United States: Adopting A Naloxone In The Workplace Program: What Employers Need To Know

These days it seems like almost every American has either been directly impacted by the increase in opioid-related deaths or knows someone who has. My own experience is indirect but demonstrated to me the far-reaching impact of opioid deaths. My daughter's brother-in-law died of an opioid overdose in February 2017. Both my son and daughter knew Travis for many years before my daughter married his brother, my now son-in-law. He was the little brother of their group. The tag-along. The sweet kid who you bought ice cream for or raced through Walt Disney World for one last ride on Space Mountain before closing. His death was devastating to his immediate family and close friends and triggered shock and guilt for both my children that continues to this day.

Employers and the opioid crisis

My family is not alone in this experience. Given the statistics, it is not an overstatement to refer to U.S. opioid-related deaths as a "crisis." From 1999 to 2017 more than 700,000 people died in the U.S. from a drug overdose.1 Of this number, almost 400,000 were due to an overdose involving an opioid.2 In 2017, around 68% of the more than 70,200 drug overdose deaths involved an opioid.3 According to the Centers for Disease Control, on average 130 people in the U.S. die daily from an opioid overdose.4

More and more discussion at conferences and in articles suggest that employers are on the front lines of the opioid crisis, and, therefore in the best position to take action. Arguably, employers have a vested interest in addressing the crisis. U.S. employers provide health benefits to more than 178 million people.5 According to the Kaiser Family Foundation, employer health plan expenditures on opioid addiction increased by more the 800% since 2004 to $2.6 billion in 2016.6 Emergency room visits attributable to opioid-related incidents doubled between 2005 and 2015.7 In the same time period, inpatient stays attributable to opioid-related events increased by 84%.8 In addition to health plan expenditures, it is estimated that, on average, employers lose $10 billion per year from lost work and lower employee productivity due to the crisis.9 In short, the opioid crisis is having a direct and significant impact on employers' bottom lines.

Unions are beginning to include the opioid crisis in negotiations. According to a March 21, 2019 article in the Detroit Free Press, Rory Gamble, a United Auto Workers (UAW) international vice president and director of the UAW Ford Department, identified combating opioids as a key priority for the collective bargaining talks scheduled for summer 2019.10

U.S. Surgeon General appeal for employer action

In April 2018, the United States Surgeon General, Jerome Adams, spoke to the National Business Group on Health and asked employers to assume a direct role in combatting the opioid crisis.11 Among recommendations made by the Surgeon General was that employers include the opioid reversal agent naloxone (also commonly known by its brand name, Narcan) in their onsite first aid supplies. The Surgeon General stated,

"For a heart attack, we train employees how to do CPR until the paramedics arrive. Why is that not the case with naloxone and Narcan? We need to make these emergency treatments as ubiquitous as knowing CPR and calling for a defibrillator when someone is having a heart attack, or using an EpiPen when someone's having an allergic reaction."12

Notwithstanding the Surgeon General's appeal to employers in April 2018, providing access to naloxone in the workplace is a decision to be made by each employer.

Considerations before adopting a workplace naloxone program

In late 2018, the National Institute for Occupational Safety and Health (NIOSH) published a fact sheet, titled "Using Naloxone to Reverse Opioid Overdoes in the Workplace: Information for Employers and Workers." The publication is addressed to employers that are considering implementing a naloxone program to prevent overdose deaths in the workplace.

In Publication 2019-101, NIOSH encourages employers to consider the following factors before adopting a workforce naloxone program:13

  • Does your state allow the administration of naloxone by non-licensed providers in the event of an overdose emergency?
  • A related consideration: Does your state's Good Samaritan law14 cover emergency naloxone administration?
    • According to the Network for Public Health Law,15 all 50 states and the District of Columbia have laws relating to the administration of naloxone. The Network's website includes a table describing the scope of protection provided to lay individuals under these laws as of December 31, 2018.16
  • Are the risks for opioid overdose greater in your industry or among occupations at your workplace?
  • Are the risks for opioid overdose greater in your geographic location?
  • Does your workplace have clients or other visitors that may be at increased risk of opioid overdose?
  • Have you experienced an opioid overdose at your workplace or is there evidence of opioid drug use onsite?
  • How quickly can professional emergency response personnel access your workplace to provide assistance?
  • Do you have staff willing to be trained and willing to provide naloxone?
  • Do you provide other first aid or emergency response interventions in your workplace, such as automated external defibrillators (AEDs) and first aid kits?  Can naloxone be added?

Steps to establish a program

NIOSH suggests that employers take the following steps to establish a workplace naloxone program:17

  • Conduct a risk assessment before commencing the naloxone program that includes the following elements:
    • Identify employees, clients, or visitors at risk of overdose.
    • Identify staff willing to take training and provide naloxone.
    • Meet with local emergency responders and medical professionals who treat opioid use disorders.
  • Assess potential liability and other legal issues related to such a program.
  • Develop procedures for documenting incidents, including safeguarding the privacy of affected individuals.
  • Define roles and responsibilities for all persons designated to respond to an overdose.
    • Include these roles and responsibilities in first aid or emergency response policies and procedures, such as first aid kits, AEDs, and training for first-aid providers.
  • Train staff to lower their risks when providing naloxone.
    • Recognize the symptoms of possible opioid overdose;
    • Call 911 to seek immediate emergency medical assistance
    • Know the dangers of exposure to drug powders or residue;
    • Assess the area for safety concerns before entering;
    • Exercise caution if drug powders or residues are visible and exposure to staff could occur;
    • Wait for emergency responders when drug powders, residues, or other unsafe conditions are seen;
    • Use personal protective equipment (e.g., nitrile gloves) during all responses to protect against chemical or biological exposures including opioid residues, blood, or other body fluids;
    • Administer naloxone and recognize when additional doses are needed;
    • Address symptoms that may arise during the response of the overdosing individual, such as agitation or combativeness;
    • Use additional first aid, CPR/basic life support measures for related reactions such as respiratory and cardiac arrest.
  • Stock a minimum of two doses of naloxone.
    • Some workplaces may choose to stock more depending on the characteristics of the workplace.
    • Consider replacement time when determining the number of doses to stock.
  • Store naloxone in accordance with manufacturer instructions for storing naloxone.
  • Store personal protective equipment and other first aid equipment close to the naloxone for quick response
  • Develop a plan for immediate care by professional healthcare providers, referral for follow-up care, and ongoing support for any worker who has overdosed.
  • Evaluate your program periodically for new risks, maintain equipment and restock of naloxone as needed.
  • Monitor developments on best practices for naloxone workplace programs.
  • Schedule regular refresher training.18

Conclusion

Statistics are not readily available regarding the percentage of U.S. employers that currently include naloxone as part of their emergency response interventions.

One insurer, Blue Cross and Blue Shield of Massachusetts, instituted a pilot program in late 2018 under which it provides free opioid overdose reversal toolkits to select large employers in industries with high opioid overdose rates.19 Each kit contains two doses of naloxone in nasal spray form. Each kit also has a surgical mask, gloves and instructions for administering naloxone. Blue Cross Blue Shield also provides support in naloxone administration so employers can train their employees in the administration of naloxone. The pilot program could provide prototype by which employers can adopt workplace naloxone programs with a degree of confidence.

Given the scope of the opioid crisis and the heavy toll on employers and employees alike, employers should consider a risk/benefit analysis to determine whether to provide naloxone as part of their emergency response interventions in their workplaces.

Footnotes

[1] https://www.cdc.gov/drugoverdose/epidemic/index.html

[2] Id.

[3] Id.

[4] Id.

[5] https://www.americanbenefitscouncil.org/pub/16e9bbe3-9b27-d7aa-ec7c-e9f86419c786

[6] https://www.kff.org/health-costs/press-release/analysis-cost-of-treating-opioid-addiction-rose-rapidly-for-large-employers-as-the-number-of-prescriptions-has-declined/

[7] Opioid-Related Demand for Emergency and Inpatient Care Continues to Rise, Politico Pro, Datapoint on Health Care (October 1, 2018)

[8] Id.

[9] American Society of Addiction Medicine cited in https://www.workforce.com/2016/02/02/pain-points-2/

[10] https://www.freep.com/story/money/cars/2019/03/21/worker-injury-opioid-addiction-uaw-contract/3213920002/

[11] https://www.shrm.org/resourcesandtools/legal-and-compliance/employment-law/pages/employers-naloxone.aspx

[12] Id.

[13] https://www.cdc.gov/niosh/docs/2019-101/program.html

[14] Good Samaritan Laws are laws granting some immunity to those providing emergency assistance, including those seeking emergency medical help in the case of an opioid overdoses.

[15] https://www.networkforphl.org/resources_collection/2017/06/08/396/resource_legal_interventions_to_reduce_overdose_mortality

[16] Id.

[17] https://www.cdc.gov/niosh/docs/2019-101/establish.html

[18] Id.

[19] https://home.bluecrossma.com/opioid-toolkit-pilot-program

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