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Abstract
Drug overdose fatalities have risen sharply and the impact on US workplaces has not been described. This paper describes US workplace overdose deaths between 2011 and 2016. Drug overdose deaths were identified from the Census of Fatal Occupational Injuries and fatality rates calculated using denominators from the Current Population Survey. Fatality rates were compared among demographic groups and industries. Negative binomial regression was used to analyse trends. Between 2011 and 2016, 760 workplace drug overdoses occurred for a fatality rate of 0.9 per 1 000 000 full-time equivalents (FTEs). Workplace overdose fatality rates significantly increased 24% annually. Workplace overdose fatality rates were highest in transportation and mining industries (3.0 and 2.6 per 1 000 000 FTEs, respectively). One-third of workplace overdose fatalities occurred in workplaces with fewer than 10 employees. Heroin was the single most frequent drug documented in workplace overdose deaths (17%). Workplace overdose deaths were low, but increased considerably over the six-year period. Workplaces are impacted by the national opioid overdose epidemic.
- overdoses
- workplace
- surveillance
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Introduction
The US overdose epidemic is ongoing. Drug overdoses kill more people annually than car crashes and gun crime.1 Substance use disorders have a negative impact on individuals and their families, but they also impact the productivity of US industries. A 2017 survey by the National Safety Council found that 70% of employers report that their businesses had been impacted by drug use, including absenteeism, positive drug tests, workplace injuries, and workplace overdoses.2 A better understanding of the inter-relationships between drug use and the workplace is important for several reasons. First, the overwhelming majority of overdose deaths are in those of working age (ie, 15–64 years of age).1 Second, studies have found that the use of certain drugs, mainly opioids, after a work-related injury is associated with long-term disability and the loss of productive life.3 This paper adds to the scientific literature by enumerating and describing overdose deaths of workers occurring in US workplaces between 2011 and 2016, which has not been previously described. This paper describes all drug overdoses, but highlights those associated with opioids since opioids account for the greatest percentage of overdose deaths. In 2016, 66% of drug overdose deaths involved an opioid.1
Methods
Drug overdose deaths in US workplaces between 2011 and 2016 were identified from the most recent data from the Bureau of Labor Statistics’ (BLS’s) Census of Fatal Occupational Injuries (CFOI) database. BLS compiles data on all work-related fatalities occurring to non-institutionalised people while on the premises of their employer or working off-site using multiple administrative and public records. Denominator data for rate calculations were obtained from the BLS’s Current Population Survey (CPS). CPS is an annual survey of 60 000 civilians aged 15 years or older who are non-institutionalised wage and salary workers, self-employed, part-time workers, or unpaid workers in family-oriented enterprises to create national workforce estimates.4
Overdose fatalities were identified using the Occupational Injury and Illness Classification System primary and secondary injury source codes: '1840' (Drugs, alcohol, medicines, unspecified), ‘1842' (Drugs – nonmedicinal), '1843' (Medicines, except vaccines), '1848' (Multiple drugs, alcohol, medicines), and '1849' (Drugs, alcohol, medicines, not elsewhere classified.).5 By searching both primary and secondary codes, we ensure that we included all potential overdoses. No deaths were included that were solely due to alcohol. Major industry groups were defined using the 2002 North American Industrial Classification System (NAICS) codes.6 This system classifıes industries based on the goods or services they provide. Narrative text fields were used to classify the type of drug associated with the fatality into five main categories: ‘Illicit drugs’ which included methamphetamines, Phencyclidine (PCP), narcotics, cocaine, and heroin; ‘Opioids not including heroin’ such as fentanyl, morphine, oxycodone, and codeine; ‘Prescription Drugs not Including Opioids’ which included all types of prescription drugs, amphetamines, and benzodiazepines; ‘Multiple Drug’ when the narrative text was limited to the term ‘multiple drug’; and ‘Unknown’ when no particular drug was listed. Heroin, while pharmaceutically an opioid, was included in the illicit drug category because a feature of this analysis was the role of illicit substances in the workplace. Due to a lack of detail in the narrative text fields, the authors were unable to determine whether the drugs associated with the fatality were obtained legally.
Analyses were performed with SAS, version 9.2. Fatality rates were calculated using standard methods that divide number of deaths by estimated full-time equivalent (FTE) workers (40 hours per week, 50 weeks per year). This was done for overall work injury deaths, overdose fatalities, and overdoses by major industries and sociodemographic characteristics. Sociodemographics of the decedent and workplace characteristics (size and region) were compared with rate ratios (RRs) and 95% confidence intervals (CIs). Negative binomial regression was used to assess trends in drug overdose fatality rates and overall work-related fatal injury rates.
Results
Between 2011 and 2016, 760 drug overdose deaths occurred in US workplaces, resulting in a fatality rate of 0.9 per 1 000 000 FTEs figure 1. The annual workplace overdose fatality rate decreased from 2011 to 2012, then increased annually until 2016, resulting in a 24% (95% CI 18% to 30%) increase annually across the 6-year period. The overall work-related fatal injury rate fluctuated during the 6-year period. Because of these fluctuations, the overall work-related fatal injury rate increased 0.2% (95% CI −1.0% to 1.4%) annually during the same period, although non-significantly. Men had significantly higher workplace overdose fatality rates than women (RR 4.1, 95% CI 3.3 to 4.9) (table 1). Workplace overdose fatality rates were highest among those aged 25–44 years (1.1 per 1 000 000 FTEs). One-third of workplace overdose fatalities came from workplaces with fewer than 10 employees (n=249, 33%). Workplace overdose fatality rates were significantly higher for non-Hispanics than Hispanics (RR 1.6, 95% CI 1.20 to 2.0).
Rate of workplace overdose deaths and overall workplace deaths by year: Census of Fatal Occupational Injuries (CFOI) 2011–2016. *Drug overdose fatality rate and overall work-related fatality rate are on two different scales. NB. Totals and rates were generated by the authors with restricted access to CFOI microdata. FTE, full-time equivalent.
Selected sociodemographic and workplace characteristics of workplace overdose fatalities: Census of Fatal Occupational Injuries (CFOI) 2011–2016
The three industries with the highest number of workplace overdose fatalities were transportation and warehousing, construction, and healthcare and social assistance (n=116, n=114, n=96, respectively) (table 2). The three industries with the highest overdose fatality rates were transportation and warehousing, mining, and construction (3.0, 2.6, and 2.0 per 1 000 000 FTEs, respectively).
Selected industry of workplace overdose fatalities: Census of Fatal Occupational Injuries (CFOI) 2011–2016
The largest category of drugs used in workplace overdose deaths was illicit drugs (n=460, 44%), followed by opioids not including heroin (n=282, 27%) (table 3). Heroin was the single most frequent drug associated with workplace overdose deaths (n=176, 17%) (data not shown). When heroin is removed from the illicit drug category and included within the opioid category, opioids become the largest category of drugs associated with workplace overdose deaths (n=458, 44%), followed by illicit drugs (n=284, 27%).
Type of drug used in workplace overdose fatality: Census of Fatal Occupational Injuries (CFOI) 2011–2016
Discussion
This study used a well-established occupational surveillance system to describe workplace overdose deaths. While the workplace overdose fatality rate was low, there was a significant increase in the number and rate of overdose deaths over the 6-year period studied. There were several noteworthy findings. Nearly half of workplace overdose deaths occurred in three industries: transportation and warehousing, construction, and healthcare and social assistance. One-third of workplace overdose deaths occurred in businesses with fewer than 10 employees. Also, these findings mirror trends outside the workplace that demonstrate the increasing role of heroin in overdose deaths.7 Our findings correspond to other recent research in the occupational safety and health field.
A recently published study reported on occupations of drug-involved overdose decedents and found that construction occupations had the highest proportional mortality ratios (PMRs) for both heroin-related and prescription opioid-related overdose deaths.8 The Massachusetts Department of Public Health also published a report of opioid-related overdose deaths by industry and occupation and found that construction and extraction workers had a high rate and number of opioid-related overdose deaths that was six times the average rate for all Massachusetts workers.9 These findings closely relate to theories on the social and economic determinants of the opioid crisis.10 Dasgupta et al. suggest that the most profitable jobs in poor communities are those with elevated physical hazards that may increase risk of on-the-job injuries and chronic musculoskeletal conditions.10 These medical events could lead to prescription opioid use for the injury and later misuse.10 Indeed, construction and transportation and warehousing occupations can be physically demanding and are industries known to have high rates of work-related injuries and illnesses.11
Regarding limitations, CFOI likely underestimates workplace overdose deaths because there had to be evidence, such as drug paraphernalia, for postmortem drug testing to be performed. Second, we are unsure of the validity of the coding of the drugs in the CFOI record associated with the fatal overdose. Also, we are not sure if those that overdosed in the workplace had an ongoing use disorder or not. Third, our results are univariate in nature and not adjusted for potential confounding factors of age, race, or region. Finally, fentanyl was included in the ‘opioid’ category and herion was included in the ‘illicit’ category due to our inability to determine whether the drugs were obtained legally or not. Since there has been an increase in overdose deaths involving illicitly manufactured fentanyl, our illicit drug category may be an underestimate.7
The role of the workplace in the prevention of drug overdoses is uncertain. While workplace-based drug testing is commonplace, there is not strong evidence that drug testing improves workplace safety.12 Additionally, workplace-based drug testing could displace workers with substance-related issues to other workplaces where drug testing is not occurring. Traditional drug tests do not test for some commonly abused prescription drugs and, if they did, separating those that misuse drugs from those using drugs prescribed for legitimate medical purposes would be important.13 The Substance Abuse and Mental Health Services Administration and the National Safety Council provide information and resources to employers on how to address prescription drug use and misuse in the workplace.14 15 Our findings have implications for the development and dissemination of prevention programmes, messages, and strategies. Programmatic efforts must consider small businesses in addressing worker safety and health related to drug overdoses.16 More research is needed to understand the impact of the epidemic on workplaces and the most effective employer-based interventions.
What is already known on the subject
Drug overdose fatalities have risen sharply in recent years .
US industries are being impacted by drug use.
What this study adds
The rate of fatal workplace overdoses varied by industry and sociodemographic characteristics of the decedents.
While the workplace overdose fatality rate was low, there were significant increases in the number and rate of overdose deaths that should be addressed.
Footnotes
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.