#6534
#14
Newsday
November 5, 2002
Russian Gas Still Mystifies; Experts baffled by type,
death toll
By Robert Cooke
Staff Writer
Russia's tactics in using a gas to end last week's hostage standoff in a Moscow theater have generated more questions than answers.
On Oct. 23, Chechen rebels took about 750 theater-goers hostage for 58 hours. Russian forces ended the siege by pumping a gas into the theater, killing all of the rebels and at least 118 hostages.
It is not clear whether the gas the Russians said they used - fentanyl - was actually all that was pumped into the room to end the deadly standoff. Several anesthesiologists in the United States said fentanyl isn't used as a gas, at least in clinic settings. It also is not clear, the experts said, how rescuers were protected from the roomful of gas, and why medical people on the scene didn't seem to have the correct antidote - naloxone, a common drug - ready to go when the assault began.
The questions were raised because fentanyl is a well-known and widely used anesthetic. It has been in medicine's armamentarium as a pain killer since the 1950s, when it was developed as a stronger version of morphine.
The experts also questioned the use of such a potent anesthetic without rigorous dosage control. People who experience overdoses become very ill; their breathing becomes shallower and shallower, and may stop. Death can result.
In a hospital setting, fentanyl is given via intramuscular injection, or through infusion into a blood vessel. Small amounts also can be given via lollipops to children, or through skin patches, for pain relief.
These traditional, well-established methods for giving fentanyl are what have mystified some anesthesiologists about the Russian use. The drug usually isn't prepared as a gas, vapor or dust. So experts were asking whether the gaseous stuff used in Russia actually was fentanyl, something similar or a mixture of agents.
"It's not used in any kind of vapor or aerosol way in medicine," said anesthesiologist Fred Spielman, at the University of North Carolina School of Medicine. "If they'd put it in powder form that might be a better way for people to breathe it in."
Anesthesiologist John Booth, at Duke University, said "I was very skeptical about that myself. Most narcotics' molecular structure is quite large, so these are not drugs that become gases easily."
To make fentanyl airborne, he explained, "you have to put energy into it, say heat or vibration." Even then, "you can see it and it falls to the ground quite quickly. So the idea of putting it in through the air conditioning system is hard to imagine. It would tend to settle out in the ducts."
Dr. Roger Johns, chief of anesthesiology at the Johns Hopkins Medical Institutions in Baltimore, noted, however, that other drugs related to fentanyl - such as karfentanyl, a veterinary anesthetic - are in use in aerosol form. And they could be modified for use in riot control or similar emergencies.
Spielman also wondered why rescue workers entering the Moscow theater weren't overcome by the gas, too, unless they were protected in advance by an antidote, or wore gas masks. In addition, "It seems curious to me why [the Chechen rebels] didn't have time to blow up the building," since the explosives were wired and ready to go instantly.
One reason so many died, the experts agreed, was that very little could be done to control doses in that setting. Big, even potentially lethal doses, were likely. Also, the victims were debilitated from lack of water and food during their captivity, so their blood volume had been depleted.
"When you have a group of people with blood volume decreased then the effect [of anesthesia] is magnified markedly," Johns explained.
Under any circumstances "if you get too much, you stop breathing and you die," said Harvard University biologist Matthew Meselson.
Johns agreed, but said maybe "it was introduced as a percentage of the atmosphere" in the room to minimize doses. Even so, "to get a dose that will put someone to sleep, you also get a dose that will cause airway collapse. And without having continuous management of the patients, we would expect some difficulties."
According to Meselson, who has spent much of his career studying issues of biological and chemical warfare, exposure to fentanyl "makes you feel like you're in kind of a dreamy state. Then you go unconscious. You wake up remembering nothing."
He recently experienced fentanyl himself, during surgery, Meselson said, and recalled that "it's quick-acting, and it wears off quickly."
Because fentanyl is a synthetic opiate, akin to morphine, it often is produced illicitly for use as a street drug, a substitute for heroin. It is, like heroin, a habit-forming, addictive drug, a narcotic.
Booth, at Duke University, said the antidote to fentanyl, naloxone, also is used against heroin. Early in his career, in Scotland, "I worked in the emergency room and we had a lot of overdose patients. We'd give them an intramuscular injection of naloxone, followed by IV [infusion]. It was amazing; when the IV hit them they'd just suddenly come straight out, cold turkey, and run away."
Indeed, some addicts would rip all their infusion tubes out and dash out of the hospital - but not very far. "The naloxone would wear off and they'd stop breathing" within a few blocks of the hospital. Fortunately, the slower-acting intramuscular injection would keep them from dying.
Meselson said the U.S. Department of Defense has put much work into studying and developing agents such as fentanyl for riot control and similar emergencies. The research started in the 1970s, he said, but it was not clear how far it actually went.
"It was studied as an advanced riot control agent," Meselson said, but after years of research "it disappeared from the budget," suggesting it either was dropped, "or it went black," into secrecy.
An official at the Defense Department's Chemical and Biological Defense Information Analysis Center, in Aberdeen, Md., declined to discuss the subject.
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