The Intersectionality of Activism and Public Health in New York State: Can Labor/Health and Safety Move Addiction Recovery Forward?

Abstract

People affected by overdose deaths are advocating for prevention and increased access to treatment. Activist coalitions challenged the deadly impact of stigma, discrimination, and inadequate access to life-saving substance use disorder (SUD) and mental health care. Advocacy by coalitions resulted in federal and state funding and legislation, improving access to care. New York State is a model for these reforms. Occupational safety and health activists have largely been absent from this critical policy work even though 70% of people who are struggling with substance use are working. Antiquated workplace policies discipline workers who have substance use problems, silencing those who need support. Pain related to hazardous and stressful work are drivers of the crisis. Prevention and recovery-friendly workplace programs are part of the solution. Partnerships among employers, unions and safety and health activists with the recovery movement can prevent SUD and help affected workers build and sustain their recovery.

Keywords

Overdose deaths prevention treatment recovery unions workplace advocacy substance use mental health addiction

Introduction

For more than a decade, a highly stigmatized, killer epidemic has silently spread devastation across the United States. An exponential rise in drug overdose deaths calls for an end to the stigma and discrimination surrounding substance use disorders (SUDs). SUDs are wreaking lethal consequences, eerily akin to those seen during the HIV/AIDS pandemic, which in 1994 was the leading cause of death for all Americans ages twenty-five to forty-four.¹ From 1999–2019, nearly 500,000 people died from drug overdoses involving opioids, including prescription and illicit opioids.² Driven by the recovery advocacy community, New York State has engaged in comprehensive policy reforms to address this crisis for more than a decade. Similar reforms are needed in every state. It is essential that labor and occupational safety and health activists join the recovery movement to fight for these reforms that will save workers’ lives. Stigma and lack of access to treatment are major roadblocks for workers who are addicted to opioids. This paper reviews some of the key elements of the New York State program and the advocacy that has empowered it and promotes the adoption of similar reforms nationally. We call for establishing coalitions that bring together employers, unions, government officials, and recovery activists to confront opioids and other substance use in the workplace and develop needed reforms in the workplace and in state policies.

Activism has been key to public policy reforms as exemplified by the labor and civil rights movements. An example of the impact of activism on stigma and public health reform was when in 1987, activists in New York City launched a massive public health campaign designed to address the stigma and discrimination around HIV/AIDS.³ The visual symbol for their campaign was an inverted pink triangle that had been used decades earlier by the Nazis to identify homosexual “undesirables” in concentration camps. AIDS activists reclaimed this symbol, turning its attempt to stigmatize on its head, and added the words: SILENCE = DEATH. Activists organized by the AIDS Coalition to Unleash Power (ACT UP) recognized that the stigma and discrimination surrounding HIV/AIDS was killing hundreds of thousands of people. Their call to action demanded that government officials, medical communities and the pharmaceutical industry prioritize development of more effective treatment options for people diagnosed with HIV/AIDS.

The SILENCE = DEATH campaign became the rallying cry to step out of the shadows of shame and break through the wall of silence surrounding the most important public health issue of the time. The ACT UP coalition transformed the way the world viewed people with HIV/AIDS, and the way people with the illness viewed themselves. The coalition members demanded people with HIV/AIDS be involved in the development of research and evidence-based treatment for their health conditions. These advocates successfully collaborated with government and public health officials to push the Food and Drug Administration (FDA) to restructure the way drugs were approved, and secured harm reduction policies (like needle exchange) and funding for recovery-oriented systems of care, including housing and health care access for people with HIV/AIDS.⁴

The Opioid Overdose Crisis is an Occupational Safety and Health Emergency

The recovery advocacy movement in New York State has employed direct action tactics used by AIDS activists such as die-ins, lobby days, marching, theater, art and culture and mobilized successfully for significant policy changes related to one of the most important public health crises of the current time – the epidemic of opioid use.

Labor and occupational safety and health (OHS) activists also have a rich history of direct action and advocacy⁵ in establishing laws and standards to protect workers from occupational morbidity and mortality. In the aftermath of the 1911 Triangle Shirtwaist Fire that took the lives of 146 mainly immigrant workers, massive protests led to unionization, establishment of workers’ compensation laws, fire and life safety standards, and state labor departments. The labor movement played a key role in establishing the OSHA Act of 1970 and the Mine Safety and Health Act of 1977.

An example of common approaches among the recovery and OHS movements is the emphasis on empowerment of people who are directly affected. In New York State, the recovery activists use the slogan (inspired by the disability rights movement), “Nothing About Us Without Us”. Similarly, a fundamental principle among labor and OHS activists is the need for worker involvement in all facets of a workplace health and safety program. Workers have direct knowledge of workplace hazards and great insight into solutions. This approach should be extended to preventing workplace injury and stress-induced pain and reforming punitive workplace drug policies. The power and energy of labor and OHS activists is critical to developing reforms that impact the root causes of occupational injury and stress and the resulting physical and emotional pain that frequently leads to prescription or illicit drug use. Reports from the National Institute for Occupational Safety and Health (NIOSH) and the Massachusetts Department of Health have documented that hazardous jobs—such as construction, mining, warehousing, and health care —are more highly associated with opioid overdoses.^6,7 Workers are also subject to family and community traumas that are important risk factors for addiction, such as a history of family violence or exposure to a community disaster.

A significant group of labor union leaders and OHS researchers have begun taking on the opioid crisis in the workplace. The unions have mainly been in the construction industry, whose workers, in Massachusetts alone, have a six-times higher rate of overdose fatality compared to the average for all industries.⁷ The United Auto Workers has conducted training and negotiated contract language with the big three automakers to fund research and intervention activity. This emerging trend in labor should be expanded and supported with federal funding. Several occupational health researchers as well as NIOSH have also begun documenting and evaluating the impact of the opioid crisis on workers and employment.

Stigma

Stigma – the negative public perception that people with SUD brought their illness upon themselves – has contributed to hundreds of thousands of deaths over the last decade. Even though SUD was identified decades ago as a complex brain disorder,⁸ the public, some health care providers, and many employers continue to blame people with SUD for their illness.⁹ The dehumanization of individuals with SUD stems from the uninformed concept that addiction is the result of a moral failure or failure of will. People struggling with SUD are still referred to in disparaging terms, as “junkies”, “crackheads” and “GOMERS” (Get Out My Emergency Rooms). Workers have expressed fear of being treated as outcasts by supervisors and co-workers and terminated from employment due to punitive workplace drug policies. A National Safety Council survey has documented infrequent and inadequate workplace training on substance use prevention.¹⁰

The shaming bias of stigma labels people who use drugs as “bad people”, rendering them undeserving of care and compassion, and this false narrative permeates public policies that prevent individuals from seeking life-saving health care, and has a cascading effect on access to care. The unintended consequences of stigma have impacted the way in which services are delivered to people with SUD/Mental Health (MH) conditions, as well as their families, by the health care system. Despite more than 70,000 Americans dying of overdoses in 2017, insurers spent only 1% of their total health care dollars on treatment for SUD/MH.¹¹

In the 2019 seminal Milliman Report, authors Melek, Davenport, and Grey confirmed what health care advocates have long reported: that insurers grossly failed to adequately cover lifesaving care for individuals needing SUD/MH services, despite reports (CDC, 2014−2017) that life expectancy in the U.S steadily declined due to overdoses, alcohol, and suicides.¹² These have been referred to as “Deaths of Despair.”¹³ Decades of changes in employment such as de-industrialization, cuts in government programs, loss of union density, elimination of pensions, cuts in benefits and frozen wages have caused debilitating despair among affected workers and communities. This has resulted in a four-year drop in life expectancy in the United States. The COVID-19 pandemic has fed a 1.13-year drop in life expectancy in 2020 due to the combined impact of COVID-19 fatalities, and drug, alcohol, and suicide deaths. with a disproportionate impact on Black and Latino communities where employment is more concentrated in higher risk-essential industries.¹⁴

Impact on the Workplace

The impact of the opioid and substance use crisis on the workplace has been underappreciated. Research indicates that opioids have been linked to declines in labor force participation in the U.S., with an estimated one million workers out of the work force.¹⁵ In a 2017 study, Krueger found that 50% of men who are out of the labor force report taking prescription opioids daily.¹⁶ Analysis done by Mark C. White, PhD, found that Opioid Use Disorder (OUD) suppressed Missouri's work force participation by an estimated 2.7 to 3.4% in workers ages twenty-five to fifty-four, resulting in an estimated loss of $934.5 million in labor income, $1.56 billion in value added, and $4.36 billion in output.¹⁷

While opioids have significantly affected labor force participation, many individuals with a drug or alcohol related problem are employed. Estimates of self-reported substance use in the workplace range from 60 to 70% of all employees.¹⁸ According to the National Survey on Drug Use and Health, almost 4% of respondents ages eighteen and above reported misusing illicit and prescription drugs.¹⁹ Of those who self-reported misuse, an estimated 63% were employed full or part-time. Similarly, a recent survey by the National Safety Council found that while 75% of employers report negative impacts of opioid use on the workplace, only 17% were able to address the issue.²⁰ More concerning, unintentional overdoses have been reported by states such as Massachusetts as being the leading cause of workplace injury death.²¹

Primary prevention of work-related pain due to unsafe and unhealthy working conditions should be a priority for employers, and labor and health and safety advocates who care about the well-being of workers. Punitive workplace drug policies and stigmatizing workplace cultures are a deterrent to workers who are addicted in getting access to treatment and recovery resources. The importance of addressing these gaps is bolstered when taking into account the estimate that more than 70% of individuals who have a SUD are currently in the work force.¹⁸ In addition, one study estimated that non-medical opioid use cost the U.S almost $125 billion in productivity from 2015−2019.²² Workers with a current SUD miss an average 14.8 days per year, while those on pain medication miss an average of twenty-nine days per year.²³

The benefits to employers and workers of supportive workplace policies include retention of skilled and trained workers, reduction in health care and workers’ compensation costs, improved safety on the job, and contributing to resolving the crisis.²⁴ Recovery friendly workplaces encourage workers to come forward if they are struggling with mental health or substance use issues so they can get into treatment and recovery programs.²⁵ Workers who are in recovery from SUD on average miss 9.5 days of work, less than the average of 10.5 missed days for most employees, an added health and productivity benefit for both employees and the workplace.²³ They also use less health care and workers’ compensation benefits and are less prone to impairment- related accidents. Work is a key element in recovery as it provides stability, meaning, and income. People in recovery who attain stable employment are less likely to return to using opioids and other substances.²³

Parity and Discrimination

Access to treatment is a major obstacle for people with OUD because of the sparsity of providers, discrimination against people with SUD/MH by health care providers and insurance companies, and lack of parity in insurance coverage. New York State has made steps towards addressing these gaps but there are still major obstacles to getting people who are ready for treatment into an appropriate program on a timely basis.

Timothy's Law. In New York State, public demand for health insurers to cover SUD/MH care resulted in several policy interventions. The 2006 enactment of the landmark Timothy's Law, named after a young boy from Schenectady, New York, who committed suicide at the age of twelve after his parents’ insurance plan denied treatment for his behavioral health disorders, prohibited insurance coverage that discriminates against mental health conditions. This law mandates that health insurance policies provide certain minimum benefits for mental illness.²⁶ While some insurers modified their plans to satisfy the law, this did not always translate into an increase in coverage for vulnerable individuals needing access to care.

Federal Mental Health Parity Addiction Equity Act (MHPAEA)/Affordable Care Act Under the Affordable Care Act (ACA)

Two years after Timothy's Law was passed, the federal Paul Wellstone and Pete Domenici MHPAEA was enacted.²⁷ In 2010, the Affordable Care Act (ACA) amended MHPAEA to be applicable to individual health insurance coverage. The ACA asserted that SUD/MH services are Essential Health Benefits (EHBs) as described in the ACA, requiring insurers cover substance use disorder treatment equally to medical and surgical services. Centers of Medicare & Medicaid Services (CMS) listed these services as State Required Benefits (SRBs) for all individual and group plans.²⁸ Under the law, pre-existing conditions are covered, and no spending limits are allowed. Covered services include inpatient MH care; outpatient MH care; outpatient SUD treatment; and inpatient SUD treatment. It also required that all essential health benefits must be covered by ACA impacted plans.²⁷ While the quantitative impact of the passage of MHPAEA and ACA projected an additional sixty-two million people to be covered by these laws,²⁹ in reality, the laws have not been enforced, and plans continue to deny people access to the insurance benefits they are entitled to receive.

Despite this mandate and the urgent need for increased and timely access to SUD treatment, discrimination by health insurers is pervasive. Between 2013 and 2017, utilization of out-of-network SUD inpatient facilities relative to medical/surgical inpatient facilities increased from 4.7 times more likely to 10.1 times.⁹ The Milliman report concluded that restricting access to affordable behavioral health care at a time when escalating overdose and suicide rates continued to climb violated state and federal parity laws. Former Congressman Patrick J. Kennedy (D-R.I.), the co-author of the Mental Health Parity and Addiction Equity Act (MHPAEA), noted that “access restrictions fan the flames of the opioid crisis and suicide deaths, two of the most urgent public health challenges we face as a nation.”³⁰

Discrimination impacts workers when employer-provided health care provides inadequate access to treatment for mental health and substance use care. Many self-insured plans exclude access to treatment altogether.³¹ Workers are often terminated from their employment if they come forward for treatment or test positive on a workplace drug test, resulting in loss of access to care. Even those with health care are subject to discrimination by payors.¹⁸ As mortality rates associated with drug overdose and suicide continued to climb, it became apparent that the discriminatory internal guidelines used by insurers to deny coverage needed greater oversight by government regulators.

Attacking these problems has been a central part of New York State reforms. We summarize here the history of the advocacy for and content of these reforms to provide an example for the OHS movement to join in with recovery activists who want to pursue similar reforms in their states and/or nationally.

New York State Legislative Reform

New York's 2014-2019 Response to The Opioid Epidemic

As overdose deaths continued to climb, recovery advocates recognized that the direct effect of stigma was exacerbating discrimination experienced by people with SUDs – in particular, the difficulty they faced when attempting to access to treatment and recovery support services. SUD advocates recognized they needed to humanize the face of addiction, create a targeted, multi-pronged platform, and mobilize communities across the U.S. to change public policy. A statewide Recovery Community Organization (RCO) in New York State, Friends of Recovery – NY (FOR-NY), developed a strategy that centered around the need to combat addiction by ending the stigma and discrimination of addiction, and that demonstrated the power and promise of recovery.³²

First, like HIV/AIDS activists in the 1980s, families and people with SUDs needed to break the silence around their health condition by sharing their stories of resilience to be humanized in the eyes of the public and the health care system. Second, advocates needed to organize around a set of principles and best practices for building a recovery ecosystem in communities impacted by addiction that included a focus on education on SUD prevention, access to evidence-based treatment and ongoing supports and services to help people build and sustain their recovery. Third, organized recovery community members needed to mobilize as a constituency of consequence and influence with local, state, and national decision-makers to increase funding for capacity-building and for laws that would address the needs of the recovery community. This included addressing racial inequities caused by the War on Drugs that would involve direct inclusion of Black and Indigenous people in decision-making public policy focused on initiatives intended to address historical and current disparities in treatment and recovery support services.

FOR-NY advocated that members of the statewide RCO be part of all discussions pertaining to people affected with and by SUDs. They did so by building local coalitions that issued policy platforms with robust legislative agendas. Thousands of members mobilized each year for a spirited lobby day at the state capital that included education, music, motivational speeches, marching and scheduled meetings with elected officials to advocate for resources and funding to support treatment and recovery supports and services.³³

FOR-NY's partnership with NYS government officials resulted in comprehensive legislative changes to NYS insurance law to address parity and access to SUD/MH treatment and recovery supports. Prior to these reforms it was common for people who were ready to go into treatment to experience delays, as insurance companies spent weeks or months using different assessment tools to determine the appropriate level of care they would approve. Delays in access to care can be fatal, as the window of opportunity for someone who is ready for treatment can be small, and withdrawal or continued use can have lethal consequences. In collaboration with the NYS Department of Health (DOH) the Office of Mental Health (OMH), the Department of Financial Services (DFS) and the Office of Addiction Services and Supports (OASAS), a clinical review tool called the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) was created and mandated for utilization review decisions for all SUD treatment under NYS-issued insurance plans. Expedited time frames for coverage determinations and payment during pendency of appeals was also written into statute. NYS insurers were mandated to use tools designated by the OASAS Commissioner, consistent with the OASAS treatment system. The reforms included a mandate for immediate access to medically necessary SUD inpatient and outpatient treatment with no concurrent review for twenty-eight days that included detox, inpatient, and residential services, as well as immediate access to medication to treat Opioid Use Disorder (OUD) with no prior authorization for formulary forms of Medication-Assisted Treatment (MAT). Commercial plan coverage for naloxone became law.

The reforms addressed affordability by mandating that co-payments for SUD/MH outpatient treatment could not be greater than a primary care visit, and co-payments of one per day were limited to individuals needing treatment services. Insurers were permitted to limit in-network to NYS OASAS licensed, certified or authorized providers, and out-of-state providers were required to be licensed by their own state and otherwise accredited. Medicaid-managed care for court-ordered treatment was limited to NYS OASAS programs when possible, and enhanced network adequacy reporting by insurers and enforcement by DFS and DOH were also written into statute. These measures were created to address predatory brokering practices by some out-of-state-providers that brokered admissions into their program; and to prohibit inaccurate, overinflated insurance directories that misdirected members seeking SUD/MH services. Similarly, retaliation by insurers against providers who complained of parity violations was prohibited by law. Furthermore, NYS insurance plans were mandated to enhance SUD/MH parity law compliance by providing consumers with more detailed information, and NYS parity protections for MH/Autism services were implemented. Hospitals were required to have protocols for MAT (buprenorphine) induction in emergency departments and/or linkages to subsequent care with community MAT providers.³⁴⁻³⁶

Community Health Access to Addiction and Mental Health C are Project

Despite multiple state legislative reforms, in 2018 access to insurance benefits and care for people with OUD and SUD continued to be a primary problem³⁷ U.S. public health officials had became cautiously optimistic when the number of reported drug overdose deaths slowed for the first time since 1999.³⁸ The NYS County Opioid Quarterly report, after years of rising opioid-related overdose deaths among New York State residents, finally saw a 15.9% decrease in 2018, from 2170 deaths in 2017 to 1824 deaths.³⁷ Families and advocates identified that timely access to treatment was still a major contributor to preventable overdose fatalities.

After years of advocacy, the 2018 Executive Budget established the first-in-the-nation Office of the Independent Substance Use Disorder and Mental Health Ombudsman program, Section 33.27 of the Mental Hygiene Law.³⁹ The function of the program, also known as the Community Health Access to Addiction & Mental Healthcare Project (CHAMP), is to assist individuals with an SUD/MH condition with using their health insurance coverage and to identify, investigate, refer and resolve complaints made by, or on behalf of, consumers regarding their coverage.

Data collected by the CHAMP program informs state officials working to resolve parity and access to care issues. Unfortunately, the data that is being collected does not include information about occupation and industry or whether the complainants were in an employer-funded health insurance program. Addressing these gaps would help further illuminate access issues among workers. In one case, a construction union staff contacted CHAMP when a member who was ready to go into treatment needed assistance because his employer's self-insured health care plan did not provide coverage. CHAMP was able to get a residential placement for this worker within twenty-four hours in a state-operated program. This is a clear example of the potential power in an alliance of government, recovery, and labor advocates. Workers also benefit from the other services of CHAMP detailed below.

Sentinel Issues Identified Through CHAMP

CHAMP identifies and tracks sentinel issues impacting access to SUD/MH services in New York State and reports them directly to the Ombudsman Project Director. Sentinel issues detailed below have been identified while providing direct client services, technical assistance, bi-weekly case specialist review meetings, and monthly CHAMP network case review meetings.

Misapplication of the LOCADTR: CHAMP has worked with clients whose health plans have misapplied LOCADTR in determining whether clients’ SUD care is medically necessary. In one case example, Keith (name changed) has co-occurring SUD/MH diagnoses. His plan completed the LOCADTR and determined that the recommended level of care was outpatient, but the plan overrode the recommendation, approving only six days of intensive outpatient (IOP) SUD treatment. After the first six days of treatment, Keith’s plan denied coverage of additional IOP treatment. In denying additional IOP care, the plan failed to complete a new LOCADTR. After a detailed review of Keith's medical records, CHAMP determined that his plan answered at least three sections of the LOCADTR in a manner that was inconsistent with his medical records. CHAMP filed an external appeal for Keith, and the plans’ denial was overturned.

Insurer Delays Processing Consent Forms: Insurers often tell CHAMP they need weeks to “process” client consent forms and authorization of designated representative forms. During the processing period, plans will only speak to CHAMP if the client is also on the line. People in need of MH/SUD care often are not in a position to spend hours on the phone with CHAMP and their insurance plans, particularly if they are receiving treatment in a residential or inpatient SUD program that takes patients’ phones away from them during treatment. This administrative burden slows down CHAMP's advocacy work on behalf of all its clients.

Network Adequacy: CHAMP continues to identify issues with network adequacy. In one case example, Rachel (name changed), a teenage client with co-occurring SUD/MH diagnosis, was admitted to an out-of-state residential facility for treatment. Prior to seeking treatment at the out-of-state-facility, Rachel's parents had contacted her plan, who informed them it had no in-network residential facilities within 120-miles of their home. Rachel's plan denied coverage of her residential treatment in part because the facility was a non-participating provider. Despite the best efforts of CHAMP, this unsatisfactory outcome reveals that further reforms are needed.

Union-Sponsored Plans: CHAMP learned that one major plan which provides health insurance to 450,000 people nationwide does not cover residential MH/SUD treatment. This exclusion has created a barrier to treatment for CHAMP clients with SUD, eating disorders and other mental health conditions. It may also violate the federal parity law, as the plan covers skilled nursing homes for hospice care and covers home care for medical/surgical conditions. Skilled nursing home care for medical/surgical conditions are considered analogous to residential treatment for SUD/MH.

A second issue related to union-sponsored local government plans is that under MHPAEA, self-insured state and local government plans are permitted to opt-out of complying with the law. This exception to MHPAEA compliance is not an issue for most state and local plans in New York, because they are required to follow NYS insurance law, which has incorporated and codified the requirements of MHPAEA. Thus, even if they opt out of complying with MHPAEA, they would be required under state law to comply with parity requirements.

However, CHAMP has had cases of union-sponsored municipal government plans that have opted out of MHPAEA compliance and are also not required to comply with NYS insurance law. These specific plans, employee welfare funds established under Article 44 of the NYS insurance law, are not required to follow state or federal parity law if they have opted out of MHPAEA compliance. People insured by these plans are left vulnerable to the types of disparities in coverage that led to the passage of parity laws. For example, one such plan limits its members to twenty outpatient mental health visits per year. These policies create barriers to SUD/MH care for New Yorkers working in certain municipal governments, and their families.

Solution: A New Model of Care: Recovery Support Services

As recovery community coalitions expanded, so did the call for a more recovery-oriented system of care for people with SUD/MH. Advocates called for a more person-centered approach to SUD/MH that would build upon the strengths and resilience of individuals and families to create new models of care for SUD based on lived experience. Peer recovery support services (PRSS) are peer-driven mentoring, education and support services delivered by individuals who have lived with SUD recovery. These trained peers engage people with SUD outside the four walls of traditional clinical practice. Their proven ability to fill critical care gaps has led to increased state funding to employ certified peer advocates into the full continuum of care.⁴⁰ Research findings provide evidence of the impact of peers based on outcome measures that include reduced substance use and SUD reoccurrence rates, improved retention with treatment and reintegration into the community.⁴¹

In New York State, a shift from the acute care model to a recognition of the chronic nature of SUD transformed the OASAS treatment system. Medicaid managed care approval was obtained from CMS for in-community services, with a new continuing care component that included peer support services and family support navigators. Expanded access to care through the staffing of peers in outpatient programs and emergency departments, and the creation of Centers for Innovative Treatment (COTIs) expanded 24/7 access to treatment and recovery.

Throughout New York State, peer engagement specialists (PES) have been hired to use their experience to engage people on the street and in hospitals, developing brief, person-centered service plans, providing referrals and linkages to needed services. The peers have been particularly effective with people who have been reluctant to participate in traditional behavioral health services. Understanding that families are impacted by the SUD of their loved ones, peers designated as Family Support Navigators (FSN) assist families and individuals with navigating insurance and treatment options and linkages to prevention providers. FSNs develop relationships with local SUD prevention, treatment and recovery services, managed care companies, area SUD councils, and community stakeholders to assist families with accessing life-saving treatment and support services.⁴²

In addition, federal and state funding sources were appropriated for Recovery Community & Outreach Centers (RCOC) to provide health, wellness and other critical supports to people and families recovering from a SUD or seeking recovery services for a loved one. These centers provide a community-based, non-clinical setting that is safe, welcoming and substance-free for any member in the community. RCOCs promote sustained recovery through skill-building, recreation, employment readiness, access to other community services, and the opportunity to connect with peers facing similar challenges.

Conclusion

New York State recovery activists in coalition with community, government, and treatment providers have made great progress in reforming stigmatizing and discriminatory systems of treatment and care for people with OUD and SUD. There is a profound need for labor and OHS activists to initiate or join in these coalitions to advocate for similar reforms throughout the states and federally. Workers and family members are dying due to inadequate access to treatment, discrimination by insurance companies, health care providers, and employers. Even co-workers frequently treat as outcasts fellow workers who are struggling with SUDs. Labor and OHS activists have always made saving workers’ lives a primary focus of their work. Legislation such as New York State's, which establishes programs to fight discrimination, are urgently needed. Education of employers, union officials, community leaders, and workers has always been a priority for safety and health activists. Developing model programs that attack the causes of injuries and stress-related pain at their roots should be a primary function of OHS organizations and labor unions.

Overdose deaths have been surging during the COVID-19 pandemic⁴³ with more than 88,900 Americans dying of drug overdoses over the twelve-month period that ended in October, according to preliminary federal data,⁴⁴ the highest numbers ever recorded since public health officials began tracking the opioid epidemic during the 1990s.⁴⁵ The need for action is urgent.

Advocates across all sectors have laid out similar priorities for addressing the OUD crisis. In an April issue brief by the American Medical Association (AMA), health advocates urge states to take immediate action to:

Adopt Substance Abuse and Mental Health Services Administration and Drug Enforcement Agency rules and guidance in full for the duration of COVID, including flexibility for evaluation and prescribing requirements using telemedicine;

Removing prior authorization, step therapy and other administrative barriers for medications to treat OUD;

Meaningful enforcement of SUD/MH parity laws; and

Implement and support harm reduction strategies to address SUD⁴⁶

The Biden-Harris Administration has made addressing the overdose and addiction epidemic a priority for 2021. In an April statement released by the Office of National Drug Control Policy, priorities to address the exacerbation of COVID and the rise in overdose mortality include:

Expanding access to evidence-based treatment;

Advancing racial equity issues in our approach to drug policy;

Enhancing evidence-based harm reduction efforts, such as overdose antidote naloxone, sterile syringes, fentanyl testing strips, and testing for HIV/HepC;

Enhancing evidence-based prevention efforts to reduce youth substance use;

Reducing the supply of illicit substances;

Advancing recovery-ready workplaces and expanding the addiction work force; and

Expanding access to recovery support services.⁴⁷

Notably absent from the Biden/Harris agenda is a focus on primary prevention of work injury and stress that may lead to mental health, opioid, and other substance use problems. To date, the federal agenda on OUD and employment has been devoted to establishing recovery friendly workplace programs. Labor and OHS advocates can play a key role in achieving this goal while also working on injury prevention. Although the issues of mental health and substance use have not been primary safety and health foci, there are clear connections and common goals: (a) saving workers’ lives, (b) promoting healthy work, (c) identifying and controlling hazards that cause physical or emotional pain and (d) treating workers with dignity. Labor and OHS activists are best situated to challenge discrimination, stigma, and punitive workplace policies. Worker and union involvement is key and joining forces with recovery communities can help bridge gaps in knowledge and resources.

The American Public Health Association (APHA) has issued a policy calling for prevention measures that include destigmatizing MH/SUD in the workplace; preventing workplace pain and reducing emotional distress; supporting workplace education and training; and reforming stigmatizing, punitive workplace SUD programs. In addition, APHA advocates for reforming punitive workplace programs that discourage workers from coming forward when they have mental health or substance use problems with supportive programs that increase access to treatment and recovery resources and increases access to alternative pain treatment to help prevent opioid and other drug misuse. Lastly, APHA calls for cultivating a climate of recovery in the workplace that includes peers supports and recovery-oriented systems of care. These key policy recommendations will reduce the shame and stigma that has been a driving force behind individuals and their families seeking recovery and facilitate health and wellness in the workplace.⁴⁸ The New York State reforms are consistent with these recommendations and may serve as a model for other states and federally.

It is time for labor and OHS activists to join forces with the recovery movement to combat the opioid epidemic and advance an agenda that addresses the impact of the crisis on workers, employers, and communities. Recovery coalitions should reach out to labor and OHS activists and seek their knowledge of workers and employment in advocacy efforts. Timely access to care is a critical issue for workers and community members. Prevention of work-related pain should be recognized as an important pathway to addiction and employers, unions and OHS activists should begin the important work of identifying and controlling hazards and job stressors that are associated with opioid misuse.

Footnotes

Conflicts of Interest

The authors have no conflicts of interest to declare. Stephanie Campbell is the former Executive Director of FOR-NY and the current Director of the NYS Behavioral Health Ombudsman Office.

Funding

Jonathan Rosen received partial funding for his contribution to this publication from MDB Inc. 47QRAA20D0028/75N96020F00166.

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: Xxxxxxx. As noted in disclosures in the article, this author previously served with FOR-NY and currently serves in the NYS Office of the Ombudsman, both organizations which are referenced in the article.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

ORCID iDs

Stephanie M. Campbell

Jonathan Rosen

Authors’ Biographies

Stephanie Campbell received her MA from Columbia University, an MS from University at Albany, and an MSW from New York University. She joined Friends of Recovery – New York (FOR-NY) in 2015 and worked at the state and national levels to humanize, organize and mobilize individuals impacted by addiction. She now serves as the NYS Ombudsman Project Director to oversee a statewide program to help New Yorkers access behavioral health care and is an adjunct professor at NYU Silver School of Social Work.

Jonathan D. Rosen, MS, CIH, FAIHA, of Schenectady, New York, is a safety and health and industrial hygiene consultant for the National Clearinghouse for Worker Safety Training and numerous international labor unions. He is a member of the American Industrial Hygiene Association's Opioids Working Group and the American Public Health Association's Intersectional Council Opioid Work Group. He can be reached at jrosen396@gmail.com.

References

U.S. Department of Health & Human Services. Minority HIV/AIDS Fund. A Timeline of HIV and AIDS, https://www.hiv.gov/hiv-basics/overview/history/hiv-and-aids-timeline/(2021, accessed 29 May 2021).

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