14 Jun 2022

Study on COVID-19’s Impact on Drug Overdose Deaths by Occupational Is a Cause for Alarm

By Hon. Susan V. Hamilton, Former Assistant Secretary and Deputy Commissioner, California Workers’ Compensation Appeals Board

Take a look at the headlines in any newspaper or listen to the highlights of your favorite daily news broadcast and you are almost certain to receive an update on COVID-19. Perhaps you will be informed that Shanghai is expected to end its COVID-19 lockdown by the end of June 2022, or that Alameda County (California) has reimposed masking requirements due to an upsurge in new cases. Although we have been living with the pandemic for two and one-half years, we are still in our infancy in terms of comprehending how broadly and significantly COVID-19 has impacted every facet of our lives, including our work. Researchers have begun to enhance our understanding of COVID-19’s multi-faceted challenges to the workforce through a number of studies. For example, researchers from the RAND Corporation examined the pros and cons of expanding workers’ compensation to cover the costs for workers required to work outside the home who contract COVID-19 (COVID-19 and Workers’ Compensation: Considerations for Policy Makers [RAND, January 2022].) Another group of researchers also from RAND examined COVID-19 claims in California’s workers’ compensation system and evaluated the effectiveness of various presumptions related to compensability of COVID-19 (COVID-19 in the California Workers’ Compensation System [RAND, January 2022].) Yet another team of researchers at RAND released the lengthy report, A Study of COVID-19 Claims and Presumptions Under Senate Bill 1159 [RAND, May 2022].) Another recent study, this one conducted by researchers from the Massachusetts College of Pharmacy and Health Sciences (MCPHS University), examined the effect, if any, of drug poisoning (overdose) deaths by occupation during 2020, the first year of the COVID-19 pandemic. The results of that study, Changes in drug poisoning mortality before and after the COVID-19 pandemic by occupation in Massachusetts (Hawkins, D. ad Phan, Anh Tuan, Am. J. Ind. Med. 2022:1-11), raise alarm bells.

The Study:

Drug overdose deaths in the United States are at record proportions. The Centers for Disease Control and Prevention (CDC) reports that during the 12-month period ending April 2021, there were over 100,000 estimated drug overdose deaths in our country, which represents a 28.5% increase from drug overdose deaths during the same period the year before. (https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2021/20211117.htm) Before the emergence of COVID-19, the authors observed what appeared to be a plateauing in the trend of increasing drug overdose deaths over prior decades. Because risks for drug overdose deaths have been shown to differ according to occupation, the aim of the current study was to determine whether workers in certain occupations had drug overdose death rates that increased in the first year of the COVID-19 pandemic (2020) when compared to the average mortality rates of drug overdoses in the prior three years (2017-2019).

The study used official death certificate data for all deaths in Massachusetts between 2017 and 2020 involving drug overdoses. This data set includes cause of death, date of death, usual occupation, usual industry, age, sex, educational attainment and race/ethnicity. The authors only used data pertinent to Massachusetts residents between the ages of 16 and 64, and anyone identified in the data as unemployed or not in the labor market was excluded. The authors then computed numbers, percentage, and average annual mortality rates according to usual occupation, age, race/ethnicity, and educational attainment, stratified according to deaths that occurred between 2017-2019 and deaths that occurred in 2020.

The Findings:

The data revealed that between 2017-2019 and 2020, the overall mortality rate for drug overdose poisonings increased slightly in Massachusetts from 48.8 deaths per 100,000 workers/year to 50.0 per 100,000 workers/year. Interestingly, mortality rates declined among workers aged 16-35 and 45-54. However, the mortality rate for workers between the ages of 35-44 increased by 30% during these time periods. Next, looking at racial/ethnic differences, the data showed that during the time period from 2017-2019 mortality rates were highest among Hispanic and White workers, but in 2020 mortality rates for Black workers were higher than those of White workers and nearly as high as the mortality rates among Hispanic workers.

The slight increase in the mortality rate for drug poisonings—48.8 per 100,000 worker/year between 2017 and 2019 to 50 per 100,000 worker/year in 2020 seems negligible, but another finding dispels that conclusion. The authors found that there was a significant increase in drug overdose mortality rates for workers in three occupational groups. Those groups are food preparation and serving; healthcare support; and transportation and material moving. The authors also observed that for the most part, the increases in mortality rates for drug poisonings for each of these occupational groups were mostly higher in those months that coincided with COVID-19’s surge throughout Massachusetts in 2020. Food preparation and serving workers had mortality rates over 100% higher in February, April and May 2020. Healthcare support workers had notable increases in mortality rates in January through March 2020, June through September 2020, and November through December 2020. Similarly, transportation and material moving workers had noticeable mortality increase in February through June and August 2020.

How can the findings be explained?

What conclusions can be drawn from these findings? The study’s authors candidly admit that their findings are not definitive and could simply be coincidental. But they readily acknowledge that several other factors during the first year of the pandemic (2020) may have played a role in the findings.

Stress

The first factor is stress related to COVID-19 and the potential for being exposed to the virus and becoming ill. Generally, each of the three occupations is considered to be “essential” and/or “frontline,” meaning that workers in these occupations continued to work during the first year of the pandemic in settings where they had a greater exposure to COVID-19 than workers who were able to work from home. Indeed, the disproportionate exposure to COVID-19 among workers in these occupations is supported by data that demonstrates significantly elevated mortality rates from COVID-19 in Massachusetts for each of the three occupations during 2020. Unlike healthcare support workers, healthcare practitioners did not have an increase in drug overdose mortality. The study’s authors suggest this finding may be explained by the fact that a higher proportion of healthcare practitioners were able to work remotely during the pandemic.

Many workers in these three occupations were also required to work longer hours during the initial year of the pandemic due to increased demands for their respective services. Such an increase in workload demands could precipitate or exacerbate stress. In the case of healthcare support workers, seeing co-workers become sick with COVID-19 and die from the disease may have been an additional source of stress.

Financial strain and unemployment

Another factor that might have played a role in the increases in drug overdose deaths experienced by the three occupational groups is financial strain and unemployment. In the early days of the COVID-19 pandemic, unemployment increased dramatically. Research has shown that unemployment and not being in the labor force are likely risk factors for drug overdose deaths. Nationally the unemployment rate among food preparation and serving workers increased over three times during the pandemic. The significant increase in drug overdose deaths among these workers could be attributable to the financial strain associated with unemployment.

Occupational injury

A third factor that may have played a role in the substantial increase in drug overdose deaths among the three occupations is occupational injury. Prior research has demonstrated that occupational injuries are a likely risk factor for drug overdose deaths. Using data from the United States Bureau of Labor Statistics Survey of Occupational Injuries and illnesses, the authors observed increases among some of the occupations in specific injuries associated with pain and opioid use, such as musculoskeletal disorders. For example, healthcare support workers had a 17% increase in the rate of musculoskeletal work-related injuries in 2020 compared to 2019. Food preparation and serving workers had a 22% increase in musculoskeletal work-related injuries in 2020 compared to 2019. While transportation and material moving workers overall did not have a similar increase in musculoskeletal work-related injuries in 2020, some specific subclassifications within that occupational grouping did have increases in work-related musculoskeletal injuries. Those subclassifications are ambulance driver and attendant. The authors suggest that these increases in musculoskeletal work-related injuries may have increased the risk for drug overdoses.

Other factors

The authors posit several other factors that may have contributed to increases in drug overdose deaths during the pandemic. In 2020 there were widespread shutdowns of businesses and services throughout the country. These disruptions may have impacted a worker’s ability to access employer-provided healthcare. Also, availability of treatment for substance use disorders was interrupted by the pandemic. Another factor could be that the pandemic contributed to changes in the potency of drugs being taken or even the type of drugs consumed. The authors point to a recent report from the Massachusetts Department of Public Health that documented increases in overdose deaths involving fentanyl among workers in the years before the pandemic. If this trend continued, it is possible that workers may have switched from taking prescriptive medications to fentanyl. Additionally, the authors raise the possibility that due to the pandemic, drug users may have had less access to emergency treatment and opioid overdose reversal medication since emergency medical services were significantly impacted by large influxes of very ill COVID-19 patients.

Race and ethnicity

Lastly, the authors suggest it may not be coincidental that the three occupational groups found to have an increase in drug overdose deaths during the pandemic are occupations that have been shown to disproportionately employ workers of color. Referencing a 2021 report by the CDC (Risk for Covid-19 infection, hospitalization, and death by Race/Ethnicity, September 26, 2021[https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html]), the authors note that it has been established that workers of color are more likely to be employed in occupations with increased risk of COVID-19 exposure and that there are elevated rates of COVID-19 hospitalization and death among people of color. Increases in drug overdose deaths among Black workers were observed in the study and the authors recommend further investigation of the extent to which occupational factors, including exposure to COVID-19, may have contributed to the increases.

Where do we go from here?

While the study’s findings are certainly disturbing, whether they have general applicability on a nation-wide level is unknown since the study was limited to Massachusetts. Indeed, the authors endorse further research on both national and state levels to examine how occupational factors may have contributed to increases in drug overdose deaths during the COVID-19 pandemic and the role played by two likely contributors to such increases: exposure to COVID-19 at the workplace and unemployment/job insecurity. Their recommendation makes particularly good sense as we continue to live and work in a pandemic.