Addiction to heroin and other opiates reaches across all socioeconomic boundaries, but a new study claims that young men in the building trades on Cape Cod are five times more likely than others to overdose and die.
The findings, presented in a study by the Barnstable County Department of Human Services issued last month, ultimately raises as many questions as it answers. Researchers don't know why, for instance, some people who enter the workforce directly from high school appear to be at greater risk of fatal overdoses than people who have attained higher education.
By The Numbers
The study, prepared for the county's regional substance abuse council, analyzed death records from Barnstable County between 2004 and 2014, identifying 281 opioid-related overdose deaths. Researchers compiled the demographic information from each of those victims, and followed up by interviewing four individuals and 25 others as part of three focus groups.
During the 10-year study period, 72 percent of those who died of overdoses were male, and the age group with the largest number of deaths was 30 to 34. Deaths by race generally mirrored the county's population by race, but 69 percent of those who died by overdose had a high school education or less, compared to 31 percent of the general population.
Using a relative risk calculation, those working in trades and services – including construction, health care support, fishing, landscaping, restaurant work, plus homemakers – had more than double the risk of dying from an opioid overdose than those in other occupations. But those working in construction, a subset of trades and services, were at nearly five times greater risk of a fatal overdose than were workers in other jobs.
To flesh out the statistics, researchers spoke with three focus groups of high school students as well as social service workers who help opioid-addicted people. They also interviewed a lobsterman from Eastham to learn about drugs in the commercial fishing industry. They were unable to interview current injection-drug users.
The high school students interviewed reported physical and emotional isolation on the Cape, particularly during the winter season.
“In addition, over one-third of participants in the youth focus groups saw their future success as depending on whether or not they would be able to leave Cape Cod in the future,” the study reads.
The social service workers reported that many of their clients are young men who work in the trades and services, “and work through their injuries by maintaining themselves on low-level doses of prescribed pain medications,” the study reads. “After their doctors restrict their access to prescription opioids they began using heroin and other opioids obtained on the black market to manage their physical pain and to continue to work.”
The lobsterman who was interviewed indicated that he does not use drugs, but said he knows several commercial fishermen who died in overdoses. “He noted that employers may have a role to play in reducing overdoses and death and in supporting recovery, and he provided valuable insight into the seasonality of work on Cape Cod and the potential effects of a cash economy upon substance misuse among seasonal workers,” the study reported.
Occupational Injuries Or Social Factors?
Harwich Youth Counselor Sheila House the said it's disheartening but not necessarily surprising that people who work in the trades are falling victim to opiate overdoses.
“On the Cape, I've been seeing a lot of those demographics,” she said. House blamed the availability of opioid painkillers, which became much more prevalent in the early 1990s. “This used to be end-of-life medication,” House said. It then became routine for health care providers to make those drugs available even for relatively minor injuries, she noted, adding that those in physically taxing trades can sometimes turn to self-medication, which can lead to addiction.
“It's concerning, obviously,” said Robert Sanborn, III, the superintendent of Cape Tech. “If we take these statistics as fact, which we're going to assume that, we've got a problem,” he said. “And it's a problem that's bigger than a school.”
In addition to a ninth grade curriculum that includes health education about addiction, Cape Tech has addiction counselors in the building three times a week to speak with students. But the prime focus, Sanborn said, is on keeping students from injuring themselves “and then the whole chain of events that occurs when someone gets injured and goes to a health care provider. We've heard this story before,” he said.
Cape Tech vocational classes focus on helping students meet standards set by the federal Occupational Safety and Health Administration, and requires every student to complete 10 hours of OSHA training, “because safety is paramount.” But Sanborn said the county study raises additional questions, like why overdose deaths are as high as they are in trades like landscaping and food service. “Those certainly don't sound as hazardous as the construction trade,” he said.
Vaira Harik, the senior project manager for the county study, agreed that the work raises questions.
“We were surprised to see such disproportionate representation of decedents with an education attainment level of high school or less,” Harik wrote in an email to The Chronicle. “Clearly there is interaction between relatively low educational attainment and the types of occupational roles available. There is also interaction between the occupation and risk for death from opioid overdose. However, we caution against drawing conclusions from these associations yet. Correlation does not imply causation.”
The study hints at social factors that might contribute to the problem, like the possibility that those with a history of substance abuse or incarceration might be unable to find employment in other sectors and could turn to the trades and service industries. It notes that alcohol use is culturally accepted among some such workers.
“Substance misuse is common and accepted. ('It's hard to be the sober person on a crew'),” the report reads.
Unstable income can discourage healthy living, the report adds, and a lack of employer-provided health insurance might affect how workers manage their pain, the researchers wrote.
Sanborn said that while he worries that the numbers could fuel a stigma against those who go directly from high school to the world of work, the statistics point to a problem. He said he plans to speak with the authors of the study to learn more, and will bring the issue to the Cape Tech school committee.
A Way Ahead
The county study has been presented to the regional substance abuse council and offers some preliminary recommendations, like increasing support services in the workplace through employee assistance programs, peer-based interventions and apprenticeships. The researchers also emphasized the need for workplace safety training, and the availability of the overdose-reversing drug Narcan.
Sanborn and House agree that progress has been made since 2014, the final year of the study. Narcan is much more widely available than before, and is now stocked by first responders and school nurses.
“There are lots of inroads being made,” House said. In recent years, databases have been developed to keep patients from “pill-shopping” between one health care provider and the next. Clinicians are being trained in strategies for prescribing painkillers, “and maybe prescribing less,” she said. And a state law passed last year limits health care providers to prescribing only a seven-day initial supply of opioid painkillers.
House said she would like the opportunity to work more closely with Cape Tech to explore the possibility of new types of training, and to find out more about what happens to Tech students once they leave the school.
“I'm very optimistic that having this information is going to make it easier to identify where we go next,” House said.