A Public Health Approach to Protecting Workers from Opioid Use Disorder and Overdose Related to Occupational Exposure, Injury, and Stress

  • Date: Oct 24 2020
  • Policy Number: 202012

Key Words: Opioid pain relievers, Addiction, Substance Abuse, Workplace Safety, Occupational Health And Safety

Opioid overdose mortality, in combination with increased deaths from alcohol and suicide, is having a profound impact on American workplaces, compromising occupational health and safety and increasing workers’ compensation and health insurance costs, absenteeism, and lost productivity. The President’s Council of Economic Advisers estimates that more than 1 million workers are out of the workforce due to the opioid crisis. The impact on workers is equally profound, including job loss, divorce and family disruption, and potentially imprisonment, injury, illness, and death. Pain from occupational injuries and illnesses and stress are important pathways to opioid use disorder. Effective workplace programs that incorporate the public health approach to prevention offer a significant opportunity to prevent and respond to the opioid crisis. To date, the nation’s efforts at combating the crisis have not included the necessary policy reforms to transform the workplace from a pathway to opioid misuse to a pathway to prevention, including education of workers, unions, employers, and health care providers and treatment and recovery of affected workers. Several key policy interventions are recommended to address this disconnect, including prevention of workplace injury, illness, and emotional distress; worker education and training; and replacement of stigmatizing, punitive workplace substance use programs with supportive programs. Increasing access to alternative pain treatment and preventing opioid misuse in workers’ compensation systems are other key policy recommendations.

Relationship to Existing APHA Policy Statements
The proposed policy will address gaps in the existing APHA opioid-related policies, including reforming workers’ compensation systems to improve access to alternative pain treatment and regulating overprescribing and misuse of opioid prescription medications.

  • APHA Policy Statement 201312: Defining and Implementing a Public Health Response to Drug Use and Misuse
  • APHA Policy Statement 20154: Prevention and Intervention Strategies to Decrease Misuse of Prescription Pain Medication
  • APHA Policy Statement 20133: Reducing Opioid Overdose through Education and Naloxone Distribution
  • APHA Policy Statement LB-12-02: Preventing Overdose Through Education and Naloxone Distribution
  • APHA Policy Statement 20134: Supporting Public Health’s Role in Addressing Unmet Needs in Serious Illness and at the End of Life
  • APHA Policy Statement LB-11-03 Reducing Unintentional Prescription DrugOverdoses
  • APHA Policy Statement 20138: Support for Workplace Injury and Illness Prevention Programs
  • APHA Policy Statement 9703: Prevention of Work-Related Musculoskeletal Disorders
  • APHA Policy Statement 20114: Musculoskeletal Disorders as a Public Health Concern
  • APHA Policy Statement 20174: The Critical Need to Reform Workers’ Compensation
  • APHA Policy Statement 20068: Resolution on the Right for Employee Free Choice to Form Unions

Problem Statement
Prescription and illicit opioids were involved in 446,032 deaths in the United States between 1999 and 2018.[1] U.S. life expectancy decreased for 3 consecutive years beginning in 2014, and midlife all-cause mortality rates increased by 6% between 2010 and 2017, largely due to drug and alcohol use and suicides—labeled “deaths of despair.”[2] The 46,802 opioid deaths in 2018, however, represented a 2% decline from 2017,[1] which contributed to a small increase in life expectancy in 2018.[3] The number of overdose fatalities due to nonmedical use of drugs or alcohol while at work increased 12% from 272 to 305 in 2018, the sixth consecutive annual increase.[4]

Working conditions are an important cause of the opioid epidemic, and workplace programs and policies should be an important target for interventions designed to treat and prevent opioid use disorder (OUD). Workers with painful injuries have frequently been overprescribed opioids, leading to chronic use of prescribed opioids and resulting in high levels of opioid dependence and OUD. This problem statement details evidence addressing (1) opioids, work, social determinants of health, and health disparities/inequities; (2) impact by industry and occupation; (3) economic impact; (4) impact of workplace stress and the organization of work; (5) the importance of ergonomics and musculoskeletal injuries; (6) workplace drug prevention programs; (7) punitive workplace drug policies; and (8) workers’ compensation issues.

Since the start of the COVID-19 pandemic, at least 35 states have reported increases in opioid fatalities.[5] The pandemic appears to be increasing OUD risk due to greater social isolation (including suspended in-person group support meetings),[6] economic hardship, depression, anxiety, and worsened ergonomics.[7] For example, Cook County (Illinois), including Chicago, has seen a doubling of overdoses relative to 2019. Unlike COVID-19, there is no real-time national counting of opioid overdose deaths.[8]

Opioids, work, social determinants of health, and health disparities/inequities: Opioid mortality rates, as well as declines in life expectancy, have been greater among individuals with lower levels of education,[2,9,10] those in occupations with median incomes below $50,000, and those in blue-collar occupations.[11,12] At the macro-economic level, trade and employment policies that lead to job loss and economic distress have been linked to opioid use and mortality.[13–15]

Opioid mortality rates have been higher among non-Hispanic White individuals than among Hispanic , non-Hispanic Black, or Asian individuals.[1] However, in contrast to White individuals, rates among Black and Hispanic individuals continued to increase in 2018, narrowing the racial/ethnic disparity. Between 2014 and 2017, Black people experienced the greatest increase of any racial/ethnic group in rates of overdose deaths from nonmethadone synthetic opioids.[16] However, the role of working conditions and workplace policies in racial/ethnic disparities and trends is not well understood.

Higher rates of occupational injuries, illnesses, and fatalities among Black and Hispanic workers can be explained, in part, by disproportionate employment in high-risk industries,[17] discrimination and workplace injustice,[18] and inadequate protection by current laws and policies.[18,19] A role for occupational exposures is suggested by Massachusetts data showing that the highest percentages of opioid deaths among White, non-Hispanic workers (33.1%) and Hispanic workers (26.0%) are in “natural resources, construction and maintenance occupations,” while the highest percentages among Black non-Hispanic workers (32.1%) are in “service occupations.”[20] A role for disparities in medical care is suggested by lower opioid prescribing rates among Black and Hispanic (versus White) construction workers.[21] A role for discrimination is suggested by Black workers being nearly twice as likely to report drug testing at work.[22] A role for inadequate workplace benefits is suggested by Black people and Hispanic people having substantially reduced access to health and substance use treatment services.[23]

A variety of risk factors for OUD, including structural and economic factors, inadequate pain management, unsafe prescribing, stigma, criminal justice policy, and poor access to addiction treatment and harm reduction services, have been described as part of a socioecological model of the opioid crisis.[24] However, such models have not paid adequate attention to working conditions and workplace policies, and thus these priorities are a focus of this policy statement.

Impact by industry and occupation: In 2018, private employers reported 2.8 million work injuries and illnesses and 5,250 occupational fatalities. Data from the National Institute for Occupational Safety and Health (NIOSH) show that 44% of workers’ compensation claims in 2017 included at least one prescription for opioids.[25] The Workers’ Compensation Research Institute reported over 1.4 million prescriptions filled for injured workers from October 2014 to September 2015 in 27 states.[26] Most (95%) drug overdose deaths occur in the working- age population (15–64 years). NIOSH identified 57,810 drug overdose deaths between 2007 and 2012. Rates were highest in the following six groups: (1) construction, (2) extraction, (3) food preparation and serving, (4) health care and technical, (5) health care support, and (6) personal care and service.[25] Construction workers and miners were more likely to be prescribed opioids (and for a longer duration) than other workers.[25] NIOSH concluded that both licit and illicit opioids should be addressed through comprehensive drug-free workplace programs, employee assistance programs, peer support networks, employee and employer education, and continued evaluation of intervention effectiveness.[25]

Several studies have examined connections between opioids and occupational factors at the state level. A Washington State study, along with other studies, revealed that opioid prescribing failed to reduce pain or help injured workers return to work.[27–29] Subsequently, Washington State developed guidelines, regulations, and health provider education that led to a 27% decline in prescription opioid deaths from 2008 to 2012.[30] Massachusetts has documented that high rates of opioid fatalities occur in industries with a high risk of occupational injury and lower availability of paid medical leave and job security.[20] Between 2011 and 2015, 4,302 opioid deaths occurred in Massachusetts. Opioid death rates among construction and extraction workers were six times higher than among all Massachusetts workers, and rates among workers in farming, fishing, and forestry were five times higher . Individuals involved in these occupations usually are paid only when working, resulting in many working in constant pain. The Massachusetts Department of Public Health recommended addressing workplace hazards that cause injuries or illnesses for which opioids are prescribed, appropriate pain management following injury (including safer opioid prescribing), access to evidence-based treatment for OUD, and overdose prevention education.

A New Mexico study revealed a 2.6-fold increased risk of suicide and drug-related deaths in women and a 1.4-fold increased risk in men who had been injured at work. The study concluded that “workplace injuries severe enough to require more than a week off work may impair workers’ long‐term health and well‐being. Drug‐related deaths and suicides may be important contributors to the long‐term excess mortality of injured workers. Improved workplace conditions, improved pain treatment, better treatment of substance use disorders (SUD), and treatment of postinjury depression may substantially reduce mortality consequent to workplace injuries.”[31]

Several studies have shown a strong correlation between work- related pain treatment and opioid misuse, addiction, and overdose fatalities. Forty percent of U.S. workers report chronic or recurrent musculoskeletal pain, 15% report pain on most days, and work-related back pain accounts for $5.3 billion in lost productivity. [32,33] The Substance Abuse and Mental Health Services Administration (SAMHSA) reports that 2.1 million people had an opioid use disorder in 2018. Approximately 10.3 million people 12 years or older (3.7% of the population) misused opioids, with 9.9 million misusing prescription opioids. The main reason for misuse of opioids was to relieve physical pain (63.6%).[34] Quantifying the extent to which physical pain is work related as opposed to resulting from other causes is a research gap.

Economic impact: The Council of Economic Advisors estimated that the total economic cost of the opioid crisis in 2015 was $508 billion, or 2.8% of the gross domestic product.[35] An estimated 66.2% of self-reported illicit opioid users were employed full or part time.[36]

Impact of workplace stress and the organization of work: Workplace stress and how work is organized are additional risk factors. NIOSH defines “work organization” as “the work process (the way jobs are designed and performed) and the organizational practices, management and production methods, and accompanying human resource policies that influence job design.” [37] A stressful work organization can increase the risk of acute traumatic injuries[38] and musculoskeletal disorders (MSDs) such as tendonitis and low back pain.[39] It can also lead employees to work in pain or return to work before an injury or illness has healed. Finally, a stressful work organization can increase the risk of common psychological disorders,[40] such as depression,[41] and thus lead to self-medication with alcohol or drugs.[42]

Emergency responders, disaster response workers, and other workers exposed to violence or emotional trauma at work may experience psychological trauma, which can increase psychological disorders and substance use. [43] Health care workers, especially nursing, psychiatric, and home health aides, are at greatly increased risk of workplace violence, [44] and health care support workers were found to be at increased risk of opioid mortality in Massachusetts.[11]

Individuals involved in nonstandard work arrangements such as temporary work and those facing workplace violence[45] are at increased risk of injury. Nonstandard work arrangements,[46] bullying, and harassment[47] increase the risk for psychological disorders. Workers facing job strain or frequent heavy lifting are at increased risk of OUD.[42]

Work/life imbalance and stress also result from long work hours, excessive use of mandatory overtime, and nontraditional work schedules. Between 1979 and 2007, family work hours increased from 6.3% to 19%.[48] In 2010, 29% of U.S. workers reported working other than a regular day shift.[49] Nonstandard work shifts and long work hours, including 12-hour shifts now common in health care, can contribute to decreased sleep duration,[50] fatigue, unhealthy behaviors, risk of injury,[51] and musculoskeletal disorders.[52] Other industries with high rates of mandatory overtime, extended hours, and split shifts include transportation, manufacturing, and warehousing.[51]

Importance of ergonomics and musculoskeletal injuries: In 2018, there were 272,780 MSD cases reported to the U.S. Bureau of Labor Statistics, representing 30% of lost-work-time cases in manufacturing alone.[53] MSDs are the single largest cause of work-related illness, accounting for more than 33% of all newly reported occupational illnesses in the workforce and approximately 77% among construction workers.[54] In November 2000, the Occupational Safety and Health Administration (OSHA) issued an enforceable ergonomics standard to prevent MSDs. It was rescinded by Congress within 4 months of a new administration under the Congressional Review Act, which prohibited OSHA from ever issuing a substantially similar standard.[55]

Workplace drug prevention programs: In a study commissioned by the National Safety Council, 70% of employers reported that prescription drugs impact their businesses; however, 76% do not offer related training, 81% lack a comprehensive substance abuse policy, and 41% that perform drug tests do not test for synthetic opioids.[56] In addition, some employer health insurance programs do not provide alternative pain therapies or coverage for mental health and/or substance use treatment.

The U.S. Department of Transportation Omnibus Transportation Employee Testing Act requires agencies to implement drug and alcohol testing among safety-sensitive transportation employees. This has resulted in these workers being denied access to medication-assisted treatment (MAT) despite overwhelming evidence of its effectiveness in treating OUD.[57] Many federal and private employers conduct routine and random drug testing, and the presence of methadone, buprenorphine, or naltrexone can lead to termination of employment. This is a deterrent to workers coming forward for treatment. Employment that does not provide access to health insurance deprives affected workers of access to mental health and substance use treatment, including MAT. Racial and ethnic disparities in health insurance coverage rates account for a sizable share of the difference in access to health care.[58]

An Ohio survey showed only half of workplaces have a significant written substance abuse policy, and only about one fourth conduct annual supervisor training or drug-free workplace employee education.[59] In addition, only 45.2% of businesses believe that treatment for substance use problems is effective, and only 1 in 12 employers would consider hiring an applicant who tested positive but then tested negative and was cleared by a counselor. About one quarter of businesses would terminate an employee who tested positive. Forty percent of businesses do not have, or do not know whether they have, a professional resource identified when an employee needs help with a drug and/or alcohol problem.[59]

Punitive workplace drug policies: Punitive workplace substance abuse policies are a major obstacle to workers coming forward to discuss substance use or underlying mental health problems. In workplaces with “zero-tolerance” policies, a positive drug test leads to termination of employment. “Last chance” agreements imply that workers will have only one opportunity for treatment and recovery; however, it is recognized by the National Institute on Drug Abuse that OUD is a “chronic, relapsing disorder characterized by compulsive drug seeking and use despite adverse consequences.” Punitive drug policies do not recognize that―as a result of the nature of OUD―multiple attempts at treatment are often necessary before a person remains in recovery. Punitive policies make it unlikely that workers will voluntarily come forward for help when they know that it could lead to loss of employment.

OUD is recognized as a disease by the Centers for Disease Control and Prevention, the American Medical Association, and the American Society of Addiction Medicine. The criteria for a diagnosis of OUD are contained in the Diagnostic and Statistical Manual of Mental Disorders. However, due to lack of knowledge, stigma, and punitive policies, OUD is usually addressed differently than other diseases by employers. In 1986, the drug-free workplace and zero-tolerance policy was expanded to the entire federal government workforce through Executive Order 12564. In 1988, Congress expanded the drug-free workplace concept and zero-tolerance policy into the private sector by passing the Drug-Free Workplace Act, which requires government contractors to establish a drug-free workplace policy and penalize any violating employees.

Workers’ compensation issues: Workers’ compensation systems have been major contributors to the overuse of prescription opioids. In addition, these systems generally discourage use of alternative pain treatments―such as physical therapy, chiropractic services, acupuncture, mind-body practices (e.g., yoga, meditation, and Ayurveda), natural products, and psychological treatment[60,61]―in a misguided and counterproductive attempt to reduce costs.

The Workers’ Compensation Research Institute found a reduction in the use of opioids in 26 state systems between 2009 and 2015, but prescriptions continued to be prevalent among nonsurgical claims involving more than 7 days of lost time, for which 65% to 75% of workers received opioid prescriptions.[26] The average opioid dose varied from 900 to 3,500 morphine milligram equivalent doses per claim, illustrating the large variations in opioid dispensing practices. Non-opioid pain treatment did not increase to the same degree that opioid prescriptions were decreasing, raising a concern that injured workers may seek illicit opioids when alternative pain treatment is not available.[26]

Summary: The workplace has been an important missing link in the national response to the opioid epidemic. There is an urgent need to direct resources to developing workplace programs that are effective in preventing painful and emotionally distressing injuries related to unsafe and unhealthy working conditions and in supporting workers with OUD. Reforms are needed so that workplaces can contribute to helping workers who have received inappropriately prescribed opioids or developed OUD gain access to effective treatment and recovery programs.

Evidence-Based Strategies to Address the Problem
Public health approach to prevention: Applying a public health approach to prevention includes primary, secondary, and tertiary approaches. The goal of primary prevention is to avoid injury and illness. In the workplace, this can be accomplished through effective safety and health programs. Effective prevention of occupational exposures will result in fewer workers needing medical care including pain treatment, a potential pathway to OUD. Providing information to injured workers on how to talk to providers about pain management, how to avoid misuse of opioids, and alternative pain treatments is a key secondary prevention intervention. Tertiary interventions focus on improving workplace access to treatment and recovery programs, addressing stigma, and reforming punitive workplace drug policies.

Primary prevention: Improving occupational injury and illness prevention programs is an essential strategy. Workplace leaders can reduce exposure to hazards by evaluating risk factors and taking corrective action. Hazard evaluation includes analyzing data sources such as logs maintained by employers for occupational injury reporting (OSHA 300 logs) and workers’ compensation records. Other methods include inspections of workplaces, buildings, and equipment; interviews with injured workers and focus groups; and surveys. Such assessments are designed to identify and address potential exposures before they result in harm. In addition, evaluating the root causes of incidents is important in prevention. Once hazards are identified, hazard control should be determined via the hierarchy of control measures recognized by OSHA, NIOSH, and the safety and health profession as the appropriate approach.[62] OSHA has developed safety and health management guidelines that detail these interventions.[63] The OSHA Web site documents more than 60 success stories using this approach. The International Organization for Standardization (ISO) has developed a standard, ISO 45001, that follows other generic management system approaches such as ISO 14001 and ISO 9001. Experience rating in workers’ compensation is another approach to reducing workplace injuries and illnesses. For example, New York State Industrial Code Rules 59 and 60 provide financial incentives to employers to reduce injuries and illnesses.[64]

Addressing ergonomic hazards is pivotal to prevention: Musculoskeletal injuries and disorders are a major contributor to morbidity and lost work time; musculoskeletal pain is treated with opioids more often than is recommended.[65] Ergonomics programs decrease turnover, reduce absenteeism, and increase productivity and return on investment. For example, safe patient handling programs in health care have reduced the high rates of back injuries among nurses and nurses’ aides. These programs are cost effective, reducing workers’ compensation and related costs.[66] In one cohort study, the introduction of a safe handling program in nine hospitals reduced injuries by 71% and lost workdays by 90%.[67] In a meta-analysis of safe patient handling and management programs including 27 articles from 44 sites, the authors found a combined effect estimate for all such programs of 0.44 (95% confidence interval = 0.36, 0.54), reflecting substantial injury reductions after program implementation.[68]

Protecting emergency responders from exposure: Protecting emergency responders from exposure to highly toxic opioids is critical. Numerous reports of occupational exposures to fentanyl and fentanyl analogues have led NIOSH[69] and the InterAgency Board[70] to develop recommended standards to protect emergency responders from exposure when conducting their job duties. Also, NIOSH has conducted numerous health hazard evaluations and, along with the National Institute of Environmental Health Sciences (NIEHS) and others, has developed training resources. Protecting emergency responders, law enforcement personnel, and others with the potential for occupational exposure requires continued attention, further research, and resources for training and protective equipment.

Secondary prevention: Providing injured workers with information to avoid opioid misuse is a critical intervention. This includes training and providing information to rank and file workers such as factsheets, posters, tip cards, and social media campaigns. At the time of injury, human resource professionals, representatives of employer-based medical departments, labor union representatives, or other designated personnel should advise workers to be prepared to talk to their health care provider about alternative pain treatments. Training and information should include a listing of opioids by generic and brand names so that workers recognize them. Workers should also be given information preparing them to discuss opioid prescriptions to avoid misuse when prescribed.[71]

Tertiary prevention: Peer support is fundamental to successful workplace programs, helping those in need to access treatment and recovery programs. The International Union of Operating Engineers Local 478’s Member Assistance Program is one such best practice.[72] This program was established to address opioid and alcohol use disorder, suicide prevention, and behavioral health. Local 478 has the cooperation of 248 of 250 construction contractors under collective bargaining agreements. The program extends the definition of peer from a person in recovery to a person in recovery from the same union and industry. This model allows for more proactive support and takes advantage of peer relationships established through work.

Alternatives to discipline programs: Alternatives to discipline programs have been available for decades, especially in health care, where more than 40 boards of nursing have such programs.[73,74] Rather than being terminated and their professional license rescinded, nurses sign a consent agreement to enter substance treatment, their professional license is temporarily suspended, they participate in an individualized recovery program, they consent to periodic drug testing, and they agree to limited access to narcotics for a period of 2 to 5 years. A review shows that the least punitive workplaces have been successful in helping nurses with SUD recover and return to work.[75]

Reducing inappropriate prescribing: Reducing inappropriate prescribing through workers’ compensation prescribing guidelines has been associated with a nearly 60% drop in unintentional deaths from prescribed opioids in Washington State. Reduced opioid prescribing after the acute pain period has been associated with a dramatic reversal of long-term time loss and disability in the state workers’ compensation program.[76] The 2015 Washington Department of Labor and Industries’ Medical Director Guidelines include substantial evidence for the use of reactivation procedures, such as active physical therapy and cognitive behavioral therapy, for chronic pain.[77]

New York State legislative reforms to increase access to treatment: New York State legislative reforms have aimed to increase access to treatment. In 2013, changes were made in the way providers and payors interacted, requiring payors to use a standard tool to determine the appropriate level of care. The state laws passed in 2016 required immediate access to bedded SUD treatment, limited payor interference, and expedited access to MAT in emergencies. In 2018 these protections were expanded to outpatient services, resulting in reduced costs and co-pays, and enforceable regulations were established. In 2019, New York enacted a no prior approval rule for formulary forms of MAT and expanded immediate access to include bedded mental health services for children. As of January 2020, all state-regulated payors were required to provide access to the full continuum of SUD treatment services. In 2018, legislation funded an independent office of the ombudsman that helps individuals with an SUD and/or mental illness gain access to treatment and health insurance coverage. More than 2,000 cases were opened as of June 2020, overturning insurance denials, resolving barriers and discrimination issues with respect to health care, resolving reimbursement issues, and helping to enroll people who were underinsured or uninsured.

Workers and community members needing treatment are susceptible to the unethical practices of patient brokers who refer clients to out-of-state treatment facilities in return for compensation. Vulnerable clients who are offered travel or cash often end up stranded in other states, exposing them to relapse and death. Therefore, in 2018, the New York State Mental Hygiene Law was amended to make patient brokering illegal. The number of overdose deaths in the state decreased by nearly 16% from 2017 to 2018, the first decline in 10 years.[78] Widespread distribution of naloxone, expanded treatment and recovery centers, peer services, mobile treatment, 24/7 open access centers, and the independent ombudsman office may have contributed to this decrease. Other states in the Northeast had similar decreases in overdose deaths with varied policy changes.[79]

Organizational interventions to reduce stressful work organization: A variety of interventions to reduce stressful working conditions are available,[80] including workplace action research programs, collective bargaining language, and legislation and regulation. Targets of such programs, policies, and laws have included mandatory overtime, staffing, job control, job security, workplace violence and bullying, sexual harassment, and expanded rights to sick and family leave. For example, the California nurse-to-patient ratio staffing law has been shown to reduce injury rates among nurses in the state.[81] As of December 2019, 18 U.S. states had passed laws to limit or ban mandatory overtime for nurses.[80]

Opposing Arguments/Evidence
Opposing arguments include the belief that employers have no responsibility to support employees with OUD. Many believe that opioid use is a lifestyle choice or a moral failing rather than a disease.[82] Some believe that certain employees choose opioids over other forms of treatment.[83] There are also concerns with giving second chances to employees who are in safety-sensitive jobs that could impact their own safety or that of fellow workers or could cause property damage. Some believe that it is prudent to terminate an employee suffering from OUD and easier to hire a new employee than keep the current worker employed. Many employer-based drug testing programs aim to identify workers using opioids and other drugs to weed them out of the workforce. If test results are positive, employers may then bar job applicants from employment or discharge current employees. This approach, which treats substance use primarily as a disciplinary problem, has been ineffective in reducing opioid use.[84] Criminalization of substance use has been used extensively over the past 30 years. A professionally administered workplace program will include comprehensive drug testing but will refer those with positive tests for evaluation and appropriate treatment rather than punishing them. A large proportion of business leaders are uninformed about how opioid use disorder impacts their companies and what they can do to reduce their risks and costs.[85]

The arguments just mentioned ignore the economic and occupational benefits described in this policy statement for employers and workers alike.

Alternative Strategies
Comprehensive alternative strategies have not been proposed or implemented. The U.S. Department of Labor provides grants to states and locales to fund training to help people in recovery and their family members regain employment.[86] Some states have initiated recovery-friendly workplace programs in which employers agree to hire people in recovery.[87] New York State has implemented a $2,000 tax incentive for employers to hire people in recovery.[88] These strategies do not address the core elements of primary prevention and reforming punitive workplace drug policies.

Action Steps
APHA will take steps to advocate for:

1. Federal and state agencies to address occupational health disparities (i.e., occupational differences in the risk of OUD) and their relationship to working conditions, workplace policies, race/ethnicity, and immigration status.

  • a. Improved federal and state surveillance systems to enable collection of occupational and industry data, along with other sociodemographic data, and analysis of such data to assess the connections between work and other social determinants of health. This will allow improved targeting of preventive resources and interventions.
  • b. Funding for improved access to treatment and recovery resources by racial and ethnic minorities, and low wage and immigrant worker populations, including MAT and mental health care, should be a priority to federal and state agencies.
  • c. Funding for research, especially intervention research, that identifies solutions.

2. Federal and state agencies to create a system of real-time reporting of opioid mortality in order to better empower public health action. Currently, the latest available data on opioid mortality are for 2018, even though reports in some geographic areas indicate a doubling of opioid fatalities during the COVID-19 pandemic.

3. Provision of federal funding to NIOSH, NIEHS, and the U.S. Department of Labor to support workplace opioid prevention programs and research that address primary, secondary, and tertiary prevention, including:

  • a. Training of employers, workers, and communities to address issues related to opioids and the workplace.
  • b. Programs to promote timely access to mental health and substance use treatment and recovery programs for workers who are struggling with these conditions.
  • c. Development of nonpunitive workplace drug policies and programs. Stigma and punitive workplace drug policies deter workers who are struggling from coming forward for help as a result fear of discrimination and job loss.
  • d. Intervention research to identify best practices for preventing and responding to opioids in the workplace.

4. Federal and state legislation to address stressful work environments and practices such as mandatory overtime, inadequate staffing, nonstandard work arrangements, bullying, and workplace violence.

5. Amending or repealing punitive federal and state drug testing laws and regulations so that workers who test positive are afforded an opportunity to access treatment and recovery resources (e.g., MAT) and maintain their employment relationship. Zero-tolerance policies and last chance agreements are a deterrent to workers coming forward for help. In safety-sensitive industries and jobs, workers can be temporarily placed on leave or given modified job assignments. Rather than termination, workers can sign consent agreements with employers documenting an individualized treatment and recovery program, drug testing, attendance at recovery meetings, and counseling sessions for a set period of time.

6. OSHA and the OSHA State Plan states to promulgate:

  • a. Workplace standards to address ergonomic hazards. Sprains, strains, and musculoskeletal disorders are frequently associated with prescription pain medications.
  • b. An injury/illness prevention standard as recommended in APHA Policy Statement 20138.

7. Building of community coalitions including employers, labor unions, and government, academic, and recovery groups to address prevention of and response to substance use in the workplace.

8. SAMHSA and sister state agencies to continue to modify their recommended workplace drug policy guidelines so that they are nonpunitive and help employers reform punitive policies accordingly. Currently, SAMHSA’s guidelines provide for terminating workers who test positive or giving them a last chance agreement.

9. State workers’ compensation systems to:

  • a. Provide increased access to non-opioid pain treatments such as physical therapy, acupuncture, meditative practices and elicitation of the relaxation response, psychological treatment, and other nonpharmacological interventions that are supported by evidence.
  • b. Adopt specific dosing guidelines to prevent misuse of opioids. These standards should also avoid abrupt discontinuation of opioid treatment in patients who have been successfully treated with opioids long term.

10. State and federal agencies to adopt enforceable regulations that prohibit patient brokering and limit access to treatment and MAT by insurance companies and treatment providers.

1. Wilson N, Kariisa M, Seth P, Smith H IV, Davis NL. Drug and opioid-involved overdose deaths—United States, 2017–2018. MMWR Morb Mortal Wkly Rep. 2020;69:290–297.
2. Woolf SH, Schoomaker H. Life expectancy and mortality rates in the United States, 1959–2017. JAMA. 2019;322(20):1996–2016.
3. Xu JQ, Murphy SL, Kochanek KD, Arias E. Mortality in the United States, 2018. Hyattsville, MD: National Center for Health Statistics; 2020.
4. National Census of Fatal Occupational Injuries in 2018. Washington, DC: U.S. Bureau of Labor Statistics; 2019.
5. American Medical Association. Reports of increases in opioid-related overdose and other concerns during the COVID pandemic. Available at: https://www.ama-assn.org/system/files/2020-06/issue-brief-increases-in-opioid-related-overdose.pdf. Accessed February 6, 2020.
6. Hoffman J. With meetings banned, millions struggle to stay sober on their own. Available at: https://www.nytimes.com/2020/03/26/health/coronavirus-alcoholics-drugs-online.html. Accessed February 6, 2020.
7. National Institute for Environmental Health Sciences Worker Training Program. The COVID-19 pandemic is fueling the opioid crisis. Available at: https://tools.niehs.nih.gov/wetp/public/hasl_get_blob.cfm?ID=12121. Accessed February 6, 2020.
8. Wolf D. Real-time data are essential for COVID-19; they’re just as important for the opioid overdose crisis. Available at: https://www.statnews.com/2020/05/20/real-time-data-essential-for-opioid-overdose-crisis-as-for-covid-19/. Accessed February 6, 2020.
9. Case A, Deaton A. Mortality and morbidity in the 21st century. Brookings Pap Econ Act. 2017;2017:397–476.
10. Case A, Deaton A. Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century. Proc Natl Acad Sci U S A. 2015;112(49):15078–15083.
11. Hawkins D, Roelofs C, Laing J, Davis L. Opioid‐related overdose deaths by industry and occupation—Massachusetts, 2011–2015. Am J Ind Med. 2019;62:815–825.
12. Hawkins D, Davis L, Punnett L, Kriebel D. Disparities in the deaths of despair by occupation, Massachusetts, 2000–2015. J Occup Environ Med. 2020;62(7):484–492.
13. Dean A, Kimmel S. Free trade and opioid overdose death in the United States. SSM Popul Health. 2019;8:100409.
14. Venkataramani AS, Bair EF, O’Brien RL, Tsai AC. Association between automotive assembly plant closures and opioid overdose mortality in the United States: a difference-in-differences analysis. JAMA Intern Med. 2020;180(2):254–262.
15. Hollingsworth A, Ruhm CJ, Simon K. Macroeconomic conditions and opioid abuse. J Health Econ. 2017;56:222–233.
16. The Opioid Crisis and the Black/African American Population: An Urgent Issue. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2020.
17. Steege AL, Baron SL, Marsh SM, Menendez CC, and Myers JR. Examining occupational health and safety disparities using national data: a cause for continuing concern. Am J Ind Med. 2014;57:527–538.
18. Okechukwu CA, Souza K, Davis KD, de Castro AB. Discrimination, harassment, abuse, and bullying in the workplace: contribution of workplace injustice to occupational health disparities. Am J Ind Med. 2014;57:573–586.
19. Siqueira CE, Gaydos M, Monforton C, et al. Effects of social, economic, and labor policies on occupational health disparities. Am J Ind Med. 2014;57:557–572.
20. Opioid-Related Overdose Deaths in Massachusetts by Industry and Occupation, 2011–2015. Boston, MA: Massachusetts Department of Public Health, Occupational Health Surveillance Program; 2018.
21. Dong XS, Brooks RD, Cain CT. Prescription opioid use and associated factors among US construction workers. Am J Ind Med. 2020;63:868–877. 
22. Becker WC, Meghani S, Tetrault JM, Fiellin DA. Racial/ethnic differences in reports of drug testing practices at the workplace level in the U.S. Am J Addict. 2014;23:357–362.
23. Double Jeopardy: COVID-19 and Behavioral Health Disparities for Black and Latino Communities in the U.S. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2020.
24. Saloner B, McGinty EE, Beletsky L, et al. A public health strategy for the opioid crisis. Public Health Rep. 2018;133(suppl 1):24S–34S.
25. Harduar Morano L, Steege AL, Luckhaupt SE. Occupational patterns in unintentional and undetermined drug-involved and opioid-involved overdose deaths—United States, 2007–2012. MMWR Morb Mortal Wkly Rep. 2018;67(33):925–930. 
26. Thumula V, Liu T-C. Correlates of Opioid Dispensing. Available at: https://www.wcrinet.org/images/uploads/files/wcri8394.pdf. Accessed February 6, 2020.
27. Webster BS, Verma SK, Gatchel RJ. Relationship between early opioid prescribing for acute occupational low back pain and disability duration, medical costs, subsequent surgery and late opioid use. Spine. 2007;32(19):2127–2132.
28. Franklin GM, Stover BD, Turner JA, Fulton-Kehoe D, Wickizer TM. Early opioid prescription and subsequent disability among workers with back injuries: the Disability Risk Identification Study cohort. Spine. 2008;33(2):199–204.
29. Ricci JA, Stewart WF, Chee E, Leotta C, Foley K, Hochberg MC. Back pain exacerbations and lost productive time costs in United States workers. Spine. 2006;31(26):3052–3060.
30. Franklin G, Sabel J, Jones CM, et al. A comprehensive approach to address the prescription opioid epidemic in Washington State: milestones and lessons learned. Am J Public Health. 2015;105(3):463–469. 
31. Applebaum KM, Asfaw A, O’Leary PK, Busey A, Tripodis Y, Boden LI. Suicide and drug‐related mortality following occupational injury. Am J Ind Med. 2019;62(9):733–741.
32. Burton WN, Pransky G, Conti DJ, Chen CY, Edington DW. The association of medical conditions and presenteeism. J Occup Environ Med. 2004;46(suppl 6):S38–S45.
33. U.S. Department of Health and Human Services. QuickStats: age-adjusted percentage of adults aged ≥ 18 years who were never in pain, in pain some days, or in pain most days or every day in the past 6 months, by employment status—National Health Interview Survey, United States, 2016. MMWR Morb Mortal Wkly Rep. 2017;66(29):796.
34. Key Substance Use and Mental Health Indicators in the United States: Results from the 2018 National Survey on Drug Use and Health. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2019. 
35. Council of Economic Advisers, Executive Office of the President. Council of Economic Advisers report: the underestimated cost of the opioid crisis. Washington, DC: Council of Economic Advisers; 2017.
36. Substance Abuse and Mental Health Services Administration. Results from the 2016 National Survey on Drug Use and Health: Summary of National Findings. Washington, DC: U.S. Department of Health and Human Services; 2017.
37. The Changing Organization of Work and the Safety and Health of Working People. Cincinnati, OH: National Institute for Occupational Safety and Health; 2002.
38. Farnacio Y, Pratt ME, Marshall EG, Graber JM. Are workplace psychosocial factors associated with work-related injury in the US workforce? National Health Interview Survey, 2010. J Occup Environ Med. 2017;59(10):e164–e171.
39. Lang J, Ochsmann E, Kraus T, Lang J. Psychosocial work stressors as antecedents of musculoskeletal problems: a systematic review and meta-analysis of stability-adjusted longitudinal studies. Soc Sci Med. 2012;75(7):1163–1174.
40. Landsbergis P, Dobson M, LaMontagne A, Choi B, Schnall P, Baker D. Occupational stress. In: Levy B, Wegman D, Baron S, Sokas R, eds. Occupational and Environmental Health. 7th ed. New York, NY: Oxford University Press; 2017:325–343.
41. Madsen IEH, Nyberg ST, Magnusson Hanson LL. Job strain as a risk factor for clinical depression: systematic review and meta-analysis with additional individual participant data. Psychol Med. 2017;47(8):1342–1356.
42. Choi BK. Opioid use disorder, job strain, and high physical job demands in US workers. Int Arch Occup Environ Health. 2020;93:577–588. 
43. Substance Abuse and Mental Health Services Administration. The Effects of Trauma on First Responders. Washington, DC: U.S. Department of Health and Human Services; 2018.
44. Workplace Violence in Healthcare. Washington, DC: Occupational Safety and Health Administration; 2015.
45. American Public Health Association. APHA letter of support for HR 1309, the Workplace Violence Prevention for Health Care and Social Services Workers Act. Available at: https://www.apha.org/-/media/files/pdf/advocacy/letters/2019/190416_workplace_violence.ashx?la=en&hash=9A72F39FC6F7A10D8C544C44E27B2011E4E71D22. Accessed February 6, 2020.
46. Howard J. Nonstandard work arrangements and worker health and safety. Am J Ind Med. 2017;60:1–10.
47. Verkuil B, Atasayi S, Molendijk M. Workplace bullying and mental health: a meta-analysis on cross-sectional and longitudinal data. PLoS One. 2015;10(8):e0135225.
48. State of Working America. Annual hours worked by married men and women age 25–54 with children, by income group, selected years, 1979–2010. Available at: http://www.stateofworkingamerica.org/chart/swa-income-table-2-17-annual-hours-work-married/. Accessed February 6, 2020.
49. Alterman T, Luckhaupt SE, Dahlhamer JM, Ward BW, Calvert GM. Prevalence rates of work organization characteristics among workers in the U.S.: data from the 2010 National Health Interview Survey. Am J Ind Med. 2013;56:647–659.
50. Luckhaupt SE, Tak S, Calvert GM. The prevalence of short sleep duration by industry and
occupation in the National Health Interview Survey. Sleep. 2010;33(2):149–159.
51. Caruso CC, Hitchcock EM, Dick RB, Russo JM, Schmit JM. Overtime and Extended Workshifts: Recent Findings on Injuries, Illnesses, and Health Behaviors. Washington, DC: U.S. Department of Health and Human Services; 2004.
52. Lipscomb JA, Trinkoff AM, Geiger-Brown J, Brady B. Work-schedule characteristics and reported musculoskeletal disorders of registered nurses. Scand J Work Environ Health. 2002;28(6):394–401.
53. U.S. Bureau of Labor Statistics. Occupational injuries and illnesses and fatal injuries profiles. Available at: https://data.bls.gov/gqt/InitialPage. Accessed February 6, 2020.
54. Reddy GMM, Nisha B, Prabhushankar G, Vishwambhar V. Musculoskeletal morbidity among construction workers: a cross-sectional community-based study. Indian J Occup Environ Med. 2016;20(3):144–149.
55. Delp L, Mojtahedi Z, Sheikh H, Lemua J. A legacy of struggle: the OSHA ergonomics standard and beyond, part II. New Solutions. 2014;24(3):365–389.
56. Hersman D. How the prescription drug crisis is impacting American employers. Available at: https://www.nsc.org/Portals/0/Documents/NewsDocuments/2017/Media-
Briefing-National-Employer-Drug-Survey-Results.pdf. Accessed February 6, 2020.
57. National Academies of Sciences, Engineering, and Medicine. Medications for Opioid Use Disorder Save Lives. Washington, DC: National Academies Press; 2019. 
58. Sohn H. Racial and ethnic disparities in health insurance coverage: dynamics of gaining and losing coverage over the life-course. Popul Res Policy Rev. 2017;36(2):181–201.
59. Working Partners Drug-Free Workforce Community Initiative. Business survey. Available at: https://www.workingpartners.com/wp-content/uploads/2018/03/Preliminary-Highlights-Survey-Report.pdf. Accessed February 6, 2020.
60. Vickers AJ, Vertosick EA, Lewith G, et al. Acupuncture for chronic pain: update of an individual patient data meta-analysis. J Pain. 2018;19(5):455–474.
61. Garland EL, Brintz CE, Hanley AW, et al. Mind-body therapies for opioid-treated pain: a systematic review and meta-analysis. JAMA Intern Med. 2019;180(1):91–105.
62. National Institute for Occupational Safety and Health. Hierarchy of controls. Available at: https://www.cdc.gov/niosh/topics/hierarchy/default.html. Accessed February 6, 2020.
63. U.S. Department of Labor, Occupational Safety and Health Administration. Recommended
practices for safety and health programs. Available at: https://www.osha.gov/Publications/OSHA3885.pdf. Accessed February 6, 2020.
64. New York State Insurance Fund. Workplace safety and loss prevention, code rules 59 and 60. Available at: https://ww3.nysif.com/Home/Employer/InjuryAndIllnessPrevention/CodeRule59_60. Accessed July 19, 2020.
65. Feldman DE, Carlesso LC, Nahin RL. Management of patients with a musculoskeletal pain
condition that is likely chronic: results from a national cross sectional survey. J Pain. 2020;21(7–8):869–880.
66. Siddharthan K, Nelson A, Tiesman H, Chen F. Cost effectiveness of a multifaceted program for safe patient handling. In Henriksen K, Battles J, Marks E, eds. Advances in Patient Safety: From Research to Implementation. Rockville, MD: Agency for Healthcare Research and Quality; 2005. 
67. U.S. Department of Labor, Occupational Safety and Health Administration. Safe patient handling programs: effectiveness and cost savings. Available at: https://www.osha.gov/Publications/OSHA3279.pdf. Accessed July 19, 2020.
68. Teeple E, Collins JE, Shrestha S, Dennerlein JT, Losina E, Katz JN. Outcomes of safe patient handling and mobilization programs: a meta-analysis. Work. 2017;58(2):173–184. 
69. Centers for Disease Control and Prevention. Field investigations. Available at: https://www.cdc.gov/niosh/topics/opioids/fieldinvestigations.html. Accessed February 6, 2020.
70. Recommendations on Selection and Use of Personal Protective Equipment and Decontamination Products for First Responders Against Exposure Hazards to Synthetic Opioids,
Including Fentanyl and Fentanyl Analogues. Arlington, VA: InterAgency Board; 2017. 
71. Centers for Disease Control and Prevention: Patients’ frequently asked questions. Available at: https://www.cdc.gov/drugoverdose/patients/faq.html. Accessed February 6, 2020.
72. Zimmer K. Follow the MAP: Helping Craftworkers with Substance Abuse Problems. Arlington, VA: Association of Union Constructors; 2018.
73. Cadiz DM, O’Neill C, Schroeder S, Gelatt V. Online education for nurse supervisors managing nurses enrolled in alternative-to-discipline programs. J Nurs Regul. 2015;6(1):25–32.
74. Monroe TB, Kenaga H, Dietrich MS, Carter MA, Cowan RL. The prevalence of employed nurses identified or enrolled in substance use monitoring programs. Nurs Res. 2013;62(1):10–15.
75. Bettinardi-Angres K, Pickett J, Patrick D. Substance use disorders and accessing alternative-to-discipline programs. J Nurs Regul. 2012;3(2):16–23.
76. Franklin GM, Mercier M, Mai J, et al. Population‐based reversal of the adverse impact of opioids on disability in Washington State workers’ compensation. Am J Ind Med. 2018;62(2):168–174.
77. State of Washington Department of Health. Interagency guideline for prescribing opioids for pain. Available at: http://www.agencymeddirectors.wa.gov/Files/2015AMDGOpioidGuideline.pdf. Accessed February 6, 2020.
78. Governor Cuomo announces first reduction in opioid overdose deaths in New York State since 2009. Available at: https://www.governor.ny.gov/news/governor-cuomo-announces-first-reduction-opioid-overdose-deaths-new-york-state-2009. Accessed July 18, 2020. 
79. Ahmad FB, Rossen LM, Sutton P. Provisional drug overdose death counts. Available at: https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.html. Accessed July 18, 2020. 
80. Healthy Work Campaign. Healthy work strategies. Available at: https://healthywork.org/resources/healthy-work-strategies/. Accessed January 12, 2020.
81. Leigh J, Markis C, Iosif A, Romano P. California’s nurse-to-patient ratio law and occupational injury. Int Arch Occup Environ Health. 2015;88:477–484.
82. Shaw WS, Roelofs C, Punnett L. Work environment factors and prevention of opioid-related deaths. Am J Public Health. 2020;110(8):1235–1241. 
83. Miller S. Employers take steps to address opioid crisis. Available at: https://www.shrm.org/resourcesandtools/hr-topics/benefits/pages/steps-to-address-opioid-crisis.aspx. Accessed October 4, 2020.
84. Hinds H. The opioid crisis and Connecticut’s workforce. Available at: https://portal.ct.gov/-/media/Departments-and-Agencies/DPH/dph/environmental_health/occupationalhealth/Opioid-conference-writeup_FINAL-FINAL_11_28_18-(2).pdf?la=en. Accessed October 5, 2020.
85. Goplerud E, Hodge S, Benham TA. Substance use cost calculator for US employers with an emphasis on prescription pain medication misuse. J Occup Environ Med. 2017;59(11):1063–1071. 
86. U.S. Department of Labor. U.S. Secretary of Labor Acosta announces new dislocated worker grants to help fight opioid public health emergency. Available at: https://www.dol.gov/newsroom/releases/osec/osec20180320. Accessed July 18, 2020.
87. Recovery Friendly Workplace home page. Available at: https://www.recoveryfriendlyworkplace.com/. Accessed July 18, 2020.
88. New York State Office of Addiction Services and Supports. Recovery tax credit program. Available at: https://oasas.ny.gov/funding/recovery-tax-credit-rfa. Accessed July 18, 2020.