Perspectives on the Opioid Crisis and the Workforce

Special Feature: Perspectives on the Opioid Crisis and the Workforce

Reproduced with permission from Benefits Magazine, Volume 55, No. 7, July 2018, pages 28-33, published by the International Foundation of Employee Benefit Plans (www.ifebp.org), Brookfield, Wis. All rights reserved. Statements or opinions expressed in this article are those of the author and do not necessarily represent the views or positions of the International Foundation, its officers, directors or staff. No further transmission or electronic distribution of this material is permitted.

28 benefits magazine july 2018 John S. Gaal, Ed.D., director of training and workforce development for the St. Louis– Kansas City Carpenters Regional Council, has spent the last two years researching the opioid crisis while he has seen its impact on the construction industry. Gaal offers his Perspectives on the Opioid own perspective on the matter and interviews four experts who recently participated in International Foundation panel discussions on opioids to get their views on how the opioid crisis started and efforts to treat and prevent the spread of opioid use disorder Crisis and the Workforce (OUD).

John S. Gaal, Ed.D. John S. Gaal: As I’ve re- Hillbilly Elegy, refers to these phenom- Director of Training and searched the problem, ena as diseases of despair (Campbell, Workforce Development I’ve received input from 2017). St. Louis–Kansas City Carpenters a multitude of sources on Regional Council the opioids/heroin-relat- Mental Health, Chronic Pain St. Louis, Missouri ed crises. A recently re- and the Opioid Crisis [email protected] leased report from the state of Missouri Gaal: The opioids/heroin crisis has Joseph Ricciuti showed that nearly $13 billion per year negatively impacted people across all Co-Founder (approximately $35 million per day) spectrums within our communities. How Mental Health International is spent on economic issues related are the issues of chronic pain, depres- President and CEO to opioid use disorder (OUD) (HIDI, sion and mental health interconnected, SEB Benefits and 2018) in Missouri. Shockingly, Wyman and how has the medical profession’s re- HR Consulting Inc. (2017) asserts that opioids claimed sponse led to today’s state of affairs? Toronto, Ontario 64,000 lives in the United States during [email protected]. 2016 alone (or, in other words, approxi- Joseph Ricciuti: The opi- mately 170 people per day)—more than oid and heroin epidemic Jenny Armbruster car accidents or guns. Since many In- has become a national Director of Community Services ternational Foundation members are crisis in both Canada National Council for Alcoholism involved with the construction indus- and the U.S., but it didn’t and Drug Abuse (NCADA) try, it should be of interest that con- happen in isolation. Two St. Louis, Missouri struction workers are among the most other health care issues were quietly [email protected] vulnerable to opioid abuse, behind percolating behind the scenes—mental Paul Finch only food service industry workers health and chronic pain—and they Treasurer (March, 2017). Finally, when it comes fueled the demand for opioids, which British Columbia Government to a cyclical industry that tends to place created the crisis we have today. and Service Employees’ Union enormous pressures on a craftperson’s The prevalence of mental health is- Vancouver, British Columbia long-term ability to perform, Dasgup- sues has dramatically increased over [email protected] ta, Beletsky and Ciccarone (2017) posit, the last 50 years and more than doubled “the [opioid] crisis is fundamentally fu- in the last 20 years. The World Health Don Willey eled by economic and social upheaval. Organization projects that mental Business Manager . . . Overreliance on opioid medications health will become the second-leading Laborers’ International Union of is emblematic of a health care system cause of disability next to heart disease North America Local 110 that incentivizes quick, simplistic an- by 2020. Mental illness also has an ex- St. Louis, Missouri swers to complex physical and mental ponential effect on health care costs, [email protected] health needs.” J. D. Vance, the author of performance issues and occupational

july 2018 benefits magazine 29 opioid crisis

injuries. Approximately seven out of ten people with de- safety of working populations. It starts with leadership and pression are in the workforce, and depression is a chronic the will to prevent the sources causing opioid and heroin ad- disorder that is clinically linked to a number of other physi- diction from happening in the first place. cal disorders. Because of stigma, most don’t get professional help. One in three people with depression struggles with a The Impact of OUD substance addiction. Gaal: What is OUD, and what impact has it had on fami- Chronic pain, which can be caused by injuries, illnesses lies and the workforce? What are some effective evidence-based and complications from surgery, has also been on the rise, prevention and treatment methods for battling OUD? and 50 million Americans now live with chronic pain at any given time. Being saddled with chronic pain stymies the abil- Jenny Armbruster: It’s becoming increas- ity to work, exercise or enjoy life. ingly difficult to get through the day without The relationship between mental illness and chronic pain hearing at least one horrible piece of news is complex and comorbid. They can exist as a dual condition, about the country’s opioid epidemic. We have and disorders such as depression and anxiety can be present reached a point where virtually everyone both before and after the onset of pain. knows someone whose life has been affected— Pain causes sleep disturbances and, when chronic, can or taken—by this awful and seemingly intractable problem. trigger symptoms of depression. It is crippling and emo- OUD is a brain disease. Using an opioid, such as a pain- tionally draining, and the need to relieve its effects are often killer or heroin, creates changes in the brain over time. It urgent and desperate. The neurology that underlies chronic also takes time for these changes to heal once a person finds pain conditions and major depression are very similar. Some recovery and stops using. The fact that it is a brain disease researchers tend to view the relationship between chronic means that someone does not choose to become addicted. pain and mental health as an interaction between biological, Substance use disorder has no boundaries and can happen to psychological and social influences. anyone. Stopping is not just about willpower. When mental health issues and chronic pain include a Awareness of the dangers of misusing opioids has in- pharmacology treatment plan, there is a risk of drug depen- creased, but people continue to die. A record-high number dency and/or an adverse drug reaction, which creates a vol- of Americans died from fatal overdoses in 2016, with more atile environment for abuse and illegal use. When medica- lives lost to drug overdoses in 2016 than in the entirety of the tions such as opioids (like oxycodone) or benzodiazepines Vietnam War. The total for 2017 will be higher, and no end (like Xanax®) are properly prescribed and used, the chance is in sight. for addiction is relatively low, although it can still occur. Re- Loss of life is the greatest but not the only devastating im- liance and an oversupply of legally prescribed opioids and pact of the opioid epidemic. This crisis has also contributed a black market present a toxic recipe to satisfy wants and to a smaller workforce, because OUD is most prevalent in needs. The risk is harmful addiction and a death warrant 18- to 30-year-olds, who represent the emerging workforce. by overdose. This creates a smaller pool of eligible candidates that will ap- There is plenty of blame to go around. Clearly the heavy- ply or be able to pass initial drug screenings. A 2016 survey handed marketing and promotional strategies of the phar- of men aged 25-54 who were not in the labor force, which is maceutical companies have influenced doctors to overpre- defined as not employed or looking for work, found that 47% scribe in the name of making a profit. But just as guilty are had taken a pain medication on the previous day. Misuse of organizations that fail to promote psychological health and opioids by working individuals impacts job performance and safety in the workplace. increases employer costs. The American Society of Addic- Research has shown that the work environment and tion Medicine has estimated that opioid abuse costs employ- chronic job stress are risk factors for mental and physical in- ers approximately $10 billion in absenteeism and presentee- juries and can contribute to substance use and abuse. These ism losses alone. issues can’t be ignored, and they underscore the need to im- Prevention of substance use disorders must begin early prove awareness and training to secure the mental health and with consistent education to young people. Parents and oth-

30 benefits magazine july 2018 opioid crisis

ers also must receive messaging and education about the BCGEU recognized early on that employers were not pro- dangers of opioids and the connection between prescrip- viding the occupational health and safety (OHS) training, tion painkillers and opioids; two-thirds of people who use materials or psychological support that was required to cope heroin began by misusing prescription painkillers. Commu- with the scale of the crisis. nity interventions also are necessary to promote the safe use, One of our first actions was to canvass our membership storage and disposal of prescription medications. Physicians to explore and examine the scope of the crisis. The union in- should be having conversations with patients about the dan- vited members to share their stories with us directly and also gers of misuse and should prescribe low amounts of opioid with the general public, on our campaign website—https:// medications only as needed. fentanyl.bcgeu.ca—and we invited them to register to receive To reduce the harms of opioid use and decrease the risks e-mail and information updates. of overdose deaths, it is important for overdose education BCGEU put together comprehensive OHS training in- and naloxone distribution to be widely available. Naloxone cluding discussions of posttraumatic stress disorder (PTSD), (Narcan®) is the antidote medication that will reverse the im- trauma and harm reduction. We then hosted a series of pub- pact of the overdose and revive an individual. lic forums that were shared online, and we did a series of site The current best practice for treatment of OUD includes visits to speak directly with impacted members and put on the use of medication-assisted treatment (MAT) and tradi- targeted OHS training for frontline workers and members. tional treatment modalities such as counseling and social Some of our response has been public facing—not only supports. MAT includes the use of methadone, buprenor- trying to build political awareness that BCGEU members are phine (Suboxone®) and naltrexone (Vivitrol®). often the “hidden” first responders but also lobbying govern- ment to provide funding for better equipment and training A Hands-On Canadian Perspective for those on the front line. Gaal: How has the opioids/heroin crisis impacted the com- munity your union serves? In addition, please briefly explain A Hands-On U.S. Perspective the innovative measures your union has undertaken to help Gaal: As a labor leader in the construction industry, how members overcome OUD. have you seen the opioids/heroin crisis affect the community in which you live? And what measures has your union taken Paul Finch: BCGEU is situated at the epicen- to increase access to proven prevention and treatment methods ter of the opioid crisis in Canada. The densely for your members? populated metro-Vancouver area in particular has been the epicenter for overdose deaths, Don Willey: As the business manager of a thousand of which in 2017 were linked to LiUNA Local 110 (approximately 3,200 mem- the powerful and cheap opioid fentanyl, a bers), I have a very personal perspective on this synthetic form of heroin that can be up to 100 times more epidemic and a practical business outlook. On powerful. March 29, 2016, after seven days in the ICU, With over 74,000 members in the public and private I took my son, Matthew, off his respirator to spheres, BCGEU members come in contact with the fen- let him pass on. Matthew struggled with OUD for 15 years tanyl crisis in many ways. Some members are employed in a and put his family through hell in the process. The point is network of shelters across the lower mainland and are often OUD not only destroys opioid users, but it often destroys the equipped and trained with naloxone kits for rapid overdose families caring for them. An employee may be a caregiver response. These workers administer critical life-saving aid, dealing with a loved one struggling with OUD, and on many sometimes up to a dozen times a day. days will experience a concept known as presenteeism. So Other members come into direct and indirect contact employers can’t isolate the effects of this problem with a working as social workers, librarians, trades instructors, drug-testing program alone. sheriffs and corrections officers, and a host of other profes- We need to directly deal with the stigma of this disease, sions and trades. like we have with AIDS, breast cancer, diabetes and other

july 2018 benefits magazine 31 opioid crisis

diseases. As the latest campaign slogan on site at the union halls and training tween opioids and other kinds of pain from NCADA says, we need to “Talk school, and soon Local 110 business medications, patients who took opioids About It” openly with our kids, family, representatives will carry it in their fared no better over the long term than friends and strangers. vehicles. patients who used safer alternatives” The employee benefits fund for Lo- Nicole Browning of NCADA, Dr. (i.e., Tylenol®, ibuprofen and lidocaine). cal 110 members, the St. Louis Labor- Gaal and I also gave a talk on OUD However, when it comes to OUD re- ers’ Welfare Fund (SLLWF), has added and Narcan training at a recent Asso- covery, the one thing that seems to be mental health and addiction vendors ciated General Contractors of St. Louis clear is that no silver bullet exists to to the annual members health fair and annual safety banquet. The goal was to overcome the opioids/heroin crisis. wellness program to build awareness. educate the three-dozen-plus contrac- What works for one person may not When treating members, these vendors tors and 500 tradesworkers. It’s our work for another due to a variety of use intensive outpatient MAT therapy hope that contractors will soon add factors (i.e., personal support system, along with counseling and social sup- Narcan to their first aid equipment on genetic makeup, etc.). Therefore, the port. The goal of the SLLWF addiction the jobsites. health care system must remain open- treatment program is to keep mem- In an example of outside-of-the- minded to different (empirical) ap- bers employed while in treatment, thus box thinking, a group of community proaches to pain management beyond eliminating the stress and stigma that stakeholders is having roundtable that of merely prescribing drugs. To this come with unemployment. The SLLWF discussions with Washington Univer- end, a recent proclamation from the waives the deductible if the six-month sity medical staff and key personnel at American College of Physicians (ACP) program is successfully completed. UnitedHealthcare, which is the insurer recommends that doctors consider non- Families are often emotionally and fi- for other area Laborers health funds. drug therapies (e.g., heat, massage, acu- nancially spent, and a deductible can be Two of the many topics discussed were puncture, spinal manipulation) for pa- a huge barrier to treatment. Allowances best practices for MAT and exploring tients with acute (lasting less than four for relapses are also built in to treat- the possibility of using a well-regulated weeks) and subacute (lasting four to 12 ment. These programs are promoted recovery house model with measured weeks) lower back pain (2017). through print and social media. outcomes as an alternative or supple- When it comes to (residential) re- SLLWF is looking into how to get ment to inpatient care. I believe that re- covery, Whalen (2018) warns, “The health care providers to comply with covered addicts (with clinical training) rehab field is highly fragmented with the American Medical Association opi- helping people struggling with OUD to thousands of small providers offering oid-dispensing recommendations. This obtain sobriety could be a win-win for treatment that isn’t grounded in sci- will cause a backlash from some mem- all parties involved in this fight. ence.” To this end, “parents and fam- bers because they believe that opioids ily members desperate to keep their are the quickest way to get back to work Closing Thoughts From Gaal loved ones from overdosing find pain-free. Not all doctors are trained themselves shelling out again and to talk about the family genetics of ad- Look Before You Leap again through rounds of recovery and diction and mental illness or the social Unfortunately, in this fast-paced relapse.” Please note that “relapses are triggers that might lead to abusing pre- age of instant gratification, it seems common in most chronic diseases.” scribed opioids. that more and more people are seeking SLLWF also is looking into cover- a magic pill to cure their pain-related Carrot or Stick ing the prescription cost of Narcan. ills and, as noted above, this attitude President Trump recently rolled out Meanwhile, NCADA has trained the plays a role in what got us into this pre- a new plan to tackle the opioid crisis, staff at the Laborers Training Center dicament. Interestingly, Kaplan (2018) including the death penalty for high- in High Hill, Missouri, along with re- reports that a recent study found that intensity drug dealers. Nonetheless, gional Laborers union representatives, “in the first randomized clinical trial to Merica, Gray and Drash (2018) state, on the use of Narcan. It is available make a head-to-head comparison be- “Trump’s talk of stricter penalties for

32 benefits magazine july 2018 opioid crisis

drug crimes has worried some treatment advocates, who their problems with addictive substances and/or act in harm- said there is no way the United States can punish its way out ful/destructive ways. Please contact www.afsp.org for more of the opioid crisis.” details. One means of addressing the so-called worker short- age would be to revisit substance abuse testing rules in the References current workplace. Sperance and Sudo (2017) note, “Many construction sites have zero-tolerance policies so, when a ACP. (2017, February 14). American College of Physicians issues guideline for treating nonradicular low back pain. Retrieved from www test comes back positive, it often means termination—not .acponline.org/acp-newsroom/american-college-of-physicians-issues finding the worker help.” However, Fraser and Perez (2018) -guideline-for-treating-nonradicular-low-back-pain. Campbell, C. (2017, December 1). “J.D. Vance’s View of Hillbilly Culture claim that when OUD patients couple MAT with psychoso- isn’t a Prognosis for Appalachia’s Economic Decline—It’s a Symptom. Re- cial treatment (i.e., counseling, self-help groups, mindfulness trieved from www.100daysinappalachia.com/2017/12/01/j-d-vances-view -hillbilly-culture-isnt-prognosis-appalachias-economic-decline-symptom/. training, cognitive behavioral therapy, etc.) the treatment is Dasgupta, N., Beletsky, L. and Ciccarone, D. (2017, December 21). “Opi- more effective, and those who complete it are more likely oid Crisis: No Easy Fix to Its Social and Economic Determinants.” AJPH Perspectives. Retrieved from http://ajph.aphapublications.org/doi to achieve opioid abstinence. While jobsite safety remains /pdf/10.2105/AJPH.2017.304187. an important factor, Riley II (2018) insists that people with Davis, C., Green, T. and Beletsky, L. (2017, Spring). “Action, not rhetoric, needed to reverse the opioid overdose epidemic.” The Journal of OUD who follow a prescribed MAT plan can once again be- Law, Medicine & Ethics, 45, 20-23. de Kenessey, B. (2018, March 16). People are dying because we misun- come productive members of society. derstand how those with addiction think. Retrieved from www.vox.com /the-big-idea/2018/3/5/17080470/addiction-opioids-moral-blame-choices Mining for Good vs. Gold -medication-crutches-philosophy. Fraser, K. and Perez, R. (2018). Opioid Use Disorder Case Management In the interests of their members’ well-being, since sev- Guide. Little Rock, Arkansas: Case Management Society of America. HIDI. (2018, January). “The Economic Cost of the Opioid Epidemic in eral construction-related unions administer their own Missouri.” Retrieved from www.mhanet.com/mhaimages/HIDIHealthStats health and welfare plans, it may behoove them to take a pro- /Feb2018HealthStats_Special_OpioidsEconomy.pdf. Kaplan, K. (2018, March 6). “For all their risks, opioids had no pain active role by mining their insurance data to detect poten- -relieving advantage in a yearlong clinical trial.” Retrieved from www tial problems (Mueller, 2017). Accordingly, Mueller claims .latimes.com/science/sciencenow/la-sci-sn-opioid-painkillers-no-better -20180306-story.html. one Midwest union saw opiate-positive drug tests (without March, M. (2017, October 31). “Construction workers among most sus- ceptible to opioid abuse.” Retrieved from www.constructiondive.com/news a valid prescription) nearly double between 2014 and 2016. /construction-workers-among-most-susceptible-to-opioid-abuse/508546. Among other actions, this union now refers members who McLellan, T. (2018, March 13). “Saving Lives Is Not a Moral Hazard. Retrieved from www.shatterproof.org/blog/saving-lives-not-moral-hazard. test positive to counseling that must be completed before Merica, D., Gray, N. and Drash, W. (2018, March 19). Trump’s opioid returning to work, limits the number of pain medications plan to take three-pronged approach, including death penalty for high -volume traffickers. Retrieved from www.cnn.com/2018/03/18/politics participants can have following an injury or surgery, and /trump-opioid-plan/index.html. limits the member to one pharmacy for (opioids-related) Mueller, A. (2017, June 16). “Employers grapple with an $18 billion opi- oid epidemic.”Retrieved from www.bizjournals.com/stlouis plan coverage. /news/2017/06/16/employers-grapple-with-an-18-billion-opioid.html. Riley II, R. (2018, February 16). Opioids/heroin crisis. Presentation at the Carpenters’ Hall, St. Louis, Missouri. Act Now Sperance, C. and Sudo, C. (2017, October 26). “The Silent Killer On The Job Site: Inside Construction’s Battle With Opioids.” Retrieved from www Have you considered adding Narcan to the first aid kits .forbes.com/sites/bisnow/2017/10/26/the-silent-killer-on-the-job-site in your office and on the jobsite? If not, why not? McLellan -inside-constructions-battle-with-opioids/#646731. Strait, R. (2017, June 27). American Foundation for Suicide Prevention’s (2018) asserts naloxone reverses the deadly effects of opioid Mental Health First Aid presentation at the St. Louis Carpenters Training overdoses. It was never intended as a long-term treatment Program, Affton, Missouri. Whalen, J. (2018, March 8). “After Addiction Comes Families’ Second solution, but it saves lives. Blow: The Crushing Cost of Rehab.” Retrieved from www.wsj.com/articles Finally, Strait (2017) declares that preventive measures, /after-addiction-comes-families-second-blow-crushing-cost-of -rehab-1520528850. like Mental Health First Aid, an eight-hour certification Wyman, N. (2017, December 12). “America’s Workforce Is Paying A course, can help supervisors and peers identify employees Huge Price For The Opioids Epidemic.” Retrieved from www.forbes.com /sites/nicholaswyman/2017/12/12/americas-workforce-is-paying-a-huge who may require counseling before they turn to masking -price-for-the-opioid-epidemic/#5bad3ae171bd.

pdf/618

july 2018 benefits magazine 33