Did we just have a secondhand smoke moment for fentanyl?

From time to time public health professionals, physicians, and policy makers have asked me what lessons from tobacco control apply to the drug problem. I have had a hard time answering this question because the most important change in the tobacco debate — the emergence of the health effects of secondhand smoke and concerns by and about nonsmoking bystanders — didn’t seem to exist when talking about illicit drugs.

The adverse effects of secondhand smoke drove two important changes: First, it created a constituency of nonsmokers, who previously had not been engaged in tobacco control issues, who organized to press for smoking restrictions to control and later eliminate secondhand smoke pollution. Second, as smokers came to understand that their smoking was not only harming themselves but bystanders, they became more self-conscious and started limiting where they smoked even beyond where it was legally restricted.

While this was not a goal of our clean indoor air efforts, a positive side effect was undermining the social acceptability of smoking and creating an environment that made it easier for smokers to quit and less likely for youth to start.

Illicit drug use, in contrast, did not seem to affect people beyond the immediate users (and their families and the health care providers taking care of them), a situation similar to tobacco control before the advent of the secondhand smoke issue in the 1970s.

An incident involving fentanyl last week in San Francisco revealed that there are bystanders in the same sense as secondhand tobacco smoke.

Fentanyl is a powerful anesthetic that is widely used in carefully controlled medical situations. (When I had a colonoscopy recently, I’m pretty sure the anesthesiologist used fentanyl.) But it is also sold or added to illicit drugs, sometimes without disclosing that it is there. It is so powerful that even a tiny dose can kill almost immediately (photo above for adult fatal dose).

Last week a 10 month old toddler was paying in a San Francisco park far away from the neighborhood commonly associated with drug use when he suddenly developed respiratory arrest. His care giver called 911 and paramedics delivered Narcan to reverse the fentanyl effects and revived the boy. Subsequent lab work at the hospital confirmed the presence of fentanyl in his body.

Given how small toddlers are, the dose must have been tiny to have allowed him to live long enough to be revived. There was no obvious evidence of drug paraphernalia at the park. It may have been that a little fentanyl dust was on the grass or elsewhere in the park that got on the child’s hands, which he then put in his mouth (similar to what happens with thirdhand tobacco smoke exposure).

This incident has generated concern among city political leaders. It will be interesting to see where it leads.

(This situation differs from marijuana where it is already demonstrated that secondhand smoke is a big problem (study 1, study 2, study 3, weakening clean indoor air laws to allow cannabis, other examples)