Abstract
The workplace has been a neglected element in the national response to the opioid crisis. This ignores that workplace safety and health and drug policies have become important factors in opioid use disorder among workers. This results from physical or emotional pain related to workplace injuries, illnesses, and stress, and through punitive workplace drug policies, failure to address stigma, and inadequate access to treatment and recovery resources. This comprehensive New Solutions special issue encompasses timely cutting-edge research, commentaries, activism, and calls for action on primary prevention in the workplace and intervention research. It also addresses the convergence of the COVID-19 and the opioid crises, high-risk occupations and industries, health inequalities, employer and union programs, peer advocacy and member assistance programs, worker training, health parity for addiction treatment and recovery services, protection of first responders and site clean-up workers, working conditions of substance use treatment workers, and calls for necessary funding.
Introduction
We present this special issue of New Solutions to further expand the evidence base on opioids and the workplace and to share exciting and innovative approaches in this field. Prescription and illicit opioids were involved in 446 032 deaths in the United States between 1999 and 2018. 1 Rates of opioid overdose mortality have been increasing over the last 20 years 2 and have increased dramatically during the COVID-19 epidemic.3,4 Various explanations for this epidemic have been described, including structural and economic factors, inadequate pain management, unsafe prescribing, stigma, criminal justice policy, and poor access to addiction treatment and harm reduction services. 5 Pharmaceutical companies played a major role by aggressively promoting prescription opioids to physicians and other providers based on false claims that they were not addictive and were necessary for treatment of chronic noncancer pain. 6
Since 2015, the increase in opioid overdose deaths has been driven by synthetic, and largely illicit, opioids, such as fentanyl and its analogs. The dramatic increase in deaths related to synthetic opioids is related to prescription opioid use, which may act as a gateway to “street” drugs, especially as practices were put into place that made prescription opioids, such as OxyContin, far more difficult to obtain. 7 Fentanyl is a powerful synthetic opioid that is similar to morphine but is 50 to 100 times more potent. It is a prescription drug that is also made and used illegally. 8 There are many analogs (chemical compounds that have similar physical, chemical, biochemical, or pharmacological properties to one another) of fentanyl that have similar potency and are produced both legally and illegally. 9 In 2019, overdose deaths involving synthetic opioids were nearly 12 times higher than in 2013. Nearly 73% of all opioid deaths involved synthetic opioids. 9 The market for illicitly manufactured fentanyl continues to change, and it can be found in combination with heroin, counterfeit pills, and cocaine. 10 In 2019, 10.1 million people misused prescription opioids and 1.6 million had an opioid use disorder. Synthetic opioid overdoses accounted for 48 006 deaths in the 12-month period ending June 2020, the largest number of such fatalities ever recorded. During this period, synthetic opioid deaths increased 38.4%.7,11
In 2017, the US Department of Health & Human Services declared the opioid epidemic a public health emergency. However, the workplace has been a neglected element in the national response to the opioid crisis, even though workers and their families have been particularly impacted nationwide. A number of studies have documented that certain industries and occupations, such as construction and extraction, are at high risk for opioid misuse, addiction, and overdose fatalities, but policies and practices have lagged behind this knowledge. The Substance Abuse and Mental Health Services Administration (SAMHSA) has estimated that 66% of people who misuse opioids are working full or part-time. 12 The workplace has been a pathway to opioid use disorder (OUD) due to physical or emotional pain related to workplace injury, illness, and stress. Increased risk of injury, and thus, working in pain, occur in construction and healthcare, 13 2 industries with high rates of opioid overdoses. 14 Healthcare workers are at increased risk of workplace violence 15 and low back pain. 16 Job insecurity and limited paid sick leave, common in construction, are risk factors for opioid overdose deaths. 13 In addition, the opioid epidemic puts workers at risk for other hazardous exposures: first responders are at risk from exposure to fentanyl or fentanyl analogs, workers in safety-sensitive jobs may have an increased risk of injury when working with co-workers who are impaired by opioids or other drugs, and workers in addiction treatment may be at higher risk of work stress due to growing demands for services in an underfunded industry.
Need for Intervention Research, Primary Prevention
A major research gap is intervention research targeting identification and control of occupational risk factors that contribute to the potential for OUD. Federal funding has not been directed at primary prevention, but rather has focused on helping workers who are in recovery get back to work. Undoubtedly, working is a lifesaving element of successful recovery, and this support must continue. However, funding should also be directed at identifying and addressing the root causes of work-related injury, stress, and pain that promote prescription and illicit opioid use. The Centers for Disease Control and Prevention (CDC) estimate that 25% of long-term opioid prescription users develop addiction. 12 It is time to put an end to the conditions that have contributed to the addiction “pipeline.”
In this special issue of New Solutions, the article, “It is time to implement primary prevention in the workplace to ameliorate the ongoing US opioid epidemic,” Le and Rosen 17 describe primary prevention efforts to address the connection between workplace hazards and opioid misuse, dependence, and addiction, including examining patterns of work injury and stress with records of opioid prescription. Government funding should be expanded to support primary prevention and intervention research efforts to strengthen the evidence-base to support workplace primary prevention endeavors.
Two reprints that address policy are included in this special issue. First, is “A Public Health Approach to Protecting Workers from Opioid Use Disorder and Overdose Related to Occupational Exposure, Injury, and Stress,” American Public Health Association (APHA) Policy Statement Number 202012, issued October 24, 2020. Authored by Rosen et al, 18 the action steps describe key federal, state, and local actions to combat the opioid crisis in the workplace.
Second, Rosen and Harnett 3 “Confronting Two Crises: The COVID-19 Pandemic, the Opioid Epidemic, and the Industrial Hygienist.” This article was originally published in the January 2021 issue of the Synergist, a monthly publication of the American Industrial Hygiene Association. The article addresses the convergence of the COVID-19 and opioid crises, the impact of the opioid crisis on the workplace and workers, and the role that industrial hygienists (IHs) can play in developing workplace programs to prevent and respond to opioid misuse. While the article is specifically written for IHs, the review and recommendations will be useful to others who are developing workplace opioid prevention programs.
Deaths of Despair
Increasing rates of opioid mortality have occurred in conjunction with increases in mortality from 3 other major stress-related causes of death—suicide, alcohol use disorder, and cardiovascular disease.2,19 Mortality increases from these 4 specific causes, especially in working-age populations (25-64 years), led to a decreasing life expectancy between 2014 and 2017. 2 US life expectancy is lower than and has been diverging from our “peer” (wealthy industrialized) countries since about 1980. 2 Case and Deaton 20 have used the phrase “Deaths of Despair” to describe the substantial increase in deaths from alcohol, drugs, and suicide, especially pronounced in populations affected by deindustrialization, job loss, and declining socioeconomic status. The COVID-19 pandemic has also caused a significant drop in US life expectancy in 2020 due to COVID-19 and a related increase in deaths of despair.4,21,22 The pandemic has increased social isolation, mental health problems, and disrupted access to drug, alcohol, and mental health treatment and recovery programs.
The roots of the increase in deaths of despair can be traced to neoliberal economic and political policies, which have led to increased corporate power, deindustrialization, deregulation, privatization, loss of union jobs and fixed-benefit pensions, increasing income inequality due to stagnant wages for many workers, and resultant hopelessness. 20 For example, trade and employment policies that lead to job loss and economic distress have been linked to opioid use and mortality.23,24
Another important factor is the expensive US healthcare system. Healthcare costs in the United States rose from being 5% of national income in 1960 to be more than 18% in 2018, about a fifth of the entire economy. 20 , p. 203 We have the most expensive healthcare system in the world, and it's not delivering the best health in the world. Case and Deaton point out that the Swiss, who have the next most expensive healthcare system, live 5 years longer than Americans and spend 5% less of their GDP than what Americans spend. That adds up to a trillion dollars a year, $8300 per family, of pure waste. 25 “That money gets sent up the income distribution to big, expensive hospitals, device manufacturers, Big Pharma, and doctors, who make up the largest single occupation in the top 1% of all incomes. So we have this system that's taking money out of the pockets of regular people and sending it up the distribution to very wealthy people.” 25 Pharmaceutical companies have used their accumulated wealth for massive promotion and marketing of opioids to physicians and other providers based on false claims that they were not addictive and were necessary for treatment of chronic noncancer pain in the1990s and 2000s. 6 Workers’ compensation systems have contributed immensely to the overuse of prescription opioids. These systems generally discourage the use of alternative pain treatments such as physical therapy, acupuncture, chiropractic services, and psychological healthcare. 26
The roles of occupational injury, illness, and stress that result in pain as a driver of the epidemic of opioid use are made clearer by Cooper and Bixler 27 in “Comprehensive workplace policies and practices regarding employee opioid use.” The authors note that a high number of US workers report chronic pain, and trace a pathway from exposure to opioid prescriptions to opioid use or misuse to high morbidity and mortality rates, extended work disability, and increased worker compensation costs. This paper reviews National Safety Council tools and resources and identifies barriers to addressing opioid use in the workplace.
While construction and healthcare have been hit hard by the work-related opioid crisis, there is limited understanding about unique circumstances arising in various other industries and occupations. In “Commercial Fishing as an Occupational Determinant of Opioid Overdoses and Deaths of Despair in Two Massachusetts Fishing Ports, 2000–2014,” Fulmer et al 28 found that commercial fishermen were 4 times more likely to die from opioid poisoning and more likely to die from other “diseases of despair” than nonfishermen living in the same fishing ports.
Stigma
Reforming punitive workplace drug policies that treat OUD as a disciplinary matter rather than as a chronic disease is particularly important. Zero-tolerance policies, Executive Order 12564—Drug-free Federal workplace, and related federal, state, and company regulations have contributed to stigmatizing work cultures where workers who have mental health or substance use issues fear being ostracized by employers and co-workers. An important gap in the nation's opioid public health crisis is identifying effective methods of transforming discriminatory workplace policies and cultures into supportive ones. The Substance Abuse and Mental Health Services Administration (SAMHSA) estimates that 70% of people who misuse opioids are working full or part-time. Establishing workplace policies and cultures where workers can talk about the uncomfortable issues of mental ill-health and substance use without fear of job loss or discrimination is key to getting workers access to treatment and recovery resources. Emerging research, training, and worker protection case studies and advocacy programs are described and assessed in this issue.
Also in this special issue, in the article “The Intersectionality of Activism and Public Health in New York State: Can Labor/Health and Safety Move Addiction Recovery Forward?”, Campbell and Rosen describe the key role of community activists in confronting stigma and fighting for health parity for addiction treatment and recovery services, and challenge labor and health and safety activists to join those in the recovery movement in a coalition. 29 Coalition work in New York State led to partnerships that improved funding for treatment and recovery and set standards and established government oversight to prohibit discrimination by healthcare and insurance companies; labor and health and safety activists should be part of this given the profound impact on workers and the intersection of work and OUD use.
Importance of Worker Training and Union-Based Programs
Worker training using participatory training techniques facilitated by peer trainers is recognized as a key intervention in effective workplace safety and health programs.30,31 This is addressed in several articles in this special issue. In “Promoting Opioid Awareness Through a Union-Based Peer Training Model,” Roelofs et al 32 describe an opioid awareness union-based peer training model implemented in collaboration with union locals of the Ironworkers’ and Teamsters, and a state-wide nurses’ union, along with an evaluation of the impact of the training program. Training evaluations revealed positive changes in opioid knowledge, the stigma around help-seeking, and confidence in helping others with substance use disorder (SUD).
In “Opioids and the Workplace Prevention and Response Awareness Training: Mixed Methods Follow Up Evaluation,” Persaud et al 33 describe and evaluate a National Institute of Environmental Health Sciences Worker Training Program (NIEHS WTP) pilot to train workers and employers about the extent of the opioid crisis, its impact on workers and work sites, that OUD is a brain disease and not a “moral failing,” the impact of stigma, and preventive methods. The evaluation found that the training increased participant knowledge about opioids and opioid use disorder and its relationship to workplace injury and stress, and found that it more frequently influenced individual—as opposed to workplace-level actions.
In “Preventing Opioid-Related Harms in the Construction Industry,” Roelofs et al 34 describe the National Association of Building Trade Unions’ Opioid Task Force projects developed by the Center for Construction Research and Training (CPWR). These resources provide construction workers with information and training to increase awareness, reduce stigma, and avoid opioid misuse. An additional initiative assesses the state of union peer-support programs.
Voices Section of This Special Issue
Construction union efforts are further described in the “Voices” section through interviews with union leaders and the director of the Center for Construction Research and Training (CPWR), all of whom have pioneered efforts to prevent addiction and promote treatment and recovery for their members, including:
Cheryl Ambrose of United Association of Journeymen and Apprentices of the Plumbing and Pipe Fitting Industry of the United States and Canada describes how the union adapted opioid prevention training developed by the NIEHS.
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During a week-long instructor training, participants and guest speakers broke down barriers by telling their own stories of addiction and recovery. This openness provided inspiration and hope, including cases where members who overcame addiction had risen to leadership in the union. The instructors spent time planning how they would tailor the program to meet their members’ needs. Kyle Zimmer, health and safety and Members Assistance Program director for the International Union of Operating Engineers Local 478 in Connecticut, developed a union-based member assistance program to address mental health, suicide, substance use, and stigma among members and their families.
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This innovative peer assistance program has gained the support of the contractor employers and has been highly successful in getting members into treatment and back to work. Chris Trahan Cain, executive director of CPWR—which is, affiliated with North America's Building Trades Unions, has been working with construction unions and employers to develop primary, secondary, and tertiary prevention programs to help combat the opioid epidemic, other SUDs, and to improve worker mental health.
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Other Critical Topics Addressed in the Special Issue
Protection of First Responders
The opioid crisis has led to increasing reports about first responders being exposed to fentanyl and fentanyl analogs. “Occupational Safety and Health and Illicit Opioids: State of the Research on Protecting against the Threat of Occupational Exposure” by Basham et al 38 written for the National Institute for Occupational Safety and Health (NIOSH) Opioids Research Gaps Working Group, examines the state of worker protection to prevent accidental occupational exposure to illicit opioids. The literature review identified gaps in worker protection concerning personal protective equipment (PPE), decontamination methods, and engineering controls, compliance with OSHA standards, as well as technical knowledge about PPE, decontamination, and understanding how these measures are utilized by employers and workers.
Cerles et al 39 describe an innovative video-based participative training module for first responders that was piloted with emergency medical services and law enforcement personnel. The awareness program described in the article “Development of Novel Video-Based First Responder Opioid Hazard Refresher Training” provides evidence that worker training can enable workers to recognize potential opioid exposures and to ensure the proper use of protective equipment and measures. The training provides a useful resource to emergency responders who may encounter potent synthetic opioids when responding to medical calls involving people who have overdosed on fentanyl or fentanyl analogs.
Standards for Clean-Up of Sites Contaminated With Fentanyl and Fentanyl Analogues
“Establishing Standards for the Assessment and Decontamination Clean-up of Opioid Contaminated Properties” by Polkabla 40 describes a case where a property was used as a clandestine opioid (fentanyl and carfentanil) lab resulting in potentially lethal contamination. The environmental assessment and sampling procedures, clean-up worker protection methods, and decontamination processes used to mitigate the property are described. A safe re-occupancy criterion was established and used as the basis for the adoption of a state standard for residential clean-up in California. Regulatory hurdles and key lessons are presented so that others may consider the development of similar public health policies in other states and federally.
Corporate Social Responsibility
In “Answering a Call to Action on American Workplace and Community Opioid Concerns,” Harnett et al 41 describe their experience at Leidos Inc., a Fortune 500® government science and technology company with more than 42 000 employees, with a new model of corporate social responsibility in relation to the opioid epidemic. When an employee reached out to the CEO and described the loss of his son to opioid addiction, corporate management responded by committing to a long-term program examining the impacts of the opioid epidemic on workplaces and communities and initiating programs that included reducing stigma around discussions of opioid use, use of healthcare plans to impact physician-prescribing behaviors, enhancing employee assistance services. Corporate leadership used its influence in reaching out to other companies to collaborate on substance use and broader well-being issues. Company resources have been used in community initiatives such as sponsoring public service information campaigns, naloxone (opioid antidote) training and distribution, and drug take-back days. The CEO has appeared on national television to promote the program and spoken on several national panels including one on opioids and the workplace at the American Public Health Association's annual meeting. The internal and external initiatives in this case study serve as a model for other companies. The fact that Leidos has a history of employee ownership, an open corporate culture, and a responsive CEO facilitated their work, and as such their actions may not necessarily be replicable in other companies.
Impact of Managerialism on the Substance Abuse Treatment Workforce and Services
The substance use treatment workforce is key to helping workers recover from OUDs (tertiary prevention efforts). However, for more than 40 years, neoliberal policies have relied on privatization and other tactics to down-size government services, transforming human service organizations in the process. In “On the Front Lines: Managerialism in Addiction Treatment Programs”, Lewiskin et al 42 examine this approach, also known as new public management, or managerialism, in addiction treatment, where the opioid epidemic has intensified the need for services. This new system of work organization appears to result in high caseloads and productivity demands; threats to service quality including standardization of practice, loss of professional discretion and serving only those most likely to succeed; and threats to worker well-being, marked by stress, burn-out, and low morale. Managerialism thus appears to be a threat to the treatment workforce at a time when it is most needed.
Race/Ethnicity, Work and Opioids
Unintentional drug overdose mortality for working-age adults (25-64 years) increased significantly for Whites, Blacks, and American Indian and Alaska Natives between 1999 and 2005. However, after 2005, rates for Whites and American Indian and Alaska Natives continued a sharp increase. Rates for Blacks began to rise substantially again after 2015 and are now nearly as high as Whites and American Indian and Alaska Natives. Rates for Latinx and Asian and Pacific Islanders have been increasing but at much lower overall rates.1,43 Various factors have been proposed to help explain these disparities, including access to prescriptions, illicit, or synthetic opioids, negative representations, stereotyping and stigma, and separate and unequal prevention and treatment. 44 They are discussed in the APHA policy document 45 and in Rosen and Harnett's 46 “Confronting Two Crises: The COVID-19 Pandemic, the Opioid Epidemic, and the Industrial Hygienist.” In addition, Lewiskin et al 42 describe how Nixon's “war on drugs,” and related policies, criminalized substance use and users, thus justifying low levels of funding for treatment. The focus on funding law enforcement played a major role in mass incarceration for people and communities of color. Further research is needed on the legacy of mass incarceration, modern law enforcement practices, and trends in employment conditions and working conditions as potential explanations of racial/ethnic opioid overdose inequalities.
NIOSH Response to the Opioid Epidemic
NIOSH, within the CDC, is the nation's premier government occupational safety and health research agency. Established under the Occupational Safety and Health Act of 1970. NIOSH defines its mission as “To develop new knowledge in the field of occupational safety and health and to transfer that knowledge into practice.” As such, addressing the devastating impact of opioids on US workers and employers is an essential area of work for NIOSH.
In “NIOSH Responds to the U.S. Drug Overdose Epidemic,” Osborne and Chosewood 47 describe NIOSH research efforts to inform opioid prevention policy and practice and to develop accessible resources and tool kits to support workers, employers, and workplaces in combatting the opioid overdose crisis. Maryland currently lacks a recovery-friendly initiative (RFI) to guide workplaces in efforts to reduce stigma and support recovery. In “Workplace Support for Employees in Recovery from Opioid Use: Stakeholder Perspectives,” Imboden et al 48 present their approach to convening key stakeholders in a collaborative approach to shaping an RFI responsive to the needs of Maryland's workplaces.
Conclusion—Call to Action
Many of those who contributed to this issue have been personally affected by the opioid epidemic, and have responded with activism, advocacy, and commitment to bringing these topics into the light of day, reducing stigma, and seeking new solutions based in the workplace. Workers are dying from opioid overdoses related to work-related injury, illness, stress, and inadequate or harmful workplace drug policies and programs that frequently hinder workers from coming forward for help because they emphasize drug testing and discipline rather than treatment and support. These punitive approaches are ineffective, drive workers who are struggling underground, and must be reformed if the cycle of addiction and death related to workplace conditions is going to change. Although working conditions as an underlying cause have been acknowledged by NIOSH, OSHA, and other government agencies, funding for intervention research for primary prevention is absent from the nation's response to the crisis. This must be corrected. Funding should be directed for workplace primary prevention of opioid misuse research, worker and leadership training, and development of supportive drug policy initiatives. These are key gaps in the nation's response to the opioid crisis. Prevention and treatment have common elements across all jobs, but multifactorial causation specific to each industry and occupation should be evaluated and considered fully when developing solutions. Resources for training industry and labor leaders are key to enable the implementation of solutions. Musculoskeletal injuries and illnesses caused by inadequate protection from ergonomics hazards is a leading cause of lost-time injuries and illnesses, comprising 30% of all lost-time injuries and illnesses reported to the Bureau of Labor Statistics in 2018. 49 Musculoskeletal Disorders (MSDs) are frequently treated with prescription pain medication. When prescription pain medication is not available, injured workers may turn to “street” drugs. 50 The need for enforceable ergonomic prevention standards is clear. The repeal of the OSHA ergonomics standard under the Congressional Review Act in 2000 has allowed for the continuation of needless pain and suffering among workers exposed to ergonomic hazards across many industries that require lifting, pushing, pulling, bending, twisting, reaching, material or patient handling, and repetitive motion.51,52 It is no surprise that these industries also have higher rates of opioid addiction and death. Enacting an enforceable OSHA ergonomics standard is paramount to solving both the MSD and the opioid crises in the workplace.
Protection of first responders who are on the front lines responding to overdoses requires funding of the research identified by the NIOSH Opioids Research Gaps group. Assessing compliance with OSHA's respiratory protection standard by employers of first responders should be a priority, as respiratory protection from inhalation of fentanyl and fentanyl analogs is key to preventing occupational exposure in moderate and high-risk cases, according to NIOSH and the Inter-Agency Board. Addressing stigma, punitive workplace drug policies, and inadequate access to treatment and recovery resources are urgent needs. Policies that silence workers who are struggling and prevent them from coming forward for help must be reformed. Funding and support to implement these reforms are key to addressing the devastating impact of opioids on workers and workplaces. This includes increasing NIOSH's budget for intervention research and OSHA's budget for inspections and worker training on these issues. The US Congress must undo the ban on OSHA promulgating an ergonomics standard and mandate that OSHA issue standards to prevent risks, and adverse outcomes that are causing death and serious harm due to work injury, illness, stress, and related opioid misuse. The Protecting America's Workers Act, introduced by Representative Joe Courtney should be passed so that OSHA can do what needs to be done. 53 Finally, occupational health and safety and labor activists should join in coalition with the recovery activist community and government public health authorities to reform the discriminatory and disparate treatment of mental health and addiction treatment by healthcare providers, insurance providers, and employers.
A good example of moving this key response to the opioid crisis forward was in Connecticut where a coalition of state officials, subject matter experts, unions, recovery and treatment organizations came together to produce 2 conferences, a report, and other resources on the opioid crisis and Connecticut's workforce. 54 Similar coalitions could be established in every state. The labor and occupational health and safety movements are in prime positions to advocate for and help organize such coalitions. Strong advocacy is also needed for truly universal healthcare that includes parity for mental health services, including appropriately funded addiction services and alternative pain management.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Jonathan Rosen received partial funding for his contribution to this publication from MDB Inc. 47QRAA20D0028/75N96020F00166.
Authors’ Biographies
) on reducing job stress and increasing healthy work.