Interrelationship Between Personal and Occupational Risk Factors Complicates Opioid/Benzodiazepine Crisis

December 01, 2017 (6 min read)

Building on prior research, a recent study sponsored in part by the National Institute of Occupational Safety and Health (NIOSH) and the Health Resources and Services Administration (HRSA) identifies eight models that demonstrate the interrelationships among occupational risk factors (ORFs), personal risk factors (PRFs), and prescription drug (PD) use involving opioids and/or benzodiazepines in the occupational setting [see Michele Kowalski-McGraw, MD, MPH, et al., “Characterizing the Interrelationships of Prescription Opioid and Benzodiazepine Drugs With Worker Health and Workplace Hazards,” Journal of Occupational and Environmental Medicine (JOEM), Vol. 59, No. 11, November 2017].

Qualitative Approach Evaluated Published Scientific Literature

The study used a qualitative approach to evaluate published scientific literature from 2000 to 2015. Initially identifying some 1825 separate publications, the researchers used a multi-step process ultimately to narrow the pool of literature to 133 sources. The researchers relied on publications from both the occupational and nonoccupational settings, since not only do risk factors in the workplace contribute to health problems, but the reverse is also true. The researchers were careful to point out that the focus of such a qualitative study is not to discern “definitive causal pathways,” but rather to identify relationships that might warrant additional exploration.

Generally speaking, the researchers identified health outcomes that are associated with PD use, pairing them with activities that might occur both at work and away from the workplace. Using a recognized research framework that considers the interplay of occupational and personal risk factors to address overall worker health, the researchers modeled their findings, coming up with two sets of interrelationships, with each set comprised of four models.

Opioid/Benzodiazepine Use May Combine with Occupational Risk Factors to Affect Injury or Illness

Within their first four models, the researchers observed that the use of opioids and benzodiazepines has the potential of being a personal risk factor for adverse outcomes in the occupational setting.

Model 1.1: Opioid/Benzodiazepine Use, Combined with Shiftwork Produces Hazard

Noting earlier reports that show the use of opioids and benzodiazepines are linked to reductions in psychomotor skills and dexterity, and that drowsiness is a common side effect of opioid use and that fatigue and somnolence have been reported in a significant number of persons receiving benzodiazepine treatment, the researchers determined the literature supported the notion that combining shiftwork with PD use (either opioids or benzodiazepines) leads to hazards associated with decreased psychomotor performance.

Model 1.2: Opioid/Benzodiazepine Use Increases Risks of Occupational Motor Vehicle Crashes

Noting that there have been few studies specifically examining the causal connection between PD use and occupational motor vehicle crashes, the researchers nevertheless indicated that risk assessments by the ACOEM and others regarding the use of opioids by commercial drivers seem supported in the scientific literature.

Model 1.3: Increased Risk of Falls Associated with Opioid/Benzodiazepine Use

Observing that trips and falls typically account for one quarter of all nonfatal occupational injuries and more than 14 percent of all fatal occupational injuries, and further, that a significant number of falls are associated with the use of ladders, the researchers report the scientific literature supports the notion that there is an important interrelationship between opioid and/or benzodiazepine use and ladder-related workplace injuries. Use of either medication can, of course, result in altered balance and postural control, with of which can result in falls.

Model 1.4: Opioid/Benzodiazepine Use Associated with Increased Claim Costs

Many within the workers’ compensation community associate higher claim costs with opioid and/or benzodiazepine use on the part of injured workers. Such use also was determined to be associated with the use of multiple medical care providers. Obtaining PDs from multiple physicians also has been associated with increased risk of fatal overdoses.

Occupational Risk Factors May Combine with Personal Risk Factors to Contribute to Opioid/Benzodiazepine Use

Within their second set of four models, the researchers observed that the literature supports the notion that there are multiple workplace situations in which occupational risk factors may combine with personal risk factors to contribute to the use of opioids and benzodiazepines.

Model 2.1: Work-Related Stress and Advancing Age Combine to Impact Opioid/Benzodiazepine Use

The studied literature suggests that work-related stress, such as job insecurity, “high demand/low control” jobs are associated with anxiety disorders and depression—among the medical conditions for which the prescription of benzodiazepines and other drugs is common. Anecdotal medical information supports the suggestion that where a worker is happy with the job, he or she is much less likely to seek PDs. Age-related increases in the use of benzodiazepines were also noted. The researchers observed that 13 separate studies appeared to link work-related stress with the personal risk factor of increasing age.

Model 2.2: Occupational Factors May Impact Opioid/Benzodiazepine Use

The researchers indicate the literature supports the widely-held view that ergonomic workplace factors, such as sitting and raising arms frequently contribute to fatigue and pain, often cascading to increased use of opioids and benzodiazepine.

Model 2.3: Drug Free Workplace Rules Impact Opioid/Benzodiazepine Use

While the data is complex and not always discernible to specific interpretation, the scientific literature buttresses concerns that as many as two-thirds of current non-medical drug users are employed at least part-time and that an important segment of this group is subject to workplace substance abuse prevention activities. While drug testing has generally been shown to lead to reduction in drug use, drug testing has little, if any, effect on prescription opioid abuse since any drug testing results are reported to the employer as negative, based on the existence of a valid prescription. The researchers note that this does not mean there are no adverse effects from PD use, however; 60 percent of all opioid overdoses occur among patients with valid prescriptions. The researchers indicate that the literature points to an interrelation between prior substance abuse and prescription opioid use and that in turn prescription opioids are associated with substance abuse.

Model 2.4: Occupational Injury (and Other Factors) Impact Opioid/Benzodiazepine Use

The researchers point to a number of studies that show that in spite of increasing use of prescription opioids in recent years, no association with improvements in disability and health status have been seen. Studies show that the less a worker is paid, the more likely he or she will suffer a disabling work-related injury. Occupational injury generally leads to an increase in the likelihood that the worker will receive an opioid or benzodiazepine prescription.

Study Limitations

The researchers acknowledge a number of limitations with their study. First, of course, the study is limited by its type: it represents a qualitative approach to the evaluation of published literature. It has not been refined by a more rigorous statistical approach. Qualitative research tells “the why,” whereas quantitative research tells “the what.” Since there data is observational in nature, the researchers acknowledge that there are gaps. The researchers also acknowledge that in this form of study, there are challenges in distinguishing between appropriate and inappropriate levels of prescription drug use.

Additional Observations

In recent years, considerable and appropriate attention has been given to the growing problem of opioid and/or benzodiazepine prescription abuse among injured workers. Not only have the numbers of prescriptions risen to what many feel are staggeringly dangerous numbers, the human toll that is being paid in terms of lost time, reduced productivity, and destruction of wage-earning ability is enormous. The Kowalski-McGraw study reminds us, however, that the risks and dangers flow in two directions, not just one. Prescription opioid and benzodiazepine drugs appear not only to be a personal risk factor for work-related injury; they also are a consequence of workplace risk exposures. To the extent that we can better understand the important interplay between personal and occupational risk levels, we can begin the long and tedious process of getting out of the hole we’ve dug with opioid and benzodiazepine prescription abuse. Common sense tells us that the important, first step is to stop digging. The Kowalski-McGraw study is an aid in that process.