Hostname: page-component-7c8c6479df-nwzlb Total loading time: 0 Render date: 2024-03-28T14:03:07.380Z Has data issue: false hasContentIssue false

Opioid Attack and the Implications for Counter-Terrorism Medicine

Published online by Cambridge University Press:  11 October 2021

Derrick Tin*
Affiliation:
Senior Fellow, BIDMC Disaster Medicine Fellowship; Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Cambridge, MassachusettsUSA
Zachary Kallenborn
Affiliation:
Research Affiliate, Unconventional Weapons and Technology Division, START, University of Maryland; Policy Fellow, Schar School of Policy and Government, George Mason University, Fairfax, VirginiaUSA
Alexander Hart
Affiliation:
Director of Research, BIDMC Disaster Medicine Fellowship; Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Instructor, Harvard Medical School, Cambridge, MassachusettsUSA
Attila J. Hertelendy
Affiliation:
Faculty, BIDMC Disaster Medicine Fellowship; Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts USA
Gregory R. Ciottone
Affiliation:
Director, BIDMC Disaster Medicine Fellowship; Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Associate Professor, Harvard Medical School, Cambridge, MassachusettsUSA
*
Correspondence: Dr. Derrick Tin Senior Fellow Disaster Medicine Department of Emergency Medicine Beth Israel Deaconess Medical Center and Harvard Medical SchoolCambridge, MassachusettsUSA E-mail: dtin@bidmc.harvard.edu
Rights & Permissions [Opens in a new window]

Abstract

While the opioid epidemic engulfing the United States and the globe is well-documented, the potential use of powerful fentanyl derivatives as a weapon of terror is increasingly a concern. Carfentanyl, a powerful and deadly fentanyl derivative, is seeing a surge in popularity as an illegal street drug, and there is increasing congressional interest surrounding the classification of opioid derivatives under the Chemical Weapons Convention (CWC) given their potential to cause harm. The combination of the potency of opioid derivatives along with the ease of accessibility poses a potential risk of the use of these deadly agents as chemical weapons, particularly by terrorist organizations. Disaster Medicine specialists in recent years have established a sub-specialty in Counter-Terrorism Medicine (CTM) to address and research the unique terrorism-related issues relating to mitigation, preparedness, and response measures to asymmetric, multi-modality terrorist attacks.

Type
Guest Editorial
Copyright
© The Author(s), 2021. Published by Cambridge University Press on behalf of the World Association for Disaster and Emergency Medicine

While the opioid epidemic engulfing the United States and the globe is well-documented, the potential use of powerful fentanyl derivatives as a weapon of terror is increasingly a concern.Reference Felter1,Reference Morell2

Due to a thriving but under-regulated pharmaceutical sector, China remains a global source of illicit fentanyl, fentanyl precursors, and fentanyl analogues such as remifentanyl and carfentanyl, despite recent changes in regulatory legislation and multilateral agreements to thwart illicit supplies.Reference Connor3,Reference Felbab-Brown4

For the United States, illegal imports direct from China or via Mexico and Canada remain problematic, and in the first four months of 2021, the United States’ border authorities seized 6,494 pounds of fentanyl, compared to 4,776 pounds in all of 2020.Reference Barr5,Reference Dudley, Bonello and López-Aranda6

Carfentanyl, a powerful and deadly fentanyl derivative, is seeing a surge in popularity as an illegal street drug. In September 2019, Canadian police seized 42 kilograms of carfentanyl, the largest volume ever seized in North America.7,Reference Kassam8 While opioids have been extensively discussed in the past decade, particularly amongst counter-narcotic agencies, there is increasing congressional interest surrounding their classification under the Chemical Weapons Convention (CWC) given their potential to cause harm.Reference Caves9

Fentanyl and its analogues’ use as possible incapacitating agents have long been investigated, however, issues around the margin of safety (optimum dosage to incapacitate but not kill) were never resolved and the project was subsequently abandoned by the United States Department of Defense (Virginia USA) in the 1990s. In 2002, Russia’s Spetsnaz operators employed an aerosolized combination of fentanyl analogues in a counter-terrorism operation during the Moscow Theatre Siege, killing both perpetrators and approximately 130 hostages.Reference Riches, Read, Black, Cooper and Timperley10Reference Pearson12 While the operation at the time was hailed as a success by Russian law enforcement officials and subsequent investigation found no violation of Article 2 of the CWC, the incident highlighted the lack of collaboration between Russia’s Federal Security Services (Moscow, Russia) and the medical emergency services.Reference Vajić, Kovler, Steiner, Hajiyev and Sicilianos1315 Medical workers were expecting to treat victims of gunshots and explosions, and delays in identifying the chemical culprit and administering the appropriate antidote to reverse the effects potentially cost lives. A chemical weapon toxidrome recognition algorithm has since been published by Disaster Medicine and Counter-Terrorism Medicine (CTM) specialists after identifying educational gaps in this area.Reference Ciottone16

The combination of the potency of fentanyl and its derivatives, along with the ease of accessibility, poses a potential risk of the use of these deadly agents as chemical weapons, particularly by terrorist organizations.Reference Caves9 The median lethal dose (LD50) for the fentanyls is not precisely known for humans, particularly for inhalation or dermatological exposure, which are the most likely exposure routes in a chemical terror attack. However, the high casualty rate in the Moscow Theatre Siege and low LD50 rate in rats suggest an overall high lethality.Reference Leen and Juurlink17 The accessibility of fentanyl is particularly significant for terrorist groups, because developing traditional chemical weapons agents such as sarin gas requires significant chemical engineering capabilities, specialized equipment, and the resources to put it all together. While Aum Shinrikyo’s 1995 sarin gas attacks on the Tokyo subway and the Islamic State of Iraq and Syria’s limited chemical weapons usage show the threat of chemical terrorism is real, these examples are outliers to date. The Executive Council for the Organization for the Prohibition of Chemical Weapons (The Hague, The Netherlands) recommended CWC members recognize central-nervous system agents, including fentanyls, as being included under existing prohibitions on chemical use in warfare, which would apply to the 165 CWC member states.18

Furthermore, the mass proliferation, increasing affordability, and capacity for home-modification of civilian drones increase the threat of their use by terrorists as a chemical weapon delivery platform and is of significant concern.Reference Koblentz19,Reference Lambert20 Agriculture crop spraying drones, riot control drones, and stadium decontamination drones now seen as a result of the COVID-19 pandemic could be easily repurposed to deliver chemical weapons in the form of opioids (aerosolized or in particle form) and induce a complex mass-casualty event.

While the risks associated with malicious drone use by rogue actors are being examined, the positive utilities of drones in disasters are also at the forefront of CTM discussions.Reference Lockwood21,Reference Tin, Kallenborn, Hart, Hertelendy and Ciottone22 In the case of chemical attacks, drones can be used to provide rapid aerial mapping of victims, monitor air quality and presence of harmful chemicals in warm zones, and provide rapid mass delivery of antidotes, such as naloxone in opioid attack, to first responders on the ground. Early studies of first responders have shown that they are interested in adding drones to their repertoire of tools.Reference Hart, Chai, Griswold, Lai, Boyer and Broach23

While terrorist attacks have historically fallen under the man-made banner of Disaster Medicine, terrorist events are unique in their intentionality to kill and injure. Disaster Medicine specialists in recent years have established a sub-specialty in CTM to address and research the unique terrorism-related issues relating to mitigation, preparedness, and response measures to asymmetric, multi-modality terrorist attacks.Reference Tin24Reference Tin, Hart and Ciottone26 The potential use of opioids as a weapon that can induce mass casualties requires on-going discussions: risk mitigation strategies need to be discussed, the health care implications of such an event should be anticipated, and the vulnerabilities of response plans need to be addressed, in particular, the need for stockpiling of naloxone at potential soft-target events, such as mass gatherings. This can best be achieved by strengthening regular collaborative discussions among disaster, tactical, and CTM specialists and experts in law enforcement and counter terrorism. While the risk of opioid attack is real, CTM strategies can mitigate and prepare for these potentially deadly events.

Conflicts of interest/funding

The authors have no conflict of interest or financial disclosure to declare.

References

Felter, C. The US Opioid Epidemic. Council on Foreign Relations; 2019. https://www.cfr.org/backgrounder/us-opioid-epidemic. Accessed May 31, 2021.Google Scholar
Morell, M. The Opioid Crisis Becomes a National Security Threat. The Cipher Brief. 2017 https://www.thecipherbrief.com/column/expert-view/opioid-crisis-becomes-national-security-threat. Accessed November 1, 2020.Google Scholar
Connor, S. Fentanyl: China’s Deadly Export to the United States. US-China Economic and Security Review Commission; 2017. https://www.uscc.gov/research/fentanyl-chinas-deadly-export-united-states. Accessed May 31, 2021.Google Scholar
Felbab-Brown, V. Fentanyl and Geopolitics: Controlling opioid supply from China. Foreign Policy and Global Economy and Development programs; 2020. https://www.brookings.edu/research/fentanyl-and-geopolitics-controlling-opioid-supply-from-china/. Accessed May 31, 2021.Google Scholar
Barr, L. More fentanyl seized by CBP so far in 2021 than in all of 2020. ABC News. 2021. https://abcnews.go.com/Politics/fentanyl-seized-cbp-2021-2020/story?id=77744071. Accessed May 31, 2021.Google Scholar
Dudley, S, Bonello, D, López-Aranda, J, et al. Mexico’s Role in the Deadly Rise of Fentanyl. Wilson Center. 2019. https://www.wilsoncenter.org/publication/mexicos-role-the-deadly-rise-fentanyl. Accessed May 31, 2021.Google Scholar
Police make massive seizure of carfentanil in home east of Toronto. CTV News. 2017. https://www.ctvnews.ca/canada/police-make-massive-seizure-of-carfentanil-in-home-east-of-toronto-1.3634673. Accessed May 31, 2021.Google Scholar
Kassam, A. “Dose as small as a grain of sand can kill you:” alarm after Canada carfentanil bust. The Guardian. 2017. https://www.theguardian.com/world/2017/nov/12/carfentanil-bust-canada-fentanyl-opioid-crisis-dangers. Accessed May 31, 2021.Google Scholar
Caves, JP. Fentanyl as a Chemical Weapon. Centre for the Studies of Weapons of Mass Destruction. National Defense University Press. 2019. https://ndupress.ndu.edu/Media/News/Article/2031237/fentanyl-as-a-chemical-weapon/. Accessed May 31, 2021.Google Scholar
Riches, JR, Read, RW, Black, RM, Cooper, NJ, Timperley, CM. Analysis of clothing and urine from Moscow theatre siege casualties reveals carfentanil and remifentanil use. J Anal Toxicol. 2012;36(9):647656.CrossRefGoogle ScholarPubMed
Pilch, R, Dolnik, A. The Moscow Theater Hostage Crisis: the perpetrators, their tactics, and the Russian response. International Negotiation. 2004;8(3):577611.CrossRefGoogle Scholar
Pearson, A. Incapacitating biochemical weapons science, technology, and policy for the 21st century. Nonproliferation Review. 2006;13(2):151188.CrossRefGoogle Scholar
Vajić, N, Kovler, A, Steiner, E, Hajiyev, K, Sicilianos, L-A. In the case of Finogenov and Others v. Russia. 2003.Google Scholar
Tucker, J. The future of chemical weapons. The New Atlantis. 2009. https://www.thenewatlantis.com/publications/the-future-of-chemical-weapons. Accessed June 24, 2021.Google Scholar
“Incapacitating Chemical Agents” Law Enforcement, Human Rights Law and Policy Perspectives. International Committee Red Cross. 2012. www.icrc.org. Accessed June 24, 2021.Google Scholar
Ciottone, GR. Toxidrome recognition in chemical-weapons attacks. N Eng J Med. 2018;378(17):16111620.CrossRefGoogle ScholarPubMed
Leen, JLS, Juurlink, DN. Carfentanil: a narrative review of its pharmacology and public health concerns. Can J Anesth. 2019;66(4):414421.CrossRefGoogle ScholarPubMed
Organization for the Prohibition of Chemical Weapons (OPCW). Aerosolization of Central Nervous System-Acting Chemicals for Law Enforcement Purposes. The Hague, The Netherlands: OPCW; 2018.Google Scholar
Koblentz, GD. Emerging technologies and the future of CBRN terrorism. Washington Quarterly. 2020;43(2):177196.CrossRefGoogle Scholar
Lambert, C. The Chemical and Biological Attack Threat of Commercial Unmanned Aircraft Systems. Assoc United States Army. 2020. https://www.ausa.org/sites/default/files/publications/SL-20-5-The-Chemical-and-Biological-Attack-Threat-of-Commercial-Unmanned-Aircraft-Systems.pdf. Accessed March 23, 2021.Google Scholar
Lockwood, L. Use of Drones in Disaster Medicine. American College of Emergency Physicians; 2020. https://www.acep.org/how-we-serve/sections/disaster-medicine/news/october-2019/use-of-drones-in-disaster-medicine/. Accessed June 2, 2021.Google Scholar
Tin, D, Kallenborn, Z, Hart, A, Hertelendy, AJ, Ciottone, G. Rise of the unmanned aerial vehicles: an imminent public health threat mandating counter-terrorism medicine preparedness for potential mass-casualty attacks. Prehosp Disaster Med. Epub ahead of print.Google Scholar
Hart, A, Chai, PR, Griswold, MK, Lai, JT, Boyer, EW, Broach, J. Acceptability and perceived utility of drone technology among emergency medical service responders and incident commanders for mass casualty incident management. Am J Disaster Med. 2017;12(4):261265.CrossRefGoogle ScholarPubMed
Tin, D. Enhancing medical preparedness to meet the changing threat of terrorism. The Strategist. 2021. https://www.aspistrategist.org.au/enhancing-medical-preparedness-to-meet-the-changing-threat-of-terrorism/. Accessed April 24, 2021.Google Scholar
Tin, D, Hart, A, Ciottone, GR. Rethinking disaster vulnerabilities. Am J Emerg Med. 2021. Epub ahead of print.CrossRefGoogle Scholar
Tin, D, Hart, A, Ciottone, GR. Hardening hospital defenses as a counter-terrorism medicine measure. Am J Emerg Med. 2021. Epub ahead of print.CrossRefGoogle Scholar