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A Constellation of Challenges

Illustration by Stuart Briers

Opioids in the Workplace: Impairment, Illicit Substances, and Insider Threat

American employees are in crisis. In 2017, an estimated 1.7 million people in the United States suffered from a prescription opioid-related drug disorder and more than 47,000 people died of opioid overdoses, either from prescribed opioid pain relievers, heroin, or illicitly manufactured fentanyl.

Americans are more likely to die from an accidental opioid overdose than a motor vehicle crash, according to 2019 National Safety Council (NSC) data.

And opioid dependencies are affecting the workplace. A 2019 survey from the NSC found that 75 percent of U.S. employers have been directly affected by opioids, but only 17 percent feel extremely well prepared to deal with the issue. Thirty-one percent reported an overdose, an arrest, a near-miss, or an injury because of employees’ opioid use.

Opioids were not the only substance at work in these incidents, but the level of opioid use across the United States is a cause for concern for security and workplace safety professionals alike. The National Survey of Drug Use and Health found that 4.3 percent of respondents older than 18 reported illicit opioid use within the past year, and two-thirds of these self-reported users were employed full- or part-time.

Overdose deaths from nonmedical use of drugs or alcohol in the workplace increased by at least 25 percent each year between 2013 and 2017, accounting for 5.3 percent of occupational injury deaths in 2017.

While the epidemic was previously concentrated in areas hit hardest by the 2008 recession, every region of the United States is now affected, says Dr. L. Casey Chosewood, director of the Office for Total Worker Health within the U.S. Centers for Disease Control and Prevention (CDC) National Institute for Occupational Safety and Health (NIOSH).

“Some of the hardest hit areas are levelling off, over the past year or so, but unfortunately other states—especially those that were a little bit late to this crisis—are seeing continued increasing rates of overdose deaths,” Chosewood says. “While there have been some geographic differences across the country, unfortunately the epidemic of overdose deaths is widespread, with many regions impacted.”

The term “opioids” refers to any substance—natural or synthetic—that binds to the brain’s opioid receptors, which are responsible for controlling pain, reward, and addictive behaviors. Examples include prescription painkillers hydrocodone (Vicodin) and oxycodone (OxyContin), as well as fentanyl and methadone. Opiates are a subset of opioids, including only those naturally derived from poppy plants, such as heroin, morphine, and codeine.

Opioids are often prescribed to effectively manage pain, but a side effect of the drugs can be impairment. Pain management approaches vary widely among physicians, and guidelines on what to prescribe, dispense, and cover change frequently as more research into opioid effects emerges.

In acute use cases—when someone is using the painkiller as directed to treat a specific, short-term condition—the drug can cause drowsiness and slowed reaction times, posing a safety concern especially around heavy machinery or manufacturing facilities. In cases of chronic or long-term opioid use and opioid use disorders, additional side effects include cravings or uncontrollable use, mood alteration, difficulty fulfilling obligations, and withdrawal symptoms, Chosewood says.

The powerful sedative qualities of opioids can also cause people to stop breathing, which is a leading factor in opioid overdose deaths.

“This constellation of challenges when it comes to work makes it quite difficult for workers with either prescribed or illicit use—especially if it’s misused or used heavily—to function in the workplace,” Chosewood says.

While the United States has had high rates of prescription opioid use, which can lead to misuse and abuse, he adds, other countries also are struggling with the effects of these substances, especially as illicitly manufactured fentanyl—a synthetic opioid 50 times more powerful than heroin—crosses international boundaries. (For more on global opioid use, see the sidebar “Opioids Worldwide.”)

In 2016, there were 1.3 million high-risk opioid users in Europe, according to the European Monitoring Centre for Drugs and Drug Addiction’s 2016 European Drug Report. Opioids—primarily heroin—were found in 82 percent of fatal overdoses. Synthetic drugs like fentanyl are also on the rise, often mixed in with other illicit substances.

“It’s a problem in the United States, but fentanyl is making its way to other countries around the world,” Chosewood says, “and they’re having increasing rates of overdose deaths as well.”

These substances are more addictive than other drugs, such as marijuana and cocaine, says Mark Giuffre, CPP, director at security consultant firm Hillard Heintze and a former U.S. Drug Enforcement Administration (DEA) agent.

Opioids are “far more addictive than many other illicit drugs, and they’re much tougher to beat in terms of treatment and rehabilitation,” Giuffre adds. “Secondly, they are far more deadly, as the numbers show. One American somewhere in America drops dead every eight minutes from an opioid overdose… We have never had a drug this devastating before.”

Opioids at Work

In addition to the compounding health risks of opioid use, the crisis has lasting business effects.

During her 2017 testimony before the U.S. Senate Banking Committee, then-Federal Reserve Chair Janet Yellen said the opioid crisis is related to the decline in labor force participation in prime-age workers. The U.S. Bureau of Labor Statistics found that labor force participation has fallen since the 2008 recession and stagnated near 63 percent. Yellen remarked that the United States is seeing an increase in death rates in this population, partly reflecting opioid use.

In 2017, 95 percent of U.S. drug overdose deaths occurred among the working-age population (people between 15 and 64 years old), according to the CDC. More than 5 percent of workplace deaths are overdoses.

Employees who abuse opioids have higher absenteeism rates and are more likely to lose their jobs, compounding emotional and economic hardships that can make disorders worse. Workers with substance abuse disorders miss an average of 14.8 days of work a year, but those with a current pain medication use disorder miss an average of 29 days per year—compared to 10.5 for most employees, the CDC reports.

Some industries are more impacted by the crisis than others, Chosewood says. Certain jobs, such as construction work, put workers at risk for injury that could result in an opioid dependency or don’t provide adequate benefits such as sick leave—which could pressure an employee to take opioids to work through pain or illness to keep a job.

Mining, oil and gas extraction, fishing and agriculture, and some healthcare positions are also at higher risk for the effects of the opioid epidemic within the workforce, he adds.

Safety and Security

Opioid use and abuse have multifold impacts on the workplace, says Rachael Cooper, senior program manager for substance use harm prevention at the NSC. It’s essential to remember that regardless of how or why an employee is taking an opioid—whether legally taking the medication as prescribed, misusing prescription opioids, or dependent on the drug—its presence at work poses a safety concern from multiple angles, she says.

Impairment. According to the NSC survey, 86 percent of employers believe taking opioids even as prescribed can impair employees’ job performance, but only 60 percent have policies in place that require employees to notify employers when they are using opioids. In addition, 79 percent of employers are not very confident that employees can spot warning signs of opioid misuse to report it before an incident.

Impairment from opioids is not as easy to detect as alcohol impairment, Cooper says. But well-educated employees and supervisors can be on the lookout for physical signs of impairment such as an inability to focus or walk straight, as well as warning signs: stumbling, slurring, irritability, or sudden mood shifts.

They might not be able to determine why the employee is impaired in the moment, she adds, but the important thing is to get the safety hazard—the impaired employee—off the floor and somewhere safe.

Crime. According to the National Institute on Drug Abuse, between 21 and 29 percent of patients prescribed opioids for chronic pain misuse them, and between 8 and 12 percent develop an opioid use disorder. As prices for opioids climb, however, opioid-dependent people may turn to cheaper choices for pain management, such as heroin or fentanyl.

Highly addictive drugs such as opioids drive users into a cycle of addiction, where the clock is ticking between doses. Addicts will do almost anything to find and pay for the next dose before they become sick from withdrawal symptoms, Giuffre adds. When someone’s tolerance to opioids drives them to need $300 worth a day, he says, the person begins to turn to criminal methods to fund his or her addiction, including theft or fraud.

Security professionals should also be wary of the insider threat element of the opioid crisis. The workplace is a safe environment with trust between employees, and everyone knows when payday is and the approximate pay scale, making it an ideal place to sell drugs.

Giuffre cites a DEA operation in which an individual—a member of a Mexican cartel—was storing drugs in his locker at work. Security and law enforcement personnel confiscated a stash of pure fentanyl which, if employees had been exposed to it through the ventilation system, could have proven deadly to thousands of people.

Compromised individuals can be targeted by transnational crime groups that take advantage of their addiction to pressure inside information or assets out of them or coerce them to carry drugs with them on business travel or to the workplace.

“It’s easy for employees who are in positions of trust to be compromised because of dependency,” Giuffre says.

Health. First responders are also at risk from opioids; emergency healthcare professionals, fire fighters, law enforcement, and security personnel responding to or investigating a drug-related incident can be exposed to hazardous powders, tablets, or liquids.

Particularly where illicitly manufactured fentanyl is involved, security personnel could be exposed to the drug through accidental needlesticks, ingestion, skin contact, or inhalation, leading to potential health risks or even an accidental overdose, according to NIOSH.

For example, if first responders arrive on the scene to help an overdose victim, there might be large amounts of drugs or powder nearby that could be disturbed or aerosolized, endangering responders, Chosewood says.

He recommends that organizations and first responders develop policies around established work and safety practices when arriving at scenes where fentanyl might be present. Responders should not eat, drink, smoke, or use the bathroom while working in the area. They should not touch their eyes, mouth, or nose after touching any surface potentially contaminated with fentanyl and wash their hands thoroughly with soap and water immediately after a potential exposure.

Field testing for fentanyl is not recommended outside of critical incident response due to the risk for airborne exposure to responders, and responders should bring personal protective equipment when responding to a site that may contain fentanyl.

Working dogs are particularly at risk of exposure to fentanyl when processing scenes. Additional resources are available on the CDC website.

Drug Testing

Drug testing and background screening during onboarding is a critical piece of drug-free workplace programs, says Dennis Wichern, director of Prescription Drug Consulting, LLC, and a former DEA agent. Security professionals will need to work closely with HR to set up a drug testing program, although consequences will differ for each case and each industry.

Some healthcare organizations will either terminate an employee who is self-abusing drugs or transfer them to a less sensitive position, but either way, they offer treatment, Wichern says.

“Having that follow-up makes those organizations stand out so much better instead of just a termination,” he adds.

Ongoing screening and testing beyond the initial onboarding will address any changes in employees’ lives that may produce a stressor or dependency, Giuffre says. The key is consistently and clearly communicating the policy with employees.

“Everyone brings baggage to work, and the baggage we don’t want to bring to work is someone who is involved in trafficking, someone bringing illicit substances on campus, or people who may inadvertently or with intent tamper with products,” says Richard Widup, CPP, global corporate security director for RB (Reckitt Benckiser), a global manufacturer of home, hygiene, and health products.

Illicit substance use could involve meet-ups or deals in the parking lot, posing both a morale problem and a security risk, especially because drug deals can turn into workplace violence.

To address these risks, Widup starts with an effective onboarding process and ongoing screening for everyone, including outside contractors. Two years ago, RB enacted a mandatory, routine urinalysis program after an incident in the workplace. All employees are subject to unannounced drug testing without requiring probable cause.

Employees are encouraged to self-disclose to HR if they have been prescribed an opioid, and they might be temporarily reassigned to a less hazardous role while the risk of impairment is high. If the drug test comes back positive without a self-disclosed underlying reason, additional action may be taken on a case-by-case basis.

Every individual case is unique. There are a lot of factors to consider, including repeat offenses, but the underlying goal is to help the employee, Widup says.

There was some resistance from HR about the potential impact on morale before the program was implemented. However, the company was missing the opportunity to improve morale, he adds. The program sent a strong message that drug use at work was not tolerated, but that the company wanted to get employees education and help.

“We should be talking about substance abuse concerns and challenges as much as we talk about workplace violence,” Widup says. “It’s almost like we don’t want to talk about substance abuse problems until they happen. On any given day, there’s a fair percentage of people at every business, at every site, who have some kind of substance abuse problem that needs to be addressed, and we’re not encouraging that dialogue.”

Recovery-Friendly Workplaces

Workplace safety is the first step employers can take to mitigating opioid-related risks in their organizations. Many workers’ opioid use begins with workplace injuries, Chosewood says.

“Perhaps the most important step workplaces can take is to make sure that the work is safe so that people are not prone to get injured on the job and get prescribed an opioid,” he adds.

“I don’t want to leave the impression that opioid use disorder is a hopeless condition,” Chosewood says. “There are effective treatments available for opioid use disorder; there are sources for help, and I think that’s an important takeaway for employers, safety managers, and security leaders to know that there are ways that workplaces can become recovery-friendly.”

Apart from workplace safety, there are four steps to promoting a recovery-friendly workplace, Chosewood says: acknowledge that drug abuse and dependency is a problem, invest in a high-quality employee assistance program (EAP) and provide training on-site, have a naloxone rescue program in the workplace, and educate employees about effective treatment and recovery options.

Awareness. “Informed people make good decisions,” Giuffre says. “Just having people know more about the drugs and the effects of the drugs helps them be better parents, it helps them be better coworkers, it helps them be better friends, better neighbors, and better community members. But it also helps them be members of their organization and gives them the knowledge to know what to look for and understanding the importance of reporting those activities to managers and to coworkers.”

Openly talking about substance abuse and paths to wellness can have impacts far beyond the organization, Cooper says. Sometimes a worker isn’t taking opioids but is still affected. Employees’ family members or friends may be taking opioids, and the emotional toll of their care may spill over into the workplace or affect employee morale. Offering flexible time off or remote work options can help employees address these challenges without skipping work. (For more tools for employers to address drug use, see the sidebar Drugs at Work Toolkit.)

“This whole problem of opioid addiction is so multifaceted that any education campaign needs to also take into consideration the externalities of how this happens in the first place,” Widup says.

While there are many resources and training organizations available, few organizations are bringing them in for brown bag lunches or town hall sessions.

“That’s where it needs to start—understanding the complexity of substance abuse in general starts with an education about how it starts, how to prevent it in your own home, and measures of how to report issues or concerns,” he adds.

“If we make it easy for people to get information or spot those warning signs, it not only helps the employee stay out of harm’s way or be able to report someone who they believe is impaired, but it also may help them in their home life,” Widup says.

EAPs. Strong, funded, well-rounded employee assistance programs (EAPs) can go a long way in helping employees who may be dealing with drug dependencies or risk, Giuffre says. These programs can provide initial counselling and provisions for referrals to additional treatment.

Some of the heaviest drug abusers will seek out workplaces without EAPs or drug-free workplace programs, Giuffre adds. Often small and midsize businesses find these programs cost-prohibitive, but some EAPs cater to groups of smaller organizations to reduce costs without sacrificing coverage.

Naloxone. Naloxone, also known as NARCAN or EVZIO, is a drug that can temporarily restore breathing and reverse the heavy sedation common during an opioid overdose. Chosewood recommends that organizations consider implementing a naloxone rescue program, so each workplace would have at least two doses of naloxone nasal spray available to use during an overdose incident.

Chosewood notes that this program may not be right for every workplace; consult local laws and legal counsel before proceeding and conduct a risk assessment beforehand to ensure the program fits the organization’s needs. Additional guidance on naloxone programs is available on the NIOSH website.

Recovery. More than 10 percent of Americans live in recovery, Cooper says.

“We can get people to recovery, but it takes a little time,” she says. “Remember that they’re people first, and this is something that’s happening to them, not something they chose.”

Chosewood also emphasizes that an important element of a recovery-friendly workplace is “the value of understanding that treatment does exist, that people can be treated for opioid use disorder, they can get better, and they can return to meaningful employment.”

In addition, some organizations in industries heavily affected by the epidemic—such as construction—are providing peer-support networks to aid in education and recovery programs. Construction workers who recovered from an opioid use disorder can help other employees in similar situations, with the support of their employers.

“A lot of employers are worried about bringing people back to work who had an opioid use disorder,” Chosewood adds, “but the gold standard of treatment—medication-assisted treatment—is effective, and it can return workers back to work. People can get better.”


Opioids Worldwide

The opioid epidemic reaches far beyond the borders of the United States. According to the United Nations’ 2019 World Drug Report (WDR), 53 million people worldwide used opioids in 2017—corresponding to 1.1 percent of the global population. In comparison, 188 millionpeople used cannabis and 29 million used amphetamines and prescription stimulants in 2017. 

Opioid world mapThe WDR reports that the first, large-scale national drug use survey in Nigeria, conducted in 2017, found that out of 200 million people, just over 14 percent of Nigerians between 15 and 64 years old abused drugs—more than twice the global average percentage of 5.6 percent. The survey also found a high prevalence of nonmedical use of prescription opioids—second only to the use of cannabis. Nonmedical use of prescription opioids in Nigeria affects 6 percent of men and 3.3 percent of women.

Survey findings from India in 2018 revealed a higher pre­valence of opioid and opiate use in Asia than previously estimated. Estimates of last-year opioid users in Asia climbed from 13.6 million in 2016 to 29.5 million in 2017.

“In terms of numbers of users, 35 percent of the global opioid users and almost half of all opiate users worldwide reside in South Asia,” WDR reports.

Approximately 35 million of the total estimated 271 million past-year users of any drug are estimated to suffer from drug use disorders, “meaning that their drug use is harmful to the point where they may experience drug dependence and/or require treatment,” the WDR notes.

In 2017, the use of opioids accounted for 66 percent of the 167,000 deaths attributed to drug use disorders, according to the Institute for Health Metrics and Evaluations.

In Australia, opioid-related deaths jumped from 439 in 2006 to 1,119 in 2016, according to the Australian Institute of Health and Welfare. Most of those deaths were related to prescription opioids, instead of illegal ones like heroin. More than 3 million Australians get at least one opioid prescription a year.


Drugs at Work Toolkit

Drugs at Work ToolkitThe U.S. National Safety Council released a toolkit in September 2019 for employers responding to the opioid epidemic or other impairing drugs in the workplace.

“There is no right or wrong answer on this; every workplace has to figure this out for themselves,” says Rachael Cooper, senior program manager for substance use harm prevention at the National Safety Council. “Developing policies that really match your values as a company and keeping people safe is a pan-drug approach, so if methamphetamines are a bigger problem in your area than opioids, it’s still a substance abuse disorder and can fall under the same policies.”

The Opioids At Work Employer Toolkit prioritizes eight steps, but not all of them are feasible for all organizations, Cooper says. However, a blend of these steps can make a difference in supporting employees and improving workplace safety.

  1. Obtain senior leadership engagement and support.
  2. Educate or engage employees. This can encompass multiple factors, from brown bag lunches to providing “warn me of opioids” labels for insurance cards to improve employees’ awareness when taking prescription drugs.
  3. Train managers and supervisors about their roles, from recognizing signs and symptoms of impairment to using non-stigmatizing language.
  4. Ensure human resources has compassionate policies that are well-communicated to employees.
  5. Avoid a one-size-fits-all approach. Each organization and region has different drugs of concern—a Los Angeles program may not be appropriate for the needs of an organization in Minneapolis or a regional facility in rural Louisiana. Review workers’ compensation data or a pharmacy benefit manager’s breakdown of opioids prescribed to the workforce.
  6. Update health insurance plans and pharmacy benefit programs to address substance abuse disorder treatment and to cover opioid alternatives like acupuncture to reduce reliance on opioid painkillers to return to work.
  7. Invest in workplace safety and remove hazards from the workplace to avoid employee injuries that may result in an opioid prescription.
  8. Develop workplace culture of health and wellness that reduces stigma and supports recovery. This can include paid time off, the capacity to work from home, or other flexible work policies to ensure employees can schedule doctor’s appointments or be available to help friends or family in crisis.

Claire Meyer is managing editor at Security Management. Connect with her on LinkedIn or contact her at [email protected].