Work Environment Factors and Prevention of Opioid-Related Deaths

Opioid use disorder (OUD) and opioid overdose deaths (OODs) are prevalent among US workers, but work-related factors have not received adequate attention as either risk factors or opportunities for OOD prevention. Higher prevalence of OOD in those with heavy physical jobs, more precarious work, and limited health care benefits suggest work environment and organizational factors may predispose workers to the development of OUD.

Organizational policies that reduce ergonomic risk factors, respond effectively to employee health and safety concerns, provide access to non pharmacologic pain management, and encourage early substance use treatment are important opportunities to improve outcomes. Organizational barriers can limit disclosure of pain and help-seeking behavior, and opioid education is not effectively integrated with workplace safety training and health promotion programs.

Policy development at the employer, government, and association levels could improve the workplace response to workers with OUD and reduce occupational risks that may be contributing factors.

Opioid use disorder (OUD) is an overwhelming public health problem in the United States. Drug overdose is now the leading cause of accidental death in the United States, with two thirds of all drug overdose deaths involving an opioid. Many of these deaths result from use of prescription painkillers, and synthetic opioids (e.g., fentanyl, tramadol) have outpaced commonly prescribed opioids as the leading cause of opioid overdose deaths (OODs) since 2015. The dramatic increase in both prescription and illicit opioid use since 2000 is attributed, in part, to a marked liberalization of opioid prescribing practices for the treatment of acute and chronic pain. Opioid prescribing rates have shown a gradual decline since 2010, but opioid fatality rates have increased to 47 600 lives lost in 2017. Also, some policy changes designed to reduce opioid prescribing (e.g., prescription drug monitoring programs) may have contributed to individuals transitioning to use of illicitly manufactured opioids such as heroin and fentanyl. Alternative policy perspectives beyond prescribing limits should be explored.

Much of the public health response to the opioid crisis has been in the health care system. Besides policy changes to prevent multiple prescribers, the Centers for Disease Control and Prevention (CDC) and medical societies have revised medical guidelines for prescribing opioids for pain management, and more federal funds have been allocated to improve availability of OUD treatment. The complexity of this problem involving substance use behaviors, pain management, physician and insurer practices, community services, and other factors suggests a need for a comprehensive analysis of root causes to reduce OUD prevalence and OOD rates. One upstream cause rarely highlighted is the origin of pain symptoms for which individuals seek treatment and the extent to which these factors can be prevented or mitigated.

Relieving physical pain is the primary reason given (63.4%) for a recent episode of prescription pain reliever misuse among individuals aged 18 years or older. Forty percent of US workers report chronic or recurrent musculoskeletal pain, 15% of workers report pain most days or every day, and work-related exacerbations of back pain account for $5.3 billion per year in lost work productivity. Work-related factors may also influence access to opioids as well as OUD treatments, as many US workers depend on employer-sponsored health insurance or workers’ compensation insurance. Attending to conditions of work may have significant potential for effective public health action to combat the opioid crisis.

The magnitude and specific causes of OUD in employed individuals have been difficult to pinpoint, in part because of difficulties in assessing substance use or addiction among working people and in part because of a common assumption that individuals struggling with substance use are not in the workforce. However, the workplace is an important public health venue and, to date, employers have not been adequately included in state and local efforts to combat the opioid crisis. In this article, the ways in which working conditions and work organization may contribute to initiation of pain medication and to chronic pain syndromes and the opioid use that may follow, are highlighted. Many recommendations are concluded for public health researchers, practitioners, and employer organizations to incorporate workplace factors in prevention efforts.