Reducing Substance Use and Improving Mental Health Among Construction Workers: An Interview With Chris Trahan Cain

Introduction

The opioid epidemic has been especially difficult for construction workers. With a high rate of injuries, working in pain, lack of paid-time leave, excessive work hours, and a work culture that focuses on production, too many construction workers have relied on opioids to enable them to work. The Center for Construction Research and Training (CPWR) and North America’s Building Trades Unions (NABTU) are working on preventing, controlling, and treating substance abuse disorders and mental health issues. In order to better understand how the opioid pandemic has impacted the construction trades, we spoke with Chris Trahan Cain, Executive Director of CPWR, which works with NABTU. Chris has been successful in operating a task force that is focused on understanding what leads to over reliance on opioids as well as educating employers, unions, workers, and physicians on prevention, support, and treatment programs for construction workers.

Introduction to CPWR—The Center for Construction Research and Training

Interviewer: Can you tell us about CPWR and how you became involved in this organization?

Chris Trahan Cain: CPWR is a nonprofit and is affiliated with NABTU, North America’s Building Trades Unions, which is the umbrella organization of fourteen national and international unions in the United States, representing about three million construction workers. As a nonprofit of the building trades, we pursue funding to do work around occupational safety and health. We have three main areas of work: research, service, and training. Our research is funded primarily by a multiyear cooperative agreement with National Institute for Occupational Safety and Health (NIOSH), where we compete for money every five years and must propose multiyear projects. We work with a university consortium to do so. We carry out the research and we have been successful in getting that funding since 1990, through many competitive cycles. We have a very close partnership with NIOSH.

Our service work is primarily funded by the U.S. Department of Energy, where we are funded to do a former worker screening program, a medical screening program for workers who have been employed on our nation’s nuclear weapons sites. We enroll these workers in this medical surveillance program, provide medical exams, as well as CT scans for early lung cancer detection. And we are up to about 40,000 workers screened since we started this program. It is a great opportunity to do research with the medical surveillance data. It has led to things like the Energy Employees Occupational Illness Compensation Program Act for workers in that sector, who get certain types of cancers and have worked on our nation’s weapons complex, as well as just discovering patterns of disease in the construction work force. So, we focus on construction workers in that work, and we partner with clinics all over the country. Right now, we are trying to figure out how to restart things, given COVID.

Our training program is funded primarily through a cooperative agreement with the National Institute of Environmental Health Sciences. We compete for that money every five years, and that training program is focused on doing occupational safety and health, hazardous waste, and environmental training within the building trades unions. We do not have any dedicated funding to deal with the opioid crisis and mental health, but we are seeking funding to do that.

I have worked at CPWR since 1998 and became the executive director of CPWR in 2017. That also makes me the safety and health director of NABTU. So, I work to coordinate the work of the building trades around occupational safety and health issues. I have asked NABTU President Sean McGarvey what CPWR’s role should be, as we were becoming more aware that the opioid crisis is targeting and is creating a “perfect storm” of death for construction workers.

Interviewer: What led to your interest in substance use and mental health, and what motivated you to get involved in addressing the opioid and addiction crisis through CPWR?

Chris Trahan Cain: In the fall of 2017, the Cleveland Plain Dealer published probably the first documented evidence that construction workers were a lot more likely to die of fatal opioid overdoses than workers in all industries with seven times the death rate of all industries. Concurrently, the Massachusetts health department was working on a study where they were seeing similar trends. While they did not end up publishing their study until August of 2018, by the fall of 2017, we really knew there was a problem. President McGarvey determined that it was necessary to establish an opioid task force for NABTU, and I said, great, I’m really looking forward to working with that group, because I think CPWR has a role in the prevention side. He told me I was going to chair it, and I was stunned because I’m an industrial hygienist, not a mental health person or substance use person. So, this was a big challenge for me. In January 2018, we had our first task force meeting and the task force brought together representatives that were appointed by all the general presidents in the building trades unions, as well as invited health insurance companies, employer organizations, and other individual employers, who we knew were working on this problem.

We have got an incredible situation, where construction workers are overdosing and dying, so we started to try to “break down” things we could do to affect the problem. Ultimately, the task force adopted a public health model to address the issue and identify primary, secondary and tertiary “buckets” or “boxes.” These are all boxes that we are working on.

Primary prevention is education and training and increasing occupational safety and health in the construction industry to reduce pain. In construction, there is no paid leave to recover from that pain, or repetitive injuries, or any traumatic injuries. All these issues add to the pain burden in our industry, between the perfect storm of the doctors who were prescribing prescription opioids way too freely, and the fact that in our industry, you don’t have a lot of resources and ways to deal with pain other than to go to work. We felt that this was a real important thing about preventing pain through primary prevention and secondary prevention. We’re talking about preventing or educating and trying to prevent workers from getting their first prescribed dose of opioids.

Interviewer: So, Chris what made you choose this path? What made you became someone involved in-depth in the construction world?

Chris Trahan Cain: I started out as an industrial hygienist; I went to work as a compliance officer, and I really liked that. Then I moved to Washington, DC, and did a little bit of this, a little bit of that. But then when I got to the building trades, I felt at home. I moved here in 1994, and then in 1996, I joined a nonprofit that was related to this one, but it was just building trades work, and there is still so much to do in our industry. There is so much that we have to do on the traditional safety and health challenges, that I really felt that this industry was where I wanted to be and luckily, I was able to find jobs, and eventually, get to the point where I’m leading. But we still just have so much work to do on the traditional, safety, and health front. We have too many people dying and getting sick still in 2021, from traditional safety and health hazards in our industry, and I like the union side of it.

Factors Contributing to Substance Use

Interviewer: Since there is no paid leave and workers work through the pain, how does the work culture affect the use of drugs and alcohol?

Chris Trahan Cain: You have to feed your family, and so there’s an enormous pressure to work in construction, you work when there’s work and you don’t work when there’s no work. So as an employee, if you were offered overtime, like 7–10 s, or 6–12 s (7–10 s is seven days of the week and 10 h a day, 6–12 s is six days of the week and 12 h a day) or other crazy situations, you take it. What adds to it is having unpredictable schedules, you may have long commutes, lack of sleep if you’re working a 16-h shift, and you have an hour drive after that, and you have to drive an hour back in the morning, how much sleep are you really going to get? All these things are contributing factors and then you also have the fact of pain you have to work through. So, we really thought that trying to address the pain through our traditional methods and occupational safety and health was important. We put that in the primary prevention bucket.

We do have this historic culture in our industry of “tough guys” go into construction, and people who can sit at the bar all night. So, you have some of that predisposition to being macho and that’s a huge issue. When we started the opioid task force, for the first couple of months, I spent a lot of time interviewing all the task force members, and I had people tell me things that were just stunning. One of the unions was involved in a joint labor management effort, in a particular state; they provided drug testing; because the employers require it, and somebody’s got to do it, some of this was funded through a joint labor management fund. The representative said that 30 percent of their members and 50 percent of all members were on prescribed opioids, that would show up in the drug test, but if you have a prescription, you are not breaking any law. But to think that half of the people in a particular state going through these drug screens were on prescribed opioids, it is just stunning.

Anecdotally, hearing about people on long-term opioids, we know that it doesn’t take long to become dependent on the medicine. So, we thought it was really important to try to do something to interrupt that. We are trying to educate folks not to accept that first prescription and talk about alternative ways to deal with pain. We’ve got a lot of construction workers on long-term prescribed opioids, and now the pharmacies and the insurance companies are trying to limit those prescriptions. So, we have to think about tertiary prevention when someone has a substance use disorder, even if it’s a result of a prescription from their doctor. So, we asked, how can the industry support them? I think when we talk about opioids and construction, that’s where everybody goes first, asking what can we do to support workers who have issues? We wanted to look at it all along the spectrum to try to work on the prevention side, along with how can those workers be supported.

Interviewer: You stated that you wanted to get to workers before they get that first prescription. What training or education programs do you have? What would be alternative ways of pain remediation, instead of using an opioid? What type of programs would you set in place, or have set in place?

Chris Trahan Cain: We started with putting out a hazard alert card on pills and trying to get brief direct information into the hands of workers saying, if you have pain, ask about your medicine, be more aware. We also developed information for a worker to bring to their physician, we call them physicians alerts. If you go to a general practitioner, sometimes they don’t even ask about industry, or occupation, or what you do. So, this was a communication device that we hoped people would use. We have not really seen how well it’s being used, but it would say “I’m a construction worker,” this is what I have to do, and these are the types of equipment I have to work with. If you are prescribing me medicine for pain, I don’t want this list of medicine.

This was a communication intended for the worker to bring to their doctor. So those were two things we did right away. We also developed a training program under the leadership of the task force, to raise awareness and destigmatize opioid use in the industry. These tools have been rolled out in different ways through the building trades unions, and employers have access to them and are using them in some cases. We’ve been focused on when you get to the point where someone has a substance use disorder, you really need to think about what support can the industry give that individual, particularly in seeking help. We’ve got tons of people in recovery from substance use disorder, and so how do you support people in recovery? So, we explored that last year, we were able to get a little bit of money to do a second round of in-depth interviews with the NABTU opioid task force members, where we really looked at what folks were doing for peer support. We did not look at what’s happening in a company’s employee assistance program, we really looked at what the unions were doing and what they were doing is different across the different unions.

Substance Use Among Members

Interviewer: Is CPWR working with different unions, throughout the United States, to make changes, and are the unions making similar changes, or do they all have their own programs?

Chris Trahan Cain: Unions approach things differently. When we started the task force, we found out that the Sheet Metal workers union, now called the SMART union, has a program that they had launched several years before. The SMART MAP program is a program where they train individuals to understand substance use disorders, understand mental health disorders, and to provide basic support for their brothers and sisters. Since we started the task force in the beginning of 2018, they’ve expanded and built on that program, but that national program was in place prior to the task force. The International Union of Bricklayers & Allied Craftworkers (BAC) has licensed clinicians that are separate from the health insurance policies. So, every BAC member can call a 1 800 number and speak to a counselor and the counselor aids them to identify help in their local area, even if they didn’t have the work hours to keep their health insurance. In the building trades, if you do not book enough hours, you lose your health and welfare. So, these professionals at the International Union work with their members, regardless of their status and their health insurance plan to try to identify help for them. Another union entered into agreements with substance use disorder treatment facilities that they had vetted and negotiated taking members from anywhere in the country.

There are communities in New York City that have an informal but strong relationship between the trades, where an iron worker can call up an elevator worker and they can say, I’ve got one member who’s got this situation; I’ve got a wife who’s got that; I’ve got this other member has this; this kid who needs treatment. A lot of those informal networks are tied together through an organization called labor assistance professionals or LAP. LAP is a kind of loose organization that provides education and training. Kind of like EAPA, which is Employee Assistance Professional Association, but at a more personal level. They bring union members together to educate and to talk about how they can support their brothers and sisters who are struggling with mental health disorders or substance use disorder. The LAP has local chapters where they meet and discuss and explore things. They also have national meetings where they provide education to their members. There is another program I have heard wonderful things about. In Massachusetts, the Laborers Union actually has two or three full time people who are laborers, but they are also trained to support their brothers and sisters who are struggling and trying to be in recovery or are in recovery. I mean, it is different all over the place. There is another organization that we are working closely with called the Allied Trades Assistance Program in Philadelphia, and they’re a very mature program, basically an EAP, for all the participating local unions.

COVID Impact

Interviewer: I understand that COVID has changed things. What lessons have you learned, and how have policies been affected or changed in regard to the opioid epidemic?

Chris Trahan Cain: I think it has gotten worse with the COVID-19 pandemic. I don’t know what policies are changing. I think that we have policies that are in place to try to limit prescribed opioids. You have to educate doctors that somebody who’s coming off of a surgery or an injury should get three days of prescription instead of seven or thirty days, so those things are all going on. As far as policy changes that help construction workers in our industry, we are still struggling, we are still documenting and trying to research, what exactly about the construction industry needs to be changed. What is it about our industry that contributes to these bad outcomes and suicides? We are up there at a similarly high rate above all industries with suicides. These things are connected. The first few meetings with the task force dealt with testimonies, such as “my brother Sam killed himself, because he couldn’t get off heroin.”

Think about primary prevention because industrial hygiene and safety folks know the injuries are pushing these numbers, we know the pain is pushing it. What is the schedule of work; what is the organization of work; and the lack of paid sick leave? It is those types of things that are really hard to prove scientifically. So, first we must do the science, and then you have to yell about the science for a decade before someone listens. We’ve looked at as much data as we can look at, but we really need to focus down on work. What about work contributes to this? And what can we do better?

Interviewer: Do you find that employers are open to suggestions regarding helping unions and helping their workers with self-care, and all the issues that they have, or is that a difficult issue?

Chris Trahan Cain: I have large, sophisticated employers who understand that this is an issue that they need to be engaged with. Because the construction industry is always looking for skilled workers and good workers, and when you have a skill shortage, you need to invest in the work force. It’s not like there’s somebody just waiting to come in and be a master welder and help you finish that plant on time. There’s a real self interest in the big, sophisticated employers tackling this issue and investing in the work force. I’ve got a couple examples of really stellar employers, but it really comes with size, with capacity and it comes with capital. When we look at the construction industry, those employers who have size, capacity, capital, and resources are also the ones who have the safest workplaces. They have the fewest fatalities, they have the fewest injuries, because they have the infrastructure. What’s troubling in our industry, of course, is that 90 percent of the employers have fewer than twenty employees.

The small companies have disproportionate number of fatal injuries, because they don’t have the capital to invest. With a ten-person company you are working with the tools, trying to get work, and trying to run the business side. You don’t have any bandwidth left to say, I wonder if I could get a better EAP for Jim, because I think he needs more help than he’s getting from the doctors that his health insurance is paying for. We know that construction workers are disproportionately at risk, but we don’t really know the size of the employer that they typically work for. We also don’t have that same information for fatal overdose or for suicide. We can only speculate for the most part.

Interviewer: So, more research and more data are needed to be able to make a change?

Chris Trahan Cain: We need more science; we need more studies.

Interviewer: Have you had success in overcoming fear and stigma in the workplace? How important is it to develop a culture where workers can talk about mental health, suicide and substance use?

Chris Trahan Cain: We are constantly striving for that and that is what our training programs aim to do. We still fight stigma, it’s constant. I don’t know where it all comes from. But, part of it might be the culture, that you just are having so much trouble overcoming. Construction is a male-dominated industry, and at least in my experience, men are a lot less likely to talk about their feelings and what’s bugging them than women are. When you get a couple of them together, perhaps as we get more women in the industry, and hopefully, with the tools we’re going to see some changes with stigma. But the women are facing these challenges as well. It is not a male-only problem.

Interviewer: Now to the big elephant in the room, how has COVID impacted your efforts?

Chris Trahan Cain: COVID impacted everything. I mean, it’s been a really rough year and if it hasn’t been a rough year for you, you’re not here, you are not paying attention.

I think everything is harder with COVID. You have a situation where construction work has continued in many places and has not been affected by the shutdowns that affected people in other industries. If you have a family whose breadwinner is a construction worker, and they have children and he/she is at work and working long hours, and folks at home are trying to get to kindergarten or figure out how to do online schooling, that just adds to the burden, right? I mean, we all have more stress now. So, it’s even tougher. We have a drain on our mental health system, because there’s so many people seeking mental health support and can’t find it, because there’s not enough counselors. But we also have a couple of shining spots that have helped. My understanding is that it became a little easier for more people to do distance counseling and distance medical services. So that’s been helpful for some who can get access to the healthcare, but we’re all pretty frazzled, and we’re all pretty frayed after this past year. I’m terrified when the numbers come out, and when we see more about what happened in 2020, that we’re going to be really stunned because the few reports I’ve seen have been bad.

Interviewer: So finally what major issues do you feel CPWR, the unions and employees need to deal with going forward?

Chris Trahan Cain: We do have roadmaps of what we need to deal with. In August 2020, the building trades had a convention, a political convention, that they do every five years where the officers are elected. This time Sean Garvey was reelected as president of the building trades. In each convention they pass a series of resolutions, sometimes thirty resolutions, and these are items that the building trades unions agree to work on for the next five years that lays out a roadmap. This year because of COVID they did a remote convention and they only had ten resolutions, but of the ten resolutions, they said, we need infrastructure, we need jobs, we want pension reform, and we want to make sure there’s a pathway to the middle class for all Americans through the building trades. But another resolution that passed was that we need to deal with the opioid and suicide crisis as an industry. It gives CPWR a roadmap of what we have to do together with the building trades and with the industry to push this issue. We are looking at how to study and expand peer support systems in our industry. We are looking at how to better educate members, and how to try to stop the first opioid prescription from happening, also how to destigmatize mental health issues and substance use disorders. We are seeking funding actively to do this work; we’ve had very few resources to devote to this work, so it’s been a real challenge. But we have moved the ball forward with limited resources so we’re just hoping that come September 2021 we’re going to have a new funding source in place, and, if we don’t get that, we’re going to keep looking. We are trying to find where the federal government funds people to address this issue from a prevention standpoint and a recovery standpoint. The money just doesn’t flow to nonprofits like CPWR, but we still try to address this issue the best we can.

Resources

Centers for Disease and Control and Prevention (CDC): https://www.cdc.gov/niosh/topics/opioids/framework.html

The Center for Construction Research and Training (CPWR): https://www.cpwr.com/

North America's Building Trades Unions (NABTU): https://nabtu.org/