The COVID-19 Pandemic, the Opioid Epidemic,
and the IH
Confronting Two Crises
Opioid overdoses in the United States have risen sharply during the COVID-19 pandemic. In the absence of a real-time federal surveillance system, the Overdose Detection Mapping Application Program (ODMAP), an online platform that supports reporting and surveillance of suspected fatal and nonfatal overdoses, provides near real-time overdose data across jurisdictions. ODMAP indicates a 17 percent increase in overdoses in April–June 2020 compared to the same period in 2019. According to ODMAP’s report on the effects of COVID-19 on the national overdose crisis (PDF), approximately 70 percent of those overdoses were associated with opioids. (ODMAP is available to state, local, federal, and tribal agencies that are responsible for public safety and health, and a map of participating agencies by county can be found on the ODMAP website.) In addition, a recent report from the American Medical Association (PDF) reported increases in overdoses in 40 states during the pandemic. Overdose fatalities in Chicago, Illinois, and Buffalo, New York, were double the number reported during the same period in 2019.
Increased stress related to pandemic conditions and its effect on mental health are important factors driving the increase in opioid overdoses and fatalities as well as increased suicides and alcohol consumption, as described in recent research published in CDC’s Morbidity and Mortality Weekly Report (MMWR) and JAMA Network Open. Anxiety, depression, and increased risk of post-traumatic stress disorder are some of the common mental health effects of concern.
This increase in fatalities indicates the importance of addressing occupational injuries and illnesses and workplace mental health issues associated with prescription opioids. Attention to these issues has the potential to reduce prescription and illicit opioid use among workers.
Industrial hygienists are well positioned to assist employers in addressing the expanding opioid epidemic and related mental health crises during the COVID-19 pandemic. Work-related physical and emotional pain is contributing to the worsening of the opioid crisis, and this connection presents a valuable opportunity for industrial hygienists to share their skills, help American workers, and expand their professional influence.
EFFECTS OF COVID-19
Essential and returning workers are under significant stress during the pandemic. Many are concerned about being infected on the job, infecting their family members, and adjusting to major changes to workplace policies and procedures, including adjustments to shifts and working hours. Additional flash points include customers assaulting essential workers over the enforcement of public health requirements such as mask usage. Workplace changes to prevent the spread of the virus may also increase the risk of injury and stress. For example, social-distancing requirements may result in one person performing what was previously a two-person task. Reduction in teamwork and communication, decreased access to supervisory and management personnel, and limited social contact with coworkers during meetings, training, breaks, and in lunchrooms are further examples of potential stressors.
In addition to workplace stressors are effects on children and families. Restricted visitation policies for loved ones who are hospitalized or in nursing homes are examples of stressors that workers may bring with them to the job.
Representative panel surveys of adults across the U.S. during late June aimed to assess mental health, substance use, and suicidal ideation during the COVID-19 pandemic. The results of the survey, which are detailed in MMWR, indicate that approximately 40 percent of U.S. adults reported struggling with mental health or substance use at that time. Nearly 31 percent of respondents reported symptoms of anxiety or depression, about 26 percent reported trauma or stressor-related disorder symptoms, and around 13 percent said that they had started or increased substance use. Almost 11 percent of respondents reported seriously considering suicide during the month preceding the survey.
These mental health challenges were having a significant effect on Americans’ health before the pandemic. CDC reports that life expectancy in the U.S. declined three years in a row—from 2014 to 2017—due to increased mortality related to drug overdoses (mainly opioids), suicide, and alcohol-related diseases. The decrease in life expectancy occurred alongside self-reported increases in physical and mental morbidity.
Managing Workplace Stress
It is important to create a work environment where:
- workers feel safe talking about the uncomfortable issues of mental health, suicide, and substance use without fear of discrimination or job loss
- employers provide health benefits that adequately cover treatment for mental health and substance use
- employee assistance and peer support programs are being used effectively
VULNERABLE WORKERS
A CDC report published in 2019 found that although African Americans and Hispanics have rates of opioid misuse similar to the general population, they experienced the greatest increase in overdose death rates from synthetic opioids such as fentanyl from 2014 to 2017.
COVID-19 is also having a disparate impact on African Americans. As of April 15, 2020, African Americans comprised 13 percent of the U.S. population but 30 percent of COVID-19 cases. People of color often work in jobs that require a physical presence in the workplace and are more likely to use public transportation, which puts them at increased risk for exposure to COVID-19. White Americans are 17 percent more likely to receive mental health treatment than Black or Hispanic people, and 20 percent more likely than Asian Americans. These disparities are important to consider when addressing the effects of the opioid crisis in the workplace.
Workers who are in recovery from drug and alcohol addiction are also especially vulnerable during this time. The COVID-19 pandemic has resulted in the shutdown of many treatment and recovery programs and harm reduction sites, which can perpetuate social isolation. Social interaction and support are critical linchpins in maintaining sobriety. However, COVID-19 has led to an increase in the use of telehealth for the provision of medically assisted treatment and related counseling, which has helped offset these problems to some extent.
WORK-RELATED PAIN AND OPIOID MISUSE
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 percent report pain most days, and work-related back pain accounts for $5.3 billion in lost annual productivity (see the articles from Spine, the Journal of Occupational and Environmental Medicine, and MMWR, which are listed in the resources section below). According to reports from the U.S. Bureau of Labor Statistics, musculoskeletal disorders; slips, trips, and falls; and workplace violence are leading causes of work-related pain. Occupational stress is also considered an important factor in substance use.
Recent state-level studies (such as this one from MMWR) show that construction workers are six to seven times more likely to die of an overdose than workers in other occupations. One state-based study published in 2013 in the American Journal of Industrial Medicine found that 57 percent of people who died from an opioid-related overdose death had experienced at least one work injury, with 13 percent of overdose deaths preceded by a work injury within the prior three years. Long hours of physically demanding work, related fatigue, and lack of access to paid sick leave are key predictors of increased opioid use. Figure 1 shows how a variety of factors can contribute to an individual developing opioid use disorder (OUD).
Figure 1. Pathway to Opioid Use Disorder: “Look Beyond the Tip of the Iceberg.”
Tap on the graphic to open a larger version in your browser.
MENTAL HEALTH AND COVID-19
Work-related stress can significantly affect individuals’ mental health. In a 2017 workplace health survey of more than 17,000 employees across 19 U.S. industries (PDF), 63 percent of workers reported that workplace stress had a significant impact on their mental health, with more than one in three reporting that they engaged in unhealthy behaviors in response to that stress. Unhealthy responses to stress include self-medication. For workers in recovery from opioid use disorder, workplace stress may lead to returning to use.
The COVID-19 pandemic has intensified this mental health crisis, disrupting the lives of millions of Americans at home and at work. Most U.S. workers are employed in occupations that cannot be performed at home. According to a study published in August 2020 in the American Journal of Public Health, this places 108.4 million workers at increased risk for adverse health outcomes related to working during a pandemic. Many of these individuals are lower-income workers, have less access to health insurance, and lack paid sick leave. Coupled with job insecurity, these stressors could result in a large burden of mental health disorders in the United States.
Examples of Workplace Stressors during COVID-19
- job loss or reduction in hours
- loss of income
- inability to pay bills
- work-family imbalance
- discrimination due to race or ethnicity
- lack of access to COVID-19 testing
- inadequate workplace safety measures
- inadequate access to personal protective equipment and respirators
- fear of getting infected or infecting family members
- constantly changing work and government safety and health guidelines
PUBLIC HEALTH APPROACH TO PREVENTION
Dr. Letitia Davis of the Massachusetts Department of Health and colleagues pioneered the application of a public health approach to preventing opioid use in the workplace. It features primary, secondary, and tertiary approaches to prevention, as outlined in Table 1. Workplace leaders can use this framework to identify gaps and opportunities for improvement in each category and then develop a relevant plan of action.
Primary prevention involves evaluation and control of workplace hazards, especially those that correlate with potential opioid use, like ergonomic hazards, workplace violence, and slips, trips, and falls. The goal is to reduce workplace injuries, averting the need for an opioid prescription. In addition, identifying and addressing work-related stressors may result in less self-medication, which is a common non-adaptive reaction to stress and a key factor in opioid misuse.
Secondary prevention involves developing systems for providing information to injured workers when they go out on occupational injury leave so that they are prepared to discuss opioid avoidance and alternative pain treatments with their healthcare providers. Adjuvant and alternative pain treatments help workers avoid post-injury opioid misuse. Alternative pain treatments may include over-the-counter nonsteroidal anti-inflammatory drugs (such as ibuprofen or naproxen sodium), physical therapy, chiropractic care, ice, and mindfulness therapy.
Tertiary prevention focuses on workplace programs intended to assist employees in accessing mental health and substance use treatment and recovery resources. Under this approach, workplace leaders should consider evaluating the use and impact of employee assistance programs. Other aspects of tertiary prevention include appropriately structured workplace drug testing and supportive workplace drug prevention policies. Accountability is a key component in a proactive workplace drug program that typically includes individual consent agreements, drug testing, and ongoing participation in recovery programs for workers in recovery upon reentry to the workplace. Employers should also seek to develop a positive workplace culture that encourages employees who are struggling to come forward without fear of recrimination.
Table 1. Preventing Opioid Use, Misuse, and Overdose Among High-Risk Worker Groups
Tap on the graphic to open a larger version in your browser.
STIGMA
A negative workplace culture of stigmatization can deter workers who need help from seeking it, while a supportive culture encourages workers to talk about the uncomfortable issues of mental health and substance use and provides quick access to support services. Non-punitive policies and programs can help create an environment where affected workers are more likely to come forward. Peer support programs are fundamental when it comes to encouraging difficult conversations. Peers who are in recovery and have been trained as advocates can have great influence on coworkers who are struggling with mental health or substance use issues.
It’s important to understand that OUD is a chronic medical disorder that affects the brain and changes behavior and is not primarily a criminal or disciplinary matter or a moral issue. (The National Institute on Drug Abuse publication “Drugs, Brains, and Behavior: The Science of Addiction” discusses how science has changed our understanding of drug addiction.) Progressive employers have established “alternatives to discipline programs,” which include written consent agreements where affected workers go into treatment and, upon returning to work, agree to individualized recovery programs and periodic drug testing for a designated period.
TRAINING AND RESOURCES
Comprehensive training programs for workers, supervisors, and leaders should be interactive and create a space where participants feel safe to talk about mental health, substance use, and other uncomfortable issues. The National Institute of Environmental Health Sciences (NIEHS) Worker Training Program has developed comprehensive educational programs and resources that are in the public domain and available online for organizations to adapt to their specific needs. CPWR, the Center for Construction Research and Training, has extensive resources for preventing opioid deaths in the construction industry, and the National Safety Council has established an “employer toolkit” for addressing opioid use at work.
In addition, NIOSH has assembled a variety of resources related to evidence-based policies and programs to reduce risk factors for substance misuse. This NIOSH webpage provides useful links to information on topics such as protecting workers at risk, medication-assisted treatment of OUD, and naloxone, a drug used to reverse opioid overdoses.
63 percent of workers reported that workplace stress had a
significant impact on their mental health.
A series of “Back to Work Safely” guidelines developed by AIHA provides recommendations for limiting the spread of COVID-19 at workplaces operating during the pandemic. These resources are freely available at backtoworksafely.org. Addressing the spiking opioid crisis, its connection to work-related physical and emotional pain, and the effects of the pandemic on worker health should be recognized as an essential part of these efforts.
TAKING ACTION
Industrial hygienists are well equipped to provide leadership as part of a multidisciplinary team to address the increase in mental health and substance use problems associated with the COVID-19 pandemic. IH analytical and problem-solving skills can help solve this crisis. Here are 10 ways IHs can start to tackle these issues:
1. Form a multidisciplinary team to develop a workplace action plan for opioid misuse prevention. This team may include human resources, medical, and operations staff; labor union representatives; and front-line employees.
2. Evaluate injury trends by reviewing OSHA logs, examining incident reports, interviewing injured workers, inspecting work processes and environments, and conducting ergonomic evaluations.
3. Access workers’ compensation data to determine departments and job tasks with significant lost-time injuries that correlate with opioid prescriptions.
4. Implement a program to evaluate and track occupational stress issues. While these issues may go beyond the usual boundaries of industrial hygiene practice, many of the evaluation methods (worker surveys, review of absenteeism and sick leave data, and focus groups) are similar.
5. Develop a system to provide information and support to injured workers at the time of injury. A PDF fact sheet that can be used or adapted for this purpose is available from the NIEHS Worker Training Program. The fact sheet also provides a comprehensive list of opioids in both generic and brand names. A construction-oriented fact sheet is available from CPWR (PDF).
6. Review the design and use of employee assistance, member assistance, and peer support programs to ensure they are effective and accessible.
7. Review and update drug policies so that they are supportive (not punitive) and appropriately address stigma that may discourage workers who are struggling with mental health and substance use problems from coming forward.
8. Review and consider the adequacy of sick leave policies.
9. Review whether insurance coverage for substance use and mental health treatment are adequate.
10. Develop worker, supervisor, and leadership training that addresses stigma and motivates all employees to be proactive in preventing injury, including physical and emotional pain, and encourages people to talk about difficult issues such as mental health and substance use.
The link between the mental health effects of COVID-19 on the workforce and the growing opioid crisis is clear. While it is understandable that organizations have focused their efforts on developing safety plans to maintain operations during the pandemic, we must not ignore these other present dangers. Industrial hygienists should collaborate with other workplace stakeholders to improve the work lives of employees and the overall productivity and well-being of workplaces. We can and must contribute to solving this combined crisis.
JONATHAN ROSEN, MS, CIH, FAIHA, of Albany, New York, is a safety and health and industrial hygiene consultant for the National Clearinghouse for Worker Safety Training and numerous international labor unions. He is a member of the AIHA Opioids Working Group.
PETER HARNETT, MS, MPH, CIH, CSP, FAIHA, is chair of the AIHA Opioids Working Group and a member of the Leidos anti-opioid task force. Both groups are involved in community and workplace efforts to address the opioid problem. Prior to Leidos, Peter’s work included providing EHS consulting services to two opioid manufacturers. Peter lost his brother to a heroin overdose in 1987.
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Background on the Opioid Crisis
Prior to the 1990s, opioids were mainly used for treating cancer-related pain and end-of-life palliative care. In the mid-1990s, opioid pain relievers were prescribed at greater rates to manage pain associated with injuries, including those occurring at work, and after routine medical procedures.
In 2018, 67,000 people died from drug overdoses, making it a leading cause of injury-related death in the United States (see CDC's website). Of those deaths, almost 70 percent (46,900) involved a prescription or illicit opioid. Sixty-seven percent of all opioid-involved overdose deaths involved synthetic opioids such as fentanyls. In a recent CDC study based on provisional 2019 data, CDC reports 50,828 opioid fatalities, with more than 80 percent involving synthetic opioids. The increase in fentanyl-related opioid overdose fatalities is notable because it is consistent with drug seizure information that indicates a continued increase in fentanyls found in street drugs.
In 2018, an estimated 2.1 million Americans had an OUD. According to Substance Abuse and Mental Health Services Administration (SAMHSA) data, approximately 10.3 million people misused opioids, 96 percent of which were prescription opioids. A national survey conducted by SAMHSA found that the main reason for misuse of opioids was to relieve physical pain. Only about one in 10 people who needed substance use treatment received it in 2018. Frequently, people who overdosed on opioids were also using alcohol and other drugs, and met the medical criteria for mental illness.
According to the U.S. Council of Economic Advisers, the estimated total economic cost of the opioid crisis in 2018 was $696 billion, or 3.4% of gross domestic product. Approximately 70 percent of this cost is attributed to nonfatal consequences such as healthcare spending, criminal justice costs, and lost productivity due to imprisonment or addiction. The remainder is the result of lost potential earnings due to early death. NIOSH reports that in 2017, 95 percent of the 70,067 drug overdose deaths in the U.S. occurred within the working-age population, or those aged 15 to 64 years.
RESOURCES
American Journal of Industrial Medicine: “Comparison of Opioid‐Related Deaths by Work‐Related Injury” (March 2013).
American Journal of Public Health: “Nonrelocatable Occupations at Increased Risk During Pandemics: United States, 2018” (August 2020).
American Medical Association: “Issue Brief: Reports of Increases in Opioid- and Other Drug-Related Overdose and Other Concerns During COVID Pandemic” (PDF, October 2020).
CDC: Morbidity and Mortality Weekly Report, “Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic — United States, June 24–30, 2020” (August 2020).
CDC: Morbidity and Mortality Weekly Report, “Occupational Patterns in Unintentional and Undetermined Drug-Involved and Opioid-Involved Overdose Deaths — United States, 2007–2012” (August 2018).
CDC: Morbidity and Mortality Weekly Report, “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” (July 2017).
CDC: Morbidity and Mortality Weekly Report, “Racial/Ethnic and Age Group Differences in Opioid and Synthetic Opioid–Involved Overdose Deaths Among Adults Aged >18 Years in Metropolitan Areas — United States, 2015–2017” (November 2019).
CDC: Morbidity and Mortality Weekly Report, “Suicide Rates by Industry and Occupation — National Violent Death Reporting System, 32 States, 2016” (January 2020).
CDC National Center for Health Statistics: “Health, United States, 2017 – Data Finder: Table 14. Life Expectancy at Birth and at Age 65, by Sex” (2017).
CDC: Opioid Data Analysis and Resources.
CDC: Picture of America: Our Health And Environment, “Prevention” (PDF).
CPWR: “Resources to Prevent Opioid Deaths in Construction.”
JAMA Network Open: “Changes in Adult Alcohol Use and Consequences During the COVID-19 Pandemic in the U.S.” (September 2020).
Journal of Occupational and Environmental Medicine: “The Association of Medical Conditions and Presenteeism” (June 2004).
Massachusetts Department of Public Health: “Opioid-Related Overdose Deaths in Massachusetts by Industry and Occupation, 2011–2015” (PDF, August 2018).
Mental Health America: “Mind the Workplace” (PDF, 2017).
National Institute on Drug Abuse: “Drugs, Brains, and Behavior: The Science of Addiction” (July 2020).
National Institute of Environmental Health Sciences Worker Training Program: “Opioids & Substance Use: Workplace Prevention & Response.”
National Safety Council: “Opioids at Work Employer Toolkit.”
NIOSH: “Opioids in the Workplace.”
NIOSH: “Workplace Supported Recovery.”
Overdose Detection Mapping Application Program: “COVID-19 Impact on U.S. National Overdose Crisis” (PDF, June 2020).
PNAS: “Rising Morbidity and Mortality in Midlife Among White Non-Hispanic Americans in the 21st Century” (December 2015).
Spine: “Back Pain Exacerbations and Lost Productive Time Costs in United States Workers” (December 2006).
Substance Abuse and Mental Health Services Administration: “Key Substance Use and Mental Health Indicators in the United States: Results from the 2018 National Survey on Drug Use and Health” (PDF, August 2019).
The Synergist: “Can Ergonomics Programs Help Solve the Opioid Crisis?” (May 2019).
Trust for America’s Health: “Pain in the Nation: The Drug, Alcohol and Suicide Crises and Need for a National Resilience Strategy” (2017).
White House Council of Economic Advisers: “The Full Cost of the Opioid Crisis: $2.5 Trillion Over Four Years” (October 2019).
