obÌåÓý

Abstract

The proportion of synthetic opioid overdose deaths co-involving stimulants has increased in the United States in recent years. Although persons who use opioids have reported increasing stimulant co-use to maintain workplace productivity and alertness, occupational patterns of co-involvement in fatal overdose have not been systematically investigated. In an exploratory study, data on overdose deaths involving synthetic opioids (e.g., fentanyl) from the 2022 National Vital Statistics System were analyzed to characterize patterns of stimulant co-involvement among U.S. residents aged 15–64 years, stratified by decedents’ usual occupation and industry. Of 69,893 fatal synthetic opioid overdoses, 53.6% involved stimulants. Occupation and industry groups with the highest percentages of synthetic opioid overdose deaths co-involving psychostimulants with abuse potential (psychostimulants) were typically physically demanding (e.g., construction and extraction occupations), whereas categories with highest percentages of cocaine co-involvement were generally less physically strenuous (e.g., business and financial occupations); these patterns might reflect differences in desired drug effects, cost, and geographic availability. Work-related interventions might be useful in preventing the development of substance use disorder by decreasing rates of occupational injuries and workplace stress, connecting workers with substance use disorder to treatment resources, and reducing fatal overdose through harm reduction.

Introduction

Synthetic opioids (mostly fentanyl) now dominate most U.S. opioid overdose deaths, and the proportion of synthetic opioid–involved overdose deaths that co-involved stimulants, such as psychostimulants with abuse* potential (psychostimulants) or cocaine, more than doubled in the United States between 2018 and 2022 (1). Recent qualitative investigations have documented that some persons who use opioids report stimulant co-use to counteract the sedative effects of potent synthetic opioids such as fentanyl, thereby enhancing functionality and alertness in their daily life, particularly in the workplace (2,3). Understanding occupational differences in the types of stimulants co-involved in synthetic opioid-involved overdose deaths might therefore prove useful for tailoring workplace-oriented overdose prevention efforts (4). To this end, National Vital Statistics System (NVSS) data from 2022 were analyzed in an exploratory fashion to examine stimulant co-involvement in synthetic opioid overdoses by decedents’ usual occupation and industry.

Methods

Data Source

Mortality data for U.S. residents aged 15–64 years were extracted from the 2022 NVSS mortality multiple cause of death files, which include death certificate data reported from U.S. vital statistics jurisdictions. Synthetic opioid-involved overdose deaths were identified using International Classification of Diseases, Tenth Revision (ICD-10) underlying cause of death codes for drug poisoning^† and ICD-10 multiple cause of death code T40.4 (poisoning by synthetic opioids other than methadone). Cocaine and psychostimulant involvement were identified using ICD-10 multiple cause of death codes T40.5 and T43.6,^§ respectively; psychostimulants included substances such as methamphetamine, amphetamine, methylphenidate, and 4-methylenedioxy-methamphetamine (MDMA). Occupation and industry information within the NVSS mortality multiple cause file is based on narrative text fields, which are coded to 2012 obÌåÓý Census Occupation and Industry codes through a collaboration with the National Institute for Occupational Safety and Health. Decedents whose occupation or industry were coded as “military” were excluded.

Data Analysis

Numbers of synthetic opioid-involved overdose deaths and the percentages of synthetic opioid-involved overdoses involving any stimulant (i.e., cocaine, psychostimulants, or both) were stratified by decedents’ usual occupation and industry groupings. The percentages of synthetic opioid-involved overdose deaths involving cocaine or psychostimulants within each occupation and industry category were reported. All analyses were conducted using R statistical software (version 4.4.1; R Foundation). This activity was reviewed by obÌåÓý, deemed not research involving human subjects, and was conducted consistent with applicable federal law and obÌåÓý policy.^¶

Results

Synthetic Opioid-Involved Overdose Deaths with Psychostimulants or Cocaine Involved

A total of 69,893 synthetic opioid-involved overdose deaths among U.S. residents aged 15–64 years were identified, 53.6% of which also involved either psychostimulants or cocaine (Table). The occupation and industry groups with highest percentages of synthetic opioid overdoses involving either psychostimulants or cocaine (excluding those labeled “other”) were farming, fishing, and forestry (57.5%) and mining (55.9%). Those with the lowest percentages of such overdoses were healthcare practitioners and technical (46.7%) occupations and utilities industries (43.4%).

Overdose Deaths and Occupation

Occupations with the highest percentages of synthetic opioid-involved overdoses involving psychostimulants (excluding those labeled “other”) were farming, fishing, and forestry (41.7%); arts, design, entertainment, sports, and media (35.5%); construction and extraction (33.0%); installation, maintenance, and repair (31.9%); and architecture and engineering (30.5%) (Figure 1). Occupations with the highest percentages of synthetic opioid-involved overdoses involving cocaine were healthcare support (34.2%); community and social services (33.5%); business and financial (31.6%); legal (31.5%); and protective services (30.5%).

Overdose Deaths and Industry

Industries with the highest percentages of synthetic opioid overdose deaths involving psychostimulants were mining (42.5%); agriculture, forestry, fishing, and hunting (39.3%); management of companies and enterprises (37.5%); construction (33.0%); and arts, entertainment, and recreation (32.7%) (Figure 2). Industries with the highest percentages of such deaths with cocaine involvement included healthcare and social assistance (31.8%); management of companies and enterprises (31.3%); finance and insurance (31.2%); real estate, rental, and leasing (30.4%); administrative, support, and waste services (30.8%); education services (29.5%); and transportation and warehousing (29.7%).

Discussion

In this exploratory analysis of occupational patterns of psychostimulant or cocaine involvement in synthetic opioid-involved overdose deaths, occupations and industries with high percentages of synthetic opioid-involved overdoses co-involving psychostimulants tended to be those likely involving manual labor. Occupations and industries with higher percentages of cocaine involvement were those often considered to be less physically strenuous.

One potential explanation for these patterns is that psychostimulants are better suited for counteracting opioid-involved lethargy in physically demanding occupations, particularly given that the drug effects of psychostimulants such as methamphetamine are longer-lasting than those of cocaine (5). Previous studies have observed that persons who use opioids report intentional co-use of methamphetamine to improve functioning in their fast-paced, manual occupations (2). Similarly, workers in construction and landscaping jobs report using methamphetamine to reduce pain associated with working in these labor-intensive jobs (6). Another contributing factor could be the relative difference in cost between psychostimulants and cocaine. Persons who work in more physically demanding occupations (e.g., farming, fishing, and forestry occupations) are frequently paid lower wages than are those in occupations requiring less manual labor (e.g., business and financial occupations) (7); use of psychostimulants such as methamphetamine might therefore be more prevalent within certain occupation groups given that it tends to be less expensive than cocaine (3,8).

Geography might also play a role in the overlap between employment in certain industries and co-use of opioids with specific stimulants. For instance, data indicate that recent increases in psychostimulant-involved opioid overdose deaths were most rapid in the Appalachian region (9). Compared with other regions, Appalachia has higher rates of employment in the mining industry (10), which had the highest percentage of psychostimulant involvement of any industry in this study. Conversely, industries with high cocaine involvement, such as education services or healthcare and social assistance, might be less geographically localized. Others, such as financial services, might be more common in urban areas, where rates of cocaine-involved overdoses are higher than are those in rural areas (1).

Limitations

The findings in this report are subject to at least five limitations. First, although qualitative reports suggest that many persons who co-use opioids and stimulants do so intentionally, particularly in the context of counteracting opioid-related lethargy in the workplace, NVSS does not include data on intent of co-use. Second, usual (or longest held) occupation and industry within NVSS are collected as part of death certificate reporting; for some decedents, there might be a discrepancy between what occupation or industry they were usually employed in and that in which they were employed at the time of death. Third, this report focused on stimulant involvement in synthetic opioid-involved overdose deaths, and its findings cannot be generalized to opioid overdoses not involving synthetic opioids. However, as of 2023, synthetic opioids other than methadone were involved in approximately 70% of overdose fatalities in the U.S. and were therefore the focus of this report (1). Fourth, within-group differences in proportions in stimulant co-involved deaths tended to be small. Finally, this analysis was exploratory, with no guiding hypotheses; therefore, these findings should be considered hypothesis-generating and warrant confirmation.

Implications for Public Health Practice

These hypothesis-generating findings warrant confirmation but point to a potential role for work-related substance use and overdose prevention interventions. The National Institute for Occupational Safety and Health has developed the Workplace Supported Recovery (WSR) initiative, which guides employers in bolstering the employment and retention of persons with substance use disorders and in facilitating access to treatment (4). The WSR initiative also aims to address the determinants of substance use disorders and overdose through the reduction of work-related risk factors, including occupational injury and work-related stress (4). To maximize their potential benefit, WSR and other workplace-oriented interventions might need to tailor their approaches based on potential psychostimulant or cocaine use within a given occupation or industry. Nevertheless, increased access to harm reduction resources and evidence-based treatments for opioid use disorder and stimulant use disorder, both within and outside of a workplace setting, will be needed to address the current U.S. overdose crisis.