by Devan Hawkins
As the opioid epidemic has continued to cost the lives of tens of thousands annually and affect many others, efforts to understand its causes have simultaneously expanded. Early prevention efforts have sought to confront the high rate of prescribing of opioids and the increased number of fatalities due to fentanyl. Attention has also been given to how certain social factors may contribute to the crisis, such as the role of unemployment. Increasingly, the contribution of work in general and work-related injuries in particular to the crisis has gotten more attention.
It has been understood for some time that there is a high rate of prescribing of opioids following occupational injuries. This high rate of prescribing among injured workers may not have been an accident. According to Mitchel Denham, a Kentucky lawyer, was quoted in a piece in The New Yorker about how the practices of Purdue Pharma led to overprescribing of OxcyContin.
The company targeted “communities where there is a lot of poverty and a lack of education and opportunity… They were looking at numbers that showed these people have work-related injuries, they go to the doctor more often, they get treatment for pain.”
The media has been reporting on opioid use among fisherman, construction workers, and nurses (e.g., here, here, here). These are some of the most physical demanding occupations that take a toll on the body.
A recent report prepared by Massachusetts Department of Public Health’s Occupational Health Surveillance Program has added to these anecdotal accounts, providing data about the industries and occupations of those dying from opioid-related overdoses. The message of the report is clear: jobs with a high risk of work-related injuries are also jobs with a high rate of opioid-related overdose deaths.
The most striking finding was that over 26 percent of deaths occurred among workers in the construction industry. There were 1,155 deaths from 2011 to 2015, with a rate nearly five times higher than that of all workers. The report highlights the fact that not only do construction workers have a high rate of work-related injuries, but there is also a high prevalence of construction workers who work in pain, likely contributing to the need to use opioids.
Just as striking were deaths occurring among workers in the agriculture, forestry, fishing and hunting industry. The vast majority of the deaths were among fishermen. The total number (67 deaths) was much lower than that for construction workers because the fishing industry has far fewer workers.The rate of deaths, however, was over four times higher than the rate for all workers. Like construction workers, fishermen also have a high rate of injuries and a high prevalence of pain.
In addition to having high rates of injuries and prevalence of pain, workers in both the construction and fishing industries also tend to have high prevalence of non-standard work arrangements (such as being contractors) and temporary work. Workers in the construction industry in particular tend to have a high prevalence of job insecurity, while workers in the fishing industry tend to have higher prevalence of long working hours. These factors may contribute to the problem by compelling workers to work in pain and creating psychosocial conditions that make the usage of substances like opioids more likely.
Aside from construction and fishing, the report found that a number of other industry and occupation groups had a significantly high rate of opioid-related overdose deaths. Among females, food preparation and serving related jobs and healthcare support occupations had rates significantly higher than the rates for all female workers.
The researchers found a significant positive relationship between industry and occupation groups with high rates of injuries and more opioid-related overdose deaths among workers in those industries and occupations. Similarly, occupations with less access to paid sick leave and more job insecurity were also jobs with higher rates of opioid-related overdose deaths.
The findings from the Massachusetts study are consistent with similar reports published by two Massachusetts Community organizations: the Mystic Valley Public Health Coalition and the Barnstable County Regional Substance Use Council, as well as an investigation by the Cleveland Plain Dealer.
While these findings are not conclusive proof that work-related factors are causing higher rates among workers in particular industry and occupation groups, they are certainly strongly suggestive that such a relationship exists. The relationship, for example, is not likely explained by higher rates of drug use among any of the high rate industries. Illicit drug use has been shown to vary by industry but the differences are not nearly as profound as those seen in the data from Massachusetts.
This month researchers with the National Institute for Occupational Safety and Health published in the CDC’s Morbidity and Mortality Weekly Report an analysis on opioid-involved overdose deaths. They examined proportional mortality ratios (PMRs) by occupation in 21 states and found that construction workers had elevated PMRs for overdose deaths involving heroin and prescription opioids. While it cannot be shown whether those who died had prescriptions for the opioids that killed them, it is still suggestive that prescribed opioids are contributing to these differences.
In 2017 the Massachusetts’ Department of Public Health launched a two year pilot program called the Opioid Alternative Treatment Pathway to specifically address the needs of injured workers. It pulls together attorneys, judges, and injured workers within the workers’ compensation system to provide quicker access to medical professionals to make treatment decisions. The outreach program is designed “to involve additional stakeholders in in identifying and developing intervention strategies to prevent opioid misuse among high risk working populations.”
The role that work plays in opioid use and overdose is indeed complicated, but it deserves attention. As one element of the deaths of despair (whose potential work-related components have already been covered by the Pump Handle) these deaths are having enormous consequences for the health of the entire country, likely contributing to a decline in life expectancy in recent years. The work being done in Massachusetts and in other communities across the United States is important in bringing attention this public health problem.
Devan Hawkins is an instructor at the Massachusetts College of Pharmacy and Health Sciences. He is currently pursuing his doctorate in occupational epidemiology at the University of Massachusetts Lowell examining how work may be contributing to the deaths of despair.