Illicit fentanyls as intentional mass casualty threats: The added complexity of transdermal formulations

Authors

Ryan Boasi, PharmD https://orcid.org/0009-0000-1066-5987
Attila J. Hertelendy, PhD https://orcid.org/0000-0001-6174-0289
Fadi Issa, MD https://orcid.org/0000-0002-6208-0232
Christina Woodward, MD https://orcid.org/0000-0002-4580-7989
Asish K. Dutta, PhD, RPh https://orcid.org/0009-0002-8778-7645
Abeer Santarisi, MD, MSc
Dana Mathew, MD https://orcid.org/0009-0008-1844-3439
Van Kenyan, MD
Timothy J. Curtis, MSc, DPEM
Eric D. Miller, RN
Jacob Noel, MD https://orcid.org/0009-0009-1274-8335
Eman Alshaikh, MD, MS
David DiGregorio, MSEM, MPAS
Amalia Voskanyan, RN
Gregory Ciottone, MD https://orcid.org/0000-0002-3313-1379

DOI:

https://doi.org/10.5055/ajdm.0504

Keywords:

fentanyl, chemical weapon, mass exposure, mass casualty incident

Abstract

This study explores the threat of illicit fentanyls weaponized as transdermal agents, focusing on potency, affordability, and adaptability. Illicit fentanyls have favorable physicochemical and pharmacokinetic profiles for transdermal absorption. This paper highlights its potential for harm were it weaponized using pharmaceutical principles. Disaster implications of weaponized transdermal fentanyl exposure are significant. Diagnostic and response challenges would arise due to delayed toxidrome emergence. First responder training, strategic antidote allocation, decontamination and personal protective equipment protocols, and healthcare system surge in mass events must be revised with route- and agent-specific considerations.

Author Biographies

Ryan Boasi, PharmD

Beth Israel Deaconess Medical Center (BIDMC) Disaster Medicine Fellowship, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts

Attila J. Hertelendy, PhD

Beth Israel Deaconess Medical Center (BIDMC) Disaster Medicine Fellowship, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts; Department of Information Systems and Business Analytics, College of Business, Florida International University, Miami, Florida

Fadi Issa, MD

Beth Israel Deaconess Medical Center (BIDMC) Disaster Medicine Fellowship, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts

Christina Woodward, MD

Beth Israel Deaconess Medical Center (BIDMC) Disaster Medicine Fellowship, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts

Asish K. Dutta, PhD, RPh

Notre Dame of Maryland University School of Pharmacy, Baltimore, Maryland

Abeer Santarisi, MD, MSc

Beth Israel Deaconess Medical Center (BIDMC) Disaster Medicine Fellowship, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School; Center for Anesthesia Research Excellence (CARE) Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts

Dana Mathew, MD

Beth Israel Deaconess Medical Center (BIDMC) Disaster Medicine Fellowship, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts

Van Kenyan, MD

Beth Israel Deaconess Medical Center (BIDMC) Disaster Medicine Fellowship, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts; Montefiore Medical Center, Bronx, New York

Timothy J. Curtis, MSc, DPEM

Beth Israel Deaconess Medical Center (BIDMC) Disaster Medicine Fellowship, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts; University of Chicago Medicine, Chicago, Illinois

Eric D. Miller, RN

Beth Israel Deaconess Medical Center (BIDMC) Disaster Medicine Fellowship, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts

Jacob Noel, MD

Beth Israel Deaconess Medical Center (BIDMC) Disaster Medicine Fellowship, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts

Eman Alshaikh, MD, MS

Beth Israel Deaconess Medical Center (BIDMC) Disaster Medicine Fellowship, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts

David DiGregorio, MSEM, MPAS

Beth Israel Deaconess Medical Center (BIDMC) Disaster Medicine Fellowship, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts

Amalia Voskanyan, RN

Beth Israel Deaconess Medical Center (BIDMC) Disaster Medicine Fellowship, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts

Gregory Ciottone, MD

Beth Israel Deaconess Medical Center (BIDMC) Disaster Medicine Fellowship, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts

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Illicit fentanyls as intentional mass casualty threats: The added complexity of transdermal formulations

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Published

03/01/2025

How to Cite

Boasi, Ryan, et al. “Illicit Fentanyls As Intentional Mass Casualty Threats: The Added Complexity of Transdermal Formulations”. American Journal of Disaster Medicine, vol. 20, no. 1, Mar. 2025, pp. 43-48, doi:10.5055/ajdm.0504.

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Vol. 20 No. 1 (2025): Winter

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