In the middle of May, a police officer in East Liverpool, Ohio, Chris Green, was responding to a traffic call when he realized that white powder had spilled inside the car he was investigating. He put on gloves to protect himself from what he would later learn was a formulation of fentanyl, a potent prescription opioid, as he handled the situation. Later, when he got back to the station, another officer pointed out some dust on the back of Green’s shirt. Green brushed it off, no gloves, without thinking. Soon after (some accounts state it was mere minutes, others clock it at an hour), he was unconscious.
“I was in total shock,” he told the local paper after the fact. “ ‘No way I’m overdosing,’ I thought.”
He would go on to receive four doses of naloxone, an emergency drug that counteracts an opioid overdose, before waking up.
The story, a terrifying narrative that illustrates the dangers of opioids, spread like wildfire. The local press reported the situation as a fentanyl overdose, with Lisbon, Ohio’s Morning Journal headlining its report “Traffic Stop Almost Turns Deadly for ELO Officer.” From there, it was picked up by national outlets including the Washington Post. In CBS News’ coverage, reporter Jim Axelrod asked Green whether all of this could really have happened from simply touching fentanyl. Green confirmed that a touch was all it took, and the two men agreed that it was not overstating things to suggest he could have died. Then last week, Green appeared on the New York Times’ wildly popular podcast The Daily, vividly relating details of his terrifying ordeal. When he came to, he recounts, he found himself in the hospital surrounded by crying colleagues, nurses, and firefighters.
Did Green really experience a life-threatening overdose by briefly touching a small amount of fentanyl? That’s certainly what his story suggests. But neither fentanyl nor even its uber-potent cousin carfentanil (two of the most powerful opioids known to humanity) can cause clinically significant effects, let alone near-death experiences, from mere skin exposure. If Green’s story is true, it would be the first reported case of an overdose caused solely by unintentional skin contact with an opioid. There is one published case of a veterinarian who was squirted in the eye with carfentanil after trying to sedate an elk (the vet experienced drowsiness, which resolved shortly after receiving a whopping dose of the antidote naltrexone). But scrutinizing Green’s story from a medical perspective reveals an irresolvable conflict between the accounts that have been widely disseminated and the realities of medicine and toxicologic possibility.
Each of the medical and toxicology professionals I asked agreed that it’s implausible that one could overdose from brushing powder off a shirt. Skin cannot absorb even the strongest formulations of opioids efficiently or fast enough to exert such an effect. “Fentanyl, applied dry to the skin, will not be absorbed. There is a reason that the fentanyl patches took years [for pharmaceutical companies] to develop,” says my colleague Ed Boyer, M.D., Ph.D., a medical toxicologist at Harvard Medical School and Brigham and Women’s Hospital. In fact, according to Jeanmarie Perrone, M.D., director of the division of medical toxicology in the department of emergency medicine at the University of Pennsylvania, “the American College of Medical Toxicology has drafted a position statement about the possible routes of fentanyl exposure, debunking the likelihood that transdermal fentanyl absorption is clinically significant.” The spread of Green’s story inspired the group to accelerate the timeline for releasing its policy statement, Perrone says.
Could Green’s overdose have been the result of him accidentally inhaling the powder, instead of just touching it? It’s certainly true that actively inhaling (i.e. snorting) visible amounts of fentanyl could cause a life-threatening overdose. If a person were to snort a “line” of the substance (thinking, perhaps, it was cocaine), or sample visible quantities of powder formulations of fentanyl orally, it could certainly cause an overdose. But Green was not intentionally inhaling or swallowing the powder—he was just brushing it away from him. Perhaps when he moved to brush the substance off his shirt, some of it stuck to his fingers and he later inhaled it, or accidentally ingested it. But the amount that could have transferred from the car to the shirt to the fingers to the mouth or nose would not be a clinically significant quantity, even accounting for fentanyl’s potency. Such a chain of events would be extremely unlikely, the odds of an overdose from such a freak incident are infinitesimally small—if not strictly impossible.
This may help explain why it appeared to take so much naloxone to revive the officer after he passed out. The reports state that 16 mg of naloxone were given (four nasal doses, typically 4 mg apiece). That’s an enormous quantity—in fact it is approximately one-third of the antidote that would be used to revive someone who had received an entire “carfentanil dart,” commonly called an “elephant tranquilizer.” The proffered explanation for why such a large dose of the antidote was needed is that Green had simply encountered that extreme a quantity of opioid. But in medicine, when a medication with well-established and consistent efficacy such as naloxone does not work at its usual dose, it’s usually because we are treating the wrong illness—we’ve made a diagnostic error—not because the known treatment is flawed. For example, a common way to break a seizure is to treat someone with a benzodiazepine such as Ativan or Valium. It almost always works. When it doesn’t work, it’s often because the seizure is due to a more unusual cause—for example, a vitamin deficiency. In such cases, all the Valium on the planet wouldn’t break that seizure; only high doses of the vitamin delivered intravenously would work. Similarly, loss of consciousness that does not respond to multiple doses of naloxone is likely not to have been opioid-related at all.
I asked David Juurlink, M.D., a toxicologist at the University of Toronto, who has published dozens of articles on the dangers of opioids, about what conclusions he would draw from the circumstances of Green’s case. Juurlink said that it would be “hard to imagine someone would need multiple doses of naloxone after transient skin contact with powdered fentanyl,” and that it was more likely that naloxone had simply been deployed against the wrong problem.
To be clear, I don’t think Green, or anyone at the East Liverpool Police Department, is lying about what happened. (Green has not replied to my requests for comment.) I believe, as the paramedics believed, that he and his fellow officers honestly thought he experienced an opioid overdose that resulted from his brief contact with the powder. I understand why everyone was so rattled by the experience. I’m no apologist for opioid use, nor do I think the epidemic is an exaggeration. These police officers are the front lines of an extremely challenging fight, and it is understandable that they would be freaked out by this event. However, as a physician, I’ve also often witnessed an amazing phenomenon: Once patients believe they have a diagnosis, it is very hard to convince them otherwise, especially if the surrounding events were dramatic. People who had benign tumors removed sometimes think of themselves as cancer survivors. I can’t begin to tell you how often patients are sent home believing they had a heart attack because a physician initially expressed concern that this might be occurring, even though it was later ruled out. It’s remarkable how emotionally attached some people become to their diagnoses—they become badges of proof that what has not killed them has made them stronger.
Still, that doesn’t change the fact that this case is likely not as tidily explained as the people involved in it, and thus the media, have assumed. As Perrone put it, the immense amount of uncritical pickup of this story seems to indicate “an interesting new ‘hysteria,’ for lack of a better term,” about opioids. The hysteria is understandable. The anecdote was perfectly poised for virality: You take a known societal menace, such as the opioid epidemic, that is ravaging a segment of our nation’s otherwise healthy population, and you combine it with a frightening horror story of a cop, trying to help, getting poisoned in the process. The report also contained medical details, from the paramedics, that made it seem vetted and real. The first responders clearly thought he had overdosed, too—that’s why they gave him naloxone. But if anyone in the media had discussed the accounts with a toxicology expert, the picture would have quickly become more muddled.
What troubles me most is that the local and national media ran with this story without stopping to ask the right people the right questions. On Sunday, Julie Beck wrote about how the epidemic of “fake news” is particularly damaging and pervasive in medical reporting: “While many of the fake news stories that have gotten the most attention had to do with the 2016 U.S. presidential election,” she wrote, “fake news about health seems to be more pervasive and harder to weed out.”
Credible sourcing is what distinguishes real from fake news, whether about medicine or not. In this case, the real news got faked out. Unfortunately, this anecdote could serve to stoke more unnecessary fear in our communities around an already frightening public health crisis.
Disclaimer: The opinions expressed in this article are solely those of the author and do not reflect the views and opinions of Brigham and Women’s Hospital.