(CNN) Accidental opioid overdose is an alarming phenomenon being seen more frequently among first responders, including police officers and paramedics, which is why the US Drug Enforcement Administration issued a warning to them this week.
Illicit fentanyl, a synthetic opioid, can be 50 to 100 times stronger than morphine. It's also 30 to 50 times more powerful than heroin. That potency is what can cause police officers or paramedics to overdose if they encounter only a small amount of the drug.
The new DEA recommendations highlight the best ways to avoid accidental exposure to fentanyl-related substances. First, responders must be trained and equipped to recognize the hazard, and know how to put on personal protective equipment such as gloves, dust masks, safety glasses, paper suits and shoe covers. The level of the equipment may need to be increased or decreased depending on the situation.
The agency also recommended that first responders always have naloxone, the opioid overdose antidote, on hand. Additionally, the guide provides an overview of the methods for responding to a situation in which fentanyl may be present, how to identify and treat an overdose victim, and the ways drugs and other evidence should be collected.
Opioids: Addictive painkillers
Prescription and illegal opioids are commonly abused because they are so addictive.
Opioid medications bind to the areas of the brain that control pain and emotions, driving up levels of the feel-good hormone dopamine in the brain's reward areas and producing an intense feeling of euphoria.
As the brain becomes used to the feelings, it often takes more and more of the drug to produce the same levels of pain relief and well-being, leading to dependence and, later, addiction.
Oxymorphone hydrochloride, under the name Opana ER, was at the center of an HIV outbreak in Indiana in 2015. Some addicts began injecting and shared needles increased the spread of HIV.
In June, the Food and Drug Administration requested that Opana ER manufacturer Endo Pharmaceuticals pull the drug from the market. It was the first time the agency has asked that a opioid pain medication be pulled "due to the public health consequences of abuse." Endo announced in July that it would pull the drug.
Codeine is one of the weakest opioids, often given when painkillers such as acetaminophen or ibuprofen fail to work. Because it decreases activity in the part of the brain that controls coughing, it's frequently mixed with other liquids to develop cough syrups for colds and flu. It has frequently been used for pain relief after removal of tonsils and adenoids in children.
After an investigation, the FDA restricted the use of codeine and tramadol in children under 12 and recommend against their use in children between 12 and 18 years of age. Additionally, the FDA has warned breastfeeding mothers not to take these medications due to the risk of serious adverse reactions in breastfed infants.
You can't get heroin by prescription, but many heroin users start off abusing prescription opioids, then turn to this illegal opioid.
CNN's Chief Medical Correspondent Dr. Sanjay Gupta has reported on recent research
that shows today's typical heroin addict starts using at 23, is more likely to live in affluent suburbs and was likely unwittingly led to heroin through painkillers prescribed by his or her doctor.According to the CDC
, deaths from overdoses of prescription drugs and heroin continue to be the leading cause of unintentional death for Americans, rising 14% from 2013 to 2014.
Fentanyl citrate, pictured here, is a Class II controlled substance and one of the most powerful opioids on the market. It's often administered via injection or transdermal patch, or in lozenge form for pain after surgery, for difficult-to-manage chronic pain and for people who have developed a tolerance to other opioids.
The type of fentanyl usually associated with overdoses is bought on the street in powder or pill form and is often mixed with heroin in a clandestine lab to increase the high it produces. Street names include Apache, China girl, goodfella, jackpot, murder 8, TNT and Tango and Cash.
These pills are a more powerful form of codeine, called hydrocodone, and are often mixed with acetaminophen. Hydrocodone is the most frequently prescribed opioid painkiller, according to the U.S. Food and Drug Administration
, and the most abused. An overdose of hydrocodone can cause "cold and clammy skin, severely constricted pupils, and slow breathing that can lead to a loss of consciousness and death."
Oxycodone is a powerful narcotic pain reliever prescribed for moderate to high pain relief. It's often given in an extended-release formula for patients who will need to be on pain medications for long periods of time.
Patients are warned not to break, chew, crush or dissolve extended-release tablets because the rush of oxycodone into the system could cause serious health problems, including overdose and death.
Though highly addictive, oxycodone is not thought to be as frequently abused as hydrocodone. OxyContin, Percocet, Percodan and Tylox are some trade-name oxycodone products.
Morphine is another powerful opioid often administered via syringe for severe pain. It can come in pill form, usually as extended-release tablets and capsules, and is prescribed only to relieve difficult, chronic pain that cannot be controlled by the use of other pain medications.
As with most opioids, mixing medications, drinking alcohol or taking other meds that contain alcohol, or using street drugs while taking morphine, increases the risk of breathing problems or other serious, life-threatening side effects.
Meperidine is another narcotic analgesic, similar to morphine. It's often used to help put people to sleep before an operation and to provide pain relief after childbirth.
The most common brand name is Demerol, which comes in both tablet and liquid forms. It is usually taken with or without food every three or four hours as needed for pain.
As with all opioids, meperidine can cause drowsiness, so never drive a car or operate machinery after taking it until you know how you will react.
Hydromorphone is another highly potent prescription painkiller. It's most commonly known by the brand names Dilaudid, pictured here, and Exalgo.
Liquid hydromorphone holds the dubious honor of being frequently mistaken for morphine
in hospital "wrong drug" medication errors because of the similarity of the names and appearances.
Though methadone is used to relieve severe chronic pain, it's most commonly known for preventing withdrawal symptoms in patients who were addicted to opioid drugs, as a part of their recovery process.
Methadone has many of the same side effects as other opioids, including weakness, headache, nausea and vomiting, stomach pain, sweating, difficulty urinating, mood changes and vision problems, and difficulty falling asleep or staying asleep.
Buprenorphine is a opioid used as an alternative to methadone to help addicts recovering from heroin use. Buprenorphine is different from other opioids because it's a "partial opioid agonist," which means that when taken in proper prescribed doses, it should produce less euphoria and physical dependence, and therefore a lower potential for misuse. It's also supposed to have a relatively mild withdrawal profile.
However, if abused by crushing and snorting or injecting, it can suppress breathing and cause dizziness, confusion, unconsciousness and death.
Subutex, the brand name for buprenorphine, is taken as a tablet placed under the tongue and allowed to dissolve.
The brand Suboxone is a combination of buprenorphine and naloxone, an opioid antagonist. Antagonists block the opiate receptors in the brain, keeping the narcotic from creating the high abusers crave.
Roxanne Franckowski, a chemist with Cayman Chemical Co. in Ann Arbor, Michigan, who works with law enforcement to identify illicit fentanyl, says the guidelines are thorough.
"People in the laboratory, they're told all the time about making sure you have your personal protective equipment. But officers, who don't have the chemistry training or the background, they may not think of these things," Franckowski said. "So the fact that they're putting this guidance out there, and they're telling officers 'you may want to carry these extra pieces of personal equipment with you,' because they don't know when they roll up to a scene what they're going to encounter, is really good."
Cases of accidental overdose in police officers and paramedics have been reported across the nation.
One night in mid-May, a police officer in East Liverpool, Ohio, helped with a drug bust and brushed fentanyl powder off his uniform after returning to the station. The officer, Chris Green, then started to feel his body shutting down.
Green was given naloxone and taken to the hospital, where he fully recovered.
"This is scary," East Liverpool Police Chief John Lane said. "He could have walked out of the building and left, and he could have passed out while he was driving. You don't even know it's there on his clothes."
In another incident later in the month, a sheriff's deputy and two emergency medical technicians were treated for accidental overdoses in Harford County, Maryland.
The DEA says 2 to 3 milligrams of fentanyl is enough to cause respiratory depression, arrest and possible death -- a measurement equivalent to five to seven grains of table salt.
For other types of fentanyl-related synthetic drugs, an even smaller amount can be just as dangerous, Franckowski said.
"It can come into your system in any way. You can inhale it. You can ingest it. If it becomes airborne, it can be absorbed into your eye," she said. "If your hand is exposed and you touch fentanyl, it can be absorbed that way."
And it seems likely that accidental overdoses will continue to be a problem for first responders.
The Centers for Disease Control and Prevention says the number of synthetic opioid overdose deaths increased 72.2% from 2014 to 2015.
The DEA reported that during the first quarter of 2017, its laboratories had received 230 seized drug samples that were identified as fentanyl, fentanyl-related substances and other synthetic opioids. Fentanyl accounted for 58% of those.
That doesn't come as a surprise to Franckowski.
"I think it's probably going to get worse before it starts getting better," she said. "People continue to alter the molecule to whatever new substitution they're going to put on the fentanyl. And we don't know what those will do to the body. A lot of the substituted opioids, we don't have the data on as far as the toxicity and the potency of. And I think that means opioids are probably going to be around for a while, unfortunately."