Lethal Dose

The other day I took a call from a customer who really needed my help; her son had been killed due to an overdose of heroin laced with fentanyl. The young man’s family had stopped by to do a “wellness check” and found his body; his time of death was estimated to be one week prior to discovery.

It is much too easy to think that this guy was just another junkie, a liability to his family, a menace to his neighborhood, and a drain on society however, he was a bright, young college student who was working toward a degree in engineering. 

During the 1990’s synthetic opioids were the “go-to” remedy for many of the doctors that were operating pain clinics. When I think back on how many famous people overdosed from the use of synthetic opioids, it really puts things into perspective; some that come to mind are Mac Miller, Prince, and Tom Petty. Many of our top athletes had also become dependent upon them and ended up in rehab clinics. When the government recognized the unethical practices of some of these clinics and began to shut them down their patients were not given a transition plan or addiction support and were forced to look to at the option of street resources. 

Synthetics opioids are now being laced into cocktails with cocaine and other street drugs, increases the risk of exposure thereby increasing potential addiction and dependency on the products.  Fentanyl and carfentanil are much cheaper than heroin to produce and, due to their potency, can be shipped in small quantities right under security’s radar. The variables for distribution are pretty much endless. Below is a chart published by the National Institutes for Health (NIH) that is tracking this trend. This data is for opioids and cocaine alone. Synthetic opioids are being discovered in cannabis gummies and even vape pen compounds. 

We are in a national opioid crisis. Between April 2020 and April 2021, fentanyl claimed 40,010 lives. This is almost twice as many deaths in the 18 to 45 age range in comparison to COVID-19 (21,335), cancer (17,114), car accidents (22,442) or suicide (21,678) respectively. 

The opioid crisis has quietly snuck off to the background while Covid dominated the headlines; perhaps it is not as sensational, after all, they are just junkies, right? This is an attitude, it seems, that the general public has towards those people who are in the throes of addiction.  Opioid addiction has quietly impacted us all, whether poor, middle class, or wealthy.

Another issue people tend to only think of as an afterthought, is cross-contamination or accidental micro-dosing of co-habitants. People can be exposed to opioids that are in the “shipping chain” all the way to the morgue. Clandestine laboratories where cutting, manufacturing, and pill press operations occur are operating primarily in rental properties without the knowledge of the property owner. Considered vandalistic operations, these drug labs are often complacent to any issues with cross-contamination. The mitigation of these properties is a difficult process that only a handful of experts can tackle. The primary issue is who is going to sign on the line guaranteeing that the property is safe for re-occupancy? Below is a picture of the amount of product it takes to cause an overdose in a full-grown man; imagine this in your forced air system or between the cracks in your hardwood floor where your newborn baby just might be learning to crawl.

Photo Source: Public Health Services of San Joaquin County

Does this scare you? It should! Always searching for the next new high, illicit chemists dabbling in synthetics are working hard to service their ever growing, ever demanding, ever available market. We have all watched or gotten word of the TV series, Breaking Bad. This is really happening throughout North America at a pace that is hard to keep up with; deaths caused by hazardous substances are growing in numbers and continue to impact all aspects and levels of our society. We have lost a lot of good people and the efforts to mitigate this problem are desperately needed.  

My primary concern was the customer and her exposure to both the death scene and the risk to those people going into the space to remove her son’s belongings. Coming up with a plan to address the concerns of the next of kin and the property owner became much easier when I suggested that an “extent of contamination” study be done on the property.

I helped my customer by connecting them with an IAQ consultant who was familiar with the protocols for locating sources of cross-contamination in the facility. Points of egress, paths of extraction, tops of fan blades, the HVAC system, electronics, and the space where the occupant was “using” were all surface sampled for contaminants. Luck was with the homeowner because there were only a couple of spots that came up in the pre-remedial screening of this space, and that was the carpeting. Users tend to accidently aerosolize products in their attempt to get that high; in the end, this turned out to be a small bio recovery project.   

If this job was a clandestine drug lab, the risk for extensive damage to the property would be huge. How does insurance look at this? In my opinion, an illicit laboratory or contamination from users would fall under “vandalism.” I am not an insurance expert, but I think this needs to be addressed and legally clarified.  As far as the general users, sadly, most property owners will never know what was spilled or used. This is a hidden world until an unfortunate incident occurs.  

Restorer Risks

This drug knows no demographic race or social status. Its impact has been felt across the US and into Canada. In some cases, we could be going into a dwelling for something unrelated. Often, bio recovery teams will be dispatched into a loss for an unattended death and not know the cause of death which could have been an overdose with cross-contamination existing on the property. Exposure risk may be present from a fellow employee or a family member who is a user.

Eyes present an avenue for rapid uptake of the drug. A best practice in general is to not touch or rub your eyes without properly washing your hands first. When conducting a property evaluation, it is best practice to don safety glasses. The safety glasses will offer some protection to the eyes as well and provide a reminder to combat the inadvertent tendencies of touching your eyes.,

The Restorer/Cleaner Training Requirement Conundrum

In recent years, the Biohazard Mitigation field has developed a stigma of high financial rewards regarding its event-driven opportunity. The popularity of the field continues to grow, especially with Hollywood getting into the action with movies and shows such as “Spotless”, “Cleaner”, and “Sunshine Cleaning” promoting our industry. The industry has seen an alarming number of companies being attracted to the field without the understanding, knowledge, and training of what is involved and the potential risks.  This has allowed a lot of associations, standards bodies, independent schools, franchises, and training platforms to promote heavily into the industry; this, in turn, causing fragmented training sessions and inadequate course offerings that are placing people at risk.  

When this process started to impact North America, the American Bio Recovery Association (ABRA) went into action to develop a Risk Assessment Guideline for contractors providing bio recovery services.  Being a third-party certifying body for individuals and contractors in the industry, ABRA made several changes regarding its certification programs for its Certified Bio Recovery Technician, Supervisor, and Master Programs.  All bio recovery certification programs are now prerequisite-based and a knowledge of BSRA is just one of the multiple areas of study; we had to consider the basic information covered in the definition of bio recovery in both the body of knowledge and exam development. 

Bio recovery is defined as the act of assessing risk, mitigating threats, and remediating conditions resulting from the release of biological hazards. This may include crime and trauma mitigation (bloodborne and body fluids), suicide cleanup, outbreak response, zoonotic diseases, foodborne diseases, public health threats, illicit drugs, and clandestine drug labs.  

BSRA (Bio Recovery Site Risk Assessment)

In 2016, the ABRA’s Technical Advisory Committee published the Bio Recovery Site Risk Assessment (BSRA) document that combined most of what you could encounter when responding to a crime scene. The effort was intended to address everything from decontamination protocols for a flu virus all the way to Risk Group 4 substances which are acute hazards. This document was presented at multiple conferences including the United States Environmental Protection Agency (USEPA) Decontamination Conference and the American Biological Safety Associations Annual Meeting and addresses fentanyl and other drugs along with biological hazards.  It is available on ABRA’s website www.americanbiorecovery.org  under Education/Guidelines and Standards. The BSRA guidance document is designed to be used as a check list and can be updated at moment’s notice to address novel substances that may impact our industry and employees. ABRA offers this document as a free download to help establish a scope that helps to mitigate risks to employees and occupants alike. 

Hazardous Substances

How much of our industry is really dealing with hazardous substances?  To determine this, the industry needs to look at the definitions under the OSHA Hazardous Waste Operations and Emergency Response Standard (CFR 1910.120). In 2019, ABRA received a letter of interpretation form OSHA regarding the requirements for biohazard workers dealing with hazardous substances. 

OSHA 1910.5(c)(1) states, “If a particular standard is specifically applicable to a condition, practice, means, method, operation, or process, it shall prevail over any different general standard which might otherwise be applicable to the same condition, practice, means, method, operation, or process.” (OSHA, 1970). 

So, the real question is “Which federal training standard fits best?”  On September 6, 2019, a response to this question finally guided us.  “Does OSHA require employers to train employees that perform biohazard remediation according to the training requirements outlined in its HAZWOPER 1910.120 Standard?”

“Generally, biohazard remediation workers who respond to a declared emergency for the release of a hazardous substance at a particular site must be trained in accordance with the HAZWOPER standard at 29 CFR 1910.120(q)(6)”. (Occupational Safety and Health Administration [OSHA], 2019).

After reading the response, a question remained, “What is an ‘emergency’ and what does OSHA consider a ‘hazardous substance’?   Don’t we as restorers conduct emergency mitigation?

Under definitions – OSHA 1910.120, a “hazardous substance” means “any substance designated or listed under (A) through (D) of this definition, exposure to which results or may result in adverse effects on the health or safety of employees.”  Since we are not dealing with Comprehensive Environmental Response, Compensation and Liability Act (CERCLA) sites, we will refer to Definition B. 

“[B] Any biological agent and other disease-causing agent which, after release into the environment and upon exposure, ingestion, inhalation, or assimilation into any person, either directly from the environment or indirectly by ingestion through food chains, will or may reasonably be anticipated to cause death, disease, behavioral abnormalities, cancer, genetic mutation, physiological malfunctions (including malfunctions in reproduction) or physical deformations in such persons or their offspring.”

Hazardous waste means [B] Those substances defined as hazardous wastes in 49 CFR 171.8.

• Hazardous waste operation means any operation conducted within the scope of this standard. Hazardous waste sites or site means any facility or location within the scope of this standard at which hazardous waste operations take place.

• Health hazard means a chemical or pathogen where acute or chronic health effects may occur in exposed employees and includes stress due to temperature extremes.

The term “health hazard” includes chemicals that are classified in accordance with the Hazard Communication Standard, 29 CFR 1910.1200, as posing one of the following hazardous effects: 

• Acute toxicity via any route of exposure: skin corrosion or irritation; serious eye damage or eye irritation; respiratory or skin sensitization; germ cell mutagenicity; carcinogenicity; reproductive toxicity; specific target organ toxicity through single or repeated exposure; aspiration toxicity or simple asphyxiant. (See Appendix A to § 1910.1200—Health Hazard Criteria ((Mandatory)) for the criteria for determining whether a chemical is classified as a health hazard.) (OSHA, 1970).

Now that we understand that OSHA declares and considers agents that exhibit acute toxicity and biologicals to be a hazardous substance, we needed to find out what it declares to be an “emergency.”

Within 1910.120, emergency response or responding to emergencies means a response effort by employees from outside the immediate release area or by other designated responders such as mutual aid groups, local fire departments, etc. to an occurrence which results, or is likely to result, in an uncontrolled release of a hazardous substance. Responses for incidental releases of hazardous substances where the substance can be absorbed, neutralized, or otherwise controlled at the time of release by employees in the immediate release area or by maintenance personnel are not considered to be emergency responses within the scope of this standard. Also, responses to releases of hazardous substances where there is no potential safety or health hazard i.e., fire, explosion, or chemical exposure, are not considered to be emergency responses. (OSHA, 1970).

Not everything in a traditional HAZWOPER training is practical for the restoration industry but few in our industry ever took the time to “tailor” the training to fit the potential exposures to restoration professionals. When the HAZWOPER standard was created, the primary concern was chemical spill response and toxic waste dumps and releases.  These types of opportunities are often not a market target for the restoration industry, but we often deal with a lot of hazardous substances in our daily operations with a risk for exposure to them.  The Center for Disease Control (CDC) and National Institute for Occupational Safety and Health (NIOSH) have released their recommendations that includes compliance with the HAZWOPER Standard when dealing with hazardous substances. 

Naloxone

Is your team trained on the “Buddy System” as defined in the HAZWOPER Standard and are they trained to administer naloxone at a moment’s notice to save somebody’s life?  Naloxone can be picked up at any local pharmacy and is always a good practice to keep on work trucks – it does expire so please keep tabs on expiration dates.  Store naloxone in temperatures between 68°F and 77°F.  Do not let naloxone sit in a hot truck all day.  A good practice is to keep it in a response bag during the day and bring back to your shop to store correctly.  

Skin Absorption Information 

Fentanyl and its analogues can be rinsed off your hands with soap and water without risk of dermal absorption. According to the American College of Medical Toxicologist, fentanyl is amenable to transdermal absorption because of its low molecular weight and lipophilicity. Depending on the specific product, transdermal delivery systems (“patches”) take between 3 to 13 hours to produce a therapeutic serum fentanyl concentration and 35 hours to reach peak concentration.

NEVER USE ALCOHOL HAND SANITIZER or BLEACH TO CLEAN OR WASH YOUR SKIN –
this can help facilitate absorption through the skin or through cracks in the skin.

Waste Disposal Information 

According to the USEPA Fact Sheet, fentanyl and fentanyl analogs do not typically meet the definition of the Resource Conservation and Recovery Act (RCRA) hazardous waste per 40 CFR Part 261; however, the fentanyl analogs possess hazardous waste-like qualities and the EPA recommends that they be managed as hazardous waste when there is no longer a use for the material in a medical setting.  64 Fentanyl-containing materials may be disposed of by encapsulation, incineration, or by inertization (mixing with water, cement, or limestone to form a solid mass). 

For our industry, contaminated contents, porous materials, cleaning cloths, and other items used in the remediation process are drummed up in 35 or 55 gallon open top plastic containers and are sent off for incineration.   

With no vaccine for addiction, what does our future look like and what is the source for a positive outcome? Today there are services and remediation companies that can help. Education for all the variables discussed above is starting to expand rapidly. When novel opportunities present themselves, use caution when considering training providers as there are people looking to cash in on this trend; they might even try “scare tactics” to get you to take their training.  Please fact check their claims and research their qualifications. 

From the onset of an opportunity, it is always recommended to engage the BSRA document and retain an Indoor Environmental Professional (IEP) such as a Certified Industrial Hygienist (CIH).  The purpose of the IEP is to document the risk with real analytical data.  This helps to establish that there is a risk present that warrants a proper cleanup.  When the restorer is finished, the IEP can document the clearance of the remedial action and declare the property safe for occupancy.    

As we are gaining a further understanding of the issues that create such chaos in society, the most important thing that we can do is extend the “olive branch” to assist those in need and continue to gather resources that help create success stories.