CLEVELAND, Ohio — The carpenter framing a new home on your street. The ironworker erecting that massive office building downtown. The roofer hauling and laying shingle after shingle to repair a historic church. The road-crew worker filling potholes on the highway.
Construction workers in Ohio were seven times more likely to die of an opioid overdose last year than were workers in other professions, according to a Plain Dealer analysis that included records from more than 12,000 opioid drug overdose deaths in the state from 2010 through 2016.
Read how we analyzed this data at the bottom of this story.
As an industry, construction had the most deaths. Some singular occupations did stand out, however. Tree trimmers had an opioid overdose fatality rate higher than all the rest, putting them at the top of the list.
Most Ohio opioid deaths are from heroin or fentanyl now. But it’s clear many started with a prescribed painkiller, one deceptively marketed as safe. That may be even more true for construction workers who have a high risk for on-the-job injuries and were often prescribed potent and long-acting opioids by state-supported workers’ compensation doctors, or who got the pills, prevalent on work sites, from a co-worker as a way to work through the pain.
Ohio isn’t the only place where the hard-hat-wearing working class is the hardest hit by the opioid crisis. Outside Boston, public health workers researching opioid-related deaths found that building and construction workers accounted for 42 percent of overdoses in a swath of suburbs. Like The Plain Dealer analysis, they used occupation information provided by family members and funeral homes on the death certificates.
There isn’t a single reason that men in these skilled jobs are losing battles with addiction and dying so often; there are many.
Pain and pills
Construction work is physical. Swinging a hammer over and over for hours. Hauling beams and bricks and coils of wire. Or kneeling all day to smooth cement or lay bricks.
Tough, repetitive work wears down even the strongest bodies over time, often causing chronic lower back, shoulder and knee pain.
Until about 20 years ago, doctors could do only so much to help. People with chronic pain generally got only weak prescriptions. Stronger drugs, opiates such as morphine, were notorious for causing addiction. Doctors offered them only to patients in excruciating pain, from acute trauma or terminal cancer.
But then drug makers introduced new opioids, such as OxyContin, and told doctors they had addiction rates as low as 1 percent. Everyone seemed to come out a winner. Pharmaceutical firms could profit from the far larger group of Americans suffering from chronic pain. Doctors could offer relief to patients. And the workers were grateful, because in most construction jobs, there’s no sick time. If you aren’t on the job, you don’t get paid.
Taking a pill to get through the day became routine for some, especially for those who had families to feed and mortgages to pay.
But, it turned out, addiction rates weren’t around 1 percent. They were higher, as much as 12 percent.
Generally, four out of five people who try heroin started out misusing a prescription painkiller, whether prescribed by a doctor or obtained from another source, according to the American Society of Addiction Medicine.
Deceptive marketing leads to overprescription
The physical toll of construction work can be seen in the number of on-the-job injury claims filed with the state Bureau of Workers Compensation (BWC) since 2010. Construction workers were about three times more likely than other workers to file.
And, in 2010, more than 80 percent of construction workers whose injuries were treated with medication were given narcotics, according to BWC data. Often got medications like Vicodin, Percocet and OxyContin, which are opiods or semi-synthetic opioids.
That was three years after several executives of Purdue Pharma, the pharmaceutical company that makes OxyContin, admitted in federal court that they misled doctors, regulators and patients about the potential for addiction and abuse.
A North Carolina construction worker, Johnny Sullivan, starred in one of the original videos Purdue Pharma produced, in 1998, to convince doctors to prescribe their drug for ailments like back pain.
“I got my life back,” Sullivan says, standing on a construction site.
A decade later, Sullivan was unemployed and addicted to OxyContin. In 2008, he nodded out at the wheel of his truck, which flipped into a ditch, killing him instantly, his wife, Mary Lou Sullivan told the Milwaukee Journal-Sentinel in 2012.
In 2011, BWC reviewed its records of injured Ohio workers and found that 8,000 of them had been prescribed potentially addictive amounts of opioids. In 2012, BWC stopped covering OxyContin as a “first choice” for workers to treat injury-related pain. It soon started to limit what doses of other opioids doctors could prescribe to injured workers, and required those prescriptions be reviewed by a doctor after 60 days.
Nick Trego, who now manages BWC’s clinical pharmacy operations, said that based on the bureau’s consultation with addiction specialists, those workers were prescribed doses equivalent to 12 5 mg tablets of Vicodin a day for more than 60 days. The highest recommended dose for that medication is eight 5 mg tablets a day, according to prescribing guidelines.
Workers with prescriptions at that level or higher were likely to be physically dependent on opioids and experience withdrawal if their medications were cut off, Trego said.
“We have paid for long-term opioids for injured workers for a long time because that was, unfortunately, the standard of care,” Trego said.
By the end of 2016, with those standards changing, the number of injured workers being “overprescribed” opioids dropped by about half to 4,100, according to BWC.
Still, even with that reduction, 73 percent of injured construction workers last year received a prescription for a narcotic painkiller. That is 13 percent of the prescriptions for all on-the-job injuries statewide.
We don’t know how many of those injured workers became addicted. Or how many later switched to using cheaper heroin, or its deadlier synthetic cousin, fentanyl. Or how many of those workers have overdosed and died.
One way to find out would be to compare the state’s lists of injured workers who were prescribed opioids, which is not a public record, to those who have died from overdoses of the medications and illicit drugs.
BWC has not done that, a spokeswoman said.
Trego acknowledged that some injured workers who were weaned or cut off from prescription opioids could have turned to illicit drugs.
Last October, BWC started to offer injured workers with open and active claims up to 18 months of addiction treatment if they had been prescribed opioids at a level that could cause dependence, and if the worker and their doctor agreed the treatment was necessary.
The treatment can include medical detoxification, as well as Medication Assisted Treatments (MATs) with relapse-prevention medicines such as methadone, buprenorphine or Vivitrol, in addition to in-patient or outpatient treatment.
However, fewer than 10 injured workers have received treatment through the new program. BWC says it is working to raise awareness about it among workers and treatment providers.
Adding injury to substance abuse
There are other reasons that construction workers may be unusually vulnerable to abuse of alcohol, drugs and opioids. Most are men, often young and white. Most went straight to work right after high school.
More than 275 Northeast Ohio roofers, carpenters, laborers, electricians, bricklayers and other construction workers died of a heroin or opioid overdose since 2010. All but one were men; 98 percent were white. Compared to other Ohioans, they were more than twice as likely to be divorced.
Some 15 percent of all construction workers nationally have a substance abuse disorder, compared to the general population of adults, where the national average is 8.6 percent, according to the most recent National Survey on Drug Use and Health.
The workplace culture is primed with bravado, social drinking and drug use, said Eric Goplerud, a researcher who studies public health and substance abuse at the nonpartisan research organization NORC, at the University of Chicago.
“I worked construction… and at lunch you’d go out for a drink and after work you’d go out for a beer and a shot,” Goplerud said. That was almost 40 years ago, he said, but the culture lingers.
Other industries, such as the restaurant, hotel and hospitality industries — where people are paid to be around alcohol — also have high risks of substance abuse, including opioids and cocaine.
But those workers “don’t get hurt in the same way,” Goplerud said.
Goplerud said he hasn’t seen evidence that draws a direct line from construction work injuries to opioid overdose deaths.
But add the well-established shift to heroin and fentanyl among people who become addicted to opioids and “that could be what’s driving the deaths,” Goplerud said.
“I don’t have any data on that. But anecdotally, I think that’s probably the case.”
A perpetual cycle
Daniel Macklin, of Cleveland, was one of about 500 construction workers who died of opioid overdoses statewide last year.
Macklin got his GED at 18 and went straight to work doing union labor on construction and road jobs, according to his fiancee and family members. Lots of his friends did likewise; union jobs paid well for semiskilled labor, $20 or more an hour.
Early on, Macklin injured his leg and was taken to a hospital. As is routine for on-the-job injuries, he was tested for drugs.
He “popped” positive for marijuana, which he smoked recreationally on weekends. To keep his union job, he had to complete treatment for marijuana use.
There, his family said, he met a girl who introduced him to harder drugs and eventually heroin.
Macklin spent the next 19 years fighting his addiction to heroin. He tried treatment eight times. When he couldn’t get into treatment, he’d sometimes use his own money to buy relapse-prevention medicines, such as Suboxone, which contains an opioid and naloxone together.
“I could taste his will to be sober,” said Amy Darkovich, who was Macklin’s fiancee when he died.
Only one of Macklin’s stints in treatment was involuntary; he went as a condition of probation after he stole pain pills from a roommate.
Darkovich met Macklin when he was part of construction crew working on a home she rented in Little Italy. The two started talking and, after chatting on Facebook, they decided to meet again.
Macklin was fit and funny. He was guided by a strong faith in God. The two both came from big families.
On their first date, he told her, “I’m a recovering addict.”
She told him she had serious medical problems.
“We shared our scary things and went from there,” she said.
Darkovich said that since Macklin could no longer work as a trade laborer, he worked for what she called “fly-by-night” construction companies, doing roofing or carpentry work.
“It’s the job you get when you are an addict,” she said. “You can start late, after getting a fix in the morning, and you get paid in cash daily.”
The work makes it hard to stay clean, she said. But Macklin managed to do it for stretches of time. Most of the other crew members used or were trying quit. Often someone on the crew paid for his own habit by dealing drugs to the others.
On the day Macklin died, he saw a doctor about the pain he felt from decades of physical labor. His body, especially his shoulders, ached from the repetitive motion of laying roof shingles.
The doctor recommended physical therapy, but wouldn’t prescribe a non-narcotic medicine, gabapentin, that Macklin told him he’d had found helpful and had bought on the streets. Used to treat nerve pain, there’s increasing concern the medication can be abused.
Macklin was working 12 hours a day and under a court order to attend treatment and Narcotics Anonymous meetings. Finding time for physical therapy seemed nearly impossible.
Darkovich didn’t suspect that Macklin had relapsed or was thinking of using. “He was having a really good day that day,” she said.
Later, though, as they chatted on their porch, he seemed distracted. He said he was going to take a “spirit walk” to clear his mind, something he learned in treatment.
Darkovich was on the phone with her mother when Macklin returned and went into their bathroom. She knocked on the door, then waited and knocked again. Sensing something was wrong, she broke down the door and found him collapsed on the floor with a needle in his arm.
One dose of Narcan can reverse a heroin overdose in some people. Macklin had four doses in a kit from Project Dawn. The paramedics had two more. All six failed to revive him. He’d shot up with fentanyl, strong and pure.
Macklin was 40 years old, the average age at which Ohio construction workers have died of opioid overdoses over the last seven years.
Getting out in front of the problem
The levels of opioid use and addiction among construction workers don’t shock those who work in the industry.
“It is a very physical job,” said Tim Linville, CEO of the Construction Employers Association, which works with more than 160 companies that employ trade workers on in Ohio. “And [workers] get wear and tear on their bodies over the years…It makes sense that the need for painkillers or to treat injuries is there.”
In recent years, unions, employers and the administrators of the health and welfare plans they jointly manage, started to notice that powerful painkillers were among with top five medications prescribed to members along with others such as Lipitor, used to reduce cholesterol.
The health plans started to adopt new policies that included warnings on opioid use for pain relief and limited which medications and dosages would be covered, according to Linville and Dave Wondolowski, executive secretary of the Cleveland Building and Construction Trades Council, which represents more than 10,000 workers in 31 unions in Northeast Ohio. They said workers on union jobs undergo stringent drug testing when in apprenticeships, then annually and randomly as they work on their job sites.
A quarter of the worker pool is randomly given urine screens each month for drugs that include oxycodone, hydrocodone, methadone and morphine, as well as marijuana, cocaine, amphetamines and benzodiazepines.
Wondolowski said those tests lower the risk of those who are misusing drugs being on union construction jobs.
Ohio’s overdose data doesn’t consistently indicate whether the construction workers who died were union trade laborers or nonunion construction workers before they died, though some who died had their trade union listed as their employer.
For those with substance abuse problems, Wondolowski said, the unions also offer treatment through employee assistance programs.
The programs can have an unintended consequence, some construction workers said. Once a person fails a drug test or asks for help with addiction, they are off the job. They can get treatment, but they won’t get paid for union construction work while they do.
“I think we do a good job,” Wondolowski said. “The key to this is education, and the continuance of discussion and dialog. We can’t not talk about this and expect things to change.”
Linville said construction and building trades industries were caught off guard by the mounting deaths, just like everyone else.
That opioid addiction often starts with painkillers has caused unions and employers to view and treat opioid use differently than recreational drugs, like marijuana or cocaine.
“Heroin might be a recreational drug, but it doesn’t usually start that way,” Linville said. “Often it starts as a prescription for a legitimate issues and you have to have compassion because of that.”
Stricter rules to limit addiction
Among the first to sound the alarm about growing addiction among injured workers was Gary Franklin, medical director for the Washington State Department of Labor and Industries.
The most excessive use, he said, was among workers with low back pain, knee pain or other musculoskeletal injuries.
Not long after long-acting opioids were introduced to treat those injuries, Franklin, a research professor at the University of Washington, noticed the first opioid overdose deaths for injured workers in his state. Workers prescribed opioids for back pain were also ending up on disability in high numbers.
By 2010, there was a clear association between the prescriptions and overdose deaths.
The state changed its prescribing guidelines, lowering the doses allowed and the length of the treatment with opioids. Overdose deaths among injured workers dropped substantially, Franklin said.
Ohio was among a few states to follow Washington’s lead to curtail opioid prescribing for injured workers, and more recently for the general public.
But overdose deaths have continued to climb in Ohio and nationally.
Franklin doesn’t believe reducing the number of opioid prescriptions or dosages resulted in more overdose deaths by those who might have sought illicit drugs.
Those deaths were steadily rising before the prescribing laws and regulations were put in place, which many attribute to the introduction of pure and potent heroin mixtures including fentanyl and carfentanil.
The deaths, Franklin said, have continued to rise in states with and without more stringent rules.
It doesn’t really matter whether injured workers were “cut off because insurers stopped covering it or [if] they started getting black tar heroin cheaper on the streets of Columbus,” he said. “You are still going to have the same large swath of people on opioids chronically.”
Lessons to learn
Two strategies are important moving forward, Franklin said.
Limit opioid prescriptions for people with sudden injuries or dental procedures, like tooth extractions.
Implement better therapies and treatment for chronic wear-and-tear job related injuries.
It takes only days or weeks for some patients to get addicted to strong opioid painkillers, the latest research from the CDC shows, with the likelihood of chronic use increasing after the third day and with higher doses and long-acting formulations.
“If someone is on opioids for more than three months, it’s almost too late,” Franklin said.
Opioid overdose deaths continue to rise for younger people under 30. Many of those people were prescribed opioids for so-called acute injuries, or trips to the dentist to get a tooth pulled, Franklin said.
Washington state changed its prescribing guidelines to address acute injuries, and in August, so did Ohio. Doctors and dentists now are only allowed to prescribe seven days of opioids for adults with short-term pain.
For the workers who construct our schools, bridges and roads, the long hours and wear and tear on muscles, joints, tendons ligaments won’t go away.
But the cheap and easy route of using opioids to treat those ailments must be curtailed, Franklin said.
Opioids don’t even work well to alleviate lower back or shoulder pain or knee pain for which construction workers and other physical laborers often have them prescribed, Franklin said.
Anti-inflammatory medications and non-opioid pain medications work far better, he said.
In July, the Ohio BWC took steps to discourage the use of spinal fusion surgery and opioid prescriptions for workers with lower back injuries, requiring that they first undergo at least 60 days of physical therapy, chiropractic care, rest, ice and anti-inflammatory medications before considering surgery.
Studies, including one done at Case Western Reserve University School of Medicine, showed surgery and opioid treatment led to chronic opioid dependence and long-term disability, BWC officials said.
In Washington, where Franklin works, and at the U.S. Department of Veterans Affairs, they are “betting the bank” on non-opioid options such as pain clinics and therapies that address not only the body but the mind and behaviors.
“That is the path forward,” Franklin said.
How we analyzed opioid drug overdose occupation data.
The Plain Dealer analyzed drug overdose deaths in Ohio between 2010 and 2016. The database provided to us by the Ohio Department of Health included more than 16,000 overdose victims’ occupations. The information included on death certificates is provided by coroners, medical examiners, family members and funeral homes. The occupation listed could be the person’s job at the time of death or the job they worked the job before becoming addicted.
We used Bureau of Labor Statistics categories to classify the occupations and to see how many people worked in those occupations. Comparing that with how many people died told us which workers were at the highest risk for opioid overdoses.
Not all of the jobs in our database could be classified. Many of the dead were described as homemakers, disabled or unemployed. In more than 1,500 cases, the death certificate said that the victim’s occupation was unknown.
Our estimates of death rates in each occupation are probably low, as they don’t include people whose jobs were not identified on their death certificate.
ORIGINAL ARTICLE: http://www.cleveland.com/metro/index.ssf/2017/11/ohio_construction_workers_seven_times_more_likely_to_die_of_an_opioid_overdose_in_2016.html#incart_river_home