— Pre-pandemic study finds that RNs and others faced elevated risks.
by Shannon Firth, Washington Correspondent, MedPage Today | August 7, 2023
Certain healthcare workers including registered nurses (RNs) were at increased risk for fatal drug overdoses, a longitudinal study from 2008 to 2019 found.
After adjustment for various factors, the risk for overdose death was more than twofold higher for RNs (HR 2.22, 95% CI 1.57-3.13) and social or behavioral health workers (HR 2.55, 95% CI 1.74-3.73) when compared with non-healthcare workers, reported Mark Olfson, MD, MPH, of Columbia University Irving Medical Center in New York City, and colleagues.
Increased risk was seen among healthcare support workers as well (HR 1.60, 95% CI 1.19-2.16), while physicians, health technicians, and other treating or diagnosing health workers had no higher risk, according to the findings in the Annals of Internal Medicineopens in a new tab or window.
“When people think about who’s at risk for drug overdose deaths, what comes to mind are often young, white, unemployed men,” Olfson told MedPage Today. “So the finding that there were several groups of healthcare workers that were at significantly higher risk than other workers, that was a surprise.”
Overall, approximately 0.07% of the 176,000 healthcare workers and 0.07% of the 1.66 million non-healthcare workers in the study died of a drug overdose during the more than 10 years of follow-up. Age- and sex-standardized total overdose deaths rates per 100,000 ranged from 2.3 for physicians to 11.0 for nurses to 15.5 for social or behavioral health workers, as compared with 7.3 for the non-healthcare worker group.
Results were “generally similar” when broken down by either opioid-related overdose deaths or unintentional overdose deaths, according to the researchers.
Broadly speaking, healthcare workers are not seen as having a higher risk for drug overdose because of their “low-risk sociodemographic profile,” according to the researchers, with Olfson adding that the field is disproportionately female and includes people with higher education and higher incomes.
The researchers suggested that several factors could place healthcare workers at increased risk for drug overdose death including:
- Relatively easy access to opioids and other controlled prescription drugs
- Job stress and job-related burnout, which have been tied to increased risk for opioid use disorder and/or risk for overdose
- Routinely doing physically strenuous tasks that can lead to musculoskeletal injuries and use of opioids to manage pain
Olfson stressed that these factors were “somewhat speculative.”
Previous researchopens in a new tab or window has indicated higher rates of prescription drug misuse among RNs, so data on higher risk of overdose deaths among that group was not surprising, according to Olfson. In addition, studiesopens in a new tab or window have found that RNs working in positions with “higher levels of psychological or physical strain” are more likely than their peers with lower levels of strain to report nonmedical drug use.
But Olfson said he had not expected that healthcare support workers would have nearly twice the risk of an opioid-involved overdose death (adjusted HR 1.84, 95% CI 1.22-2.54).
He noted that there are more than 6 million healthcare support workers, such as nursing home workers and home health aides. The positions are low-paid, repetitive, and offer little opportunity for advancement, he said, adding that these workers are disproportionately middle-age women of color compared with other workers in healthcare.
Support workers who frequently lift and move patients, have “among the very highest rates of occupational injury … higher than even construction workers. So there may be a hidden risk in that,” Olfson said.
As for the higher rates of drug overdose deaths among social or behavioral health workers, that is “unlikely to be explained by occupational access to controlled substances or physical strain,” Olfson’s group wrote. However, there may be subgroups of individuals — substance use disorder (SUD) counselors, for example — who have a personal history of substance use problems that may place them at higher risk of overdose, Olfson noted.
Given the attention to higher rates of suicide among physicians and that some overdoses are intentional, Olfson said he expected overdose deaths in that group would be higher. But a 2020 meta-analysisopens in a new tab or window found that suicide death rates were lower among male physicians than men in general, and males still dominate the profession, Olfson’s group stated.
Study Details
Olfson and colleagues used the Mortality Disparities in American Communitiesopens in a new tab or window sample, which links data from the 2008 American Community Surveyopens in a new tab or window (ACS) to cause-of-death certificate records from the National Death Index from 2008 to 2019. The 2008 ACS data was administered to 2.9 million addressees and had a 97.9% response rate.
“We took essentially 1% of American adults who are employed and just followed them forward to see who dies of what,” Olfson explained.
In terms of demographics, a majority of the RNs, social or behavioral health workers, and healthcare support workers were white, female, married, and living in urban settings. RNs were on the younger side (ages 26-35) while the other two groups were older (ages 46-55).
The primary outcome measure was total drug overdose deaths — those coded with an underlying cause-of-death code for unintentional, intentional, or undetermined-intent drug poisoning in combination with other cause-of-death poisoning codes related to opioids, cocaine, and other drugs.
Study limitations included the fact that it did not capture the “recent shifts in the opioid landscape,” that occupational status was assessed only once, and the risk for “misclassification” within the death certificate due to stigma and “social pressure” from family members not to classify a death as an overdose.
Expanded Resources
In terms of addressing this issue, Olfson urged employers to educate their staff about the addiction potential of opioids and other medications, as well as to train supervisors to look for warning signs of substance use problems.
He stressed the importance of healthcare workers with SUDs receiving confidential evidence-based treatment, given the stigma around the problem.
While a few specialized programs tailored to physicians with SUDs have been developed, Olfson said he could not find comparable programs for other healthcare workers.
He pointed out that physicians account for roughly 5% of the healthcare workforce. Based on the current analysis, this group is at a lower risk for overdose death than other non-healthcare workers, he added.
“It’s not that they [physicians] don’t deserve access to quality care — everyone does,” Olfson said. But “in terms of targeting scarce resources, there are higher-risk populations to focus on,” he stated.
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Shannon Firth has been reporting on health policy as MedPage Today’s Washington correspondent since 2014. She is also a member of the site’s Enterprise & Investigative Reporting team.