https://www.infirmiere-canadienne.com/blogs/ic-contenu/2025/02/24/risques-fentanyl-personnel-infirmier
Viable solutions that promote the safety of everyone, including people who use drugs
By Corey Ranger, Patty Wilson, & Serena Eagland
February 24, 2025
istockphoto.com/OcusFocus
Hospitals are not always safe environments for people who use drugs because of the stigmatizing treatment they receive.
“Our once-safe hospitals are being destroyed by criminals and hard drugs, with the B.C. Nurses Union ringing the alarm bell, saying that patients and staff have been exposed to harmful, illegal drugs.”
The above quote is from an announcement posted online by the Conservative Party of Canada on May 14, 2024 (Chief Agent of the Conservative Party of Canada, 2024) . This statement followed a leaked memo from a hospital in B.C. that instructed nurses not to search personal belongings even if drugs are suspected in response to the province’s recent decriminalization of drugs for personal use (Kulkarni, 2024). This led to media and political scrutiny about possible drug exposure for nurses and potential safety concerns.
While incidental exposure to fentanyl may occur, the associated risks are generally low, and current discussions tend to disproportionately emphasize these risks or propagate misinformation. B.C.’s decriminalization of drugs for personal use has become a political wedge issue, and stories of nurses experiencing accidental illicit smoke exposure through patient smoking has legitimized a discussion that increases anger or fear against people who use drugs. As a result of increased public pressure, B.C. has recriminalized possession of drugs for personal use.
However, these statements do not reflect actual risks nor perspectives of nurses who specialize in outreach, addiction, and harm reduction (Canadian Nurses Association & Harm Reduction Nurses Association, 2024). The authors of this paper are nurses with over 28 combined years of experience working in harm reduction, in supervised consumption services (SCS), and doing outreach in the homes of people who use drugs. We know the absence of evidence for risk does not diminish the ongoing concerns of health-care workers and their patients; it would be distressing to work in an environment perceived as dangerous, regardless of the actual risk.
We believe that evidence must drive policy, not fear and misinformation. We believe that both worker safety and upholding the rights and dignity of people who use drugs are achievable without resorting to punitive policymaking. We support inhalation overdose prevention services in all hospital settings.
This analysis will shed light on the risks for nurses associated with fentanyl exposure, the harms of perpetuating exposure misinformation, and viable solutions that promote the safety of everyone, including people who use drugs.
Analyzing risk
Let’s tackle the easy part first. There has never been a confirmed overdose from touching fentanyl (BC Centre for Disease Control, 2024). Smoke exposure has also been cited as a possible risk to patients and health-care workers. The harm to someone inhaling second-hand fentanyl smoke is extremely low (Cuffaro et al., 2024). This is because fentanyl is not smoked like a cigarette or cannabis, which can cause second-hand effects. Fentanyl is heated and the individual inhales the vapour. This poses minimal risk of harm compared to smoke, as its low vapour pressure makes significant exposure unlikely.
According to the American College of Medical Toxicology and the American Academy of Clinical Toxicology (Moss et al., 2017), the primary concern when it comes to fentanyl smoke exposure is when it is aerosolized, such as manufactured into a puffer. Most workplace safety policies are based on an abundance of caution rather than actual risks, so it is important for nurses to be aware of the evidence-based risks in their workplace.
A systematic review of occupational exposure to fentanyl concluded that passive exposure to fentanyl simply did not result in observable opioid-related symptoms (Adams, Maloy, & Warrick, 2023). One study from the University of Washington School of Public Health examined fentanyl and methamphetamine in the air and on surfaces of transit vehicles — and what they found was that despite fentanyl and methamphetamine being detected in the air, “there is no evidence of acute medical conditions resulting from passive exposure to fentanyl or methamphetamine (such as from touching contaminated surfaces or inhaling second-hand smoke)” (Baker, Beaudreau, & Zuidema, 2023, p. 5). Indeed, even the Washington State Department of Health (2024) wrote in bold on their website, “There is no evidence of first responders experiencing an overdose from second-hand smoke exposure” (para. 2).
In instances where people did report symptoms following an exposure event (e.g., walking through smoke in a crowded hallway), symptoms that are often reported are sweating, light-headedness, perhaps an elevated heart rate or heart palpitations (Adams et al., 2023). These symptoms are not consistent with an opioid overdose; they are more likely caused by other health conditions, including anxiety. Symptoms of opioid overdose include a decreased level of consciousness, very slow or no breathing, cyanosis, low oxygen saturations, pinpoint pupils, and cold and clammy skin.
It’s especially important for nurses who provide care to people experiencing vulnerability to use evidence-based frameworks to analyze risk and to dispel misinformation. Understanding why people smoke drugs in health-care settings is important in order to understand their needs and the limitations placed by the health-care system in providing appropriate care.
Hospitals are not always safe environments for people who use drugs because of the stigmatizing treatment they receive. This includes inadequate pain management, such as when pain medication doses are not high enough or not given frequently enough. The only option for them to manage their pain is often to smoke or inject illicit fentanyl. These challenges are not the fault of people who use drugs or the nurses trying their best to manage such challenging situations.
Why it matters
For decades, harm reduction nurses working in hospitals have been advocating for the implementation of policies to make hospitals safer for people who use drugs. That’s because people who use drugs often experience stigma and discrimination at the hands of the health-care system, resulting in reduced access to care and concealed drug use (Biancarelli et al., 2019). The misinformation about risks associated with second-hand fentanyl smoke is one of the factors that drive stigma in health care, and in turn, can lead to patients’ early discharge or leaving care against medical advice (Aronowitz & Meisel, 2022).
Recent news stories caused nurses in Canada to believe that they should be worried about serious health implications when they are unintentionally exposed to fentanyl smoke; this can lead some to reduce interactions with or avoid patients who smoke drugs altogether. This means that people may be driven to leave the hospital to treat their own pain, which is a recipe for preventable death in the context of the toxic drug supply.
Given existing media and political conversations about the health risks of fentanyl exposure, it is understandable that nurses are concerned. While there have been workplace exposures, none have resulted in symptoms that can be attributed to drug exposure, including in safe consumption sites (Adams et al., 2023; Cuffaro et al., 2024).
Today, most toxic drug-related deaths are from smoking, including fentanyl. The change from primarily injecting drugs to smoking drugs has been happening for years before drug decriminalization in B.C., and is also seen in Alberta and Ontario (BC Coroners Service, 2024). Over 225,000 British Columbians access unregulated drugs (BC Coroners Service, 2023), but there are only 50 overdose prevention sites in B.C. and fewer than half of them cater to people who smoke their drugs (BC Government, 2024). Even fewer of these sites are available in hospitals.
The response to this prolonged public health emergency has failed to keep pace with the evolving nature of the unregulated drug supply, including the recent shift of the predominant method of using drugs from injection to smoking. Decriminalization in B.C. has not increased drug smoking, yet policies have recently been created and adapted based on fear and concern that is not rooted in evidence. These policies may increase the reticence of nurses to engage in care activities with people who use drugs. When moral panic leads to reactive policy-making, we must use evidence and expertise to fight back.
The public is being led to believe that in order for patients to use drugs in the hospital, nurses must be put at risk. This is not true. To propose effective solutions, a critical analysis of the actual risk is needed, and occupational health and safety recommendations created to address real, rather than perceived, risk for nurses.
Why not both?
Even though the evidence related to passive exposure to fentanyl demonstrates little to no actual risk to health-care staff and the public, the authors agree that it’s still not ideal. It is okay for health-care workers to want to avoid exposure to smoke from illicit drugs through certain controls, such as requesting that fentanyl be smoked in monitored, ventilated spaces. Newest research demonstrates that N95 particulate respirator masks provide acceptable protection while working with people smoking in indoor, poorly ventilated locations. Employers can and should supply N95 particulate respirator masks readily (Cuffaro et al., 2024).
A health service that bans unregulated drugs won’t stop people from using drugs — but it will increase the likelihood that people will leave before they can receive care or may die from using those drugs when alone and isolated. Instead, we should explore practical harm reduction strategies that prioritize safety for both nurses and patients. Designated negative pressure rooms, similar to smoking rooms, could help contain smoke exposure. By embracing these strategies, health-care workers can be protected while patients receive the support they need, ensuring a safer environment for everyone.
Nurses have an important role to play in making hospital settings safer for people who use drugs. Studies have demonstrated that providing a safe supply of drugs while people access health-care services improves retention and completion of care (Kolla et al., 2024). A safe supply of drugs helps people reduce or stop using unregulated fentanyl and address their pain and withdrawal needs. This helps people stay in hospital without needing to smoke their own, unregulated supply.
Nurses can advocate for a legally regulated, and accessible, safe supply of drugs, such as a PRN prescription for fentanyl or hydromorphone that could be administered via various routes including sublingual, intravenous, or transdermal (for fentanyl), which could help mitigate a lot of concerns seen in hospitals and in the public.
Another promising practice is the implementation of safer use spaces that allow for smoking in acute care hospitals. St Paul’s Hospital in Vancouver saw over 8,000 visits to their safer use space in the first seven months of operation from hospital patients. That is 8,000 instances where people would have needed to smoke off property grounds, putting themselves at risk, or in unventilated areas in hospital. Using this space also prevented any issues for nurses, as clients were outside the hospital building, meaning that nurses were not exposed to smoke.
Nurses can advocate to their unions, employers, and professional associations to support the implementation of safe inhalation spaces to make their workplaces safer. There are plenty of observable, ongoing safety risks that should be focused on, including staffing shortages, mandatory overtime, and high turnover rates; shifting focus from drug use to these working conditions is what will create real solutions and improve working conditions for nurses. This is not a fight of drug users versus nurses. This is a fight for safety and accessibility for all.
References
Adams, A., Maloy, C., & Warrick, B.J. (2023). Does occupational exposure to fentanyl cause illness? A systematic review. Clinical Toxicology (Philadelphia, Pa.), 61(9), 631–638. https://doi.org/10.1080/15563650.2023.2259087
Aronowitz, S., & Meisel, Z.F. (2022). Addressing stigma to provide quality care to people who use drugs. JAMA Network Open, 5(2). https://doi.org/10.1001/jamanetworkopen.2021.46980
Baker, M.G., Beaudreau, M., & Zuidema, C. (2023). Assessing fentanyl and methamphetamine in the air and on surfaces of transit vehicles: exposure assessment results final report, September 2023. Retrieved from https://deohs.washington.edu/sites/default/files/2023-09/UW%20exposure%20assessment%20final%20report%20Sept%202023_authors.pdf
BC Centre for Disease Control. (2024). What to do if you accidentally touch fentanyl. Retrieved from http://www.bccdc.ca/resource-gallery/Documents/Harm%20Reduction/Exposure_posters_Fentanyl.pdf
BC Coroners Service [death review panel]. (2023). An urgent response to a continuing crisis. Retrieved from https://www2.gov.bc.ca/assets/gov/birth-adoption-death-marriage-and-divorce/deaths/coroners-service/death-review-panel/an_urgent_response_to_a_continuing_crisis_report.pdf
BC Coroners Service. (2024). Unregulated drug deaths – mode of consumption. Retrieved from https://app.powerbi.com/view?r=eyJrIjoiY2NhOWZhNzMtZTFlNC00NTI2LTkwNTgtNzdmYjNjMTViMTQzIiwidCI6IjZmZGI1MjAwLTNkMGQtNGE4YS1iMDM2LWQzNjg1ZTM1OWFkYyJ9
BC Government. (2024). B.C. moves to ban drug use in public spaces, taking more steps to keep people safe. Retrieved from https://news.gov.bc.ca/releases/2024PREM0021-000643#:~:text=There%20are%20currently%2050%20overdose,these%20sites%20provide%20inhalation%20services.
Biancarelli, D.L., Biello, K.B., Childs, E., Drainoni, M., Salhaney, P., Edeza, A., Mimiaga, M.J., Saitz,R. (2019). Strategies used by people who inject drugs to avoid stigma in healthcare settings. Drug and Alcohol Dependence, 198, 80–86. https://doi.org/10.1016/j.drugalcdep.2019.01.037
Canadian Nurses Association, & Harm Reduction Nurses Association. (2024). An open letter to the Honourable Mark Holland, Minister of Health; the Honourable Ya’ara Saks, Minister of Mental Health and Addictions; the Honourable Adrian Dix, British Columbia Minister of Health; and the Honourable Jennifer Whiteside, British Columbia Minister of Mental Health and Addictions on harm reduction practices in B.C. hospitals. https://hl-prod-ca-oc-download.s3-ca-central-1.amazonaws.com/CNA/2f975e7e-4a40-45ca-863c-5ebf0a138d5e/UploadedImages/documents/policy-advocacy/Harm-Reduction-is-Part-of-Nursing-Practice_E.pdf
Chief Agent of the Conservative Party of Canada. (2024, May 14). Safe Hospitals. Conservative Party of Canada. https://www.conservative.ca/safe-hospitals/
Cuffaro, F., Dahm, G., Marson, C., Berlemont, P., Yegles, M., Allar, C., Fauchet, L., Creta, M., & Schneider, S. (2024). Contamination of a drug consumption room with drugs and potential risks for social health care workers. Harm Reduction Journal, 21(1), 149. https://doi.org/10.1186/s12954-024-01074-y
Kolla, G., Tarannum, C.N., Fajber, K., Worku, F., Norris, K., Long, C., Fagundes, R., Rucchetto, A., Hannan, E., Kikot, R., Klaiman, M., Firestone, M., Bayoumi, A., Laurence, G., & Hayman, K. (2024). Substance use care innovations during COVID-19: Barriers and facilitators to the provision of safer supply at a Toronto COVID-19 isolation and recovery site. Harm Reduction Journal, 21(1), 17. https://doi.org/10.1186/s12954-024-00935-w
Kulkarni, A. (2024). B.C. hospital memo raises safety concerns over patients’ drug use. In CBC British Columbia. Retrieved from https://www.cbc.ca/news/canada/british-columbia/bc-northern-health-illicit-drugs-memo-1.7163121
Moss, M.J., Warrick, B.J., Nelson, L.S., McKay, C.A., Dubé, P.-A., Gosselin, S., Palmer, R.B., & Stolbach, A.I. (2017). ACMT and AACT Position Statement: Preventing Occupational Fentanyl and Fentanyl Analog Exposure to Emergency Responders. Journal of Medical Toxicology, 13(4), 347–351. https://doi.org/10.1007/s13181-017-0628-2
Washington State Department of Health. (2024). Fentanyl exposure in public places. Retrieved from https://doh.wa.gov/community-and-environment/opioids/fentanyl-exposure-public-places
Corey Ranger (he/him) is based in unceded Quw’utsun Territory and is a registered nurse and president of the Harm Reduction Nurses Association.
Patty Wilson is a family care nurse practitioner in Mohkinstsis (Calgary) on Treaty 7 Territory.
Serena Eagland is a clinical nurse specialist for overdose prevention and response and a member of the Harm Reduction Nurses Association in Vancouver.
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#addictions
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#nurses-health-and-well-being
#stigma
#substance-use