Abstract
Introduction
The exponential growth of opioid use, abuse, and overdose in the last 15 years has resulted in a serious global crisis affecting public health, social, and economic welfare (American Association of Colleges of Nursing (AACN), 2016; National Institute on Drug Abuse (NIDA), 2017). Opioids include prescription pain relievers (hydrocodone, oxycodone, morphine, codeine, e.g.), synthetic opioids such as fentanyl, tramadol and methadone, and illicit drugs such as heroin (AACN; NIDA). Opioids are powerful, highly addictive drugs used to treat moderate to severe pain and often prescribed after surgery or injury, or for conditions such as cancer (Centers for Disease Control (CDC), 2017). Opioids have increasingly been used to treat legitimate injuries and health conditions, and need to be taken as directed. Regrettably, prescription opioids are often misused, leading to addiction. Four in five heroin users reported starting out by misusing prescription opioid pain medications and nearly half of all opioid overdose deaths involved a prescription opioid (Colorado Academy of Emergency Physicians (ACEP), 2017; The White House, 2015).
The American Association of Occupational Health Nurses (AAOHN) joins the American Nurses Association (ANA) acknowledging the central role nurses can play in addressing this crisis and the multifaceted approach that is necessary to reduce opioid morbidity and mortality. Occupational Health Nurses (OHNs) are well-positioned to lead workplace efforts by ensuring workplaces are safe and support the health of employees, employers, and their families.
Rationale
Opioids have become the leading cause of injury death in the United States (US) despite efforts to curb the upward trends in morbidity and mortality (CDC; The White House, 2017). Prescription opioid sales have quadrupled since 1999 (fentanyl 1,000%, morphine 49%, oxycodone 15%, and hydromorphone 12% increase, respectively) (ACEP). The crisis affects public health as well as social and economic welfare (NIDA; Randolph, 2017). The total US economic burden resulting from opioid misuse is climbing with an average of $78.5 billion a year and an estimated $92 billion spent in 2016 from costs related to health care, lost productivity, addiction treatment, and criminal justice involvement (Hodge, Wetter & Noe, 2017; NIDA). In August 2017, President Donald Trump declared the opioid crisis in the United States a national emergency (Achenbach, Wagner & Bernstein, 2017; Randolph).
The opioid epidemic poses a unique challenge for employers with the potential for significant impact in the workplace. Evidence demonstrates serious risks to employees and substantial costs for employers (National Safety Council (NSC), 2015). Challenges unique to opioid use in the workplace include (NSC)
health and safety risks,
increased costs related to healthcare,
increased costs related to benefits such as disability, workers’ compensation, and employee assistance programs (EAPs), and
impact on productivity.
Valid, legal use of a prescription opioid for a legitimate work or non-work related condition has the potential to quickly turn to addiction that can negatively impact work performance, place an employee at risk for injury, and provide a gateway to potentially illegal activities. Workers who use opioid painkillers for more than a week to treat on-the-job injuries have double the risk of being disabled one year later (NSC). Furthermore, it is more difficult to detect opioid use in the workplace than other drugs such as alcohol or marijuana, making it difficult for employers and workplace health clinicians to make the connection between performance and attendance and drug use. The National Safety Council is calling on employers to develop workplace policies regarding the use of opioid prescription painkillers to help protect injured workers and mitigate liability, stating that “employers have a moral and legal responsibility to protect employees”.
Various public health and political initiatives have begun to address this crisis by strategies including (AACN; ACEP; ANA, 2016; CDC)
raising awareness about the problem through educational initiatives among the general public as well as healthcare providers,
recognizing that opioids are inherently dangerous, highly addictive drugs with significant abuse potential,
improving and standardizing opioid prescriber training across health provider groups, to include: offering other pain treatment modalities, discussing realistic function and pain management goals, exploring potential risks and side effects, screening for abuse and co-morbidities, prescribing buprenorphine for treatment, and facilitated referrals for treatment and recovery,
programs to monitor opioid use and prevent inappropriate access to prescription opioids,
instituting standing orders to allow rapid treatment of opioid overdose and increased access to opioid antagonists (naloxone) in the workplace, community centers, and homes for family, friends, and caregivers of known chronic opioid users, and
increasing access to harm reduction agencies, community programs, and medication-assisted treatment programs.
A multifaceted approach is necessary to reduce opioid morbidity and mortality (Kolodny, et al., 2015). OHNs are skilled in assessing, diagnosing, and managing workers who are at risk for injury or addiction, related to opioid use and are well-positioned to lead efforts to prevent opioid-related injury, dependence, overdose and death. OHNs should be actively involved in their workplaces, collaborating with employers in (Wong, 2017):
reviewing existing workplace drug testing policies,
creating educational initiatives,
implementing policy and outlining disciplinary actions, the circumstances leading to them, and drug testing procedures (testing should include screening for synthetic and non-synthetic opioids),
evaluating potential legal implications when considering drug testing procedures and ensuring compliance with Americans with Disabilities Act (ADA) laws and regulation to avoid disability discrimination claims, and
ensuring that benefit carriers and workers’ compensation carriers have conservative programs for use of prescription opioids, opioid/prescription benefit management programs to identify and prevent prescription medication abuse, and EAPs to help employees avoid or address addiction.
Additionally, OHN case management should ensure collaboration among the prescribing provider and the worker regarding safe job performance and alternative treatment regimens (Randolph).
Educational initiatives should involve OHNs and target workers, support personnel, and management. Topics should include the following (Randolph):
safe use of prescription opioids, including not sharing medications with friends and relatives;
risk of dependency and addiction;
sources of assistance (e.g., EAPs and quality community addiction programs that utilize evidence-based treatment regimens);
opioid safety at home (e.g. secure storage of medications, appropriate disposal of unused opioids, avoidance of mixing medications with alcohol, sedatives, or other psychotherapeutic medications);
signs of dependency and opioid misuse (e.g. drowsiness, problematic attendance, depression, concentration problems, anxiety, and mood swings);
training for managers focused on identifying impaired employees and recognizing signs of dependence and opioid misuse.
Conclusion
In April 2017, The United States Department of Health and Human Services outlined its five-point Opioid Strategy, which provides the overarching framework to leverage the expertise and combined resources of various federal agencies in a strategic and coordinated manner (Federal Efforts to Combat the Opioid Crisis, 2017). The comprehensive, evidence-based Opioid Strategy aims to
improve access to prevention, treatment, and recovery support services to prevent the health, social, and economic consequences associated with opioid addiction and to enable individuals to achieve long-term recovery;
target the availability and distribution of overdose-reversing drugs to ensure the broad provision of these drugs to people likely to experience or respond to an overdose, with a particular focus on targeting high-risk populations;
strengthen public health data reporting and collection to improve the timeliness and specificity of data and to inform a real-time public health response as the epidemic evolves;
support cutting-edge research that advances our understanding of pain and addiction, leads to the development of new treatments, and identifies effective public health interventions to reduce opioid-related health harms; and
advance the practice of pain management to enable access to high-quality, evidence-based pain care that reduces the burden of pain for individuals, families, and society while also reducing the inappropriate use of opioids and opioid-related hams.
OHNs are well positioned to lead the efforts in the fight against opioid dependence. They are able to provide employee training and education, identify and address opioid use and abuse in the workplace while ensuring confidentiality, and advocate for comprehensive corporate policy making, comprehensive drug testing, and benefit programs. AAOHN is working in partnership with other occupational health, public health, and nursing organizations to create a multifaceted approach to reduce opioid morbidity and mortality. AAOHN recognizes the need for OHNs to be actively involved in their workplaces, and is providing information and resources (e.g. educational initiatives, governmental advocacy and policy implementation) to support OHNs in promoting a safe work environment for themselves, workers, employers, and their families.
Footnotes
01/18 (AAOHN Practice Committee)