Opioids and the Workplace Prevention and Response Awareness Training: Mixed Methods Follow-Up Evaluation

Abstract

The National Institute of Environmental Health Sciences Worker Training Program piloted an Opioids and the Workplace: Prevention and Response training tool and program in 2019. The pilot trainees (N = 97) were surveyed (n = 27) and interviewed (n = 6) six months posttraining, and those who downloaded the training tool from the Worker Training Program website (n = 87) were surveyed (n = 19) and interviewed (n = 1) two to six months postdownload, to evaluate the impact of the training program. Workplace policy and program-level actions were reported less frequently than individual-level actions by trainees, except for planning and conducting training and education. Barriers to taking actions included not being able to make changes on their own without supervisor support and lack of upper management support and approval. We found some evidence that the Opioids in the Workplace training program and materials contributed to helping workers introduce policies and programs related to opioids within their workplace or union.

Keywords

workplace training opioid prevention opioid response occupational health program evaluation

Introduction

Opioids are a class of drugs medically prescribed for pain relief, but opioid use can also lead to addiction, overdose, and death.¹ The opioid epidemic is a multidimensional public health problem.² The evidence concerning risk factors for and prevention and treatment of opioid use disorder (OUD) and overdose is continuously evolving.³ There are possible connections between working conditions and workplace policies and the opioid epidemic through multiple pathways.⁴ First, workers with chronic pain due to work-related injuries or illnesses, such as acute traumatic injuries or musculoskeletal disorders, seek pain medication, a pathway to opioid addiction and disorder.⁵ Second, international trade agreements have led to a loss of well-paying, often unionized manufacturing jobs, which has contributed to economically depressed communities, with higher rates of opioid mortality.^6,7 Third, work stressors can increase the risk of musculoskeletal disorders,⁸ possibly increase the risk of acute traumatic injuries,⁹ and increase psychological disorders, such as depression and anxiety.^10,11 Mood disorders can increase the risk of higher dose and longer term opioid treatment and OUD.^12,13 Lastly, punitive or “one-strike and you’re out” workplace substance use policies may contribute to stigma toward those in treatment and recovery and create barriers to prevention and treatment.¹⁴

Rates of OUD and death are significantly higher in high injury risk industries, such as construction and commercial fishing.⁵ Job insecurity and lack of paid sick leave (job stressors) were risk factors for opioid overdose deaths in Massachusetts,⁵ and job strain (high-demand, low-control work) was a risk factor for OUD in a national survey.¹⁵ Prevention strategies include the prevention of workplace injury, illness, and stressors, worker education and training, and changing punitive workplace substance use programs to supportive programs.¹⁶

The National Institute of Environmental Health Sciences Worker Training Program (WTP) has historically funded and supervised worker occupational safety and health training and education on a variety of topics, including disaster preparedness and response, and therefore was well positioned to take action on addressing the opioid epidemic and its relationship to work.¹⁷ In 2018, the WTP began discussions with stakeholders about the development of materials and training programs to raise awareness about workplace risk factors for opioid use, misuse and addiction, and workplace-based prevention strategies.¹⁸ This led, in the summer of 2019, to four pilot one-day awareness training programs titled “Opioids and the Workplace: Prevention and Response” (OWPR).¹⁹ In addition, in October 2019, the WTP posted materials from the training program for free download on its website, to those who provided their email address.²⁰

The current study was designed to evaluate outcomes of the WTP OWPR training tool and program at six-month follow-up. The evaluation uses the Kirkpatrick Four-Level Model,²¹ starting with individuals’ reactions to the training, such as satisfaction with the training (Level 1), then, learning during the training, such as improvements in knowledge, attitudes, and actions immediately following the training (Level 2), next, actions following the training, such as engaging in safer work practices, exercising employee rights, and participating in activities that create a safer and heathier work environment (Level 3), and finally longer term results in meeting intended outcomes, such as improvement in organizational capacity to prevent worker opioid use, reductions in occupational injuries and illnesses, and establishment of opioid prevention and treatment programs (Level 4).

The OWPR training tool development was guided by the WTP logic model, which describes increasing workers’ knowledge of workplace hazards and empowering them to advocate for and to take actions to improve workplace health and safety. Training occurs within a supportive framework, in which the National Institute of Environmental Health Sciences administers funding for training and evaluation. The funding creates a community of grantee organizations who train workers and trainers across sectors and organizations and develops resources and training tools on selected health and safety topics. The program builds national capacity for workplace health and safety and provides a platform for updated policies and recommendations that support a healthy worksite.²² The WTP model builds upon empowerment approaches to health and safety training (workplace change through worker action),^23,24 the social ecological model (empowerment at individual, workplace, community, and policy levels),²⁵ and the recognition that, in unionized workplaces, collective bargaining and labor-management committees, combined with worker empowerment training, are important mechanisms for improving workplace health and safety.²⁶

We therefore hypothesize that the OWPR training program is effective in helping workers to introduce or to advocate for policies and programs within their workplace or union on opioid prevention and response (H1).¹⁹ Factors that might facilitate trainees’ ability to change policies or programs in their workplaces include their status or role in the agency/company or union.¹⁹ About half of the summer 2019 pilot program participants were occupational safety and health trainers (n = 37); thus, we anticipated that one important area of workplace change would be more training and education programs on opioids and work. However, the summer 2019 trainings included those with and without workplace leadership positions. Those not in leadership may face greater obstacles in their ability to bring about or observe workplace change. Thus, we may not have been able to assess all organizational changes that resulted from this training. Instead, we assessed both individual behavior and workplace changes and hypothesized that individual behavior changes, such as actions that can be taken without support and approval from upper management, would be a more likely outcome of the summer 2019 training program (H2).

Finally, those who downloaded the training materials from the WTP website were surveyed at two to six months and therefore often had less than six months to take actions. In addition, reading materials may be less effective in changing knowledge, attitudes, and actions than in-person participation in a training program in which participants learn from each other, as well as from the trainer.²⁷ Therefore, we hypothesized that persons who downloaded materials would have taken fewer individual or workplace actions to address opioids and the workplace than training program participants (H3).

Methods

The OWPR training was piloted in four locations in the summer of 2019 across the United States: Hanford, Washington at the Department of Energy HAMMER Training Facility on July 23; Lowell, Massachusetts by the New England Consortium for Health and Safety Training at the University of Massachusetts Lowell on July 30; New York, New York at the New York District Council of Carpenters Training Center on August 6; and Huntington, West Virginia at the local union for United Steel Workers on August 12.

These training programs enrolled ninety-seven participants, that is, twenty-two at Hanford, thirty-three at Lowell, twenty-four at New York, and eighteen at Huntington. The trainees came from different cities or regions throughout the country and do not only reflect or represent the geographical area in which the training was held. At the end of each training, participants completed a nineteen-item posttest on knowledge and attitudes toward opioids and work, as well as an evaluation form where they assessed the process of the course, consisting of a nine-item quantitative Likert scale of agreement on training effectiveness and four open-ended responses on training content, suggestions for improvement, and actions planned to take as a result of the course. Analysis of those data showed that the pilot training program was delivered in a manner that increased awareness and knowledge of opioids in the workplace. The training program, training methods, and target audience are described in an October 2019 report.¹⁹

However, briefly, the objectives of the six-hour in-person participatory trainings were to raise awareness about “the scope and severity of the opioid crisis,” “the relationship between work place injuries and illnesses, working conditions, and opioid use disorder,” “occupational exposure, prevention, and response,” and “actions that might be taken at the work place to prevent and respond to opioid use and misuse.” The instructor used PowerPoint slides, five small group and large group activities, and participant discussion to deliver the OWPR training. Slides included suggestions to avoid stigmatizing language and how words such as “abuse, user, or addict” tend to promote the idea of “opioid use disorder” as being due to a lack of willpower and may be used to justify punitive policies. In addition, the slides suggested the term “misuse” as a way to avoid stigmatizing language.

The training module consisted of eleven sections including “background on the epidemic,” “fentanyl and synthetic opioids,” “understanding opioid use disorder,” “stigma,” “prescription opioids,” “related infectious diseases,” “occupational exposure,” “opioids and work,” “prevention: identifying program gaps and risk factors,” “employee assistance and peer assistance programs,” and “workplace substance use prevention programs.” The target audience for the trainings were rank-and-file workers and occupational safety and health instructors. The WTP intended that the piloted training tool and supporting materials, such as fact sheets, be used by those who receive grants to conduct workplace training from the WTP and the occupational health and safety community at large. The training was designed with the intention it may be adapted and used across various occupations and industries.

Participants completed a follow-up action planning exercise at the end of the training. Included on the activity sheet were examples of individual- and workplace-level actions, which were described by the instructor. While the program was awareness-based, participants were asked to identify actions they could take over the following three to six months to help prevent injury or illness, or improve workplace substance use treatment and recovery programs. Trainees were asked to list their ideas for action, key people to consult or involve, potential barriers and resources, and a timeline.

At each pilot training in the summer of 2019, emails were collected from the trainees by the site organizers during registration. Those collected emails were provided to the study researchers by the site organizers. Six months following each individual training date, a follow-up survey was sent to each available participant’s email (n = 85) with a link to a consent form and a survey made available on Qualtrics software. Each trainee was contacted three times, posttraining; the first on six months posttraining, the second a week later, and the third a week after that as reminders to complete the six-month follow-up survey. Participants provided informed consent prior to engaging in the survey. The Qualtrics surveys were confidential and voluntary, as it did not collect personal identifying information and the links were sent to the participants’ emails. If an email address was invalid or ineligible to read from the photocopied registration lists, the study researchers contacted the site organizer. If possible, the site organizer was able to provide the corrected email address. Eighty-five participant emails were provided by the site organizers from the pilot training’s ninety-seven trainees. Two of the emails were “not deliverable” and thus those persons were lost to follow-up.

The training tool and supporting materials were made publicly available online in September 2019 for download. Those who downloaded the online training tool materials were asked to provide their email address for a voluntary follow-up. The “downloader” email list was collected by the National Clearinghouse for Worker Safety and Health and provided to the study researchers. The downloader list contained emails from those who downloaded materials between October 18, 2019 and February 19, 2020.

The surveys for trainees and downloaders took approximately ten minutes to complete and were identical, other than the question pertaining to location of training as there are four different pilot locations from the summer 2019 OWPR training. The first email was sent to downloaders the week after pilot training participants had received at least their first email asking for participation on February 24, 2020. Downloaders received an email reminder with a survey link each week for three subsequent weeks.

The instrument used to collect trainee and downloader responses was available online through the Qualtrics platform. Questions included: (1) where the participant attended the training in person or if they downloaded the training tools online; (2) their main role or job title in the company or union; individual- and workplace-level actions taken; (3) if the training tool was used in their workplace for a training program; if yes, how many people participated; (4) how long was the training, and which activities from the training tool were included in workplace opioid training program; (5) any obstacles that prevented them or their coworkers from being involved in or conducting such activities; and (6) what further actions they plan to take. “Individual actions” are defined as personal actions or behaviors a trainee may take following the OWPR training to address opioids and the workplace, such as reaching out to coworkers to see how they are doing. “Work place-level actions” are systemic organizational issues a trainee may attempt to address following the OWPR training, such as planning and conducting training and education or reforming punitive drug programs.

At the end of the survey, the respondent was asked if they would voluntarily participate in a ten-minute phone interview at a time convenient for them. These interview participants were asked questions to provide more detailed information on individual- or workplace-level actions taken since the summer 2019 pilot trainings and if they have any flyers, reports, or other documents from their workplace about training programs or changes in policies and programs related to opioids, substance use, or injury prevention that they can share. The phone interview was not linked to a respondent’s survey responses. A trained graduate assistant collected the interviews using a digital recorder. The responses were transcribed by the trained graduate assistant. No identifying information was collected during the interviews other than the training location the participant attended or the broad industry and occupation category of the person who downloaded the training tool.

During the follow-up data collection time period, a national emergency due to COVID-19 emerged; we anticipated that the study target population may have become more difficult to reach, given their likely roles in the response to COVID-19. Therefore, the survey was closed on April 1, 2020 with agreement from the training site organizers.

Data Analysis

A mixed method convergent design, described by Creswell,²⁸ was used to analyze the data collected quantitatively and qualitatively. Quantitative data collected from the closed-ended survey items were tabulated for frequency and percentage of responses. Chi-square tests were used to compare groups that we hypothesized would differ in their responses to the closed-ended survey items: trainers/leadership versus others, individual versus workplace actions, and trainees versus material downloaders.

Qualitative data collected were analyzed by grouping responses to open-ended survey items and interviews by topic and specific questions. Grouped responses were reviewed for similar answers that can be identified as common themes in the topics of individual-level actions, workplace-level actions, obstacles, and future plans.

The qualitative and quantitative data were integrated and analyzed together in a joint table for comparison of the common themes and the responses observed in the surveys and interviews.

All quantitative analyses were performed using IBM SPSS Statistics version 26.

The study was reviewed by the State University of New York-Downstate Health Sciences University Institutional Review Board and was granted an exemption (study number 1510282–1).

Results

Of the eighty-three pilot training participants with valid emails, twenty-seven (32.5%) responded and completed the survey. Six of those twenty-seven respondents volunteered for the interview (22.2% of survey respondents, or 7.2% of those with valid emails) (Figure 1).

Figure 1.

Flowchart of training participants in opioids and the work place summer 2019 pilot programs by location and completion of the six-month follow-up survey and phone interview.

A total of eighty-seven emails were sent with the survey link to downloaders and nineteen (21.8%) of those completed surveys. Twenty-four of the twenty-seven trainee survey respondents reported coming from New York (n = 11, 40.7%), Lowell (n = 8, 29.6%), Hanford (n = 4, 14.8%), and Huntington (n = 1, 3.7%).

Most trainees responding to the follow-up survey were from unions or nonprofit organizations. A participant was able to select more than one response for main role or job title. Most downloaders had roles or job titles in companies and nonprofits. Thirty-four responses from trainees mentioned either unions or nonprofit organizations in addition to ten responses for companies or universities. Thirty responses from downloaders mentioned either companies or nonprofit organizations as compared to eight responses for unions or universities (see Table 1).

Table 1.

My Main Role or Job Title in the Company or Union Among Trainees and Downloaders of the Opioids and the Workplace Training (Answer All That May Apply).

Trainees (n = 27)		Downloaders (n = 19)
	N		N
Company		Company	3
Trainer	3	Health and Safety Professional	9
Manager	2	Manager	3
Employee Assistance Program (EAP)	1	Trainer	3
Union		Health and Safety Committee Member	3
Trainer	7	Employee	1
Member	7	Union
Other	4	Trainer	1
Health and Safety Professional	2	Health and Safety Professional	1
Member Assistance Program (MAP)	2	Member	1
Elected official union leadership	0	Other	1
University based		University based
Trainer	2	Researcher	2
Researcher	1	Trainer	1
Other	1	Other	1
Nonprofit organization		Nonprofit organization
Trainer	5	Health and Safety Professional	4
Health and Safety Professional	3	Program Manager	3
Program Manager	2	Trainer	3
Other	2	Community Health Worker	1

About half of the trainees responding to the follow-up survey were professional trainers, similar to the 48.5 percent (37/97) of all pilot program trainees who were professional trainers. All twenty trainees from Hanford were trainers, as well as ten from Lowell, and seventeen from New York. One-third of the class in Huntington, or six trainees, were believed to be professional trainers, although the exact number is unknown.

Actions Taken by Trainees

About three-fifths (n = 17) of follow-up survey respondents from the summer 2019 training reported sharing fact sheets and information from the training with coworkers and sharing information about opioids and the workplace in their community (n = 16) (see Table 2). One-third (n = 9) reported participating in organizational programs geared to improve safety and health or avoid opioid misuse, taking a stand against stigma in the workplace, or reaching out to coworkers to see how they were doing (n = 8). The OWPR training program is based on a primary prevention approach (preventing occupational injury and illness), and therefore, organizational programs that focus on improving safety and health do not necessarily need to directly address opioid misuse. Only two of the twenty-seven respondents stated that they had not taken any of the listed actions since the training. Trainee responses to open-ended questions about workplace-level actions mainly focused on providing education and training programs to others.

Table 2.

Trainees’ Individual-Level Actions: “I Have Taken the Following Actions Since Participating in the Opioids and the Workplace Training in 2019” (Answer All That Apply) (n = 27).

Individual-level action	N	%
Shared fact sheets and information from the opioid training with coworkers	17	63.0
Shared information about opioids and the workplace in my community	16	59.3
Participated in organizational programs geared to improve safety and health or avoid opioid misuse	9	33.3
Took a stand against stigma in the workplace	9	33.3
Reached out to coworkers to see how they are doing	8	29.6
Refocused on self-care: exercise or movement, sleep, healthy eating, social interaction, and relaxation	5	18.5
Increased reporting of job hazards	2	7.4
Other	2	7.4
I have not been involved in any of the actions since the training	2	7.4
Recognized/addressed my own risky behaviors	1	3.7

Actions Taken by Downloaders of Materials

Among downloaders, more than one-third of respondents reported sharing fact sheets and information from the opioid training with coworkers (n = 10), participating in organizational programs geared to improve safety and health or avoid opioid misuse (n = 8), and sharing information about opioids and the workplace in their community (n = 7) (see Table 3). The proportion of downloaders participating in individual actions (Table 3) was, as expected, somewhat smaller than the proportion of trainees reporting participating in individual actions (Table 2).

Table 3.

Downloaders’ Individual Actions: “I Have Taken Since Downloading the Training Materials of the Opioids and the Workplace Training (Answer All That Apply)” (n = 19).

Individual-level action	N	%
Shared fact sheets and information from the opioid training with coworkers	10	52.6
Participated in organizational programs geared to improve safety and health or avoid opioid misuse	8	42.1
Shared information about opioids and the workplace in my community	7	36.8
Reached out to coworkers to see how they are doing	5	26.3
Refocused on self-care: exercise or movement, sleep, healthy eating, social interaction, and relaxation	5	26.3
Increased reporting of job hazards	4	21.1
I have not been involved in any of the actions since the training	3	15.8
Other	2	10.5
Took a stand against stigma in the workplace	1	5.3
Recognized/addressed my own risky behaviors	1	5.3

As expected, workplace-level actions by trainees (Table 4) were reported less frequently than individual actions by trainees (Table 2), with the exception of planning and conducting training and education. Seven of the twenty-seven respondents reported not having been involved in any of the listed workplace-level actions. This factor may be due to the relatively short time period since the training (six months) or the fact that there were not a large number of workplace leaders enrolled in the summer 2019 training programs.

Table 4.

Trainees’ Workplace-Level Actions: “I Have Been Involved in the Following Actions at Work Since Participating in the Opioids and the Workplace Training in 2019 (Answer All That Apply)” (n = 27).

Workplace-level action	N	%
Planned and conducted training and education	17	63.0
I have not been involved in any of the actions since the training	7	25.9
Evaluated use of employee assistance programs	6	22.2
Improvements to the Safety and Health Program/Committee	5	18.5
Started a Naloxone program at the workplace	4	14.8
Conducted worker interview/surveys to identify high-risk jobs	3	11.1
Started a member assistance or peer advocacy program	3	11.1
Reviewed/amended punitive workplace substance use programs	3	11.1
Conducted ergonomic evaluations of high-risk jobs	1	3.7
Other	1	3.7
Evaluated OSHA Logs/workers compensation data to identify high-risk jobs, or to examine injury trends	0	0
Negotiated improved collective bargaining language on opioids in the workplace	0	0

Note. OSHA = Occupational Safety and Health Administration.

Workplace-level actions by downloaders (Table 5) were reported less frequently than individual actions (Table 3), as expected. However, contrary to expectations, the proportion of downloaders participating in workplace-level actions (Table 5) was similar to the proportion of trainees participating in workplace-level actions (Table 4). The most common action was to plan and conduct training and education, which was reported by about half of the respondents (n = 10) (see Table 5). The proportion of downloaders reporting planning and conducting training and education was a somewhat smaller proportion than that of 2019 trainees.

Table 5.

Downloaders’ Workplace-Level Actions: “I Have Been Involved in the Following Actions at Work Since Downloading the Opioids and the Workplace Training Materials (Answer All That Apply)” (n = 19).

Workplace-level action	N	%
Planned and conducted training and education	10	52.6
I have not been involved in any of the actions since the training	6	31.6
Conducted ergonomic evaluations of high-risk jobs	5	26.3
Improvements to the Safety and Health Program/Committee	4	21.1
Started a Naloxone program at the workplace	3	15.8
Conducted worker interview/surveys to identify high-risk jobs	2	10.5
Evaluated use of employee assistance programs	2	10.5
Reviewed/amended punitive workplace substance use programs	2	10.5
Other	2	10.5
Evaluated OSHA Logs/workers compensation data to identify high-risk jobs, or to examine injury trends	1	5.3
Started a member assistance or peer advocacy program	0	0
Negotiated improved collective bargaining language on opioids in the workplace	0	0

Note. OSHA = Occupational Safety and Health Administration.

Trainee responses to open-ended questions on individual actions taken by trainees focused mainly on sharing information and education to raise awareness. Trainee responses to open-ended questions about workplace-level actions mainly focused on providing education and training programs to others. Downloader responses to open-ended questions on individual actions taken included conducting and developing training and sharing information with others. Downloaders responses to open-ended questions about workplace-level actions mainly focused on providing education and training programs to others.

Actions Taken by Trainee Role

There were no statistically significant differences in reported individual- or workplace-level actions by trainer role or leadership role among trainees (Table 6). However, one of those “nonsignificant” differences was relatively large (>15%). Trainers (12/16) were more likely to report planning and conducting training and education than nontrainers (5/11).

Table 6.

Opioids and the Workplace Trainees’ Individual- or Workplace-Level Actions by Role.

Individual- or workplace-level action	Trainers (n = 16)n (%)	Not trainers (n = 11) n (%)	χ² (p)
Shared fact sheets and information from the opioid training with coworkers	11 (68.8)	6 (54.5)	0.564 (0.45)
Shared information about opioids and the workplace in my community	10 (62.5)	6 (54.5)	0.171 (0.68)
Planned and conducted training and education	12 (75.0)	5 (45.5)	2.440 (0.12)
	Leadership role (n = 4) n (%)	No leadership role (n = 23) n (%)
Shared fact sheets and information from the opioid training with coworkers	3 (75.0)	14 (60.9)	0.292 (0.59)
Shared information about opioids and the workplace in my community	2 (50.0)	14 (60.9)	0.167 (0.68)
Planned and conducted training and education	3 (75.0)	14 (60.9)	0.292 (0.59)

Note. Limited to responses large enough to make subgroup comparisons (n = 27).

Actions Taken by Downloader Role

There was only one statistically significant difference in individual or workplace actions by the role of downloaders (Table 7). Those in a leadership role were more likely (4/4) than those not in leadership roles (6/15) to share fact sheets and information from the opioid training with coworkers. However, even though differences were not statistically significant, a relatively larger proportion (>15%) of trainers reported actions than nontrainers. A similar relatively larger proportion (>15%) of workplace leaders reported sharing information about opioids and the workplace in their community than those who were not workplace leaders.

Table 7.

Opioids and the Workplace Downloaders Individual- or Workplace-Level Actions by Role.

Individual- or workplace-level action	Trainers (n = 4) n (%)	Not trainers (n = 15) n (%)	χ² (p)
Shared fact sheets and information from the opioid training with coworkers	3 (75.0)	7 (46.7)	1.017 (0.31)
Shared information about opioids and the workplace in my community	3 (75.0)	4 (26.7)	3.170 (0.08)
Planned and conducted training and education	3 (75.0)	7 (46.7)	1.017 (0.31)
	Leadership role (n = 4) n (%)	No leadership role (n = 15) n (%)
Shared fact sheets and information from the opioid training with coworkers	4 (100)	6 (40.0)	4.560 (0.03)
Shared information about opioids and the workplace in my community	3 (75.0)	4 (26.7)	3.170 (0.08)
Planned and conducted training and education	2 (50.0)	8 (53.3)	0.014 (0.91)

Note. Limited to responses large enough to make subgroup comparisons. Statistically significant results are in bold (n = 19).

Among both trainees (40.7%, n = 11) and downloaders (42.1%, n = 8), nearly half who answered the question reported using the training tool in its full or modified format while the remainder did not. Pilot program trainees reported that they had trained at least five hundred people, and downloaders of materials reported that they had trained at least seven hundred people. The training conducted by pilot program trainees ranged from one to seven hours and was most frequently one hour in duration. The trainings conducted by downloaders did not exceed two hours. Among participants who reported using the training tool in its full or modified format, most trainees (n = 8, 72.7%) and downloaders (n = 7, 87.5%) reported using the training activity titled “prevention of injuries, illnesses, stressors that can lead to pain treatment and substance use.” Some trainees (n = 4, 36.4%) and downloaders (n = 6, 75.0%) also reported using the training action planning activity.

Few obstacles to taking individual- or workplace-level actions were reported by downloaders. The most common obstacle reported by trainees preventing them from conducting activities was time-related, reported by three trainees, see examples below:

Time, mostly. Also, the fact that we do focus on opioids and work, but in terms of others’ work places, not our own. It’s not a job with high risk of injury, though that isn’t a reason not to have some form of training. And it’s a small work place.

Five trainees and three downloaders reported conducting training as an action they plan to take in the future. Several others plan on: “presenting information to others”

“Would like to discuss with the union and local communities to possibly offer monthly or quarterly classes to help with the opioid epidemic that surrounds family, friends, and future generations”;

“Conduct more training”;

“Increase awareness and continue training.”

Interview Results

Six trainees from the summer 2019 pilot programs and one downloader of materials agreed to be interviewed. The interviews lasted on average twelve minutes (range = 8 to 19 minutes). Four interviewees were from the New York training site, and one each was from Hanford and from Lowell. Responses are grouped by theme. Overall, participants found the training useful and well presented, but they noted that the barriers to implementation were challenging, particularly as they intersected with stigmatization around addiction and drug use that made conversations on these topics difficult. Because of the need to broach difficult subject matter, participants noted that implementation was a slow and painstaking process.

The majority of trainees had favorable opinions of the training and found it to be “realistic” and “comprehensive.” One participant also noted that they found the training to be personally beneficial for themselves and their family.

“It was really good, it was realistic. Other ones I have attended talked about things that aren’t really realistic. I think the presentation was comprehensive.”

“I think it helped personally, with my own family. I think it needed to impact the entire work place.”

However, many participants described the difficulty having such conversations in the workplace:

I liked it, I definitely liked it, but we might be dealing with supervisors who have no idea, know nothing about this, other than this is a drug affecting my employee. They don’t understand anything. I would call them, for a lack of a better term, ‘opioid ignorant’.

When you start having conversations in the work place, you can see you’re getting different opinions from different people. It’s one of those things, we are still trying to wrap our head around. This isn’t going to be a boom, let’s get it out there and go. It’s going to be a learning curve for all of us. Sometimes you don’t want to go places, because you know how touchy it is.

Stigma was identified on both the labor and management sides, including denial of the problem of drug use in the organization. Stigma also seemed to play a role in the uptake of programs among workers, who might feel their jobs are at risk for participating.

The stigma, the stigma is a very big obstacle. On both sides, the labor and management. We have management saying hey, look we don’t have people with drugs on our job sites. Then, the union is saying they don’t have members (with drug problems) on the job site. It’s a double-edged sword. I know they are both wrong, but it’s hard to tell people that people are using illegal drugs on their job site.

It’s more than writing down things on a piece of paper. We’ve been on the phone every week on how we can bring this in. What they are asking us to do can’t be done here. You might as well waste an hour of everyone’s life, because no one is going to say a word. I’ll talk for an hour, and no one will say anything. It will not be discussed, you don’t know who is in the room with you, a manager or security guard. You aren’t going to open your mouth and say anything. I think we are on the right path, but I think it’s going to take a lot longer than people expect.

Still, participants were hopeful about implementing programs but recognized that they may have to be implemented more slowly. One trainer in a hazardous waste program described the effort to incorporate the opioid topic and slowly expand it, and another spoke about needing months of upfront planning time to introduce their workplace program.

For our hazardous waste program, we are going to be including a bit on opioids in there, and then we are going to look at how we can expand on that over the next couple of years. We are going to slowly implement it.

We have had conferences and discussions on the phone about it. We don’t have anything to document it, the last six months has been communication. We aren’t there yet. We just got introduced to this last year. The wheels to get something like this, I am thinking five years down the road, people are thinking next week, but it doesn’t work like that over here. We are trying to reach a lot of people. I am just the coordinator.

Finally, participants described their approach toward building training in the context of difficult conversations and stigma. In particular, noting the desire to honestly confront the denial concerning the issue of opioids in the workplace and the challenge of implementing “that kind of change.”

I am an instructor. Yes, I take this training and use it. I realize now there is a stigma now, words like junkie. I don’t want to hurt or put that on somebody.

I don’t want to say in your face, but I do want to say more in your face. To be more free and open, but be confidential. Not really too sure how to implement that kind of change just yet.

A joint display of qualitative and quantitative results is shown in Table 8. The joint display organized trainee and downloader results by the topics of individual-level actions, workplace-level actions, obstacles, and future plans. The qualitative interview results and quantitative survey results are consistent with each other. The comparison of the results supports the hypothesis that trainees and downloaders took the individual actions of educating others and planning and conducting training. In addition, both qualitative and quantitative results indicated obstacles to individual- and workplace-level actions, such as needing more time, and workplace barriers, such as supervisor and upper management awareness, and addressing stigma to implementing change and conducting activities.

Table 8.

Qualitative and Quantitative Results of Opioids and the Workplace Training.

	Quantitative	Qualitative
Topic	Survey (close-ended questions)	Survey (open-ended questions)	Interviews (6 trainees and 1 downloader)
Trainees: Individual-level actions	->50% reported “shared fact sheets and information from the opioid training with coworkers” and “shared information about opioids and the workplace in the community” -1/3 of respondents reported “participated in organizational programs geared to improve safety and health or avoid opioid misuse” -1/3 of trainees selected “took a stand against stigma in the workplace”	-Trainees report talking with their families and coworkers, educating others, and sharing information. -Trainees provide details about developing training and educational resources, building awareness, and support groups for educational purposes.	-Creation of support groups-Making their own training programs-Helped educate their own families on opioid awareness
Downloaders: Individual-level actions	- >50% reported “shared facts sheets and information from the opioid training with coworkers” -42.1% “participated in organizational programs geared to improve safety and health or avoid opioid misuse” -5.3% of downloaders selected “took a stand against stigma in the workplace”	-Conducting, developing, and adapting training reported-Sharing information with colleagues-Through education and information, assist in a safety culture
Trainees: Workplace-level actions	-63.0% of trainees report “planned and conducted training and education” -25.9% answered “I have not been involved in any of the actions since the training” -All other workplace-level action responses were <22.2%-40.7% report using the training tool-Most commonly used activity was Activity 4: Prevention of injuries/illnesses/stressors that can lead to pain treatment/substance use	-Added and delivered training on awareness-Assisted and focused on worker health and safety	-Changing policies for employees who suffer from addiction with meetings and working with unions in close partnership-Information and materials have been used in conducting training and navigating with management and locals-Need for more time to take actions-Lack of flyers, documents, or reports to share since participants need more time to implement change
Downloaders: Workplace-level actions	-52.6% of trainees report “planned and conducted training and education” -31.6% answered “I have not been involved in any of the actions since the training” -All other responses were ≤ 26.3%-42.1% report using the training material-Most commonly used activity was Activity 4: Prevention of injuries/illnesses/stressors that can lead to pain treatment/substance use	-Training materials used to conduct safety meetings-Used material to adapt presentations-No responses outside of training other than one person reporting a closed-door privacy policy for employees who need to discuss
Trainees: Obstacles	-7.4% have not taken any of the individual-level actions since the training-25.9% have not been involved in any of the workplace-level actions since the training	-Organizational barriers in the workplace exist to limit conducting activities-Time was a major factor-Having their own training materials previously developed	-Need to get supervisors and upper management knowledgeable-The logistics of workplaces can create barriers in implementing change and conducting activities-Not able to make changes on their own since facility and coordinators need to approve-Acknowledging people come in with their prejudices and the challenges of language regarding opioids and stigma, and the need to discuss those prejudices and stigmas-Difficult topic for a worker trainer to hold and discuss-Challenges in connecting with the audience on opioids if they do not have personal experiences
Downloaders: Obstacles	-15.8% have not taken any of the individual-level actions since downloading-31.6% have not been involved in any of the workplace-level actions since downloading	-There was no demand-Opioid training is not part of their normal activities -There have been no obstacles
Trainees: Future plans	-Action planning activity used 14.8% of the time in training	-Conducting and continuing further training as needed was frequently mentioned	-Slowly implementing opioid awareness into their hazardous waste program over the next couple of years-Interest in doing more community outreach and dissemination of information and training-Respondents want to help but unsure how to implement change – difficult to do on their own-Plan to attend more training
Downloaders: Future plans	-Action planning activity used 31.6% of the time in training	-To have future, additional, or continued training was mentioned

Discussion

We found some evidence that the Opioids in the Workplace training program and materials have contributed to helping workers introduce policies and programs related to opioids within their workplace or union (H1). As hypothesized, individual-level actions were reported by the trainees and downloaders more frequently than workplace-level actions (H2). However, at least one workplace-level action was taken by three-fourths of the trainees and two-thirds of the downloaders. Similarly, as hypothesized, a larger proportion of trainees than downloaders reported individual-level actions, although there were no large differences in workplace-level actions (H3). This result provides evidence of the value of providing training materials for free download from the WTP website. Downloaders reported that they were able to conduct individual- and workplace-level actions to address the relationship between opioids and work.

Worker Empowerment

Worker empowerment, including the increased ability of workers to advocate for appropriate health and safety protections, is key to the WTP training and logic model.²⁹ Our study was able to document various actions taken by trainees and downloaders to advocate for policies and programs designed to prevent and treat OUD. Individual actions typically included dissemination of information, participation in organizational programs, communication to other coworkers, taking a stand against stigma, and self-care. The most common workplace-level action reported was planning and conducting training, likely due to the majority of trainees being trainers. Of participants who used or modified the OWPR training tool, the action planning activity conducted at the end of the training was used by over one-third of trainees and three-fourths of downloaders. This may have helped trainees plan and implement activities in their workplaces, part of the process of empowerment.

However, most summer 2019 training program participants and fall and winter 2019 material downloaders were not in leadership positions in their organizations (employer or union). There were only four managers and no union leaders among trainees and four managers among downloaders in the group participating in the current study. As expected, workplace leaders were significantly more likely to share fact sheets and information from the opioid training with coworkers (four of four) than those not in leadership positions (six of fifteen) among downloaders. However, there were no other statistically significant differences in actions taken by leaders versus nonleaders or by trainers versus nontrainers in this small sample. While empowered workers may apply pressure on workplace leaders, those leaders will likely have greater influence over improving working conditions, safety climate and supportive substance use policies, and reducing stigma or work stressors. About one-quarter of trainees (25.9%) and downloaders (31.6%) had not taken any of the listed level actions since the training or download. Also, there were few flyers, documents, or reports that interviewees were willing or able to share to help validate survey results. Participants mentioned that there is a need for more time in order to take workplace-level actions, and also resistance to implementing more supportive substance use policies and programs because of workplace leadership’s stigma and punitive approach, or lack of formal substance use policies.³⁰

Stigma

One example of worker empowerment as a result of the training was that one-third of trainees reported that they “took a stand against stigma in the work place” (compared to only 5.3% of downloaders). During the pilot OWPR trainings in the summer of 2019, the instructor was able to draw on those persons in the audience who had experiences related to opioids, substance use, and addiction.¹⁹ Those experiences may have made it easier for the class to discuss the difficult topic of stigma and language used to describe people with addiction. In the interviews, participants mentioned the challenge of stigma as a topic for worker trainers and connecting with the audience who may come to the training with different attitudes toward addiction. Unlike the trainees, those who download the training materials did not have an instructor. The downloading and reading of the training materials may not be adequate to change attitudes toward addiction, and the delivery of the materials in a classroom with an instructor who can draw on those who may have experiences related to opioids, substance use, and addiction may increase the likelihood of stigma being addressed.

The WTP Model of Training and Organizational Change

In addition to worker empowerment, the WTP model of training, including organizational change, needed to create safer and healthier workplaces, incorporates a number of other key features. First, in unionized workplaces, the union can play a key role in advocating for safer and healthier working conditions.²⁶ A majority of the OWPR trainees were union members; however, none were union leaders. Thus, OWPR trainees are able to advocate within their unions for efforts to address opioid use and addiction, most often by creating training programs on this issue for their union’s members. However, none of the trainees reported the negotiation of contract language on this issue at six-month follow-up. It is possible that a six-month period is not long enough to reflect activity related to negotiation of contract language. This could suggest the need for longer term follow-up of this trainee population.

Second, the WTP model of training and logic model is based, in part, on the social ecological model of influences on worker health at the individual, workplace, community and policy levels, and corresponding efforts at each level to improve worker health.²⁵ Our study documents such efforts at the individual- and workplace levels. In addition, 59.3 percent of trainees and 36.8 percent of downloaders indicated that they “shared information . . . in my community.” Given the limited duration of a six-month follow-up, it is reasonable that advocacy at the policy level was not observed or reported.

Third, the WTP has created a supportive and trusted community of grantees and trainers with effective “listening sessions” and consultation with grantees. Doing so has allowed the WTP to develop innovative training programs, explore evaluation approaches, recruit training sites and participants, and implement program evaluation. As a result of these discussions, two new versions of the “Opioids and the Workplace” training program were developed and pilot tested in 2020—a program for workplace leaders, and a train-the-trainer course for trainers.¹⁹ Train-the-trainer programs can also help to integrate opioids and the workplace training into more general workplace safety and health training.¹⁹ Some 2019 training participants mentioned the desire to attend more training and appear willing to take part in further education on opioids and the workplace. Training for trainers may provide worker trainers the skills needed to conduct opioids in the workplace training.

Future Evaluation

Furthermore, participants in the six-month follow-up survey and interviews mentioned the need for more time to take actions and implement policies or programs. Quantitative close-ended questions were limited to only asking if action planning activities were used by trainees and downloaders. Including more quantitative items related to future plans can help to compare such items with qualitatively collected data. A one-year follow-up from the summer 2019 training and a similar amount of time for those who download the training materials could contribute to evaluating longer term outcomes. Such a further outcome evaluation can help us understand if more time enabled more actions to be taken and what contributing factors may have played a role in those outcomes.²¹ Further evaluating the OWPR training can help determine if data were translated into knowledge, and if that knowledge was used to take actions that can lead to workplace change.

Study Limitations and Strengths

Limitations of the current study include an inability to link pre- and postsurvey responses to email addresses and thus to the same individual, due to the assurance of confidentiality provided to survey respondents. Second, we did not have preintervention (pretraining) data on individual- or workplace-level actions taken by training participants to address opioid use and addiction in their workplaces. Third, the evaluation study’s response rate was low for both trainees and downloaders. The small sample size limits the study’s generalizability to other types of workers and workplaces. With a shorter period of time having elapsed to take actions as compared to trainees from the summer program, it is less likely downloaders would have responded. There was also no other means besides email of following up with downloaders, in contrast to the summer 2019 training site organizers who encouraged participation by their trainees. Therefore, we are unable to generalize our findings to all of the pilot program trainees or training material downloaders. Most attendees were either union representatives or training managers from nonprofit organizations. Including participants from private-sector companies may help reach frontline workers who were not well represented in the study.

Response rates might improve if the survey length is shortened, reducing time needed to complete it. Thirty-eight trainees and twenty-five downloaders opened the survey link. However, only twenty-seven trainees and nineteen downloaders completed the survey. Those who did not complete the survey did not go further than the consent form. The consent form may have discouraged participation among some. If the need for a consent form can be better communicated to participants prior to opening the survey, that may also increase response rates. Strengths of the study include the ability to collect both qualitative and quantitative data. To the author’s knowledge, this is the first study to evaluate the outcomes of a national training program on opioids and work by assessing individual- and workplace-level actions taken in the workplace following training.

Conclusion

We found some evidence that the Opioids in the Workplace training program and materials have contributed to helping workers introduce policies and programs related to opioids within their workplace or union. Future directions of the OWPR program can include a leadership course for those in a supervisory or management role to take actions in implementing programs and policies on opioids and the workplace, substance use, and injury prevention. An instructor course may prepare worker trainers on how to integrate opioids and the workplace training into more general workplace safety and health training. The OWPR training program could also reach a broader audience, including those who work for private-sector companies as frontline workers. Further discussion could be added on how to start and develop workplace member assistance or peer advocacy programs.

Footnotes

Acknowledgments

The authors acknowledge and thank Jonathan Rosen, MS, CIH, Deborah Weinstock, MS, Joseph Chip Hughes Jr., MPH, and Kenda Freeman, MPH, for their review and feedback throughout the study and OWPR program evaluation.

Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Eric Persaud received financial compensation to perform “Opioids and the Workplace Training Evaluation” from a grant received by the State University of New York (SUNY) Research Foundation from Michael D. Baker, Inc (Paul Landsbergis, PI). The original source of the funds was the National Institute of Environmental Health Sciences. The time period of the grant was April 21st to September 17th, 2020. Mr. Persaud is continuing to evaluate the program for Michael D. Baker, Inc. at the time of submission. All other authors have no conflict of interest to declare.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was made possible by contract number 75N96019P00312 from the National Institute of Environmental Health Sciences, NIH.

ORCID iDs

Eric Persaud

Paul Landsbergis

Author Biographies

Eric Persaud is a doctoral candidate in Public Health at the Department of Environmental and Occupational Health Sciences, State University of New York-Downstate Health Sciences University. He focuses on evaluating and researching training programs related to preparing workers for emergencies and disasters, and hazardous workplaces. He has been involved in evaluation and research associated with fentanyl and first responders, opioids and the workplace, and protecting workers from COVID-19.

Aimee Afable is an associate professor of Community Health Sciences and associate dean of Community Engagement at the State University of New York-Downstate School of Public Health. Afable has methodological expertise in process and outcome evaluation and quasi-experimental approaches to evaluation. She teaches courses in program evaluation, urban and immigrant health. Afable’s research has critically examined conceptual frameworks used to understand health disparities and health inequities. Her work has documented the declining health advantage with increasing stay among U.S. immigrants and has questioned the validity of the Healthy Immigrant Paradox.

Laura A. Geer is an associate professor and chair of the Department of Environmental and Occupational Health Sciences, State University of New York-Downstate Health Sciences University School of Public Health. In prior work, she has studied dermal exposure assessment in occupational and environmental settings, psychosocial risk factors of exposure, and risk assessment and communication. Her work complements the current line of research in the consideration of behavioral influences on exposure.

Paul Landsbergis is an associate professor in the Department of Environmental and Occupational Health Sciences, State University of New York-Downstate Health Sciences University School of Public Health. Landsbergis served as a member of the NIOSH Intervention Effectiveness Research Team and was a member of the National Research Council’s Committee on the Health and Safety Needs of Older Workers. He coedited two books on work stress and health (The Workplace and Cardiovascular Disease, 2000; Unhealthy Work, 2009) and is deputy editor of the American Journal of Industrial Medicine. He is currently participating in the development of a website () on reducing job stress and increasing healthy work.

References

Centers for Disease Control and Prevention. 2018 Annual surveillance report of drug-related risks and outcomes, https://www.cdc.gov/drugoverdose/pdf/pubs/2018-cdc-drug-surveillance-report.pdf (2018, accessed 11 November 2020).

Dasgupta

Beletsky

Ciccarone

Opioid crisis: no easy fix to its social and economic determinants. Am J Public Health 2018; 108: 182–186.

Webster

LR.

Risk factors for opioid-use disorder and overdose. Anesth Analg 2017; 125: 1741–1748.

Shaw

Roelofs

Punnett

Work environment factors and prevention of opioid-related deaths. Am J Public Health 2020; 110: 1235–1241.

Hawkins

Roelofs

Laing

, et al. Opioid-related overdose deaths by industry and occupation-Massachusetts, 2011-2015. Am J Ind Med 2019; 62: 815–825.

Venkataramani

Bair

O'Brien

, et al. Association between automotive assembly plant closures and opioid overdose mortality in the United States: a difference-in-differences analysis. JAMA Intern Med 2020; 180: 254–262.

Dean

Kimmel

Free trade and opioid overdose death in the United States. SSM Popul Health 2019; 8: 100409.

Lang

Ochsmann

Kraus

, et al. Psychosocial work stressors as antecedents of musculoskeletal problems: a systematic review and meta-analysis of stability-adjusted longitudinal studies. Soc Sci Med 2012; 75: 1163–1174.

Farnacio

Pratt

Marshall

, et al. Are workplace psychosocial factors associated with work-related injury in the US workforce?: National Health Interview Survey, 2010. J Occup Environ Med 2017; 59: e164–e171.

10.

Stansfeld

Candy

Psychosocial work environment and mental health – a meta-analytic review.

Scand J Work Environ Health 2006; 32: 443–462.

11.

Theorell

Hammarstrom

Aronsson

, et al. A systematic review including meta-analysis of work environment and depressive symptoms. BMC Public Health 2015; 15: 738.

12.

Halbert

Davis

Wee

Disproportionate longer term opioid use among US adults with mood disorders. Pain 2016; 157: 2452–2457.

13.

Martins

Fenton

Keyes

, et al. Mood and anxiety disorders and their association with non-medical prescription opioid use and prescription opioid-use disorder: longitudinal evidence from the National Epidemiologic Study on Alcohol and Related Conditions. Psychol Med 2012; 42: 1261–1272.

14.

Ahern

Stuber

Galea

Stigma, discrimination and the health of illicit drug users. Drug Alcohol Depend 2007; 88: 188–196.

15.

Choi

Opioid use disorder, job strain, and high physical job demands in US workers. Int Arch Occup Environ Health 2020; 93: 577–588.

16.

Connecticut Department of Public Health. The opioid crisis and Connecticut’s workforce, https://portal.ct.gov/-/media/Departments-and-Agencies/DPH/dph/environmental_health/occupationalhealth/Opioid-conference-writeup_FINAL-FINAL_11_28_18-(2).pdf?la=en (2018, accessed 19 November 2020.)

17.

Slatin

Dunn

ML.

From SARA to Homeland Security: the NIEHS Worker Education and Training Program confronts challenges of environmental cleanup. New Solut 2006; 16: 65–86.

18.

National Institute of Environmental Health Sciences Worker Training Program. Opioid-related hazards in the workplace developing a training framework to address exposure, use, and prevention report from Fall 2018 workshop. Durham, NC: National Institute of Environmental Health Sciences, 2018.

19.

The National Institute of Environmental Health Sciences Worker Training Program. Final report on the opioid training materials development initiative for the NIEHS worker training program. Durham, NC: National Institute of Environmental Health Sciences, 2019.

20.

The National Institute of Environmental Health Sciences Worker Training Program. Opioids & substance use: workplace prevention & response, https://tools.niehs.nih.gov/wetp/index.cfm?id=2587 (accessed 19 April 2020).

21.

Kirkpatrick

Kirkpatrick’s four levels of training evaluation. Alexandria, VA: ATD, 2016.

22.

The National Institute of Environmental Health Sciences Worker Training Program. Worker Education and Training Program (WETP) logic model, https://tools.niehs.nih.gov/wetp/1/12FallMeeting/wetp_logic_model.pdf (2012, accessed 8 April 2021).

23.

Lippin

Eckman

Calkin

, et al. Empowerment-based health and safety training: evidence of workplace change from four industrial sectors. Am J Ind Med 2001; 38: 697–706.

24.

McQuiston

TH.

Empowerment evaluation of worker safety and health education programs. Am J Ind Med 2000; 38: 584–597.

25.

Mitchell

DM.

Using the social ecological model to guide the evaluation design of the environmental career worker training program (NIEHS) 2017, https://tools.niehs.nih.gov/wetp/public/hasl_get_blob.cfm?ID=11481 (accessed 9 November 2020).

26.

Hagedorn

Paras

Greenwich

, et al. The role of labor unions in creating working conditions that promote public health. Am J Public Health 2016; 106: 989–995.

27.

National Institute of Environmental Health Sciences Worker Training Program. Minimum Health and Safety Training Criteria Guidance for Hazardous Waste Operations and Emergency Response (HAZWOPER) and HAZWOPER-supporting training. Durham, NC: National Institute of Environmental Health Sciences.

28.

Creswell

JW.

Advances in mixed methods research, https://www.ualberta.ca/international-institute-for-qualitative-methodology/media-library/international-institute-of-qualitative-methods/webinars/mixed-methods/2016/jcreswellmmira-webinar.pdf (2016, accessed 4 May 2020.)

29.

Fernandez

Daltuva

Robins

TG.

Industrial emergency response training: an assessment of long-term impact of a union-based program. Am J Ind Med 2000; 38: 598–605.

30.

Bush

Lipari

RN.

Workplace policies and programs concerning alcohol and drug use. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.