Abstract
Background:
In the U.S., opioid-involved overdose deaths rose dramatically from 21,089 in 2010 to 108,000 in 2022. Opioid use and overdoses are increasingly occurring outside clinical settings, necessitating the need for workplace-based interventions. Various industries, including hospitality and service, have reported increased naloxone training to combat workplace overdoses. This study explores the literature on Opioid Education and Naloxone Distribution (OEND) training by occupation and identifies areas for future intervention through an occupational health lens.
Methods:
This scoping review followed the PRISMA-ScR guidelines and utilized Arksey and O’Malley’s five-step framework. A comprehensive literature search was conducted across multiple databases, covering publications from January 1, 2011, to December 31, 2023. Studies were included if they reported on the occupational demographics of OEND program participants and the impact of these programs on knowledge, attitudes, and overdose response.
Results:
Seventy-five studies met the inclusion criteria. Most OEND training targeted healthcare providers (71%) and first responders (24%). Other occupational groups, such as service industry workers, construction workers, and librarians, were underrepresented. The review highlighted the need for tailored OEND training in these sectors, emphasizing pragmatic implementation measures.
Conclusions:
Increased access to naloxone and comprehensive OEND training are crucial for reducing opioid-related overdose mortality, particularly in non-traditional occupational groups.
Application to Practice:
Occupational health nurses should prioritize expanding OEND programs to underrepresented occupational groups. Tailored training and harm reduction strategies should be incorporated to address the unique needs of these workers and enhance the effectiveness of overdose response interventions in various workplace settings.
Background
In the U.S. between 2010 and 2022, opioid-involved overdose deaths rose from 21,089 to 108,000 per year, which constitutes a dramatic increase from 1999, when approximately 3,442 individuals died from opioid overdose (NIDA, n.d.). Given that the environments in which people live, work, and play often overlap, opioid use (both intentional and unintentional) and opioid-involved overdoses are becoming increasingly common outside of clinical settings (Febres-Cordero & Smith, 2022). For example, in response to overdoses occurring in their workplace, public health departments and other stakeholders have reported increased programming to train and distribute naloxone to workers in a variety of different industries, including the hospitality and service industry (Febres-Cordero et al., 2023; LaSane et al., 2022). Substance use and substance-related overdose also varies by occupation, with food industry workers having 117.9 substance-related deaths per 100,000 compared to 42.1 opioid-related deaths per 100,000 in the general workforce (Billock et al., 2023). As opioid overdoses become increasingly more common in public spaces, there has been a recent growing recognition of the role of service industry workers as de facto first responders to opioid overdoses in the workplace (Febres-Cordero et al., 2024; LaSane et al., 2022; Wolfson-Stofko et al., 2018). This contrasts with occupations such as healthcare providers and first responders, who have traditionally been expected to respond to opioid overdoses in the workplace (Howard & Hornsby-Myers, 2018). As workplace opioid overdoses continue to increase (Tiesman et al., 2019), it is imperative to identify occupational sectors and train workers to identify and respond to opioid overdoses in their communities and workplaces.
Opioid education and naloxone distribution (OEND) is one strategy for equipping workers with the knowledge and skills necessary to identify and respond to opioid overdoses (Enich et al., 2023; Lambdin et al., 2018). OEND programs are designed to educate at-risk individuals and those who may encounter an opioid-related overdose about opioid use (intentional and unintentional) and provide tools for overdose prevention, recognition, response, and treatment. A 2021 review of OEND studies found evidence suggesting that OEND programs produce long-term knowledge improvements, improve trainees attitudes toward naloxone, provide sufficient training to manage overdoses safely and effectively, and, in turn, reduce opioid-related mortality (Razaghizad et al., 2021). However, despite their potential for success, OEND programs are not always distributed to populations who are most likely to experience or witness an opioid overdose. As such, there remains a need to provide opioid education and naloxone distribution to occupational sectors that are newly recognized as being at heightened risk for identifying, encountering, and experiencing opioid overdoses by occupation and in the workplace.
The primary objective of this scoping review is to outline and examine the literature on OEND training by occupation. The secondary objective is identifying areas for future intervention through an occupational health lens.
Methods
This review was conducted per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) 2009 statement (Tricco et al., 2018). The protocol for this review is registered with the Open Science Framework and may be found at https://doi.org/10.17605/OSF.IO/TFKY5. Additionally, we utilized Arksey and O’Malley’s (2005) five-step methodological framework for scoping reviews to guide the conduct of this review. Those five steps are: (1) identification of the research question; (2) identification of relevant studies via an in-depth literature search (3) selection of studies that meet eligibility criteria; (4) charting of the studies (i.e., creation of literature tables); and (5) collating, summarizing, and reporting the study results (Arksey & O’Malley, 2005). In our case, the review aimed to answer the question: which occupations are being trained through an OEND framework?
The rationale for this review arose during data collection for a separate study with service industry workers (September 2, 2021–July 28, 2022; Febres-Cordero et al., 2023), where we concurrently reviewed the literature to assess OEND training by occupation. We sought to identify how service industry workers were being trained and what other training by occupation was being studied to determine the occupational demographics of individuals who receive OEND training. This review identifies occupations that may be underrepresented in OEND and allows for the identification of gaps in the existing literature and recommendations on how the development or implementation of OEND intervention training programs may be improved.
Information Sources and Search Strategy
Following step 2 of the framework, a comprehensive literature search was undertaken to identify relevant articles across the following databases: EBSCOhost’s CINAHL, Health Source: Nursing/Academic Edition, APA PsycInfo, and SocINDEX, Embase.com, MEDLINE/PubMed, and Web of Science Classic Core Collection. The search strategies were developed and conducted by an experienced medical librarian with input from the research team. They combined controlled vocabulary supplemented with keywords related to the concepts of opioids (e.g., oxycodone, fentanyl), overdose response (e.g., Narcan training, naloxone administration), occupational demographic (e.g., service worker, firefighter), and education (e.g., training). All searches were undertaken on August 31, 2021, and rerun for updates on March 8, 2022, and November 29, 2023. Full search strategies for each database may be found in the Supplemental Appendix.
Full-text publications published between January 1, 2011, and December 31, 2023, were included. While there are no standard periods for which a review should be conducted, we sought to include time during which naloxone formulation and access rapidly changed based on federal agencies’ approvals and policymaking, such as the rise in standing order naloxone prescriptions (Abouk et al., 2019). Records were limited to humans and published in the English language. Studies were included if they (1) reported the occupational demographics of OEND training program participants and (2) reported the impact of OEND programs on knowledge and attitudes toward using and/or carrying naloxone or responding to overdoses.
Study Selection
A total of 1,413 articles were identified through database searches and imported into EndNote X20. Duplicates (518) were manually excluded for internal tracking, leaving 895 records. These were uploaded to the systematic review software Covidence. Covidence identified 151 additional duplicates, leaving 744 records. Following step 4 of the Arksey and O’Malley framework, titles and abstracts were reviewed by four independent reviewers, with each article being reviewed by two of the four reviewers. Of these records, 578 were excluded, leaving 166 eligible for full-text review. During the full-text review, three reviewers independently evaluated each article and excluded 92 articles, leaving 74 articles that met all the eligibility criteria for inclusion in this study. Disagreements between reviewers were resolved by a third reviewer. When disagreement between reviewers arose, the third reviewer reviewed the article to vote on whether to include or exclude the article. The final decision was based on a majority vote of the three reviews. During the review of the full text, one additional study was identified for inclusion in the review, for a total of 75 articles. The study review and selection processes are summarized in the flow diagram in Figure 1.
Flow diagram of study selection process
Literature Review Results
Occupations Trained
A total of N = 75 articles were included in this review. The results of the data extraction phase of this review, as recommended by Arksey and O’Malley (2005), are presented in Table 1, with studies organized by the primary occupation trained. Trainees and students (used interchangeably throughout this manuscript) were the most commonly trained group (n = 20; for a full list of references see Table 1) Of these, only two studies focused on trainees from outside the healthcare field (Brown et al., 2023; Panther et al., 2017). included a range of professions, from healthcare providers, law enforcement officers, nurses, social workers, outreach workers, and medical professional trainees (Ashrafioun et al., 2016; Bascou et al., 2022; Dahlem et al., 2020; Jawa et al., 2020; Kottler & Reising, 2021; Madah-Amiri et al., 2016; Thylstrup et al., 2019). Other occupations trained (n = 8) included gravel miners (Roelofs, 2022), library staff (Lowenstein et al., 2021), staff members of Veterans’ facilities (Rife et al., 2021), BLS providers (Nugent et al., 2019), support workers (T. A. Taylor et al., 2019), and service industry employees (Febres-Cordero et al., 2023; LaSane et al., 2022; Wolfson-Stofko et al., 2018). Figure 2 shows the number of studies by occupation. Healthcare providers (n = 20 trainees, n = 22 healthcare professionals, n = 6 EMT/paramedics, and n = 6 interdisciplinary teams) were represented in 54 of the 76 studies (71%). The first responders most trained were police officers, who were represented in 14 of 18 first responder trainings. Other occupations represented 10.5% of people trained in OEND in this study.
Scoping Review Results
Occupations trained in overdose identification and naloxone distribution
Study Design and Sample Size
The most commonly utilized study design was a quasi-experimental, pre-post methodology (n = 37; 49.3%; for a full list of references, see Table 1). Mixed and multi-methods were used in 13 studies (Banjo et al., 2014; Cerles et al., 2021; Clark et al., 2020; Dahlem et al., 2017, 2020, 2023; Lowenstein et al., 2021; Maguire et al., 2018; McQuade et al., 2021; Monds et al., 2022; Wagner et al., 2016; Wolfson-Stofko et al., 2018). A quantitative non-RCT post-only design was used in seven studies (Dora-Laskey et al., 2022; Jacobson et al., 2018; Kottler & Reising, 2021; LaSane et al., 2022; LeSaint et al., 2022; Ray et al., 2015; Schartel et al., 2018). Six studies used a quantitative non-RCT longitudinal design (Argenyi et al., 2023; Mayet et al., 2011; Musco et al., 2022; Nath et al., 2020; Sexton et al., 2023; Thylstrup et al., 2019. Five studies used a quantitative descriptive/cross-sectional design (Devries et al., 2017; Fisher et al., 2016; Goldberg et al., 2018; Palmer et al., 2017; Winograd et al., 2017). Two studies used a retrospective descriptive and observational design (Janssen et al., 2020; Nugent et al., 2019). Two studies were randomized control trials (Franko et al., 2019; Irwin et al., 2023), one feasibility study (Moore et al., 2021), one prospective descriptive study (Rife et al., 2021), and one study design was not reported (Brown et al., 2023).
The reviewed studies showed a wide range of sample sizes. The largest study, conducted by Simmons et al. (2016), included 4,804 participants and focused on a nationwide online training program. This program was advertised in November 2014 through a listserv targeting professional first responders. In contrast, the smallest study, by Cody et al. (2023), included only eight participants. This study involved a 1-hour, one-time in-person training session for rural clinicians and staff at two Behavioral Health Centers in Alabama. Overall, the average sample size across all studies was 309.7 participants, with a median of 132.5. Four studies did not provide information on the number of participants trained (Dahlem et al., 2020; LaSane et al., 2022; Nugent et al., 2019; Sexton et al., 2023). See Table 2 for descriptive statistics of sample sizes.
Descriptive Statistics of Sample Sizes
Outcomes Measured
The most utilized outcome measures were the full or adapted Opioid Overdose Knowledge Scale (OOKS) and the Opioid Overdose Attitudes Scale (OOAS) in 23 of the 76 studies (30%; Bascou et al., 2022; Berland et al., 2017, 2019; Dahlem et al., 2020; Donohoe et al., 2019; Febres-Cordero et al., 2023; Halmo et al., 2021; Klimas et al., 2015; Kwon et al., 2020; Lowenstein et al., 2021; Madah-Amiri et al., 2016; Monteiro et al., 2017a, 2017b; Murnane et al., 2019; Oliver et al., 2022; Purviance et al., 2017; Ray et al., 2015; Simmons et al., 2016; Wagner et al., 2016; White et al., 2021; Winograd et al., 2017; Wolfson-Stofko et al., 2018; Zhang et al., 2018). Other noteworthy measures included overdoses reversed by police officers (Banjo et al., 2014), prescriptions for naloxone written or filled (Devries et al., 2017; Dora-Laskey et al., 2022; Moore et al., 2021; Rife et al., 2021; Sexton et al., 2023), number of naloxone kits requested by month and pick-up location (Brown et al., 2023), distribution of naloxone (Dora-Laskey et al., 2022; LeSaint et al., 2022), comfort prescribing (Hargraves et al., 2019), and time from EMS call and arrival to naloxone administration (Goldberg et al., 2018; Nugent et al., 2019; Santa et al., 2021). Stigma outcomes were reported in two studies (Oliver et al., 2022; Santa et al., 2021).
Training Descriptions
Training durations reported were from 30 minutes to 4 hours (reported in 20 studies), with 1 hour being the most reported duration in 11 studies (Brown et al., 2023; Cody et al., 2023; Crocker et al., 2019; Donohoe et al., 2019; Febres-Cordero et al., 2023; Klimas et al., 2015; Lowenstein et al., 2021; Oliver et al., 2022; Purviance et al., 2017; Saucier et al., 2016; Zhang et al., 2018), three study durations were from 30 to 45 minutes (Janssen et al., 2020; Musco et al., 2022; Rife et al., 2021), four studies were up to 1.5 hours (Dahlem et al., 2020; Hill et al., 2018; Monds et al., 2022; Thomas et al., 2021), two studies were 2 hours (Madah-Amiri et al., 2016; J. L. Taylor et al., 2018), four studies were 3 hours (Bascou et al., 2022; Jawa et al., 2020; Kwon et al., 2020; Maguire et al., 2018), and three studies were 4 hours in duration (Bachyrycz et al., 2019; Murnane et al., 2019; Thylstrup et al., 2019). See Figure 3.
Training durations
The train-the-trainer model was used in seven studies (Berland et al., 2017; Dahlem et al., 2020; Donohoe et al., 2019; Dora-Laskey et al., 2022; Madah-Amiri et al., 2016; McQuade et al., 2021; Thylstrup et al., 2019). Most of the studies did not describe the trainers in detail. However, the most reported trainers were university faculty, harm reduction workers, nurses, addiction specialists, and certified course coordinators. Most training occurred in person, but seven studies included online components or were delivered solely online (Bascou et al., 2022; Berland et al., 2019; Dahlem et al., 2023; Elmes et al., 2021; Nath et al., 2020; Roelofs, 2022; Simmons et al., 2016). Only four studies reported distributing naloxone to participants (Brown et al., 2023; Febres-Cordero et al., 2023; LaSane et al., 2022; Panther et al., 2017). Two of these studies trained service industry workers (Febres-Cordero et al., 2023; LaSane et al., 2022). Persons with lived experience (people with experience of substance use) were included as trainers in seven trainings (Dahlem et al., 2017, 2023; Febres-Cordero et al., 2023; Halmo et al., 2021, 2022; Maguire et al., 2018; Oliver et al., 2022).
Harm reduction was addressed as a component of 18 trainings; with eight of these studies published in 2022 to 2023 (Banjo et al., 2014; Brown et al., 2023; Dahlem et al., 2017, 2020; Dora-Laskey et al., 2022; Febres-Cordero et al., 2023; Halmo et al., 2021; Hill et al., 2018; Irwin et al., 2023; Kwon et al., 2020; Maguire et al., 2018; Murnane et al., 2019; Musco et al., 2022; Oliver et al., 2022; Roelofs, 2022; Sexton et al., 2023; J. L. Taylor et al., 2018; Wolfson-Stofko et al., 2018). Of these nine studies included other harm reduction interventions in addition to naloxone administration training. Descriptions of occupations trained with additional harm reduction components can be found in Table 3.
Other Harm Reduction Strategies Incorporated in OEND
Explicit use of Harm Reduction (HR) philosophy and/or collaboration with a harm reduction organization.
Medication Assisted Therapies (MAT).
Mental Health and Physical Health (MH, PH) services.
Studies were primarily conducted in the USA. Six studies were conducted globally in the United Kingdom (2; Mayet et al., 2011; T. A. Taylor et al., 2019), Denmark (Thylstrup et al., 2019), Ireland (Klimas et al., 2015), Norway (Madah-Amiri et al., 2016), and Canada (Banjo et al., 2014).
Discussion of Literature Review Results
This scoping review is among the first to examine opioid education and naloxone distribution efforts by occupation. Several reviews have shown that OEND programs save lives and are cost-effective (McDonald & Strang, 2016; Mueller et al., 2015; Razaghizad et al., 2021). However, less is known from these reviews on which audiences may be best positioned to receive targeted, evidence-based training on how to respond to an overdose based on their workplace or occupation. The unrelenting year-over-year increases in the number of fatal overdoses seen in the United States and globally (Colledge et al., 2019) necessitate urgent public health actions, including widespread dissemination on how to respond to a potential opioid-involved overdose with naloxone effectively. Estimates show that up to half of all overdoses occur in public places, further emphasizing the need for community members and individuals working where overdoses may occur to be trained to respond in a timely and effective way (Madah-Amiri et al., 2019). The U.S. Bureau of Labor Statistics reports a steady increase in workplace deaths from unintentional substance overdose from 2011 to 2020, from 73 deaths in 2011 to 388 in 2020. This trend further supports that occupations in close proximity to overdose are a potential target for increased training in OEND (United States Bureau of Labor Statistics [USBLS], 2022).
Studies reporting on occupation-specific training were included in this review. As this review shows, the preponderance of research on occupation-specific naloxone training has centered on healthcare providers. Our study found that 71% of OEND training studies involve healthcare trainees, workers, and first responders. This review found that 24% of studies examining occupation-specific naloxone training approaches included first responders specifically. A well-trained first responder workforce that can quickly arrive and administer naloxone will continue to be needed to mitigate mortality from opioid-involved overdoses. However, studies have found that individuals experiencing non-fatal overdoses may not be willing to accept transport from first responders (Bergstein et al., 2021).
Additionally, 77% of first responders trained were law enforcement officers. People who use drugs have a history of distrust of officers of the law who have had to uphold damaging war on drug policies for decades (Cooper, 2015; Cooper et al., 2022). This highlights the need for community-based training that educates responders on naloxone use and empowers them to provide community paramedicine and peer outreach after an overdose reversal.
The methodologies of studies included in this review varied, making it difficult to compare training content and cross-cutting outcomes by occupation. Other researchers reviewing overdose outcomes, not occupation-specific, have noted the common use of unvalidated measures (Franklin Edwards et al., 2020). 30% of the studies included in this review used the validated OOKS and OOAS to measure outcomes of OEND training. Workplace training should balance brevity with comprehensive information. Brief measures to capture skill and knowledge competency and self-report surveys on confidence and attitudes are advantageous. Objective metrics like naloxone kit distribution, refills, and workforce-specific outcomes, such as the number of trained workers reporting to revive an individual after overdose, provide valuable insights. While these measures may complicate comparisons of training efficacy, pragmatic implementation measures are likely more meaningful to those impacted by opioid-related overdose. A recent publication assessed whether the mass distribution of naloxone decreased mortality from overdose and found no significant decrease in opioid mortality 2 years after the mass distribution (Tabatabai et al., 2023). However, evidence to date suggests that increased access and distribution of naloxone is the most promising intervention to decrease mortality from an opioid-related overdose, specifically as it is related to synthetic opioids (e.g., fentanyl).
Findings from this review identified a gap in training occupations outside of the healthcare field. An analysis of substance overdose deaths from 2007 to 2013 by the Centers for Disease Control (CDC) identified six occupations with elevated mortality ratios from substance overdose: construction, miners, food preparation and serving, healthcare practitioners, healthcare support, and personal care and service (Harduar Morano et al., 2018). In 2023, an analysis of substance overdoses in 46 States and New York City in 2020 revealed the top occupations disproportionately impacted by overdose mortality (Billock et al., 2023). The construction, mining, and service industries bore the brunt of the impact, with distinct trends emerging within these sectors. Among construction workers, the effects were particularly pronounced, with roofers, drywall and ceiling tapers, painters, stone masons, and steelworkers facing significant challenges (Billock et al., 2023). Notably, women were disproportionately affected by overdose mortality within construction and food preparation and service roles (Billock et al., 2023). Hispanic individuals were predominantly represented in personal care and service, arts and entertainment, and recreation (Billock et al., 2023). Meanwhile, American and Alaskan Indigenous communities experienced a disproportionate burden of overdose mortality in farming, fishing, forestry, and manufacturing occupations (Billock et al., 2023).
Construction workers are being trained to identify and respond to opioid-related overdoses nationally by their employers (Association of General Contractors, 2023; BHS Construction, 2024; Naloxone Care, n.d.). It is recognized in this community that the health and safety of construction workers require training in identifying and responding to an overdose, as they are more likely to become dependent on opioids due to the physical nature of their work and the need for pain management. These trainings are tailored for construction workers and address substance use, suicide, and mental and physical well-being (BHS Construction, 2024). The National Institute for Occupational Safety and Health (NIOSH) and the CDC recognize the need to train construction workers in OEND, pain management, substance use, and strategies to promote health among construction workers and miners, the two most impacted occupations from the opioid epidemic (Centers for Disease Control and Prevention, 2022). Workplace deaths from opioid overdose in this community have increased 500% from 2012 to 2022 (USBLS, 2022). However, our review found no research for tailoring OEND training for construction workers, and only one study done with miners.
Stone, sand, and gravel miners training in OEND was embedded in a required mining safety and health training (Roelofs, 2022). The 30-minute tailored training included work-related factors that contribute to opioid use, enhanced knowledge of the opioid epidemic, and awareness of the potential for opioid prescriptions to lead to dependency. The training also included skills building to empower workers to engage with healthcare providers to advocate for themselves and others and harm reduction approaches to opioid use. This training was informed by previous research with construction workers and miners (Roelofs et al., 2021). It is important to note that not all construction and mining workers are at risk of overdose. A necessary component for reducing stigma in these populations is to be wary of creating social norms that may harm individuals in these industries. Although healthcare providers/trainers should work to tailor OEND and training for these occupations, it could be harmful to label all construction workers and miners as people who use substances. For example, most construction workers (86%) do not have a substance use disorder (Bush & Lipari, 2015). Regardless of social norms, all individuals, even those at little to no risk, are optimally positioned to become responders to support their peers, co-workers, and other members of their social and professional communities. In a 2023 study of commercial fishing industry captains, only 10 of 63 had naloxone training, only five of their vessels carried naloxone, and 86.7% of captains reported being “not at all worried” about a crew member having an overdose (Bellantoni et al., 2023). But when an overdose does happen on a vessel, it can impact the whole fleet, as was seen in a New York Times publication of how one overdose at sea led an entire fleet to train crew in OEND and stock naloxone on vessels (Chivers, 2024). Overdose deaths within industries are changing the culture regarding OEND and harm reduction.
Another example of this culture shift is in the food and service industry, which benefits from OEND training. The food and service industry has its own culture related to substance use. A qualitative study of 52 restaurant employees found a culture of social acceptance of substance use in the workplace, and substances were used as a way to de-stress from work and bond with co-workers (Shigihara, 2020). Occupational normalization of substance use can be seen as a strength or weakness, as it may reduce stigma and foster open discussions on harm reduction, despite the challenges posed by criminalization and hidden use. According to the Bureau of Justice Statistics, 114 million Americans age 12 or older (46% of the population) have reported illicit substance use at least once in their lifetime (Shigihara, 2020). Stigma related to substance use and disordered substance use also impacts the uptake or acquisition and carrying of naloxone; this “naloxone stigma” is seen even as public health agencies advocate for all to carry naloxone (Adeosun, 2023). The culture of the service industry may provide an entire workforce willing to carry and administer naloxone.
There are 15.5 million food and service workers in the US, and it is the second largest private sector employer in the US. Of those employed in the industry 50% are minorities. Sixty-three percent of adults in the U.S. report having worked in a restaurant in their lifetime (National Restaurant Industry Association, 2021, 2022). Although only three studies included the service industry in our review (Febres-Cordero et al., 2023; LaSane et al., 2022; Wolfson-Stofko et al., 2018), training in restaurants and bars is becoming more common nationwide (Allen et al., 2020). The movement to train service industry workers outside of research studies may stem from the many losses of life due to overdose in the industry. Service industry workers practice harm reduction in their communities and do not wait for others to prescribe naloxone training as a public health intervention. However, tailored training that can reach the 15.5 million service industry workers is still needed as this population seems ready to become community first responders. In urban settings, overdoses are more likely to occur in public settings, including restaurants and parked cars (Treitler et al., 2022). Service industry workers could fill this role as they are uniquely and conveniently positioned to reduce preventable deaths by opioid-related overdose.
Strengths and Limitations
The strength of this review is it adds insights into training in OEND by occupation in a replicable scoping review. However, literature may have been missed as we did not search grey literature or databases such as the National Institute for Occupational Safety and Health or the Occupational Safety and Health Administration Database. Future reviews of OEND by occupation may consider expanding to include these databases.
Conclusion
When training by occupation, occupational health nurses must consider not only the need to train to identify and respond to an overdose but also how to keep workers safe when they are using unregulated and illicit substances. OEND may be as misnomer as training tailored for occupations must confront illicit and unregulated substance use, include harm reduction strategies such as the need to never use alone and the availability and use of substance testing supplies (e.g., fentanyl test strips), and resources for healthcare. All workers should be trained with the consideration that they may be exposed to illicit or unregulated substances that put them or their coworkers at risk of an overdose. Employers need to train their staff to recognize and respond to an overdose in the workplace and ensure the availability of naloxone. Researchers should collect data on occupation and consider occupation for targeted research interventions. Policies to support the availability of naloxone in the workplace must be supported throughout the U.S. at the local, state, and federal levels.
Implications for Occupational Health Practice
This scoping review on opioid education and naloxone distribution (OEND) training reveals several key public health practice implications. As seen in this review, healthcare providers and first responders receive significant OEND training, other sectors like service industry workers, construction workers, miners, librarians, and non-traditional responders are underrepresented. Occupational health efforts should prioritize expanding OEND programs to these groups due to the increasing incidence of overdoses in public spaces and workplaces (Febres-Cordero et al., 2022, 2023).
Community-based and workplace-focused OEND programs are needed. Occupational health nurses should collaborate with industries like hospitality and service sectors to implement tailored training programs and distribute naloxone kits, recognizing these workers as de facto first responders (Febres-Cordero et al., 2024). Standardized, evidence-based training models that are brief yet comprehensive should be developed. We recommend including education on substance use, opioid use, drug checking, overdose prevention, recognition, response protocols, and harm reduction.
Incorporating harm reduction principles into OEND programs can enhance effectiveness by addressing stigma (Wild et al., 2021), increasing community trust (Wallace et al., 2021), and promoting a supportive environment for individuals at risk of overdose (López-Ramírez et al., 2023). To this end, we recommend using robust outcome measures, such as the number of naloxone kits distributed, overdose reversals, and reductions in opioid-related mortality, to evaluate the impact of OEND programs across diverse occupations.
By leveraging these insights, occupational health nurses can develop more targeted, effective, and inclusive strategies to combat overdose deaths across different occupational settings. Expanding OEND training to diverse occupational groups, enhancing program evaluation, and integrating harm reduction principles can significantly reduce the burden of overdose in communities and workplaces.
In Summary
Occupational OEND trainings should be inclusive of individuals with varying experiences, including those who may use substances.
Occupational OEND trainings should be expanded to include occupational groups that are not typically associated with the need for opioid and naloxone education.
Harm reduction principles should be included in all occupational OEND trainings to ensure a comprehensive and non-judgmental approach to substance use education in the workplace.
Increased access and distribution of naloxone is the most promising intervention to decrease mortality from opioid-related overdoses in the workplace, particularly for synthetic opioids like fentanyl.
Supplemental Material
sj-docx-1-whs-10.1177_21650799251326109 – Supplemental material for Opioid Education and Naloxone Distribution by Occupation: A Scoping Review
Supplemental material, sj-docx-1-whs-10.1177_21650799251326109 for Opioid Education and Naloxone Distribution by Occupation: A Scoping Review by Sarah Febres-Cordero, Daniel Jackson Smith, Sharon L. Leslie, Sydney Cohen, Patti Landerfelt, Abigail Béliveau, Jennifer Crook, Abigail Z. Wulkan, Biyeshi Kumsa, Fawaz Shanun and Nicholas A. Giordano in Workplace Health & Safety
Footnotes
Acknowledgements
We want to acknowledge the researchers, employers, policymakers, healthcare workers, public health practitioners, harm reductionists, and individuals who are training communities in OEND to decrease death from substance use.
Author Contributions
Sarah Febres-Cordero: Conceptualization, data acquisition, data analysis, data interpretation, and manuscript drafting and review. Daniel Jackson Smith: Conceptualization, data acquisition, data analysis, data interpretation, and manuscript drafting and review. Sharon L. Leslie: Conceptualization, data acquisition, methods, and drafting of the manuscript. Sydney Cohen: data acquisition, data analysis, and review of the manuscript. Patti Landerfelt: Drafting of the manuscript and manuscript review. Abigail Béliveau: Data acquisition, and manuscript review. Jennifer Crook: Drafting of the manuscript and manuscript review. Abigail Z. Wulkan: Data acquisition, and manuscript review. Biyeshi Kumsa: Writing of discussion, Table 1 audit, and manuscript review. Fawaz Shanun: Writing of results, data analysis, descriptive figures, and manuscript review. Nicholas A. Giordano: Conceptualization, data acquisition, data interpretation, manuscript drafting, and manuscript review.
Conflict of Interest
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
IRB Review
This study was exempt from IRB review.
Supplemental Material
Supplemental material for this article is available online.
References
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