Ideas for battling opioid misuse at the workplace level

Host Amber Smith: Be The Informed Patient with Upstate Medical University's podcast on health, science and medicine. This is your host Amber Smith. What can employers do to help curtail opioid use disorders among workers? Let's explore this topic with Jeanette Zoeckler. She's the director of preventative services for Upstate's Occupational Health Clinical Center, and she was one of the editors of a special issue of the Journal of Environmental and Occupational Health Policy devoted to opioids and the workplace. Nice to see you again, Dr. Zoeckler.

Jeanette Zoeckler, PhD: Hi. Thanks for having me.

Host Amber Smith: The National institute on Drug Abuse reported nearly 50,000 people in the U S died from opioid involved overdoses in 2019, and I've read of more than a hundred thousand overdose deaths between April 2020 and April 2021. And I also know there's concern about a growing number of people who die from opioids laced with fentanyl. So what is the connection to the workplace?

Jeanette Zoeckler, PhD: Well, we're really glad to think this through because the opioid misuse and overdose problem is serious and it's not isolated to the home environment or community environment. We see that the workplace has a major role. That's even been recognized by the surgeon general Vivek Murthy. As he's looking into mental health, he's looking into a lot of these kinds of issues and identifying the workplace as a source of health problems or a source of health promotion. And so the workplace is a super important place to think about this.

Jeanette Zoeckler, PhD: And so what we see here in the clinic. And by the way, I just want to mention that the clinic here in Syracuse is part of a network of clinics statewide that is designed to fill in a gap in healthcare services for workers who end up needing to seek workers' compensation forhow they are paying for their work-related injuries and illnesses.

Jeanette Zoeckler, PhD: So who we see in our clinic are people for whom the workplace has becom some kind of exposure has happened in the workplace. And then they end up being patients here. So what we think about in terms of injuries, in terms of work-related stress, those are the risk factors that lead to opioid use. So you can imagine you have a work that causes you to have some kind of injury or chronic pain use. You get treated for that. You begin to take pain medication to address that. Perhaps you're prescribed opioids, narcotics and those consequences can lead one to addiction. Those risk factors then, in the workplace, are things like unsafe jobs that lead to accidents in the workplace that have injuries. So slips, trips, falls, anything like that, or heavy workloads -- that will lead a person to have pain and then seek out a way to ameliorate their pain, which is a natural response. Right?

Jeanette Zoeckler, PhD: So another set of risk factors that we find at connect work to opioids is around jobs, stress job insecurity and the potential for job loss. All of those factors can also be happening at the same time. I'd like to say a little bit more about jobs stress, if I might, at this moment, because job-related stress sounds like a vague idea. It sounds like, oh, the work is stressful. Well, isn't work stressful? I mean, how much is too much? So we've been, in our field of occupational health, have been studying work-related stress for quite a long time. And we have created definitions whereby people end up having health effects. That definition that's most commonly used and most substantiated in the literature is around high demands, low control, and the lack of support on the job. When you have those three factors in place, the job more likely can produce health effects, including cardiovascular disease, a reduced immune function, and then this potential for having injuries because you're stressed. There's a greater chance for injury in the workplace...

because you just described jobs that are demanding, but that a worker wouldn't have much control over. That's a lot of jobs, a wide range of types of jobs, too.

Jeanette Zoeckler, PhD: It really is. It's found in every type of industry and occupation. And of course, really right before the pandemic, we were hot on the opioid misuse and overdose issue. It was super important. It was center focused because of these large numbers you describe of deaths. And, you know, the pandemic has only complicated the stressors in the workplace. In many cases, we see that the job stress that I described is uniquely peaked around healthcare workers and the pandemic around others that are exposed, the so-called essential workers. Now we've described workers as essential. We knew they were essential before, but it became even more heightened. They can't quit their job. They can't go home and work from home. They work in the public. So these demands and loss of control and the danger of the possibility of contracting COVID have added to the stressors. We think of teachers a lot in this specific circumstance and they're on their feet a lot, so they end up with pain, physical pain too. And the possibility of injury around teachers can center on, you know, I'm worried about the COVID exposure, possibly having to move large books or furniture around, even though maybe they're not supposed to. They're supposed to call maintenance, but they're in a hurry and they need to do this right now. They end up using their bodies in ways that can bring injury. So every occupation I can highlight in this journal that I was able to participate in, we even looked at fishermen in certain villages and how they had a four times more likely chance of misusing opioids than anyone else in their villages, that occupation, right? So we focused in on that specific occupation for what is that story? And I could tell you that every occupation and different industries could be thought about for what is their connection? It's not going to be all the same every time each occupation has this unique stressors, the unique opportunities for injuries and the unique ways in which opioids become a part of that work-related health picture.

Host Amber Smith: Let me ask you a workers' comp question. If someone is prescribed opioids after an on-the-job injury and then they develop an addiction, is that addiction treatment going to be covered by workers comp?

Jeanette Zoeckler, PhD: So that is a great question that I put to our social worker here, and I also put to a worker's comp attorney that participates on our board as well. And I got two different answers, and that's not really surprising. And that's because it's difficult to get many work-related cases through the comp system. We have to advocate for our patients. We have to make a case for the causality of their illness. Their illness has to be proven to be work-related. So when I spoke with the comp attorney who has experience in this he was saying that if you can draw the exact causal chain, which would mean like, suppose your knee was injured at work and maybe there was a bunch of delays and you weren't able to get it taken care of very quickly. Then you might be prescribed opioids. Then maybe you become addicted. If that all can be chained back to the knee injury, in a causal direct, you know, direct causal link, then worker's comp is covering. But that's something you've got to accomplish. Your doctor and your attorney have to accomplish creating the case. Then our social worker felt that the more common path for people to get the addiction treatment that they need will be that patient will come in develops an opioid addiction. And then we will refer to pain management. And from the pain management, which workers' comp will cover, they can take it from there in terms of getting addiction services for the patients. So it looks to me like it's not always clear, you know, it's not always a clear pathway in the worker's comp system, but that making that case is important. In other words, someone will come in and argue, well, is this really work-related? You were predisposed to addiction for some other reason. Very often workers are considered, you know, they have to prove a lot of times above and beyond what you would think, in order to claim, make their claims stick. So those, those claims have to be fought for.

Host Amber Smith: This is Upstate's The Informed Patient podcast. I'm your host, Amber Smith talking with Jeanette Zoeckler from Upstate's Occupational Health Clinical Center. Our topic is opioid use disorder and the workplace. Can you give me an overview of workplace policies on employee opioid use?

Jeanette Zoeckler, PhD: So the main problem is a lot of workplaces just don't have a special separate policy on this. They haven't been thinking about it. They have a workplace culture, whatever it is, and this would be considered part of their Employee Assistance Program, and most places have those. And so what we find is that's a good thing that those are in place and various employers approach this differently. But where the strength comes, where we can strengthen those Employee Assistance Programs and create a stronger policies that would be a key feature of improving the opioid misuse and overdose problem, right? So I'd like to describe what some have found to be the most important factors in strengthening what employers can do. There is a significant stigma that when people misuse or overdose on opioids, it's considered a moral failure. And when we move away from that into more of a biomedical approach where we say, this is something that needs treatment, you can get better, it's not a personal moral failure to have become addicted to these drugs. They need to be not prescribed as frequently, right, we need to look at that as an upstream way of preventing it.

Jeanette Zoeckler, PhD: But the employer programs that focus on opening these difficult conversations, being a place of where you can go in and admit that you've got this problem and you need help with it without feeling like you're going to lose your job or feeling like you are some kind of second-class worker now. That's really important.

Jeanette Zoeckler, PhD: And so, the worker training programs that people have put in place that actually make a difference, that aren't just something that people check off a box, oh good, we did our drug training or opioid training when it matters, when it makes a difference, people have gone in and raised a deeper awareness and tried to change the culture within the workplace to find it an acceptable and even a responsible thing to seek the treatment that you need.

Jeanette Zoeckler, PhD: And so that kind of employer's responsibility to create a safe and healthy workplace would include this kind of cultural shift. It's super important because you know, people will continue to try to work through pain and continue to try to work through pain by using medications. And so when they do that, they're trying to protect their jobs. And very often, you know, it's part of the workplace culture to support people not working sick, not working in pain, and to let them go out and get the healing that they need as opposed to, having to press through all the time. Employers should be promoting those kinds of shifts through awareness in their programming.

Host Amber Smith: Let me ask you, are there legal protections for someone to keep their job if they become addicted to opioids?

Jeanette Zoeckler, PhD: Yeah. I mean, when you have a work-related illness or injury, and this is established as a work-related problem seeking treatment and being treated should be thought of like any other, any other illness or injury, right? There should be and are legal protections for you. But I think what happens, and I think this is what's less often spoken about, is that even if there are legal rights and protections these are harder to achieve than at first glance. I mean, you have to know how to use your right and your legal protection. You have to be kind of savvy about it because there will be ways in which somehow you end up being the one who gets on the losing end of the stick anyway, even though the legal protections are there. And so we want to make sure people know how to seek treatment and be supported in that seeking of treatment when they run into this problem so that we can prevent their death or overdose or chronic drug addiction.

Host Amber Smith: Do you know, is there a difference between an addiction to a prescription drug versus an addiction to an illegal drug?

Jeanette Zoeckler, PhD: That nuance I think I'm not 100% familiar with, but I can say that it's a common pathway, that people will seek after they're addicted to opioids. They end up seeking the street versions. It may be easier to get in their world may be cheaper to get. And so there should not be a big distinction between those two because treating the addiction, I mean, the body doesn't know the difference, you know, unless, of course, the street drugs are not as controlled, right? So they're not as safe. But the addiction is the focus of what needs treatment, so there really shouldn't be, again, increased stigma against people for seeking drugs in that way.

Host Amber Smith: Now, one of the articles in the journal advocates primary prevention in the workplace. What is that? And how would it work?

Jeanette Zoeckler, PhD: Primary prevention, you know, from a public health perspective is to always look upstream, to find out where can we cut this off at the source, rather than putting a bandaid on things and when it's late in the game, we want to try to cut things off. So there's a good example in the journal of a company that tried to put everything together to do, to enact primary prevention. And one of their efforts was around stopping this over prescribing of opioids in the first place. So the company decided to really think about the medical management of their workers, how many were being prescribed these, and try to reduce that and find other methods for addressing pain. And I think when we look at primary prevention, that's a good place to cut it off, cut off so much prescribing.

Jeanette Zoeckler, PhD: Another really important point, which I've been driving toward in this discussion so far is the training and the awareness has to be very, uh, sensitive. It can't be just rote. We have to develop customized training that raises awareness in the workplace, that reduces the stigma and makes folks very aware that it's not a moral failure, that is something that cuts across all social economic levels. We're all interested in how to stop this. I mean, some of the more effective programs really have top-down buy-in, and very often, sadly, that happens because a CEO or someone in powerful position's family has been affected by the the addiction and possibly even death. And that stimulates the top-down approach to really support continuous awareness raising among all the workers and you know, not letting it just drop. So an ongoing look. Some of the better education efforts have centered on having workers who've been through it themselves come back to talk to other workers about how to avoid these traps. And getting those workers involved has been significant, because there's nothing like a person who's been through it themselves to speak to it rather than an educator coming in and just giving lots of facts and figures. And unions are often good at this bringing out the uncomfortable conversations, sitting in focus groups or small groups and letting people's hair down a bit and saying, Hey, we've got a problem on our hands. Let's admit it. Let's man up, if you will, and say, we're going to face this rather than keep it, keep it stigmatized and quiet.

Jeanette Zoeckler, PhD: And so people have had success in doing that by bringing in key workers who've been through the struggle and succeeded, and gotten better. So that way it brings hope into those programs. So those would be the kinds of programs and the kinds of efforts, you know, that we would look for for primary prevention, to prevent people from ever, ever getting into this problem in the first place.

Host Amber Smith: And when you mentioned you know, prescribers, if you're really targeting workers, you're having to teach workers to ask questions of their prescriber. If they're facing a surgery, say, you know, maybe they need to ask the surgeon or the team about pain control that maybe doesn't involve opioids, or maybe a short course.

Jeanette Zoeckler, PhD: Right. They need to understand the danger of becoming addicted and how to avoid that. But also one thing when we mentioned that is, the responsible medical prescription prescribing practices really are important because we don't also at the same time, want to see workers who need to address their pain and chronic pain going undertreated. You know, I mean that people are so afraid to even touch any kind of pain medication . We want to make sure they have the appropriate and supervised, use of because they really do need to alleviate their pain. And I think too getting back to the primary prevention, when we talk about work related stress and also injury prevention, those are two key areas that need serious attention. I mean, one of the articles brought out in the journal brought out an entire set of manager practices that lead people to be stressed at work. And this is prior to the pandemic, but they might as well have been describing, you know, managerial practices in the pandemic where people are having thin staffing and low pay, and people are devalued at times. And there's a whole, you know, a long list here of when low morale and burnout and turnover. And when managers emphasize standard practices and don't make allowances for different styles and thatbasically can give control back to the worker for how they're going to do their work. Those things really need attention, and there's a lot of workplace incivility and harassment and bullying that leads people to feel despair and to sense that they're not respected or cared about. So those kinds of manager attention to the management level of how things are conducted in a workplace can go a long way to preventing people from having the need to reach toward drugs to solve to self-medicate their stressors.

Host Amber Smith: What does addiction recovery look like from an employer's point of view? If someone is in recovery, does that affect their job?

One thing that we have to think about with workplaces that support recovery programs, you know, we have to think about that a one-size-fits-all-approach is not going to be useful. So a very good workplace recovery program would allow for a wider variety of possibilities for recovery. And in the best of all possible worlds, we'd be reducing the stigma. We would have a person able to go out to get the treatment they need, if they need to go out of work for their, their substance abuse, treatment, addiction treatment. And then, you know, we're going to have to have qualified occupational health care providers that would know how to make these case-by-case determinations. We'd need to have education, support, resources and stigma reduction, kind of all working together to create the kind of recovery that returns a person to their work, free of addiction to substances and ready to be returned in a full, full way. And that's going to look different depending on occupation and industry. And I think when we see this in the clinic, you know, we're able to have the sensitivities around when a person has an occupational illness or injury, we know kind of what they're going through. We can provide the kind of support that they need. Many times people are going through this without that sort of nuanced healthcare provider in front of them. You know, they don't have the extra special thought about work-related health. So that's that's the main thing about what a good recovery would look like. The person's able to go out without stigma. People aren't allowed to gossip about them and have a big problem. They don't lose their job over it. They don't get demoted. And they are able to go out just as though they had cancer, or they had any other kind of injury or surgery where they needed to go out. They should be treated and in the same vein.

Host Amber Smith: I know that this is important. In white collar, so-called white collar jobs, as well as in skilled labor or unskilled labor. And I mean, it crosses a path across all sorts of occupations, but it is going to look different depending on if you have an office job or a factory job, or whether you're, you know, out in the field. So it's gotta be challenging to come up with policies that will apply across the board to everyone.

Jeanette Zoeckler, PhD: Agreed. I mean, the story of this as that the substance abuse disorder is crossing all boundaries. So we're seeing it. You think of it as a white collar, very often, maybe in movies, we see it that way. But really we're seeing this opioid problem go across just every strata that we can think of. And I think that's why it gets the attention that it deserves because we do see it not only affecting certain types of workers, but, but everywhere. And you can see that people are using substances to perform their job. Many times they're using substances to cope with their job, or they're using substances after a work-related injury. It impacts their work. Sometimes, they have a kind of job like bus drivers or firefighters, pilots. I mean, it's a disaster, it's disastrous for them to be on some kind of substance. It impacts the way their, their job works and how productive they can be. If they're intoxicated at work, it's a lot more of a big deal, right? And then, you know, people have to have the access to medical treatment. In order to get access, a lot of times, a lot of people aren't ready for that, that shift. They need to stop using. They may not be fully ready to do that. Sometimes they don't have the coverage, their job does not afford them the coverage. So in a third of the cases, when they interviewed people in a statewide New York state interview, 32% of people did not feel they could afford the cost of the treatments, didn't have enough health coverage to cover an addiction treatment. 21% didn't even know where to get treatment, and people felt that, 17% felt it had had a negative effect on their job. People even felt, 15% felt that it would cause their neighbors and community to have a negative opinion of them if they got treatment. So there's a lot of barriers to people getting the treatment. And so we have to work on whatever we can doto reduce those, those barriers.

Host Amber Smith: And the treatment you mentioned, does that include mental health care? Because I know that's part of this.

Jeanette Zoeckler, PhD: Certainly, I mean, I think addiction recovery is about, you know, getting off of the substance that you're dependent on, but thinking about what led to the dependence in the first place will look at, mental health, and that's, of course, its own ball of wax for stigma, but I'd like to point out that many workers have short periods of strain, where their mental health is affected, and it's not thought of as a lifelong mental health condition necessarily. It's, it's very often that they are going through a struggle. They need the mental health care to get through that. But it's not as though that indicates they're going to have a life-long battle with mental illness, you know, serious mental illness. So very often we will see that a short course of therapy and counseling really does get people through the tough spots for how did they get addicted? The powerful physical addiction on the drug may not have as much to do with a serious mental illness as it has to do with, you know, getting through a tough period.

Host Amber Smith: If you could speak directly to any bosses or managers that may be listening, what would you tell them that they could do? What concrete steps could they take to make their workplace better in terms of reducing opioid addictions?

Jeanette Zoeckler, PhD: You know, the first thing they can do is to develop a policy, to face it. To face that every, every workplace in this country might have an exposure to opioids, right? Every, every workforce can have the problem of drug misuse and overdose. It can happen to you. Believe that. And decide to have a policy. And in that policy, you would have this customized, thoughtful approach to the education and awareness raising that you would be doing among your, your workers.

There's a lot of good information at the NIEHS (National Institute of Environmental Health Sciences) website (niehs.nih.gov). The clinic here, we're happy to provide more resources for developing such programs that would be, customized, according to the workers you have in front of you, thinking through their real problems. One of the best ways to conduct education is to bring workers together either in Zoom or in a room, however, you can do it with your COVID protocols and, and allow them to speak to the issue. And hear what they have to say, and find out how to customize the education piece that you're planning to provide for your workplace. And then, you know, support the workers through an EAP program that is nuanced enough to understand this particular problem among a number of other problems that EAP programs should be able to handle, such as alcoholism or tobacco,You want to have smoking cessation through EAP. You want to have a number of things that really matter to people's health. But this one should be available and strengthened through the EAP programs that you probably already have in your workplace. When people have addressed it, they report being so relieved that finally the elephant in the room was opened up and that, it didn't have to be shrouded in this sort of shame that people experience and people you know, unions have had really profound culture shifts. And so I think that every employer should seek to have that kind of culture shift go on in their place of employment. So folks can get the help they need without it being such a an area of darkness and shame.

Host Amber Smith: Thank you. My guest has been Jeannette Zoeckler. She's the director of preventive services for Upstate's Occupational Health Clinical Center, and she helped edit a special issue of the Journal of Environmental and Occupational Health Policy devoted to opioids and the workplace. The Informed Patient is a podcast covering health, science and medicine brought to you by Upstate Medical University in Syracuse, New York. This is your host, Amber Smith, thanking you for listening.