioids in their jobs, the dangers such drugs pose is generating different ways of handling the problem — and different views on whether there even is a significant danger at all.

Police officers in Vancouver administered naloxone to one another three times while on duty since they started carrying the opioid antidote in 2016.

All three incidents occurred in 2017, said Const. Jason Doucette, because of “accidental exposures to an opioid during the seizure of controlled substances,” during which “the officer or their co-worker believed the member was exhibiting signs of an overdose and appropriately administered the nasal naloxone.” All three officers made a full recovery.

Doucette, media relations officer for the Vancouver Police Department, said privacy concerns preclude further details from being released, and no VPD officers were made available for in-person interviews.

This scant information leaves many questions: What risks do first responders really face while responding to overdoses and conducting drug busts? And what do we still not know?

Occupational overdose

The rise of dangerous and potent synthetic opioids such as fentanyl in the illicit drug supply is a huge driver of the overdose crisis tearing through Canadian communities. More than 1,400 overdose deaths occurred in B.C. in 2017, according to a report from the BC Coroners Service, with fentanyl detected in more than 1,200 of those.

With multiple overdoses occurring daily around the province, first responders come into frequent contact with individuals who have used opioids, and potentially with the substances themselves.

But the risks these encounters present is much-debated, especially when few details are provided by the organizations to which responders belong.

Fire and ambulance responders in Vancouver have reported no exposures to opioid-related substances in the course of duty.

In April, Capt. Jonathan Gormick of Vancouver Fire and Rescue Services said his staff had administered naloxone 403 times since they began carrying it in 2016. During that period, VFRS responders reported no accidental opioid exposures.

A spokesperson for the Provincial Health Services Authority said paramedics with BC Emergency Health Services have not used naloxone on one another.

“Generally, accidental overdose isn’t an issue for first responders — people don’t overdose by touching fentanyl powder, for example,” she wrote in an email.

A report by the BC Centre for Disease Control found “There have been no verified cases of overdose or sickness in first responders … who have given first aid, medical care or administered naloxone, despite thousands of overdose reversals.”

The same report confirms that no B.C. health-care workers have suffered an overdose or illness because of accidental exposure to opioids at work.

Opioids, naloxone and the human brain

Drugs such as heroin, fentanyl, carfentanil, methadone, morphine, opium, and codeine are called “opioids” because they attach to the opioid receptors in the brain — specifically, in the part of the brain which controls breathing.

When someone is exposed to too much of one or more opioids, the receptors become overwhelmed.

“That’s what causes the danger in an overdose,” said Allison Tario, pharmacist and instructor at the University of Waterloo School of Pharmacy. “It actually stops a person from breathing.”

Naloxone is an opioid antagonist, which works by competing for those same receptors. Tario said naloxone enters the brain and, for roughly 30 minutes, “boots the opioid off the receptors and takes its place.”

But it doesn’t take opioids out of the bloodstream. After that first half-hour naloxone will wear off, meaning latent narcotics can reattach to the brain’s receptors.

And because modern synthetic opioids such as fentanyl and carfentanil are up to 100 times stronger than a drug such as morphine, Tario said naloxone may have to be used multiple times to treat one overdose.

“It’s all about saturating the receptors,” she said. “If you’ve taken something like fentanyl … you need more naloxone to attach to more receptors to reverse an overdose.”

Carrying naloxone has become common practice in Metro Vancouver — among public servants, but also private-sector workers and members of the public.

To date, more than 98,000 naloxone kits have been distributed through the BCCDC’s Take Home Naloxone program. More than 22,000 of those have reportedly been used to reverse an overdose, while nearly 18,000 have been lost, stolen, confiscated or have expired.

Fear and the facility

In Const. Doucette’s email to StarMetro Vancouver, he suggested the risk of officers being exposed to fentanyl is one of the reasons why the VPD is building a new $700,000 drug containment facility.

“This new facility will allow for an even safer environment to further reduce the risk of accidental exposure for our employees,” he said. “Although I don’t have an exact date for this new facility, it’s a priority for our department.”

Funding for the facility was granted through the VPD’s 2018 budget. It will be built on the site of the current VPD office on Glen Drive.

VPD Sgt. Jason Robillard said the facility will allow police officers to process large volumes of drugs for analysis and court purposes safely. The site will include fume hoods, emergency showers and self-contained processing areas.

Harm-reduction workers, however, say this facility simply isn’t necessary for the safe handling of drugs.

Aiyanas Ormond, a spokesperson for the Vancouver Area Network of Drug Users (VANDU), said fentanyl has become commonplace at the VANDU overdose-prevention site, yet none of its staff have been accidentally exposed to the drug.

“We’ve got lots of experience of people working in close conditions with folks who are using fentanyl every day,” he said. “People should take reasonable measures to protect themselves, but in these day-to-day conditions there just doesn’t seem to be any risk.”

Ormond said wearing nitrile gloves is a cheap and effective way to prevent exposure to opioids, even in emergency situations.

Const. Doucette was unable to confirm what precautions had been taken in the incidents during which VPD officers were given naloxone.

It’s in this environment of uncertainty and ambiguity that fear is able to grab hold of public discourse and twist decision-making at both the individual and governmental level, said Daniel Ciccarone, professor of Family and Community Medicine at the University of California, San Francisco.

“Fear is our worst enemy in this epidemic,” he said. “Fear makes people act in militaristic ways … Fear puts delay in the system, makes people want to wear HAZMAT suits ... which decreases the time response to getting to somebody, to getting to a victim.”

Cop risk

Tom Stamatakis, president of the Canadian Police Association, said police officers face challenges harm-reduction workers do not. Each encounter, he said, is a wild card.

“The greatest risk comes from just normal interactions with people who might either be possessing fentanyl or a similar substance,” he said. “Our police officers work in a completely uncontrolled environment. We typically don’t know anything about the facility we’re entering … including what kinds of drugs might be on the premises, or what kinds of drugs a person might be using. So it’s hard to anticipate all of those risks all the time.”

Stamatakis said the widespread presence of fentanyl-laced drugs further complicates attempts to anticipate where it might appear.

“As we’ve seen, this is a very insidious drug, and it’s affecting people across all demographics and different communities, and you just don’t know (when you will encounter drugs),” he said. “That’s part of the risk of being a police officer every day.”

Fentanyl and first responders

Ciccarone, the UCSF professor, said coming into contact with fentanyl (or interacting with individuals who have) isn’t as risky as many people believe.

Illicit fentanyl is a salt, he said, meaning it’s water-soluble rather than fat-soluble.

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“The only things that absorb through skin are fat soluble, so it’s not going in through their skin,” Ciccarone said. “Could you inhale it and get it in your mucous membranes and absorb it? Sure. But it takes a fairly intimate exposure for that to happen.”

Fentanyl patches, for instance, work by holding a fentanyl reservoir close to the skin for hours or days, Ciccarone said. Through “sweat and through persistence,” the drug dissolves slowly into the fatty layer of the skin. Uptake is very slow, taking between 12 and 24 hours.

Fentanyl, he said, is therefore nearly impossible to absorb accidentally through skin in the context of a brief, on-duty first responder encounter.

A case-by-case vetting of reports of accidental opioid exposure in American first responders, he said, showed most didn’t seem to be what they claimed. Psychological reactions to stressful situations involving unknown substances, said Ciccarone, could very well be the culprit.

The BCCDC’s report on fentanyl and first responders points out overdose symptoms can closely resemble physiological responses to the extraordinary pressures first responders experience on the job.

“It is common and normal for repeated and prolonged episodes of extreme stress to have an effect on the body and physical symptoms,” the report reads. “In some cases these symptoms, such as palpitations and rapid breathing, are part of the ‘fight or flight’ nervous system which has evolved for survival situations.”

Investigations into reports of first responder overdose, the report says, found they were not caused by opioid exposure.

“Testing of the materials and environments involved with reported occupational overdoses have been negative for opioids, including fentanyl,” it says. “Blood from the reported cases has also been negative.”

And while Ciccarone acknowledged risk does exist, his conclusions align with BCCDC’s findings.

“I’m not saying there are zero cases ... where somebody got a puff of powder in their face and inhaled it and got into a little bit of trouble,” he said. “But I have seen very few. Very few, which have actually been documented.”

Without evidence such as a toxicity screen proving an officer has been exposed to fentanyl, Ciccarone said it’s impossible to know whether reports of officer exposure are true.

“I would like to see more evidence,” he said. “I would like to see more concrete cases, not just these anecdotes.”

The supply chain

Ciccarone said one reason synthetic opioids have flooded North American cities is the drying-up of the international heroin trade. The war on drugs has whittled Western Canada’s heroin supply chain down to only two sources — Mexico and Colombia . And Colombia , he said, is pulling out.

Synthetic drugs are far less bulky and therefore pose less risk with far greater potential for reward to international traffickers, he said.

And one of the primary ways fentanyl makes it into Canada from foreign countries is through the mail, meaning postal service workers are a first point of contact for incoming opioid shipments.

Canada Post spokesperson Darcia Kmet said all international mail must first clear both customs and a screening by the Canada Border Services Agency before postal workers handle it.

And although this means the risk for Canada Post’s employees is minimal, said Kmet, naloxone kits are “available as a precaution at our processing facilities.” Canada Post has not reported any of the kits being used.

The CBSA, meanwhile, uses mail-screening methods such as X-rays and detector dogs to help identify potentially dangerous items, according to spokesperson Nicholas Dorion.

Personal protective equipment including gloves and suits are also worn during CBSA’s scanning procedures, and naloxone kits are provided in its facilities.

“Successful interceptions have shown that opioids or analogues of fentanyl are typically of laboratory grade and (extremely) potent,” Dorion said. “(This) makes them ideal for trafficking in small amounts, because if they successfully evade detection they can be cut or diluted to sell for consumption.”

The CBSA reported more than 8,500 narcotics seizures in the postal stream in 2017. There were 13,617 narcotics seizures in the postal stream the year previous.

Only one incident wherein a border service agent exhibited signs of opioid exposure has been reported by the CBSA. It occurred at Canada Post’s Léo-Blanchette postal facility in Montreal in 2017.

While the officer recovered, no details were released regarding whether a toxicity screen tested positive for opioid exposure, or whether such a screening had been conducted. No more details will be released, for privacy reasons, Dorion said.

Eyes on us

Taking reasonable precautions is always advisable, said UCSF professor Ciccarone, but misinformation — or an absence of information — can do extraordinary damage. In the early days of HIV, he said, nurses and doctors were quitting because no one yet understood the virus or how it was transmitted.

“We can’t make a mountain out of a molehill,” he said, adding this is especially crucial in Vancouver, to which the world’s eyes are turning as a leader in the field of harm reduction.

“It’s important you all get it right,” he said. “Your neighbours to the south are watching.”

Correction - June 15, 2018: This article was edited from a previous version that misspelled Colombia.

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