Improving Health and Employment Outcomes Through Workplace Opioid Policies
Phase: NA
Conditions: Opioid-Related Disorders
Sponsor: Washington University School of Medicine

 
 
 
Feasibility of Implementing Workplace Opioid Guidelines 
Intervention Protocol 1.0 
National Clinical Trial (NCT) Identified Number:  05387408 
Principal Investigator:  Ann Marie Dale 
Policies 
Sponsor: Washington University School of Medicine  
Grant Title: Improving Health and Employment Outcomes Through Workplace 
Opioid  
Grant Number: 1R34DA050044-01 
Funded by: NIH Institute  
Version Number:  1.0 
December 18, 2023 
 
 

NIH Protocol Template for Behavioral and Social Sciences Research Involving Humans 
CONFIDENTIALITY STATEMENT 
This document is confidential communication. Acceptance of this document constitutes agreement by the 
recipient that no unpublished information contained herein will be published or disclosed without prior 
approval of the Principal Investigator or other participating study leadership and as consistent with the 
NIH terms of award.  
 

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Table of Contents 
STATEMENT OF COMPLIANCE ............................................................................................................................. 1 
INVESTIGATOR’S SIGNATURE .............................................................................................................................. 2 
1 
PROTOCOL SUMMARY ............................................................................................................................... 3 
1.1 
Schema ................................................................................................................................................. 4 
1.2 
Schedule of Activities .......................................................................................................................... 6 
2 
INTRODUCTION ............................................................................................................................................ 7 
2.1 
Study Rationale .................................................................................................................................... 7 
2.2 
Background........................................................................................................................................... 7 
2.3 
Risk/Benefit Assessment .................................................................................................................. 12 
2.3.1 
Known Potential Risks ................................................................................................... 12 
2.3.2 
Known Potential Benefits .............................................................................................. 12 
2.3.3 
Assessment of Potential Risks and Benefits .............................................................. 12 
3 
OBJECTIVES AND ENDPOINTS .............................................................................................................. 13 
4 
STUDY DESIGN ........................................................................................................................................... 14 
4.1 
Overall Design .................................................................................................................................... 14 
4.2 
Scientific Rationale for Study Design.............................................................................................. 15 
4.3 
Justification for Intervention ............................................................................................................. 15 
4.4 
End-of-Study Definition ..................................................................................................................... 15 
5 
STUDY POPULATION ................................................................................................................................ 16 
5.1 
Inclusion Criteria ................................................................................................................................ 16 
5.2 
Exclusion Criteria ............................................................................................................................... 16 
5.3 
Lifestyle Considerations .................................................................................................................... 17 
5.4 
Screen Failures .................................................................................................................................. 17 
5.5 
Strategies for Recruitment and Retention ...................................................................................... 17 
6 
STUDY INTERVENTION(S) OR EXPERIMENTAL MANIPULATION(S) ............................................ 17 
6.1 
Study Intervention(s) or Experimental Manipulation(s) Administration ...................................... 18 
6.1.1 
Study Intervention or Experimental Manipulation Description ................................. 18 
6.1.2 
Administration and/or Dosing ....................................................................................... 18 
6.2 
Fidelity ................................................................................................................................................. 19 
6.2.1 
Interventionist Training and Tracking .......................................................................... 19 
6.3 
Measures to Minimize Bias: Randomization and Blinding ........................................................... 19 
6.4 
Study Intervention/Experimental Manipulation Adherence.......................................................... 19 
6.5 
Concomitant Therapy ........................................................................................................................ 19 
6.5.1 
Rescue Therapy ............................................................................................................. 19 
7 
STUDY INTERVENTION/EXPERIMENTAL MANIPULATION DISCONTINUATION AND 
PARTICIPANT DISCONTINUATION/WITHDRAWAL ......................................................................................... 20 
7.1 
Discontinuation of Study Intervention/Experimental Manipulation ............................................. 20 
7.2 
Participant Discontinuation/Withdrawal from the Study ............................................................... 20 
7.3 
Lost to Follow-Up ............................................................................................................................... 20 
8 
STUDY ASSESSMENTS AND PROCEDURES ..................................................................................... 21 
8.1 
Endpoint and Other Non-Safety Assessments .............................................................................. 21 
8.2 
Safety Assessments .......................................................................................................................... 23 
8.3 
Adverse Events and Serious Adverse Events ............................................................................... 23 
8.3.1 
Definition of Adverse Events ........................................................................................ 23 
8.3.2 
Definition of Serious Adverse Events .......................................................................... 23 
8.3.3 
Classification of an Adverse Event .............................................................................. 23 

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8.3.4 
Time Period and Frequency for Event Assessment and Follow-Up ....................... 24 
8.3.5 
Adverse Event Reporting .............................................................................................. 24 
8.3.6 
Serious Adverse Event Reporting ............................................................................... 24 
8.3.7 
Reporting Events to Participants ................................................................................. 24 
8.3.8 
Events of Special Interest ............................................................................................. 25 
8.3.9 
Reporting of Pregnancy ................................................................................................ 25 
8.4 
Unanticipated Problems .................................................................................................................... 25 
8.4.1 
Definition of Unanticipated Problems .......................................................................... 25 
8.4.2 
Unanticipated Problems Reporting .............................................................................. 25 
8.4.3 
Reporting Unanticipated Problems to Participants ................................................... 26 
9 
STATISTICAL CONSIDERATIONS .......................................................................................................... 26 
9.1 
Statistical Hypotheses ....................................................................................................................... 26 
9.2 
Sample Size Determination .............................................................................................................. 27 
9.3 
Populations for Analyses .................................................................................................................. 27 
9.4 
Statistical Analyses............................................................................................................................ 28 
9.4.1 
General Approach .......................................................................................................... 28 
9.4.2 
Analysis of the Primary Endpoint(s) ............................................................................ 28 
9.4.3 
Analysis of the Secondary Endpoint(s) ....................................................................... 29 
9.4.4 
Safety Analyses .............................................................................................................. 30 
9.4.5 
Baseline Descriptive Statistics ..................................................................................... 30 
9.4.6 
Planned Interim Analyses ............................................................................................. 30 
9.4.7 
Sub-Group Analyses ..................................................................................................... 30 
9.4.8 
Tabulation of Individual Participant Data .................................................................... 30 
9.4.9 
Exploratory Analyses ..................................................................................................... 31 
10 
SUPPORTING DOCUMENTATION AND OPERATIONAL CONSIDERATIONS .............................. 31 
10.1 
Regulatory, Ethical, and Study Oversight Considerations ........................................................... 31 
10.1.1 
Informed Consent Process ........................................................................................... 31 
10.1.2 
Study Discontinuation and Closure ............................................................................. 32 
10.1.3 
Confidentiality and Privacy ........................................................................................... 32 
10.1.4 
Future Use of Stored Specimens and Data ............................................................... 33 
10.1.5 
Key Roles and Study Governance .............................................................................. 34 
10.1.6 
Safety Oversight ............................................................................................................. 34 
10.1.7 
Clinical Monitoring .......................................................................................................... 34 
10.1.8 
Data Handling and Record Keeping ............................................................................ 35 
10.1.9 
Protocol Deviations ........................................................................................................ 36 
10.1.10 
Publication and Data Sharing Policy ........................................................................... 36 
10.1.11 
Conflict of Interest Policy .............................................................................................. 37 
10.2 
Additional Considerations ................................................................................................................. 37 
10.3 
Abbreviations and Special Terms ................................................................................................. 120 
10.4 
Protocol Amendment History ......................................................................................................... 121 
11 
REFERENCES ........................................................................................................................................... 121 
 
 
 
 

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STATEMENT OF COMPLIANCE 
 
The trial will be carried out in accordance with International Council on Harmonisation Good 
Clinical Practice (ICH GCP) and the following:  
 
• 
United States (US) Code of Federal Regulations (CFR) applicable to clinical studies (45 CFR Part 
46, 21 CFR Part 50, 21 CFR Part 56, 21 CFR Part 312, and/or 21 CFR Part 812).  
 
National Institutes of Health (NIH)-funded investigators and clinical trial site staff who are 
responsible for the conduct, management, or oversight of NIH-funded clinical trials have 
completed Human Subjects Protection and ICH GCP Training. 
 
The protocol, informed consent form(s), recruitment materials, and all participant materials will 
be submitted to the IRB for review and approval. Approval of both the protocol and the consent 
form(s) must be obtained before any participant is consented. Any amendment to the protocol 
will require review and approval by the IRB before the changes are implemented to the study. All 
changes to the consent form(s) will be IRB approved; a determination will be made regarding 
whether a new consent needs to be obtained from participants who provided consent, using a 
previously approved consent form.] 
 
 

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INVESTIGATOR’S SIGNATURE 
The signature below constitutes the approval of this protocol and provides the necessary assurances 
that this study will be conducted according to all stipulations of the protocol, including all statements 
regarding confidentiality, and according to local legal and regulatory requirements and applicable US 
federal regulations and ICH guidelines, as described in the Statement of Compliance above. 
 
Principal Investigator or Clinical Site Investigator: 
Signed: 
 
Date: 
12/18/23 
 
Name*:  Ann Marie Dale 
 
Title*: Professor of Medicine and Occupational Therapy 
 
Investigator Contact Information 
Affiliation*: Washington University in St. Louis 
Address: 4523 Clayton Avenue, MSC 8005-94-155, St. Louis, MO 63110 
Telephone: 314-454-8470 
Email: amdale@wustl.edu 
 
 
 

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1 
PROTOCOL SUMMARY 
 
Title: 
Improving Health and Employment Outcomes Through Workplace 
Opioid Policies 
Grant Number: 
1R34DA050044-01 
Study Description: 
We will implement the intervention in three local union health funds, 
evaluate the implementation using the RE-AIM framework, and collect 
the data needed to measure effectiveness of the workplace opioid 
guidelines. We will measure a) the health fund’s adoption of policies 
and programs; b) opioid prescriptions, chronic opioid use, and OUD in 
health claims and pharmacy data; c) changes in knowledge, attitudes, 
and beliefs of employers, health fund administrators, and employees; 
and d) employee participation in employee assistance programs and 
healthcare recovery services. 
Objectives*: 
 
The overall aim is to evaluate the feasibility of implementing workplace 
opioid guidelines in the construction trades; define and collect 
measures of implementation and effectiveness. 
The primary objective is to evaluate a change in opioid misuse and 
opioid use disorder from medical and pharmacy claims, and worker 
surveys following a change in policies and programs within health 
funds. The secondary objective is to evaluate a change in lost time and 
willingness to seek help among workers who are struggling with opioid 
misuse or substance use problems on worker surveys. 
Endpoints*: 
The primary endpoints are a) the change in the proportion of workers 
with opioid misuse, opioid use disorder and opioid overdose: 
administrative data and b) in the proportion of workers with opioid 
misuse: worker surveys from baseline to 6-months. The secondary 
endpoints are a) the change in the proportion of workers with lost 
time: worker surveys and b) the proportion of workers who are willing 
to seek help: worker surveys from baseline to 6-months. 
Study Population: 
Participants will be members of three participating union health funds. 
We anticipate these unions will have 33300 members enrolled 
between 2019-2023, which is the period of data used for the trial. All 
union members of the participating health funds will be enrolled in the 
study. We expect the demographics of the participants will reflect the 
demographics of the membership, which is approximately 8% female, 
and 90% Caucasian. All participants will be located within the 
geographical region of the union membership. 
Phase* or Stage: 
This is a feasibility trial. 

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Description of 
Sites/Facilities Enrolling 
Participants: 
We will ask each health fund to share the invitation for participating in 
the member worker surveys although the data will be collected 
electronically and stored on the Washington University secure servers. 
The union health funds will use their communication channels to reach 
their members.  
Description of Study 
Intervention/Experimental 
Manipulation: 
This is a single arm, intervention feasibility trial to evaluate the 
researcher’s ability to enroll union health funds, collect secondary 
claims data and primary survey data, and to monitor the health funds 
use of the intervention. The intervention will be a comprehensive 
evidence-based set of guidelines shared with each participating union 
health fund and monitored for use of the guidelines through monthly 
meetings with the research team for 6 months. Implementation 
process measures will document the use of the intervention.  
Study Duration*: 
We will enroll participants from May 2022 through May 2023. 
Participant Duration: 
Each participant will be invited to complete a survey at baseline and at 
6-months, although we will not collect identifiers that link the data 
between time points so each participant will be enrolled for one data 
collection. 
1.1 
SCHEMA  

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Flow Diagram (single arm feasibility trial) 
 
Enroll health funds 
 
  
 
 
Baseline data 
 
 
 
 
 
 
 
Introduction to  
the Intervention 
 
 
Monthly  
Meetings x5 
 
 
 
6-month data  
collection  
 
 
 
 
 
12-month data  
Collection (time 
permitting) 
 
 
 
Total N: 3 Health Funds with approximately 33300 members will be enrolled 
Complete Data Transfer and Use agreement with each Health Fund. 
Conduct an interview with the health administrator to learn about the organization’s 
policies, programs, benefits, and activities related to opioid prescriptions and monitoring 
utilization. 
Collect all medical and pharmacy claims covering the three year period prior to start of 
the study (May 2019-May 2022) from each health fund. 
Collect 300 worker (member) surveys from each participating health fund to learn about 
their knowledge, attitudes, and beliefs regarding opioid risks and opioid use. 
Collect 300 worker surveys from each health fund.  
Conduct an interview with the health administrator to summarize changes made to the 
health plan over the prior 6-months and future plans for change.  
Have the Health Administrator complete the needs assessment. 
Introduce the Workplace Opioids Guidelines to the Health Administrator 
Meet monthly to discuss the health administrator’s ideas for change to their health plans 
program based on the Workplace Opioids Guidelines. 
Complete the process assessment form. 
Collect the health claims data covering the intervention period (May 2022-May 2023) 
If feasible, collect 300 worker surveys from each health fund.  
 

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1.2 
SCHEDULE OF ACTIVITIES  
 
 
 
 
 
 
 
Baseline 
 
Visit 1 
Day 1 
Visit 2 
Day 30 ±7 
Visit  3 
 Day 60 ±7 
Visit  4 
Day 90 ±7 
Visit  5 
Day 120 ±7 
Visit  6 
Day 150 ±7 
 
Visit 7  
Day 180 ±30 
Visit 8 
Day 360 ±30 
Enroll Union Health Funds 
X 
 
 
 
 
 
 
 
 
Sign Data Transfer and Use 
Agreement (DUA) 
X 
 
 
 
 
 
 
 
 
Interview Health Administrator 
X 
 
 
 
 
 
 
 
 
Collect medical and pharmacy 
claims 
X 
 
 
 
 
 
 
 
X 
Collect worker surveys 
X 
 
 
 
 
 
 
X 
 
Complete process assessment 
 
X 
X 
X 
X 
X 
X 
X 
X 
Outcome Evaluation 
 
 
 
 
 
 
 
 
 
Opioid misuse and 
opioid use disorder from 
administrative claims 
X 
 
 
 
 
 
 
 
 
X 
Opioid misuse from 
worker survey 
X 
 
 
 
 
 
 
X 
 
Self-reported lost work time from 
worker survey 
X 
 
 
 
 
 
 
X 
 
Self-reported willingness to seek 
help from worker survey 
X 
 
 
 
 
 
 
X 
 

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2 
 
INTRODUCTION 
 
2.1 
STUDY RATIONALE  
 
The overall goal of this trial is to develop and test the feasibility of implementing best evidence workplace 
policy guidelines to reduce opioid use and misuse among working age people, the population primarily 
affected by the opioid crisis. This study will develop workplace opioid guidelines to reduce prescription 
opioid use, decrease opioid misuse and opioid use disorder (OUD), and improve health-related 
employment outcomes. After development of the guidelines, there will be a test of the feasibility of 
implementing these guidelines among construction workers, an occupational group at uniquely high risk 
of opioid use and fatal overdose. This project is significant because it will define best practices for 
workplace opioid policies, adapt these policies to a high-risk occupational group (construction workers), 
and evaluate the feasibility of implementing best practice workplace opioid guidelines via employment-
based health insurance plans and employers. The research team brings together national leaders in 
workplace health, substance use disorders, and the construction industry to develop an intervention 
based on implementing new workplace opioid guidelines. This project is innovative because it targets a 
high-risk population through employment-linked health insurance and other workplace policies - an 
understudied yet potentially powerful target for intervention. This proposed project will provide critical 
foundational information to design and conduct a future randomized trial to implement and evaluate 
health insurance and employment policy guidelines among joint labor-management health funds in the 
building trades, and uses a Total Worker Health approach to address the influence of employment-linked 
policies and programs on addiction and recovery. Following formative work with input from subject 
matter experts, academics, and stakeholders from the construction industry, we will develop a set of 
Workplace Opioid Guidelines to Prevent Opioid and Substance Abuse for the Construction Trades. Then 
we will conduct a feasibility trial to evaluate the feasibility of implementing workplace opioid guidelines 
in the construction trades; define and collect measures of implementation and effectiveness. For this aim, 
three local union health funds will be recruited, and receive the Workplace Opioid Guidelines. 
Implementation of the Guidelines will be evaluated using the RE-AIM framework, with collection of data 
needed to measure effectiveness of the workplace opioid guidelines. The outcomes measures will be a) 
the health fund’s adoption of policies and programs; b) opioid prescriptions, chronic opioid use, and OUD 
in health claims and pharmacy data; c) changes in knowledge, attitudes, and beliefs of employers, health 
fund administrators, and employees; and d) employee participation in employee assistance programs and 
healthcare recovery services. 
2.2 
BACKGROUND  
People in their working years are the population most affected by the opioid crisis. The U.S. is in the 
middle of an opioid crisis, with annual drug overdose deaths increasing dramatically in the past decade, 
now exceeding the number of annual motor vehicle deaths and surpassing the number of deaths from 
HIV in any one year at the height of the HIV crisis. In 2017, 95% of the 70,067 U.S. drug overdose deaths 

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occurred among persons aged 18-64 years.1 In the 2017 National Survey of Drug Use and Health,2 34% of 
respondents aged 18-64 years reported using prescription opioids for pain relief in the past year; of 
those using prescription opioids, 17% report misuse, meaning taking the opioids not as prescribed. Of 
those reporting opioid misuse or opioid use disorder (OUD), most were currently employed full-time or 
part-time (66% and 52% respectively). Since the majority of reported opioid use and misuse occurs 
among the employed working age population, workplace policies, programs, and health benefits should 
be considered important venues for intervention.  
The relation between employment status and opioid use can be leveraged to prevent opioid misuse 
and promote recovery for opioid use disorder. Most working age people obtain health insurance 
through their employers, meaning that opioid prescribing practices and treatment for opioid misuse are 
influenced by employment-based insurance policies for a large proportion of the population at risk. 
Health-related disability from opioid use has effects on employment, with potential loss of earnings and 
access to health insurance for individuals and their dependents, and affects the larger economy. We 
propose to leverage workplace policies as a tool to prevent opioid misuse and aid in recovery for opioid 
use disorder. 
Figure 1 shows 
our conceptual 
model for how 
the transition 
from no use of 
opioids to initial 
use and 
subsequent 
transitions to 
misuse and OUD 
influence 
employment. The 
cascade of opioid 
use and misuse often starts with an initial prescription for acute pain, and the increase in opioid 
prescriptions in the U.S. parallels the opioid overdose epidemic.3-5 Key goals include more judicious 
prescribing, and slowing or eliminating the transition from opioid use to OUD. In this conceptual model, 
corresponding work and disability outcomes are shown on the vertical axis. While every individual’s 
experience is different, this simplified model points out how opioid use at every stage is linked to work 
ability and employment outcomes. There are multiple steps along this cascade where changes in 
employer-based policies can influence the development of opioid misuse, course of recovery, and other 
important health and economic outcomes. Our goal is to develop best practices for workplace guidelines 

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and policies around opioid use, and determine if these guidelines reduce misuse, improve recovery, and 
enhance employment status as suggested in Figure 1.  
Opioid use poses major economic costs linked to employment. Though personal and social costs of the 
opioid crisis from mortality and morbidity are well known, employment costs are less appreciated. It is 
estimated that 46% of the total societal costs of prescription opioid misuse in the U.S. are workplace 
costs, driven by lost earnings from premature death, reduced compensation, and lost employment.6 
Costs to employers include lowered productivity from absenteeism, higher healthcare costs, and higher 
hiring and training costs resulting from turnover of skilled workers.7 Manufacturing and construction 
firms in hard-hit states report shortages in the blue-collar labor market because otherwise qualified 
candidates are unable to pass mandatory drug screens.8 Comparisons of labor force participation and 
unemployment suggest that more prime-aged men are dropping out of the labor force for health 
reasons, with OUD a major driver of work disability.8, 9 Nationally, about 40% of change in labor force 
participation can be accounted for by prescription opioids, and labor force participation fell more among 
prime age men in areas where more opioids are prescribed.10 These major economic costs related to 
opioid use can motivate employers to implement best practices regarding opioid use in the workplace. 
The prescription opioid crisis poses a unique challenge for employers. Only 20% of employers surveyed 
by the National Safety Council (NSC) felt prepared to deal with issues related to opioid use and misuse.11 
Few employers provide training on drug issues to workers or supervisors, and the majority of employers 
implement strict drug free policies, terminating workers for the first failed drug test instead of 
implementing “second chance” policies and providing workplace recovery programs.12-14 Lower 
availability of skilled workers, high worker replacement costs, and drug-related productivity losses 
suggest that current drug policies make little business sense, and exacerbate the social costs of opioid 
misuse.15, 16 However, there is little guidance for employers on how to avoid escalation of prescription 
opioid use to OUD and to enhance recovery from OUD, and there are no generally applicable, validated 
instruments, regulations, or guidelines for determining job-specific impairment due to taking 
prescription medications.17 The NSC has urged employers to take an active role toward opioids in the 
workplace for “saving jobs, saving lives, and reducing human costs”.11 Recommended steps include 
partnering with health insurance, pharmacy benefit managers (PBM), and employee assistance program 
(EAP) providers, re-evaluating policies, testing for prescription opioid misuse, investing in management 
and employee education, and ensuring confidential access to help and treatment.11 The National 
Institute for Occupational Safety and Health (NIOSH) has proposed a framework to be used by 
researchers and practitioners to address the opioid crisis, including determination of what guidance 
employers and medical providers need to prevent medically-prescribed opioid use from becoming 
opioid use disorder.18 

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Guidelines can help prevent new cases of opioid misuse and OUD. Recent CDC guidelines recommend 
limiting initial prescriptions of opioids for acute pain, and limiting the prescription of opioids for 
treatment of chronic non-cancer pain, in order to reduce future opioid misuse and OUD.19 These 
recommendations are supported by analyses of state level Medicaid data and state level workers’ 
compensation data.20-22 Positive evidence directly relevant to workers comes from the implementation 
of guidelines in Washington State that limited opioid prescriptions beyond the acute period for work-
related injuries.23 Prior authorization requirements, with hard stops to prescription approval, resulted in 
a large and sustained drop in persistent opioid use and a reversal of lost work patterns related to opioid 
prescribing seen in the prior decade. Similar success was seen in Texas, where requirements for pre-
authorization for many opioid medications led to a marked decrease in prescribing.24 Several states have 
now taken steps to address opioid use in their workers’ compensation systems by limiting opioid 
availability, educating health care providers on responsible opioid prescribing, and increasing awareness 
of the risks of OUD among injured workers.25, 26 While some state-level plans have implemented these 
policies, most commercial insurance programs and health funds have not and this remains a significant 
gap.27, 28 Most of opioid prescribing recommendations are written from a clinical or statewide insurer 
perspective and do not consider the influence that employers can have with prevention and support of 
chronic opioid use and misuse. There is increasing consensus that PBMs and employer based health 
funds also have an important role to play in improving health and limiting disability among their 
workforce by limiting the use of opioid medications for their employees, and by managing opioid use 
and claims more actively.29 The challenges presented to employers about what to do regarding opioid 
use in the workplace and the role that practical guidelines can play motivates Aim 1 of this proposal. In 
Aim 1, we will identify best practice healthcare and employment policies regarding opioid use and 
misuse. 
Construction workers are a large group at very high risk for opioid use and overdose. Rates of opioid 
use, misuse, and overdose vary widely by occupational group,30-32 and construction workers are among 
the top three industries reporting substance misuse.30 A NIOSH study based on surveillance of deaths 
from 21 states found that workers in construction had the highest proportional mortality rate from 
opioids among all occupations; construction workers were 6% of the working population but comprised 
13% of all overdose deaths.31 A study of death certificates in Massachusetts from 2011-2015 found that 
construction workers had the highest rate of overdose deaths (150.6/100,000 workers), a rate six times 
the average rate for all workers.32 In this study, construction workers accounted for 24% of all opioid-
related deaths among the working population. Construction workers stand out for both rate and 
number of opioid overdose deaths (13-24% of all deaths); there are several likely causes. First, 
construction is a dangerous and physically demanding industry, with high rates of workplace injuries, 
high rates of chronic pain, and higher rates of medical care for acute and chronic musculoskeletal 
disorders than the general working population.33, 34 More injuries, more common chronic pain, and more 
medical encounters increase the likelihood of being prescribed opioid pain medication. Indeed, analyses 

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of national data have shown that rates of opioid overdose deaths are significantly higher among workers 
employed in industries and occupations with higher rates of work-related injuries and illnesses.32 
Second, construction work is often intermittent, and workers are usually paid only for time worked. 
Analysis of data across all occupations showed that opioid death rates are significantly higher among 
workers in occupations with lower availability of paid sick leave and lower job security, suggesting that 
the need to return to work soon after an injury or to work while in pain may contribute to high rates of 
opioid-related overdose deaths among workers in construction and other industries.32 Third, in addition 
to having a higher chance of receiving an opioid prescription, construction workers have higher rates of 
alcohol and tobacco use than the general population,35 putting them at higher risk of developing OUD 
after initiation of opioids. National organizations of construction unions and employers are becoming 
aware of this issue and have a strong incentive to address this crisis.36, 37 Importantly, the structure of 
health benefits and employment of union construction workers makes this group well suited to test 
policy and guideline changes. In collaboration with construction industry leaders and union health plans, 
in Aim 2 we will further characterize the opioid problem in construction and create guidelines on opioid 
use by adapting best-practice healthcare and employment policies to the unique needs of the 
construction industry.   
Joint Labor-Management Health and Welfare Funds offer a unique opportunity to study workplace 
interventions. Unionized construction workers are typically covered by Taft-Hartley Health and Welfare 
Funds, which administer health insurance plans that cover approximately nine million U.S. adults.38 
These union health funds are coordinated by national unions, governed by joint labor-management 
boards at a regional or national level, and are funded by contributions from employers (contractors) and 
by the union members. These funds offer several advantages to study implementation of employment 
related guidelines. First, these funds cover a large proportion of the employed population at highest risk 
for opioid overdose. Second, eligibility for health benefits is linked to hours worked by each covered 
member, so data on both individual work hours and health care expenditures are available across 
multiple employers, allowing linkage of diagnoses and treatment to employment outcomes, regardless 
of change in employer by the member. Third, interventions to reduce tobacco use have been conducted 
across multiple Taft-Hartley plans,38, 39 indicating the potential for conducting opioid policy intervention 
studies in a similar manner. As described below, our nationally recognized team of occupational health 
and addiction researchers has worked extensively with our local construction unions and health funds to 
analyze health claims and work hour data and to implement workplace health interventions. The 
structure of these union health funds and our strong working relationships with partner organizations 
support the feasibility of our proposal to obtain data and influence workplace health policies in this 
group. 
In summary, there is an urgent need to develop and test the effectiveness of best practices 
employment policies and employment-linked health insurance plans in order to reduce OUD and 

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disability related to prescription opioid use. Employment-linked health programs and policies can 
reduce initial opioid use, decrease the risk for escalation from opioid use to misuse and OUD, and 
provide better treatment for persons with opioid misuse and OUD through early identification and 
appropriate treatment, including policies to maintain employment during recovery. Our proposed study 
will address NIDA’s strategies and priorities to strengthen our understanding of the opioid epidemic, 
understand the effects of policies, use science to improve policy, improve the connection between 
research and practice, address policy barriers that affect access to the best evidence based treatment, 
and assess employment outcomes as a key health and social indicator.40 To date, employers are still 
unsure of what to do, and there has been little or no study of implementing and evaluating evidence 
based practices to employment policies and programs. This proposal will help fill this gap.  
 
2.3 
RISK/BENEFIT ASSESSMENT  
 
2.3.1 KNOWN POTENTIAL RISKS  
From the IRB approved informed consent document: 
There are no known risks and no costs to the participants. The participants will not be penalized or lose 
any benefits for which they would otherwise qualify and participation will not affect their job. 
2.3.2 KNOWN POTENTIAL BENEFITS  
Unions, employers, and health funds will gain greater awareness of the opioid epidemic and how they can 
address it in their workforce using the Workplace Opioid Guidelines that will be created in this project. 
Workers will learn of the risks of opioid use and be made aware of workplace programs and policies 
related to opioid use and treatment. Health claims, pharmacy data, and work hours data are important 
for showing the improvement in health (changes in number of opioid prescriptions, and number of 
workers with opioid use disorder) and employment outcomes (change in lost work hours/days in work 
hour records) after the Health Fund adopts policies and programs from the guidelines. These changes will 
help determine the effectiveness of these guidelines.   
 
2.3.3 ASSESSMENT OF POTENTIAL RISKS AND BENEFITS  
The information from participation will aid in assessing the benefit of the intervention and may guide 
future changes to the health fund’s decision for policies, programs, and benefits offered to union 
members of the health fund.  The potential risks to participants are unlikely and minimal; the benefits to 
them and the construction industry outweigh the risks.  

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3 
OBJECTIVES AND ENDPOINTS  
The objective of this trial is to evaluate the feasibility of implementing the workplace opioid guidelines in 
union health funds of the construction trades and measure the implementation and effectiveness of 
changes made to the union health fund policies, programs, and benefits made in response to using the 
workplace guidelines. We will assess implementation using process measures recorded over a 6-month 
period of time using the REAIM framework. We will assess effectiveness by measuring changes in the 
administrative claims and from worker surveys collected from members. 
The primary outcomes will show a change in a) the proportion of workers with opioid misuse, opioid use 
disorder and opioid overdose collected from administrative data over a 4 year period (3-years prior to the 
intervention, and one-year of the intervention implementation) and b) the proportion of workers with 
opioid misuse measured from worker surveys from each of the union health funds over a 6-month period 
after start of implementation of the intervention. 
The secondary outcomes will show a change in a) the proportion of workers with lost time measures and 
b) the proportion of workers willing to seek help measured from worker surveys from each of the union 
health funds, and collected over a 6-month period after start of the implementation of the intervention. 
The feasibility trial will be deemed successful if the study successfully recruits three union health funds, 
and collects measures to assess the implementation of the intervention and effectiveness of health and 
behaviors during the trial period. This is not a randomized trial, nor is the study powered to expect 
statistical changes in the outcome measures. The benefit for conducting the feasibility trial is to test all 
procedures in the specific population to guide plans for a future randomized trial. 
 
  OBJECTIVES 
ENDPOINTS 
JUSTIFICATION FOR 
ENDPOINTS 
Primary 
 
 
The objective of this trial is to 
evaluate the feasibility of 
implementing the workplace 
opioid guidelines in union 
health funds of the 
construction trades by 
measuring the 
implementation and 
effectiveness of health, 
The primary endpoint(s) include a 
change in  a) Proportion of workers 
with opioid misuse, opioid use 
disorder and opioid overdose from 
administrative data and b)  Proportion 
of workers with opioid misuse from 
worker surveys 
Administrative claims data 
covers all the majority of the 
union members as most 
members are eligible for 
these benefits. Therefore, the 
data more accurately reflects 
the proportion of the 
workforce who have misused 
opioids or received a 
diagnosis for opioid use 

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  OBJECTIVES 
ENDPOINTS 
JUSTIFICATION FOR 
ENDPOINTS 
behaviors, and attitudes 
toward opioids. 
disorder. These metrics are 
useful outcomes to show the 
longer term impact of policies 
and benefits provided 
through the union health 
fund.  
Secondary 
 
 
The secondary objective(s) 
are goals that will provide 
further information on the 
use of the intervention. 
 
Secondary endpoints include a change 
in behaviors and attitudes in response 
to the intervention and will include a) 
Proportion of workers with lost time 
from worker surveys and b) the 
proportion of workers who are willing 
to seek help from opioid misuse from 
worker surveys. 
 
The worker survey data shows 
the perceived behaviors 
reported by the respondents. 
These respondents will be 
compared to the 
demographics of the 
population to explore 
potential bias by workforce 
characteristics. These 
outcomes show the 
intermediate impact of 
policies and programs 
provided through the union 
health fund. 
 
4 
STUDY DESIGN 
4.1 
OVERALL DESIGN 
This study is a feasibility trial testing the ability to recruit an appropriate population (the union health 
fund), collect outcome measures relevant to change from using the intervention (through administrative 
claims data and collection of worker surveys), and process measures of implementation over a period of 
time considered appropriate to implement organizational changes guided by the intervention.  
This is a feasibility trial evaluating procedures and success to enroll the health funds, collect data, monitor 
implementation of the intervention, and assess change in outcome measures in a 6-month period of time. 
The health funds recruited to participate in this study will be from a convenience sample using a snowball 
method of recruitment. The study does not involve randomization. 
This is a single arm trial with pre-post measures of change in the outcomes over a 6-month period of time. 
The study will attempt to collect 12-month measures if time allows. 

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This will be a single-site trial, as all data will be collected by the research team, although the invitations 
for worker survey participation will be distributed through messages from the participating union health 
fund. The administrative data will be shared with the Washington University researchers through a data 
transfer and use agreement. 
The intervention is the Workplace Guidelines to Prevent Opioid and Substance Abuse for the Construction 
Trades. These guidelines offer ideas, resources and organizational assessments on how to develop or 
advance a substance use prevention program targeting policies, programs, and benefits under the 
employer, union and their health and welfare funds. 
 
4.2 
SCIENTIFIC RATIONALE FOR STUDY DESIGN 
This is a feasibility trial to evaluate the study procedures and feasibility of recruiting and collecting the 
data for a future trial. As such, it was important to recruit a small number of groups from the population, 
and collect data for the intended period of time, but there was no need for a comparator group for the 
intended goal of this study. 
 
4.3 
JUSTIFICATION FOR INTERVENTION 
The construction industry has one of the highest overdose rates of any industry, with the majority of those 
overdoses from opioids. The industry has one of the highest injury rates with many workers suffering from 
chronic disorders incurred from work activities. Prescription opioids have been prescribed to treat these 
chronic disorders. The union health fund provides the health benefits and health programs for the union 
members. There is a need to provide union health funds with guidance on policies, programs and benefits 
that may help prevent initial use of prescription opioids and treatment for members with opioid misuse 
and opioid use disorder. The Workplace Guidelines to Prevent Opioid and Substance Abuse for the 
Construction Trades are evidence-based guidelines designed for use by the construction industry. The 
guidelines are intended to be used by construction organizations to assess their need, and provide 
guidance and off the shelf resources that may be tailored for use by the organization. The overall goal of 
the guidelines are to reduce the incidence of opioid misuse and opioid use disorder, missed days of work 
due to opioid use, and increase members willingness to seek treatment if they need help.  
 
4.4 
END-OF-STUDY DEFINITION 
The end-of-study is defined as the collection of 6-months (or 12-months) of data has been collected from 
all enrolled union health funds OR the end of the funding period (including no-cost extension time). Since 

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this is a feasibility trial, it is not known if three organizations will be successfully recruited and if it will be 
feasible to collect all data for outcomes (including administrative claims and workers surveys) by the end 
of the funding period. 
  
5 
STUDY POPULATION 
The study population are members of the participating union health funds from the construction trades. 
All of the member workers of the enrolled health funds will be considered eligible participants for the 
study. For administrative claims data, this will include all members who were benefits eligible from May 
2019 through the end of the study period (May 2023). For worker surveys, all active members of the union 
will be eligible and invited to participate. There will be no exclusions from eligibility. 
The members of the union health funds will be at least 18 years of age, with no maximum age limit. The 
study population characteristics will reflect the demographics of the workforce, with approximately 8% 
female and 10% non-Caucasian. 
 
5.1 
INCLUSION CRITERIA 
 
All members of the participating union health funds will be eligible for inclusion in the study. For 
administrative data, this will include benefits-eligible members of the union health fund from May 2019-
May 2023. For worker surveys, this will include members of the union from May 2022-May 2023.  
The members will be at least 18 years of age, as that is an age requirement of the union. There are no 
other demographic restrictions. 
 
5.2 
EXCLUSION CRITERIA 
There is no exclusion criteria for participation among the members of the participating union health funds. 
Each participating health fund must sign a data transfer and use agreement to provide the research team 
access to the administrative claims data and share requests to the members to complete a worker survey. 
Participating health funds must also be willing to review the workplace opioid guidelines for trial and to 
have regular meetings with the research team to share their plans related to using the intervention 
(guidelines). 
 Union health funds that do not complete a data transfer and use agreement, and are unwilling to facilitate 
surveying their members and are unwilling to trial the intervention will be excluded from participation. 

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5.3 
LIFESTYLE CONSIDERATIONS 
N/A 
5.4 
SCREEN FAILURES 
There are no screening requirements or restriction from participation. 
5.5 
STRATEGIES FOR RECRUITMENT AND RETENTION 
Recruitment of health funds will be communicated through intermediaries from union leadership and 
union organizations within the construction trades. Prior to the start of the study, three union health 
funds had provided verbal consent to participate. Each enrolled health funds must be willing to participate 
in all facets of the project, including data collection, and trial of the intervention. 
The research team will work with each health fund to identify potential means to invite members to 
complete the worker survey.  Possible methods for survey recruitment include distributing an online 
survey link via email or text message, posting a survey link in union newsletters, or collecting paper 
surveys at union meetings or training schools. Access to the survey will be provided through a QR code 
or electronic link to a Redcap survey which is a secure, web-based data collection tool. Worker survey 
data collection will be cross-sectional in nature and therefore we do not plan to follow individual 
workers overtime. Participants will be given the option to refuse participation without any repercussions 
to their employment, health benefits, or standing in the union.  
The survey will take approximately 10 minutes to complete. There will be no incentives offered to 
participate. 
Each health fund will seek completion of 300 surveys at two time points, baseline and 6-months for a 
total of 900 surveys from three health funds. The expected enrollment will reflect the demographics of 
the population, with approximately 8% females, and 10% non-Caucasian. The age range will be from 18 
years with no upper age limit, although the majority of the sample will range from 18-65 years. The data 
from this trial will be used to compute statistical power for a future study, should the feasibility trial be 
successful.  
 
6 
STUDY INTERVENTION(S) OR EXPERIMENTAL MANIPULATION(S) 
 

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6.1 
STUDY INTERVENTION(S) OR EXPERIMENTAL MANIPULATION(S) ADMINISTRATION 
 
 
 
6.1.1 STUDY INTERVENTION OR EXPERIMENTAL MANIPULATION DESCRIPTION 
The intervention is a set of evidence-based guidelines developed by the research team, with formative 
work and review by subject matter experts, and stakeholders from the construction industry, many of 
whom have implemented the policies, programs and benefits suggested in the guidelines. The 
intervention will provide recommendations across the continuum of disease from prevention (no opioid 
use), through treatment and recovery. It will also cover the topics for different roles including human 
resources, upper management, front-line supervisors and healthcare providers involved with the 
monitoring and treating drug-related issues.  
The intervention is intended to be used by the organization, union health fund that provides the health 
benefits and programs for the union members. The health fund has the fiduciary responsibility to provide 
health policies, programs, and benefits to maximize the health of the members. The health fund must 
receive approval for health initiatives from the Labor-Management board of trustees. The target of the 
intervention is the union members, who are the subjects of the health fund policies, programs, and 
benefits. The outcomes of the study will be measured by the clinical health claims, and self-reported 
behaviors of the union members. 
 
6.1.2 ADMINISTRATION AND/OR DOSING 
The health fund administrator will meet with the Principal Investigator from the research team to 
participate in a baseline interview to explore the current policies, programs and benefits offered by the 
health fund to protect the members from opioid misuse and opioid use disorder. The baseline health fund 
interview will cover the company background, attitudes and beliefs toward opioids, health fund policies 
and programs, (written policies, drug testing, medical health benefits, behavioral health benefits, 
pharmacy benefits, member assistance program, legal considerations, employee education on opioid 
risks, supervisor training related to opioid use, culture of care of the union, collective bargaining 
agreement related to substance and opioid use disorder, and plans to change policies and programs 
related to opioids and substance use). The baseline interview guide can be found in the Additional 
Information section: R34 Aim 3 Health Fund Baseline Interview Guide_051222. 
After all baseline data collection is completed, the intervention will be initiated. The intervention will 
include one-hour monthly meetings by Zoom scheduled at a convenient time for the health fund 

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administrator and the Principal Investigator. At the initial meeting, the health administrator will be 
introduced to the guidelines and asked about what plans they currently have to change. A copy of the 
guidelines used in the trial can be found in the Additional Information section: v3.0_WashU_Opioid 
Prevention Program in Construction_07062022. 
At each follow-up monthly meeting, the researcher will ask information from the Monthly Health Fund 
meeting script_follow up found in the Additional Information section. The intervention meetings will be 
held over a 6-month period. 
The meetings will provide an opportunity to discuss barriers to implementation and share new ideas and 
strategies. The health fund administrator will be encouraged to build a team to support the development 
and implementation of the plan ideas (as discussed in the guidelines). The meetings will also provide an 
opportunity to discuss the analysis of the administrative claims, and results of the worker surveys.  
6.2 
FIDELITY 
6.2.1 INTERVENTIONIST TRAINING AND TRACKING 
The intervention will be delivered by the Principal Investigator. Each meeting will cover the progress the 
health administrator has made toward implementing their plan, and whether the health administrator 
found new ideas or resources for their plan from the guidelines. The follow-up monthly meeting will be 
scheduled at the end of the prior meeting with reminders sent out to the health administrator 2 days in 
advance of the meeting. Interim communications will be made by email as needed.  
6.3 
MEASURES TO MINIMIZE BIAS: RANDOMIZATION AND BLINDING 
This study does not involve randomization nor blinding. 
6.4 
STUDY INTERVENTION/EXPERIMENTAL MANIPULATION ADHERENCE 
Monthly meeting attendance will be logged in OneNote (a project management log) with cancellations 
and reasons for cancellations as this will be important information to consider for the feasibility of a future 
trial. 
6.5 
CONCOMITANT THERAPY 
N/A 
6.5.1 RESCUE THERAPY 

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7 
STUDY INTERVENTION/EXPERIMENTAL MANIPULATION DISCONTINUATION AND 
PARTICIPANT DISCONTINUATION/WITHDRAWAL 
 
7.1 
DISCONTINUATION OF STUDY INTERVENTION/EXPERIMENTAL MANIPULATION 
This feasibility trial is designed to learn what barriers exist for participation in the trial, across all study 
activities throughout the study process: 
• 
the initial recruitment of health funds,  
• 
enrollment of health funds that complete the study eligibility (data transfer and use agreement) 
• 
collection of baseline data including administrative claims and worker surveys,  
• 
completion of the baseline interview with the health administrator (about existing policies, 
programs, and benefits related to substances and opioids),  
• 
attendance to monthly intervention meetings for 6 months,  
• 
follow-up data collection on worker surveys at 6-months,  
• 
final data collection at 12-months (time permitting). 
The feasibility trial will be discontinued at the end of the 6-month intervention, or if all enrolled health 
funds drop out of the study, or if no health funds are enrolled with adequate time in the study period 
remains to complete the intervention (of at least 6-months). 
7.2 
PARTICIPANT DISCONTINUATION/WITHDRAWAL FROM THE STUDY 
A health fund may be withdrawn from the study if they stop participating or request to drop out.  
No participant will be withdrawn from the study. Participants may choose to not complete the worker 
survey. The researchers may drop a participant’s survey from analysis if more than half of the items are 
not completed. 
7.3 
LOST TO FOLLOW-UP 
The health fund may be lost to follow up if they stop attending meetings. 

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The participant data is collected as cross-sectional data so no participants will be lost to follow-up. 
8 
STUDY ASSESSMENTS AND PROCEDURES 
 
8.1 
ENDPOINT AND OTHER NON-SAFETY ASSESSMENTS 
At baseline, recruited union health funds will be asked to agree to several activities before they are 
enrolled in the study. These include 1) sign a data transfer and use agreement (DUA) with the Washington 
University research team, 2) willingness to review the Workplace Guidelines to Prevent Opioid Abuse in 
the Construction Trades” and implement changes to their organizational policies, programs, and benefits 
to reduce opioid misuse and opioid use disorder among their members, 3) participate in a series of study-
related meetings to discuss their current program and plan for changes, 4) provide administrative claims 
as outlined in the DUA, and 5) communicate invitation to all members to complete a worker survey for 
the study.  The partners were asked to enroll for a minimum of 6-months but preferable 12-months of 
activities. 
Once the DUA was signed and the union health fund was enrolled, and the administrator or their 
representative was asked to participate in an interview to discuss their knowledge and attitudes toward 
OUD, describe their existing workplace opioid policies and programs and the date of adoption or 
implementation, and any changes to their policies or programs underway or plans for future changes. The 
interview also asked questions about participation rates in programs for workers, adherence to and 
enforcement of policies, and the methods for disseminating programs. See “R34 Aim 3 Health Fund 
Baseline Interview” in the Additional Information Section. 
The other baseline data collection included the administrative claims data and member “worker surveys”. 
The union health fund administrator was asked to share a pre-specified set of variables from their medical 
and pharmacy claims and covering the period from May 2019-May 2022. See the list of requested 
variables from the administrative datasets in the Additional Information Section in the file called “Data 
Variables List for opioids project_052322”.  The study team had the administrator to share a sample of 
their variables for review by study team. Once the variables were agreed upon, the administrator was 
asked to share the de-identified datasets with a linking variable so the data could be linked without using 
an employee id or social security number. The data would be shared under a waiver of consent. All data 
was stored on a secure network. Only members of the research team had access to the data.  The 
statistician and PI worked with the health fund staff to insure they had a good understanding of each 
variable (and units of each) and were able to create a database that aligned with the variables needed for 
analysis. See the data management section and analysis plans below. 

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The participating union health funds were asked to distribute a link for a Redcap survey to a representative 
sample of their members to collect 300 completed surveys. All members of the union were eligible but 
member participation was voluntary. The health fund recruited the member using methods determined 
by them to be most successful to reach the members and encourage participation. These methods 
included email, newsletter, and verbal invitations. Members were invited to participate but they were 
allowed to take as much time as they want to consider participation in the study. The health fund did not 
know which members participated in the survey. The surveys were accessed through a QR code or survey 
link shared through health fund communications. The Redcap QR code or survey link could be accessed 
through a computer or on an apple or android device. The first page of the survey showed the consent 
information (see Consent Document). The member had the option to consent by advancing to the survey 
or to decline by exiting the survey. There was no written consent and participants were not paid to 
participate. The brief survey asked about the members’ knowledge of their health fund’s benefits and 
policies, attitudes toward use of opioids by self and others, employment status, participation in union 
programs including Employee Assistance Program (EAP), and health-related productivity using widely 
used survey instruments. We did not collect names or any other identifying information and the survey 
took about 5-10 minutes to complete. A copy of the members “R34 AIM 3 Worker Survey” may be found 
in the Additional Information Section.  
The data was collected in the Redcap software program at Washington University. The electronic 
information was stored on a password protected, secured server at Washington University. Only member 
of the research team had access to the data.  Only summarized information from the worker surveys was 
shared with the health fund. During the period of data collection, the research team reviewed the 
demographics and counts of the survey, to encourage continued data collection if the desired number of 
surveys was not collected or the data did not represent the characteristics of the workforce. 
After completion of the baseline data collection, the research team met with the union health fund 
administrator to introduce the intervention. The guidelines are shown in the Additional information 
section (v3.0_WashU_Opioid Prevention Program in Construction_07062022). The team and health fund 
met on a recurring monthly basis for 6 months. The goal of the meetings was to discuss the health fund’s 
plan for changes to their opioid prevention program. A series of questions were discussed to review the 
progress on the plan, and to discuss how the guidelines were used to support the planned changes. 
Following the items in the REAIM framework, the discussion included “what” was changed or planned to 
be changed, the implementation strategies for adoption of the changes, and barriers and success for 
implementing the change. All meetings were virtual (primarily over Zoom) and scheduled a month in 
advance, with a reminder sent out 2 days before the meeting. 
 
Data Management: The following are the list of steps taken to manage the administrative health claims 
and worker surveys. The final databases were used to compute the results for outcomes.  

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See the “Data management of Administrative Health Claims and Worker Surveys” in the Additional 
Information section. 
8.2 
SAFETY ASSESSMENTS 
N/A 
 
8.3 
ADVERSE EVENTS AND SERIOUS ADVERSE EVENTS 
 
8.3.1 DEFINITION OF ADVERSE EVENTS 
This protocol uses the definition of adverse event from 21 CFR 312.32 (a): any untoward medical 
occurrence associated with the use of an intervention in humans, whether or not considered intervention-
related. 
8.3.2 DEFINITION OF SERIOUS ADVERSE EVENTS 
Should an event be reported to the research team, it will be referred to the IRB for classification as to the 
severity of the event. 
 
8.3.3 CLASSIFICATION OF AN ADVERSE EVENT 
 
8.3.3.1 SEVERITY OF EVENT 
This study will evaluate a group-level intervention of an organization’s opioid-related policies and 
procedures delivered by union health funds, and disseminated to their membership. We will not collect 
individual identifiers, thus we will likely not have data on Adverse Events or Serious Adverse Events related 
to the intervention. 
8.3.3.2  RELATIONSHIP TO STUDY INTERVENTION/EXPERIMENTAL MANIPULATION 
In the event that we learn of an adverse event, we will adhere to the following reporting timeframes:  
• Adverse Events will be reported to the NIDA Program Officer (PO) as part of the annual progress 
report. Although we will not know the identity of the individual involved, in the report we will 
describe the event, when it occurred, and the outcome (if known).  

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• Serious/Unanticipated Adverse Events will be reported to the NIDA PO within 24 hours, with a 
follow-up on the status of the event within 72 hours later, although it is unlikely an individual 
will experience a SAE as a result of participation in the study.  
• We will also report all AEs to the IRB within 10 working days of when we become aware of the 
event, as required by the IRB.  
• 
It will likely be difficult to know if the event is related to the intervention, however the event will 
be reported if the research team is notified. 
 
8.3.3.3 EXPECTEDNESS  
It is unlikely that an Adverse Event will be related to the intervention, as the implementation of the 
intervention is at the discretion of the union health fund and likely subject to the Trustee Board Approval. 
However, if an event does occur, it will be reported. 
 
8.3.4 TIME PERIOD AND FREQUENCY FOR EVENT ASSESSMENT AND FOLLOW-UP 
• 
Serious/Unanticipated Adverse Events will be reported to the NIDA PO within 24 hours, with a 
follow-up on the status of the event within 72 hours later, although it is unlikely an individual will 
experience a SAE as a result of participation in the study.  
• 
We will also report all AEs to the IRB within 10 working days of when we become aware of the 
event, as required by the IRB.  
 
8.3.5 ADVERSE EVENT REPORTING  
 
Serious/Unanticipated Adverse Events will be reported to the NIDA PO.  
 
We will also report all AEs to the IRB. 
 
8.3.6 SERIOUS ADVERSE EVENT REPORTING  
 
Serious/Unanticipated Adverse Events will be reported to the NIDA PO.  
 
We will also report all AEs to the IRB. 
  
8.3.7 REPORTING EVENTS TO PARTICIPANTS  

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N/A 
 
8.3.8 EVENTS OF SPECIAL INTEREST  
N/A 
 
8.3.9 REPORTING OF PREGNANCY  
N/A 
 
8.4 
UNANTICIPATED PROBLEMS 
 
8.4.1 DEFINITION OF UNANTICIPATED PROBLEMS 
 
This protocol uses the definition of Unanticipated Problems as defined by the Office for Human Research 
Protections (OHRP).  OHRP considers unanticipated problems involving risks to participants or others to 
include, in general, any incident, experience, or outcome that meets all of the following criteria: 
 
• 
Unexpected in terms of nature, severity, or frequency given (a) the research procedures that are 
described in the protocol-related documents, such as the Institutional Review Board (IRB)-
approved research protocol and informed consent document; and (b) the characteristics of the 
participant population being studied; 
• 
Related or possibly related to participation in the research (“possibly related” means there is a 
reasonable possibility that the incident, experience, or outcome may have been caused by the 
procedures involved in the research); and 
• 
Suggests that the research places participants or others at a greater risk of harm (including 
physical, psychological, economic, or social harm) than was previously known or recognized.] 
 
8.4.2  UNANTICIPATED PROBLEMS REPORTING  
 
The investigator will report unanticipated problems (UPs) to the reviewing Institutional Review Board 
(IRB) and to the Data Coordinating Center (DCC)/lead principal investigator (PI). The UP report will include 
the following information: 
 
• 
Protocol identifying information: protocol title and number, PI’s name, and the IRB project 
number 

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• 
A detailed description of the event, incident, experience, or outcome  
• 
An explanation of the basis for determining that the event, incident, experience, or outcome 
represents an UP 
• 
A description of any changes to the protocol or other corrective actions that have been taken or 
are proposed in response to the UP 
 
To satisfy the requirement for prompt reporting, UPs will be reported using the following timeline:   
 
• 
UPs that are serious adverse events (SAEs) will be reported to the IRB and to the DCC/study 
sponsor/funding agency within 24 hours of the investigator becoming aware of the event  
• 
Any other UP will be reported to the IRB and to the DCC/study sponsor/funding agency within 7 
days of the investigator becoming aware of the problem  
• 
All UPs should be reported to appropriate institutional officials (as required by an institution’s 
written reporting procedures), the supporting agency head (or designee), and the Office for 
Human Research Protections (OHRP) within 30 days of the IRB’s receipt of the report of the 
problem from the investigator 
 
 
8.4.3 REPORTING UNANTICIPATED PROBLEMS TO PARTICIPANTS  
N/A 
 
9 
STATISTICAL CONSIDERATIONS  
9.1 
STATISTICAL HYPOTHESES 
This is a feasibility trial to evaluate the ability to recruit and enroll health funds, collect endpoint data for 
primary and secondary outcome measures, and to collect process measures related to implementation of 
the intervention with three health funds. There is no formal hypothesis testing in this trial although we 
will calculate descriptive statistics at baseline and follow-up (6-months) to show change over time. The 
data will be used to compute statistical power for a future R01 if the current study is successful.  
 
• 
Primary Endpoint(s):  
a) We will calculate the Proportion of workers with opioid misuse, opioid use disorder and opioid 
overdose using administrative data. We will assess change of opioid misuse and  opioid use 
disorder at 6 months following delivery of the intervention 
b) We will calculate the proportion of workers with opioid misuse from worker surveys. We will 
assess change in opioid misuse at 6 months following delivery of the intervention. 
 

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• 
Secondary Endpoint(s): 
 
a) We will calculate the proportion of workers with lost time using worker surveys. We will assess 
change in reported lost time at 6 months following delivery of the intervention. 
b) We will calculate the proportion of workers reporting willingness to seek help for opioid abuse 
using worker surveys. We will assess change in reported willingness to seek help at 6 months 
following delivery of the intervention. 
 
9.2 
SAMPLE SIZE DETERMINATION 
 
There were no power sample calculations for this study as it is a feasibility pilot study. The data generated 
from this study will inform the power calculations for a future R01, if the pilot study is successful.  
 
We estimated the number of participants needed for surveys from the sample sizes needed to document 
change over time for similar behavior outcomes from past studies. The data will be collected at two points 
in time (baseline and 6-months after start of the intervention). We will collect cross-sectional data, and 
calculate the group-level change pre-post intervention. We will collect 300 surveys for each participating 
health fund at baseline and at 6-months post-intervention, and at 12-months time permitting. This will be 
a minimum of 1800 surveys, or 2700 surveys time permitting. 
 
We estimated the number of participants for the administrative data from the membership sizes of union 
health funds from past studies. In past studies, union health fund members have covered 10,200 
members. We estimate we will collect administrative data for 10,200 members for each of three health 
funds (total of 30,600) members. 
  
9.3 
POPULATIONS FOR ANALYSES 
We will calculate descriptive statistics for the full population of the administrative data. The data will 
include active and retired members from the benefits-eligible group of the period May 2019-May 2022. 
We will include any member who was continuously benefits-eligible but censor them after they drop 
eligibility or don’t self-pay to continue coverage. All retired members who self-pay will also be included I 
the analyses. 
We will calculate descriptive statistics for those members who complete the worker survey. We will 
compare the demographics (age, gender, race) of those who completed the survey to the union 

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membership to see if the two groups (surveyed versus union members) have similar characteristics. This 
will help assess the feasibility of the survey recruitment methods to obtain a representative sample. 
 
9.4 
STATISTICAL ANALYSES 
 
9.4.1 GENERAL APPROACH 
Outcome data is derived from the administrative claims and worker surveys.  
Administrative claims will be collected over two periods (06/01/2019-05/31/22) and (06/01/2022-
05/31/2023). All three outcomes of interest are primary outcomes. The analysis will examine the group 
level change of the outcome, adjusting for length of time in each period, to show a reduction in impaired 
health or behaviors that may be due to implementation of the intervention. 
Worker surveys will be collected by member worker surveys from each health fund at two points in time. 
The baseline, before implementation of the intervention, and at 6-months after start of implementation. 
All members will be invited to complete a survey. The desired sample is 300 surveys per health fund at 
each time point. The outcomes are composed of one or more items in the surveys. Group level statistics 
will be computed as the proportion of members with a positive response to each outcome. The change in 
proportion by time point may be due to implementation of the intervention. 
 
9.4.2 ANALYSIS OF THE PRIMARY ENDPOINT(S) 
a) Administrative Claims 
a. Outcome variables of interest 
i. Opioid misuse-  “Overlapping Rx” OR “Multiple Rx on same day, different 
provider” 
ii. Chronic opioid use-  more than 60 days supply in a 90 day window 
iii. Opioid use disorder- ICD-10 T40* (Poisoning by, adverse effect of and 
underdosing of narcotics and psychodysleptics) &/Or ICD-10 F11* (opioid 
related disorders) &/or prescribed MAT (Drug name contained “methadone” or 
“buprenorphine”; picks up buprenorphine, suboxone, zubsolv, naltrexone, 
methadone, narcan, and vivitrol) 
b. Compute statistics for baseline period (06/01/2019-05/31/2022) and follow-up 
(06/01/2022-05/31-2023) 

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i. Categorical data will be presented as N (%), continuous data as median (25th, 
75th %tile) 
c. Run comparisons between baseline and follow-up time points 
i. Comparisons involving two categorical variables will be made using Fisher’s 
exact test 
ii. Comparisons involving a continuous variable and a categorical variable will be 
made using Wilcoxon Rank Sum test or Kruskal Wallis test 
b) Worker Survey 
a. Outcome variable of interest 
i. Opioid misuse- Participant responded yes to one of the following two questions:  
1. Did you use the pain medication more than prescribed, or for a longer 
period than prescribed?  [pnmed_longer]x 
2. Have you used prescription pain medications that were prescribed to 
someone else? [pnmed_othersrx]x 
 
b. Compute the change at 6 months post-intervention (change of opioid misusep) of group-
level data collected from groups of health 
All endpoints are independent outcomes. 
9.4.3 ANALYSIS OF THE SECONDARY ENDPOINT(S) 
For each secondary endpoint: 
Worker Survey 
a) Proportion of workers with lost time. Responded yes to one of the questions below: 
a. Please refer to the last 12 months for the following questions:  Did you miss any 
days of work because of your pain or discomfort? [missday_pn]x 
b. In the past 12 months, have you gone to work intoxicated, high, or recovering from 
the night before? [missday_intox] [*possible reduced productivity]x 
b) Proportion of workers who are willing to seek help. Responded yes to one of the questions 
below: 
Through their workplace: 
a. If I was struggling with a substance use problem... I would be willing to seek help 
from my supervisor or someone in human resources  [help_sup_hr]x 
b. If I was struggling with a substance use problem... I would be willing to seek help 
from a professional (MAP or behavioral health)  [help_prof]x 

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c. If I was struggling with a substance use problem... I would be willing to ask a trusted 
coworker for help [help_coworker]x 
d. Have you attended Alcoholics or narcotics anonymous (AA/NA) group [aa_na_use]x 
e. Have you met with the specialist? [peer_supp_use]x 
Seek professional help (employee assistance program or behavioral health)  
f. If benefit is available…. Union sponsored Member assistance program (MAP) [eap]x; 
Have you used these benefits? Member assistance program (MAP) [eap_use]x 
g. If benefit is available…. Behavioral health (counseling) [behav_health]x; Have you 
used these benefits? Behavioral health (counseling) [behav_health_use]x 
c) Compute the change at 6 months post-intervention (change of lost time and change in 
willingness to seek help) of group-level data collected from groups of health fund members. 
 
All endpoints are independent outcomes. 
 
9.4.4 SAFETY ANALYSES 
N/A 
 
 
9.4.5 BASELINE DESCRIPTIVE STATISTICS 
 
N/A 
 
9.4.6 PLANNED INTERIM ANALYSES  
 
N/A 
 
9.4.7 SUB-GROUP ANALYSES 
If there is adequate data collected for more than one health fund, we will stratify the data by health fund 
group to assess the similarity and differences in the demographics of each of the health fund 
characteristics (age, gender, race) and by the primary and secondary endpoints. We will use these results 
to help inform future decisions toward conducting an R01 trial. 
 
9.4.8 TABULATION OF INDIVIDUAL PARTICIPANT DATA 

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Administrative claims data will be combined using a unique linking variable. The claims data will include 
the date of service in order to identify the time point. Three years of data will be collected at baseline 
(May 2019-May 2022) and one year of data for follow up (June 2022-May 2023). The data will be analyzed 
as group level data by time point. 
The worker surveys will be analyzed as group level data by time point. The data will not be tabulated by 
individual participants, nor will the administrative data be linked to the worker survey data. 
9.4.9 EXPLORATORY ANALYSES 
There are no planned exploratory analyses in this study. 
10 SUPPORTING DOCUMENTATION AND OPERATIONAL CONSIDERATIONS 
 
10.1 REGULATORY, ETHICAL, AND STUDY OVERSIGHT CONSIDERATIONS 
 
10.1.1 INFORMED CONSENT PROCESS 
 
10.1.1.1 CONSENT/ASSENT 
AND 
OTHER 
INFORMATIONAL 
DOCUMENTS 
PROVIDED 
TO 
PARTICIPANTS 
 
 
Consent forms describing in detail the study intervention, study procedures, and risks will be given to the 
participant and written documentation of informed consent will be completed prior to starting the study 
intervention.  The consent document is submitted with this protocol: materials are submitted with this 
protocol: InformedConsent_05052022. 
 
10.1.1.2 CONSENT PROCEDURES AND DOCUMENTATION 
The Health Fund organization will provide a Data Transfer and Use Agreement to share their 
administrative data with the researchers. The data will be de-identified when it is received by the health 
fund. The multiple datasets will include a unique linking variable to link the records of participants. Since 
there will be no identifiable data in the administrative data, informed consent will be waived as approved 
by the IRB. The administrative data will be shared through a secure sharefile, and stored on a secure 
network at Washington University. Only members of the research team will have access to the data. 

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The workers survey data collection will include an informed consent. Each participant will receive a QR 
code or link to a Redcap survey. Once a participant clicks on the Redcap survey link, they will see the 
consent information and from there will have the option to participate by continuing to the start the 
survey. Participants who do not want to participate will be told to exit the screen. Since the survey will 
capture cross-sectional data and the data will be analyzed at the group level, there will be no need to link 
the survey data in follow-up data collection. 
 
10.1.2 STUDY DISCONTINUATION AND CLOSURE 
 
This study may be prematurely terminated if there is sufficient reasonable cause. If the study is 
prematurely terminated, the Principal Investigator (PI) will promptly inform the participating health funds, 
the Institutional Review Board (IRB), and sponsor/funding agency and will provide the reason(s) for the 
termination.  
 
Circumstances that may warrant termination or suspension include, but are not limited to: 
• 
The participating health funds stop participating or ask to be dropped from the study 
• 
Determination of futility 
 
10.1.3 CONFIDENTIALITY AND PRIVACY  
 
Participant confidentiality and privacy is strictly held in trust by the participating investigators, their staff, 
the safety and oversight monitor(s), and the sponsor(s) and funding agency. This confidentiality is 
extended to the data being collected as part of this study. Data that could be used to identify a specific 
study participant will be held in strict confidence within the research team. No personally-identifiable 
information from the study will be released to any unauthorized third party without prior written approval 
of the sponsor/funding agency.  
 
All research activities will be conducted in as private a setting as possible. 
 
The study monitor, other authorized representatives of the sponsor or funding agency, representatives of 
the Institutional Review Board (IRB), regulatory agencies or representatives from companies or 
organizations supplying the product, may inspect all documents and records required to be maintained 
by the investigator, including but not limited to, medical records (office, clinic, or hospital) and pharmacy 
records for the participants in this study. The clinical study site will permit access to such records. 
 
The study participant’s contact information will be securely stored at each clinical site for internal use 
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long a period as dictated by the reviewing IRB, Institutional policies, or sponsor/funding agency 
requirements. 
 
Study participant research data, which is for purposes of statistical analysis and scientific reporting, will 
be transmitted to and stored on the password protected network of Washington University Box. This will 
not include the participant’s contact or identifying information. Rather, individual participants and their 
research data will be identified by a unique study identification number. The study data entry and study 
management systems used by research staff at Washington Unviersity will be secured and password 
protected. At the end of the study, all study databases will be de-identified and archived on the 
Washington University Box drive. 
 
Measures Taken to Ensure Confidentiality of Data Shared per the NIH Data Sharing Policies  
It is NIH policy that the results and accomplishments of the activities that it funds should be made available 
to the public (see https://grants.nih.gov/policy/sharing.htm). The PI will ensure all mechanisms used to 
share data will include proper plans and safeguards for the protection of privacy, confidentiality, and 
security for data dissemination and reuse (e.g., all data will be thoroughly de-identified and will not be 
traceable to a specific study participant). Plans for archiving and long-term preservation of the data will 
be implemented, as appropriate.  
 
Certificate of Confidentiality  
To further protect the privacy of study participants, the Secretary, Health and Human Services (HHS), has 
issued a Certificate of Confidentiality (CoC) to all researchers engaged in biomedical, behavioral, clinical 
or other human subjects research funded wholly or in part by the federal government.  Recipients of NIH 
funding for human subjects research are required to protect identifiable research information from forced 
disclosure per the terms of the NIH Policy (see https://humansubjects.nih.gov/coc/index). As set forth 
in 45 CFR Part 75.303(a) and NIHGPS Chapter 8.3, recipients conducting NIH-supported research covered 
by this Policy are required to establish and maintain effective internal controls (e.g., policies and 
procedures) that provide reasonable assurance that the award is managed in compliance with Federal 
statutes, regulations, and the terms and conditions of award. It is the NIH policy that investigators and 
others who have access to research records will not disclose identifying information except when the 
participant consents or in certain instances when federal, state, or local law or regulation requires 
disclosure. NIH expects investigators to inform research participants of the protections and the limits to 
protections provided by a Certificate issued by this Policy. 
 
10.1.4 FUTURE USE OF STORED SPECIMENS AND DATA  
 

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Worker survey data collected for this study will be stored at the Institute for Social Research (ICPSR) at 
University of Michigan Data Coordinating Center. After the study is completed, the de-identified, archived 
data will be transmitted to and stored at the National Addiction & HIV Data Archive Program (NAHDAP), 
for use by other researchers including those outside of the study. Permission to transmit data to a 
publically shareable data file has been included in the informed consent.  
 
10.1.5 KEY ROLES AND STUDY GOVERNANCE 
 
There is no independent safety monitor for this study. The Principal Investigator is responsible for the 
safety monitoring of the study. The Principal Investigator will be responsible for data and safety 
monitoring, executing the Data and Safety Monitoring (DSM) plan, and complying with the reporting 
requirements. 
 
Principal Investigator 
Ann Marie Dale, PhD, Professor 
Washington University in St. Louis 
4523 Clayton Avenue, MSC 8005-94-155 
St. Louis, MO 63110 
314-454-8470 
amdale@wustl.edu 
 
10.1.6 SAFETY OVERSIGHT 
Safety oversite will be done internally by study team self-assessments with oversite by the Principal 
Investigator. 
 
10.1.7 CLINICAL MONITORING 
 
Internal quality management of study conduct, data collection, and documentation will be monitored 
throughout the study. Each participating health fund will follow a common quality management plan. 
 
Quality control (QC) procedures will be implemented as follows: 
 
Source documents and the electronic data --- Data will be initially captured in the electronic Redcap 
database.  The statistician will review all surveys for completeness of information prior to including the 
survey in analysis. 
 

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Intervention Fidelity — Consistent delivery of the study interventions will be monitored throughout the 
intervention phase of the study. Procedures for ensuring fidelity of intervention delivery will include 
documentation of meetings in OneNote, monitoring data collection forms in master tracking file, and staff 
review of documents in participant folders.  
 
10.1.8 DATA HANDLING AND RECORD KEEPING  
 
10.1.8.1 DATA COLLECTION AND MANAGEMENT RESPONSIBILITIES  
 
Data collection will be the responsibility of the clinical trial staff at the site under the supervision of the 
site investigator. The investigator will be responsible for ensuring the accuracy, completeness, legibility, 
and timeliness of the data reported. The statistician will create the statistical databases and recordkeeping 
with oversight from the investigator. 
 
All source documents will be completed in a neat, legible manner to ensure accurate interpretation of 
data.   
 
Hardcopies of the study visit worksheets will be provided for use as source document worksheets for 
recording data for each participant consented/enrolled in the study.  Data recorded in the electronic case 
report form (eCRF) derived from source documents will be consistent with the data recorded on the 
source documents.  
 
Administrative data will be shared with the research team by a sharing link from each Health Fund. The 
data will be stored in Wash U Box, and only members of the research team will have access. The data will 
be managed using SAS and R statistical packages. Any personal identifiers will be destroyed as soon as 
possible, as none should be needed for analysis. The analysis journal will be documented in word and 
stored in Box.  The data system includes password protection and internal quality checks, such as 
automatic range checks, to identify data that appear inconsistent, incomplete, or inaccurate.  
 
The worker survey data will be captured electronically and stored in Redcap, with validation limits to 
insure accurate entries. The data will be downloaded, and managed using SAS and R statistical packages 
with the source code, derived variables, and data dictionary developed and updated as needed. The data 
will be stored in Box. This data system includes password protection and a secure network. 
 
The study flow and intervention data will be recorded in Microsoft OneNote, and in Word using the data 
collection templates. All data will be recorded electronically. Should hard copies be generated, they will 

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be scanned and stored electronically, and source hard copies destroyed. All study records will be 
electronic, and will be stored on a password protected, secure network through Washington University. 
 
10.1.8.2 STUDY RECORDS RETENTION  
 
General study documents including the team meetings and intervention information will be retained for 
a minimum of 1 year after the close of the study, as  these data will have no future use after close of the 
trial. The administrative data will be retained for 2 years. The worker survey data, which will be the only 
data set shared publically, will be retained for 6 years after end of data collection. It is the responsibility 
of the sponsor/funding agency to inform the investigator should these documents need to be retained for 
a longer period of time. 
 
10.1.9 PROTOCOL DEVIATIONS   
 
This study will be developing the protocol to be used in a future trial, so there will be no protocol deviation. 
 
10.1.10 
PUBLICATION AND DATA SHARING POLICY  
 
This study will be conducted in accordance with the following publication and data sharing policies and 
regulations: 
 
National Institutes of Health (NIH) Public Access Policy, which ensures that the public has access to the 
published results of NIH funded research. It requires scientists to submit final peer-reviewed journal 
manuscripts that arise from NIH funds to the digital archive PubMed Central upon acceptance for 
publication. 
 
This study will comply with the NIH Data Sharing Policy and Policy on the Dissemination of NIH-Funded 
Clinical Trial Information and the Clinical Trials Registration and Results Information Submission rule. As 
such, this trial will be registered at ClinicalTrials.gov, and results information from this trial will be 
submitted to ClinicalTrials.gov. In addition, every attempt will be made to publish results in peer-reviewed 
journals.  Data from this study may be requested from other researchers 1 year after the completion of 
the primary endpoint by contacting the Interuniversity Consortium for Political and Social Research 
ICPSR.UMICH.EDU [https://www.icpsr.umich.edu] The data will be available in the National Addiction & 
HIV Data Archive Program (NAHDAP). Considerations for ensuring confidentiality of these shared data 
are described in Section 10.1.3. 

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10.1.11 
CONFLICT OF INTEREST POLICY 
 
The independence of this study from any actual or perceived influence, such as by the pharmaceutical 
industry, is critical. Therefore, any actual conflict of interest of persons who have a role in the design, 
conduct, analysis, publication, or any aspect of this trial will be disclosed and managed. Furthermore, 
persons who have a perceived conflict of interest will be required to have such conflicts managed in a way 
that is appropriate to their participation in the design and conduct of this trial. The study leadership in 
conjunction with the National Institute of Drug Abuse has established policies and procedures for all study 
group members to disclose all conflicts of interest and will establish a mechanism for the management of 
all reported dualities of interest. 
 
10.2 ADDITIONAL CONSIDERATIONS 
 
The following are the referenced documents used in this study: 
A. R34 Aim 3 Health Fund Baseline Interview Guide_051222 
B. R34 AIM 3 Worker Survey 
C. Administrative Claims_Data Variables 
D. V3.0_WashU_Opioid Prevention Program in Construction_07062022 
E. Monthly Health Fund meeting script_followup 
F. Data management of Administrative Health Claims and Worker Surveys 
 
A. Health Fund Baseline Interview–R34 AIM 3 
We invite you to participate in a 1-hour interview as part of a research study being conducted by investigators from 
Washington University in St. Louis. The purpose of this study is to evaluate a union and health fund’s use of guidelines to 
reduce opioid misuse among their members.   The interview will ask about your knowledge and attitudes toward opioid 
use disorder or OUD, existing workplace opioid policies and programs and the date of adoption or implementation, and 
any changes to your policies or programs underway or plans for future changes.  
 
Date: ________________________________                        Interviewee: _______________________________ 
 
Organization: 
                      Interviewer: 
 

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Number 
Questions 
Response 
A 
Company Background 
 
a.1 
How many eligible members are covered by the Health Fund? 
 
a.2 
What is your role in the Health Fund? 
 
a.3 
What Unions are covered by the health fund? Does each union have 
the same health care coverage as the other unions or distinct 
coverage? Please explain. 
 
 
B. Attitude and Beliefs 
Notes 
B.1. Do you think that the use of prescription opioid misuse and related opioid issues is 
present among employees in your organization?   
 
What leads you to believe this?  
(supervisor report, claims data, positive drug test results) 
 
B.2. Has your organization had an experience with a drug related incident or overdose of an 
employee    
       
    Did this happen on the worksite? 
    Can you share the story? 
 
 
Now I will go through a series of questions to learn about your health fund and/or union policies and programs. Please 
answer each item, but if the item falls under another organization (such as the union), please let me know and we would 
like to talk to a contact from the organization to answer those questions.  
C 
Health Fund Policies and Programs (Needs Assessment) 
 
Element 
Question 
Notes: If they do not know, ask who is better 
person or organization to answer the question. 
Include date started, benefit/coverage for some/all 
members, perceptions of member utilization and 
awareness of benefits, policy under the collective 
bargaining agreement (CBA), and request for copy 
of policy to research team 
 

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C.1. 
Policies 
C.1.a. Tell us about your organizations policies related to substance 
use?  
 
    Written policy?  
    Does it cover general substances or specific substances?  
   (opioid and alcohol) 
 
C.1.b. What is covered in the policy (substance use prohibitions, 
expectations of the workforce, and consequences)? 
 
 
C.2. 
Drug 
Testing 
C.2.a. Tell us about your organizations drug testing program? 
     
Do you have a formal program? What does it include and how is it 
implemented? 
 
C.2.b. Describe the written procedures to conduct drug testing and 
actions to manage test results? 
 
C.2.c. What are the consequences if a worker tests positive?  
    
 Are the consequences formal or informal? 
 For tests done by the union 
 For tests done by the employer 
 
C.2.d. Do you use any special strategies to ensure your program is 
delivered effectively? 
    
 
 
C.3. 
Medical, 
Health 
Benefits 
C.3.a. What treatments does your medical health insurance offer to 
members for pain management? 
 
C.3.b. What non-prescription opioid pain management treatments are 
covered? 
    Chiropractic? 
    Acupuncture? 
    Physical therapy)? 
 
 
C.4. 
Behavioral, 
Health 
Benefits 
C.4.a. What programs and services are covered by your 
organization's behavioral health insurance? 
    
 
 

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C.5. 
Pharmacy, 
Health 
Benefits 
 
C.5.a. What pharmacy protections are in place related to 
prescription opioids? 
 
C.5.b. What strategies do you use to communicate your 
organization’s medical, behavioral health, and pharmacy benefits 
to members?  
 
C.5.c. Do you monitor utilization of medical, behavioral health, and 
pharmacy benefits by members? 
             (types of claims/prescriptions used)  
 
 
C.6. MAP 
C.6.a. Does your organization have an MAP?  
 
    What services does the MAP provide to your members?  
    How does a member get connected to MAP? 
    Can you expand on the options? 
    Time from first contact to meet with counselor? 
     
 
C.6.b. What strategies do you use to communicate these benefits 
(MAP) to members?  
 
C.6.c. What portion of your members use the MAP each year? 
 
 
B.7. Legal 
Considerations 
B.7.a. Does your organization have a return to work policy?  
     
    If yes does it cover employees with substance use disorder? 
i.e. does it accommodate workers returning to work after 
treatment (inpatient or outpatient)  
 
 
C.8. 
Employee 
Education 
C.8.a. Does your organization train workers about opioid risks?  
    
C.8.b. What does the training include and when do they receive it? 
[a) opioid risks, b) how to get help if they are struggling with 
opioids, and c) information on the (safety and health) impact 
opioids have on the workplace] 
 
 
C.9. 
Supervisor 
Training 
 
C.9.a.Does your organization provide training to your supervisors on 
issues related to opioids, intoxication and substance misuse? 
 
If yes, please describe what is covered, when supervisors are 
trained, duration of training, and follow up training sessions? 
 
 

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[These may be covered: Recognize reasonable suspicion, how to 
talk to and respond to someone suspected of being under the 
influence, how to manage worker in return to work, and how to 
engage with workers after a critical incident.]  
C.9.b. What strategies have you used to provide education and 
promote participation to members? 
 
 
C.10. Other 
C.10.a. Is there anything else your organization is doing that you 
feel helps prevent, treat, or manage opioid misuse? If yes, please 
explain.  
 
 
C.11. 
Culture of  
Care 
C.11.a Do you feel your organization has a caring culture for 
substance use and opioid use disorder? Please explain why or why 
not and give examples. 
 
 
C.12. 
Collective 
Bargaining 
Agreement 
C.12.a. Does the CBA contain any language or restrictions in 
policies and benefits related to substance use and opioid use 
disorder? 
 
 
D. Plans for change/improvements to policies and 
programs related to opioids and substance use 
 
D.1. Are you in the process of making any changes 
now? 
 
D.2. What do you feel are the most important 
elements you need to add or improve in your 
organization to address opioids?  
 
 
D.3. What are your next steps to address the opioid 
issue in your company? 
 
 
E.1. Please provide names and contact information for others we need to talk to get the rest of the information. 
Name 
Title 
Contact Information (email/phone) 
 
 
 

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E.2. Identify documents we need to collect:  
Example Documents 
Documents Interview will share 
• 
Employee Benefits 
• 
Written polices  
• 
Collective Bargaining 
Agreement 
• 
Written programs (if 
available) 
• 
Forms 
 
  Please complete the Checklist as another measure for us to understand their program.  

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Page 1 
Health and Safety Substance Use Survey 
Below are the instructions, consent, and survey. Please check the box at the end of the informed consent to begin 
the survey. 
Informed Consent 
We invite you to participate in a research study being conducted by Dr. Ann Marie Dale from Washington University      
in St. Louis.  The purpose of this study is to evaluate a union and health fund’s use of guidelines to reduce opioid  
misuse among their members. We are seeking workers to complete this survey to evaluate the use of the guidelines. 
If you choose to participate, you will be a volunteer for the study; you will be asked to complete a 10 minute survey; 
and you may skip any questions that you prefer not to answer. All information will be anonymous. We will not ask 
any questions that identify you. The survey questions ask about your knowledge of health benefits and policies, 
attitudes toward use of opioid prescriptions, and participation in union programs and benefits. 
There are no known risks and no costs to you for participation. You will not be penalized or lose any benefits for 
which you otherwise qualify and participation will not affect your job. There is no compensation for participation. 
Although you will not directly benefit from participation, your information may help improve health risks of others in 
the construction industry. If you choose not to participate, please do not answer any of the questions and exit out of 
this webpage. 
Your data will be stored without your name or any other information that would allow us to identify you. Your data 
may be used in future research studies and cannot be removed. By allowing us to use your data you give up any 
property rights you may have in the data. We will share your data with a large data repository (a repository is a 
database of information) for use by the research community. Your individual identity will not be known in this data 
set. 
If you have any questions about the research study itself, please contact: Sam Biver at sbiver@wustl.edu. If you feel 
you have been harmed from being in the study, please contact: Dr. Ann Marie Dale at amdale@wustl.edu. If you have 
questions, concerns, or complaints about your rights as a research participant, please contact the Human Research 
Protection Office at 1-(800)-438-0445 or email hrpo@wustl.edu. General information about being a research 
participant can be found on the Human Research Protection Office web site, http://hrpo.wustl.edu. Thank you very 
much for your consideration of this research study. 
If you agree to participate click this box, then click submit once you are finished with the survey 
How old are you? (years) 
What is your gender? 
Male 
Female 
What is your race? 
White 
Black/African American 
Asian/Asian American 
American Indian/ Alaska Native 
Native Hawaiian or other Pacific Islander 
Other 
Please specify other race 

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E. 
 

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C. Administrative Claims_Data Variables 
Label 
Variable name 
database 
Description 
Patient Identifier 
Patient ID 
Claims 
Unique identifier created by health plan to allow 
linkage of the datasets (pharmacy and claim data) 
Claim date 
claimDate 
Claims 
date of claim 
Claim type 
claimType 
Claims 
code for type of claim 
Provider identifier 
providerSrv ID 
Claims 
Unique identifier in health plan database for 
provider 
Primary diagnosis 
(ICD-10) 
 
Claims 
primary ICD-10 code 
All diagnoses (ICD-10 
codes) 
allDiagnosis 
Claims 
ICD-10 codes for the visit 
CPT and HPCCS 
codes 
procedureCode 
Claims 
CPT and HPCCS codes 
Claim start date 
serviceFrom 
Claims 
start date of claim episode 
Claim end date 
serviceThru 
Claims 
end date of claim episode 
Claim episode 
Sequence 
Claims 
number to group rows of data for each single 
episode 
Patient Identifier 
Patient ID 
Pharmacy 
Unique identifier created by health plan to allow 
linkage of the datasets (pharmacy and claim data) 
Pharmacy date of 
service 
Date of Service 
Pharmacy 
Pharmacy date of service 
Pharmacy location 
identifier 
Pharmacy RX No 
Pharmacy 
Pharmacy location identifier 
Drug name 
Drug Name 
Pharmacy 
drug name 
Drug type 
Drug Type 
Pharmacy 
drug type 
Drug identifier 
NDC 
Pharmacy 
drug identifier 
Refill number 
Rx Refill Nbr 
Pharmacy 
number of the refill 
Formulary category 
Formulary Ind 
Pharmacy 
single or combination drug 
Indication for drugs 
Most Common 
Indication 
Pharmacy 
category of indication for drugs (i.e. 
pain/inflammation) 
drug for maintenance 
Maintenance Drug 
Pharmacy 
purpose of drug 
number of days 
Days Supply 
Pharmacy 
number of days supply 
number of tablets 
Fill QTY 
Pharmacy 
number of tablets per drug 
Claim correction 
Claim count Nbr 
Pharmacy 
Used to correct misentries in data 
Relationship code 
Relshp Cde 
Pharmacy 
relationship of the patient (member, spouse, 
dependent) to identify possible non-member data in 
the dataset 
Age 
Age 
Pharmacy 
Computed by the health fund, age at time of first 
claim 
Gender 
Gender 
Pharmacy 
sex of patient 
prescriber unique 
identifier 
Prescriber NPI Nbr 
Pharmacy 
prescriber unique identifier 
pharmacy claim 
number 
Pharmacy Claim 
ID 
Pharmacy 
pharmacy claim number 
Prior authorization 
code 
Prior authorization 
type 
Pharmacy 
Prior authorization code 

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Prior authorization 
number 
Prior authorization 
Nbr 
Pharmacy 
Unique prior authorization number 
Work hours 
Work hours 
Work hours 
work hours 
 
WORKPLACE GUIDELINES TO PREVENT 
OPIOID AND SUBSTANCE ABUSE FOR 
THE CONSTRUCTION TRADES 
 
 

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This work was supported by National Institute on Drug Abuse grant R34 DA050044-01. 
 

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11 TABLE OF CONTENTS 
Executive Summary .................................................................................................................................... 55 
Background ................................................................................................................................................. 56 
The Opioid Misuse and Opioid Use Disorder (OUD) Continuum ............................................................ 58 
Brief Description of the Essential Elements of a Prevention Program .................................................... 59 
Process Guide: ............................................................................................................................................ 61 
Step 1: Needs Assessment ..................................................................................................................... 61 
Step 2: Inventory Resources ................................................................................................................... 63 
Step 3: Develop and Implement a Plan ................................................................................................... 64 
Multi-Organization Situations involving Employer and Union/Health Fund ............................................. 66 
Framework for Multi-Organization Situations involving Employer and Union/Health Fund .................... 66 
Program Resources and Trainings .......................................................................................................... 68 
Program Content Guide: ............................................................................................................................. 70 
1. 
Build a Culture of Care .................................................................................................................... 70 
Strategies: Culture of Care 72 
2. 
Employee Education ....................................................................................................................... 74 
Strategies: Employee Education .......................................................................................................... 75 
3. 
Train Supervisors on Managing Workplace Substance Misuse ..................................................... 76 
Strategies: Supervisor Training ........................................................................................................... 77 
4. 
Written Controlled Substance Use Policy ....................................................................................... 78 
5. 
Drug Testing Policy ......................................................................................................................... 81 
6. 
Healthcare Insurance and Pharmacy Coverage ............................................................................. 85 
Strategies: Healthcare Insurance and Pharmacy Coverage ............................................................... 87 
7. 
Employee or Member Assistance Programs ................................................................................... 90 
Strategies: EAP/MAP 
91 
8. 
Legal Concerns ............................................................................................................................... 92 
Strategies: Accommodations for Employee with OUD ........................................................................ 93 
Frequently Asked Questions (FAQs) .......................................................................................................... 94 
State Level Employer Resources .............................................................................................................. 100 
Special Topics/Callout Boxes.................................................................................................................... 104 
Terms List.................................................................................................................................................. 105 
References ................................................................................................................................................ 107 
 
 
 
 

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12 EXECUTIVE SUMMARY 
The opioids crisis has devastated the U.S. leading to a substantial number of people suffering 
from a chronic substance dependency called opioid use disorder. This crisis has been 
particularly hard on the construction industry. Construction workers perform physically 
demanding work that leads to high rates of musculoskeletal injuries; workers seek medical 
treatment for pain relief, even among the youngest workers. Many construction workers have 
little or no sick leave and poor job security causing these workers to more often come to work 
when in pain and possibly under the influence from substance use. Workers often receive 
prescription opioids from a physician to treat their pain. 
There is growing evidence that opioid prescription use leads to the development of opioid use 
disorders and addiction. The medical community and providers have been encouraged to 
judiciously prescribe opioids for pain and to use alternative pain-relieving treatments. 
Employers and member organizations should support limiting opioid prescriptions and should 
help employees who may already have a dependence on opioids through opioid preventive and 
supportive workplace policies and programs. The construction industry has a unique challenge 
given the complex organizational structure and employment of workers through temporary, 
union, and or subcontracts for many construction projects. Employees of these multi-
organizational situations may receive their health and safety benefits and programs from more 
than one organization, often creating gaps or conflicts between health services and the 
organization of work.  
These guidelines were created to help employers, unions, and union health funds evaluate the 
opioid prevention supports offered within their organization, and aid the development of a 
comprehensive plan of opioid prevention policies, benefits, and programs for employees to 
reduce their risk for developing an opioid use disorder. The document addresses the unique 
issues presented by multi-employer arrangements and contracts, with particular attention to 
employee benefits provided through union organizations.  The recommendations in these 
guidelines may be applied to other substance use situations such as illicit drug use or 
marajuana, but there may be additional preventive actions needed to provide comprehensive 
prevention for these other substance use situations. 

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13 BACKGROUND  
 
The opioid crisis has led to a substantial number of overdose deaths of U.S. workers. This 
substantial loss of workers from drug addiction and overdose deaths is contributing to the 
declining pool of workers, greater healthcare costs, and lower worker productivity.  The opioid 
crisis was born out of the medical system’s attempt to address the pain crisis by prescribing 
opioids, ignoring the addictive nature of opioids.  
 
• Employees with substance use disorders miss 10 days of work per year more than their 
co-workers [1] 
• Drug overdose deaths exceeded 100,000 in a single year in 2021 [2] 
• The number of fatal workplace overdoses increased in each of the 8 years to 2020 [3] 
 
The construction industry has one of the highest rates of prescription opioid use and overdose 
death rates. The construction industry has many of the factors that contribute to worker 
addiction: a large portion of workers with painful musculoskeletal health conditions caused by 
the physically demanding work, lack of sick leave to aid physical recovery, and a culture that 
prioritizes productivity over health concerns [4].  
 
• Construction workers are 7 times more likely to die of opioid-related overdoses than the 
average worker [5] 
• The construction industry has the highest rate of substance use disorder among all 
industries [1] 
• 1 out of 3 construction workers has a musculoskeletal disorder (MSD) [6] 
• Prescription opioid use is 3 times higher among construction workers with MSDs [4] 
• Workers who are using opioids have a significantly increased risk of falls and unsafe 
behaviors, putting themselves and others at risk of injury in the workplace [7] 
• Many workers use alcohol, prescription opioids, and other substances to relieve mental 
stress and physical pain [7] 
 
Substance use disorders are common in the workplace, leading to high costs for healthcare and 
lost productivity. Figure 1 shows the loss of employment as workers transition from taking 
opioids, to misusing opioids, to developing opioid use disorder. Opioid use disorder is a 

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treatable disease with good prognosis for recovery within a supportive environment. A multi-
prong workplace program can improve workplace morale, productivity, and worker health.   
 
 
• Employers spend an average of $8,817 on each employee with an untreated substance 
use disorder [8] 
• About two-thirds of people who have an opioid use disorder are in the workforce [9] 
• Workers with opioid use disorder are more likely to become unemployed and fall out of 
the workforce (as shown in Figure 1) [10] 
• Only one in four people (28%) with opioid use disorder received treatment in 2017 [11] 
• Treatment for workers with opioid use disorder decreases healthcare costs and 
improves workplace productivity [12] 
• Opioid use disorder has an exceptionally good prognosis for recovery with more than 
10% of Americans living in recovery today [13] 
 
This guideline was developed for workplace organizations, including employers, unions, and 
health funds, to help improve their opioid prevention program. Unlike other guides that 
provide general workplace information for opioid prevention, this guide is tailored for the 
construction industry. It includes a simple needs assessment to review opioid specific policies 
and programs across eight elements of an organization, and steps to create a plan to improve 
the organization’s opioid prevention program. The guide covers the multi-organization situation 
with union members working for non-union employers, which provide separate coverage of 

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opioid-related benefits, programs, and services. The guide provides links to a large number of 
off the shelf trainings and resources to aid program development. For more information, please 
visit the website, www.opioidsandconstruction.com to get other products and updates related 
to this guideline. 
 
13.1 HE OPIOID MISUSE AND OPIOID USE DISORDER (OUD) 
CONTINUUM 
 
This guide covers the full continuum of care for opioids from prevention, to treatment, to 
recovery and return to work. Optimal health is obtained and maintained through prevention, 
although a productive life can be achieved for those needing treatment and/or in recovery. 
There are three phases of the continuum of care shown in Figure 2.  Each phase of prevention 
can be addressed within each of eight essential elements.  There is strong evidence that a 
safety and ergonomics prevention program can reduce the risk for a workplace injury or 
musculoskeletal disorder, however these programs are not included in this guide as they are 
addressed in other resources [14-16].   
 

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13.2 BRIEF DESCRIPTION OF THE ESSENTIAL ELEMENTS OF A 
PREVENTION PROGRAM 
The following section provides an overview of the elements to comprehensively address opioid 
and substance abuse in a workplace program. These elements and recommendations were 
developed from a thorough review of peer-reviewed literature, previously published employer 
guidelines, and opinions from subject matter experts and industry stakeholders. A 
comprehensive program should include all elements, address all phases across the opioid 
continuum of care, and should consider meaningful strategies for program implementation and 
integration of the elements. Employers or unions with little or no current prevention program 
would benefit from using the needs assessment checklist in the Process Guide to help them get 
started. 
 

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Build a Culture of Care 
Building a culture of care starts with a sincere belief from leadership that a healthy and 
empowered workforce is more productive and committed.  Leadership demonstrates this belief 
in the mission and vision of the organization, often as a statement of commitment to the well-
being of the workers.  The commitment is consistently demonstrated though all policies, 
practices, communications, and education in the organization.  
Educate Employees on Opioid Risks  
The Substance Abuse and Mental Health Services Administration (SAMHSA) suggests educating 
all staff on the risks of opioid use, effects of opioids on health, job performance, workplace 
safety, workplace expectations/policies, and prevention strategies.  This information should be 
delivered on a regular basis to reinforce the message and to communicate the value the 
organization places on the health of employees and their families. 
Train Supervisors on Managing Workplace Substance Misuse  
SAMHSA recommends that all supervisors know the organization’s opioid prevention policies, 
their responsibilities for initiating and carrying out policies and programs related to their job, 
and how to recognize employees with suspicious substance misuse behaviors.  
Written Controlled Substance Use Policy 
A company or union’s written controlled substance use policy should be designed to meet the 
needs of the workforce and be appropriately delivered within the workplace.  The 
comprehensive policy includes a statement of purpose, and details the expectations, 
prohibitions, program elements, consequences and appeals related to substance use.  The 
policy may meet the minimum requirements mandated by law or may be more comprehensive 
to cover the overall health, safety, and well-being of the workforce.   
Drug Testing Program 
A drug testing program is designed to deter employees from coming to work unfit for duty, 
thereby keeping all employees safe and all equipment and property free from harm.  The 
program should have clearly defined steps and should be consistently communicated to all 
employees. It may be part of the written substance use policy. The testing should be performed 
by a certified lab with oversight by a medical review officer (MRO). Industries and jobs involving 
safety sensitive tasks may have specific drug testing mandates.  
Healthcare Insurance and Pharmacy Coverage 

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The healthcare plan provider (employer or union) should offer healthcare and pharmacy 
coverage for medical pain management (non-opioid pain management therapies), and 
behavioral health and recovery treatment (pharmaceutical coverage for medication assisted 
treatment, inpatient and outpatient recovery services). Pharmacy coverage and policies should 
reduce risks for over-utilization of prescription opioids. 
Employer or Member Assistance Program 
Employee assistance program (EAP) or member assistance program (MAP) are resources 
offered by the employer (EAP) or union (MAP) for services to help improve each employee’s 
work-life balance and well-being.  EAP and MAP services can help reduce negative effects of 
opioid and substance misuse through screenings and early identification, short-term 
counseling, referral to specialty treatment, and other behavioral health services. Employees 
with positive drug screens or other suspicious substance misuse behaviors may be required or 
recommended to see an EAP/MAP counselor for an assessment.  
Legal Concerns 
Ensure all legal requirements related to drug-free workplace policies, practices, and drug 
testing are met. There are several federal and state laws and regulations related to medical 
management, labor laws and contracts, return to work and Americans with Disabilities Act, 
equal opportunity and substance use that should be considered within an employer or union 
plan. Ensure compliance with protecting employee privacy of healthcare and adequate 
coverage of behavioral insurance (Mental Health Parity and Addiction Equity Act of 2008) [17].   
 
14 PROCESS GUIDE: 
A step-by-step process guide will help you develop a plan for your opioid prevention program. 
This process guide includes a needs assessment to identify the strengths and weaknesses of 
your organization’s opioid prevention program, an inventory of the available resources within 
your organization, and guidance on developing and implementing a plan. The needs assessment 
should be completed by a person who is knowledgeable about the organization’s policies and 
programs, and who can give the most accurate reflection of the organization’s current efforts 
for the prevention of opioid misuse. 
 
14.1 STEP 1: NEEDS ASSESSMENT  

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The following tool will assess your organization’s policies and programs that support opioid 
prevention, treatment, and recovery. Please respond yes or no to each question.  Items with a 
“no” response indicate areas your organization may choose to make changes. Resources and 
additional information can be found in this guide at the page number listed for each question. 
Element 
Question 
Yes/No 
Resource 
pg # 
Culture of 
Care 
Has your organization's leadership made a 
commitment to help reduce the negative effects of 
opioid misuse for your employees? 
Y/N 
APA: Leadership 
Support  
16 
Has your organization's leadership demonstrated its 
commitment to help reduce the negative effects of 
opioid misuse for employees in written forms and 
actions (e.g., newsletter, in person presentations, 
policies and practices about employee mental well-
being)? 
Y/N 
CSDZ Building a 
Caring Culture  
16 
Does your organization tell employees to avoid using 
discriminating language and actions that make 
people living with opioid and substance misuse or 
disorders feel they don't matter? 
Y/N 
NIH: Words 
Matter 
16 
Employee 
Education 
Does your organization provide employees training 
about opioid risks and how to get help if they are 
struggling while using opioids? 
Y/N 
The Hartford: 
Shatter Proof 
Addiction video 
modules  
19 
Supervisor 
Training 
Does your organization provide training to 
supervisors on recognizing suspicious behaviors and 
signs of intoxication, and how to manage situations 
involving suspicious behavior? 
Y/N 
NSC: 
Impairment 
Recognition and 
Response 
Training for 
Supervisors  
20 
Written 
Controlled 
Substance  
Use 
Policy 
Does your organization have a written drug free 
workplace policy?  
Y/N 
SAMHSA’s 
Guide on 
Developing a 
Policy for a 
Drug Free 
Workplace 
22 
Drug Testing 
Does your organization require routine drug tests to 
ensure a drug free work force? 
Y/N 
NSC: Drug 
Testing and 
Opioids  
25 
Medical, 
Health 
Benefits 
Does your organization provide medical insurance 
that covers non-prescription opioid pain 
Y/N 
Structuring 
Health Benefits 
28 

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management treatments (i.e. chiropractic, 
acupuncture, physical therapy)? 
for Drug Misuse 
Issues 
Behavioral, 
Health 
Benefits 
Does your organization's behavioral health insurance 
provide coverage (with reasonable copay) for 
inpatient and outpatient recovery services for those 
with opioid use disorder? 
Y/N 
Structuring 
Health Benefits 
for Drug Misuse 
Issues 
28 
Pharmacy, 
Health 
Benefits 
Does your organization’s pharmacy benefit set limits 
for coverage of prescription opioids (i.e. number of 
day’s supply, maximum dose, type of opioids 
allowable)? 
Y/N 
 CDC Guideline 
for Prescribing 
Opioids for 
Chronic Pain 
28 
Does your organization's pharmacy benefit manager 
include an opioid prescription monitoring program? 
Y/N 
Structuring 
Health Benefits 
for Drug Misuse 
Issues 
28 
Does your organization's pharmacy benefit cover 
medication for opioid addiction treatment (i.e. 
buprenorphine) as a long-term treatment? 
Y/N 
MAT for Opiate 
Dependence 
28 
EAP or MAP 
Does your contracted or hired EAP/MAP participate 
in your organization's programs (i.e. deliver 
customized training, help with return to work 
management after treatment)?  
Y/N 
EASNA: EAP 
Purchaser Guide  
32 
Legal 
Concerns 
Does your organization's return to work policy cover 
employees with substance use disorder?  
Y/N 
JAN-Drug 
Addiction 
34 
 
14.2 STEP 2: INVENTORY RESOURCES 
Reflect on and answer the following questions related to the resources and support available to 
start and maintain elements of a workplace opioid prevention program within your 
organization.  Be as specific as possible in your answers. 
 
a) Has leadership made a verbal or written commitment to having an opioid prevention 
program with a specific focus on opioids (and/or other substance use disorders)? 
b) Does the organization have staff designated to develop an opioid prevention program? 
c) Will staff have protected (designated) time to manage the responsibilities of the 
program? 
d) Does your organization have financial resources designated for an opioid prevention 
program?  

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e) Do you have access to individuals or organizations internal and external to your 
organization who are knowledgeable about opioid and substance use disorder and its 
management in the workplace? List the persons and their affiliation. 
f) Do you have any current health and safety trainings, policies, or programs that could be 
used to pattern efforts for an opioid prevention program (i.e. safety training that could 
add opioid awareness and prevention training)?  
g) How knowledgeable are you about signs and behaviors of opioid misuse and opioid use 
disorder? Do you feel comfortable describing the issues about opioid use in the workplace 
with other employees and managers in the organization? 
 
 
14.3 STEP 3: DEVELOP AND IMPLEMENT A PLAN 
Based on the "no's" from your needs assessment in step 1, consider what your organization 
may be ready to change and develop a plan to make the change. Organizations with little to no 
opioid prevention activities may create a simple plan with short-term goals. Organizations with 
some programs in place may choose to develop a more comprehensive plan that includes an 
evaluation of the company culture related to opioid prevention. The following are steps to help 
you create a simple plan. Organizations in need of a more comprehensive plan may find 
additional assistance in the plan from the National Safety Council. 
 
a. From your needs assessment, choose one element that may be added or expanded to begin 
to build your prevention plan. This may be a topic your organization has considered 
changing or that may be most easily addressed to start your plan. List the element on the 
line below.  
 
Element: ______________________________________________           
 
b. Write out your ideas for your plan below.  Be as specific as possible to describe the steps 
you will take to build opioid prevention in the element. Refer to the Program Content Guide 
for additional information and strategies to address each element (pages 16-35). Program 
resources and trainings may be found on pages 14 and 41.   
___________________________________________________________________________ 

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c. From your inventory of resources from step 2, list resources that you have or will need to 
help you achieve the ideas for your plan. Include information on person responsible, 3rd 
party vendors involved, costs, action items, and timelines.  Describe how the steps will be 
completed and who is responsible for each action item.   
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Consider some strategies to help you get started. 
• 
Motivate and create interest through story telling.  
• 
Look for “champions” through local presentations, providers, and people with expertise 
that you can learn from and bring into your workplace for educational purposes or 
consultation.  
• 
Convene Employee Resource Groups (voluntary employee-led groups) whose purpose is 
to support the special needs and interests of various subgroups within the organization 
(i.e. Veteran’s support group, Woman’s network, Hispanic group, Working parent’s 
group). 
• 
Get worker input through listening sessions. 
 

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14.4 MULTI-ORGANIZATION SITUATIONS INVOLVING EMPLOYER AND 
UNION/HEALTH FUND 
Employer versus Union Health Plans 
 
Most employers offer health benefits and wellness programs to their regular employees. 
Members of a union generally perform work for many different employers, so they receive 
their health plans through a “Taft-Hartley” agreement. The health benefits and wellness 
programs of Taft-Hartley agreements are from the collective bargaining process between 
union and employer representatives, and are overseen by a joint labor-management board of 
trustees. The benefits and services offered through single employers and union health plans are 
similar, and may include health care benefits, pension, unemployment benefits, training and 
education, vacation/holiday/severance benefits, and disability insurance. Taft-Hartley union 
health plans generally cover a large number of individuals so these organizations may be able 
to negotiate lower costs per member for health and disability insurance and pharmacy benefit 
plans. Some unions ensure broad access for members while others limit resources to only 
regional networks so unions should check with their national office to see what resources and 
best practices have been created. One challenge for unions whose members work at many 
different locations is ensuring members have access to services close to their work location.  
 
A challenge for workers on multi-employer projects is the benefits may differ for those on 
employer-sponsored versus union-sponsored plans. Employers who oversee multi-employer 
projects may find contracted employees have limited coverage for some services (i.e. 
behavioral health or EAP/MAP). Some general contractors or project owners have offered 
EAP services for all employees on the jobsite. This is important to consider if there is a critical 
incident on the worksite and employees need behavioral health services to manage mental 
stress after the event. Employers should contact the union and/or health fund to bring in mental 
health services for their union members; or may opt to provide these services if the union does 
not offer them for their members. 
 
 
14.5 FRAMEWORK FOR MULTI-ORGANIZATION SITUATIONS INVOLVING EMPLOYER AND 
UNION/HEALTH FUND 
A common challenge in the construction industry is the interconnectedness of employers, 
unions, and health funds. Some of the benefits, policies, and programs are under the direction 
of the employer while others fall under the union and/or health fund based on the collective 
bargaining agreement and interest of the leaders of each organization.  Although these 

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agreements are created at the local level, national unions often offer substantial support and 
programs for regional and local unions. Figure 3 is a graphic that depicts which organization 
may control or be responsible or have shared responsibility for each of the essential elements 
of a workplace opioid prevention program.  Coordination between organizations is necessary to 
optimize outcomes for employees.  
 
 
 
In the table below, list which organization is currently responsible for each program element. 
Some elements may require involvement from more than one organization.  
Program Element 
(Refer to brief descriptions 
listed in the background)  
Organization Responsible  
List the organization responsible for each element:  
Employer, Union, or Health & Welfare Fund 
Culture of Care 
 
 
Member/Employee Education 
 
Supervisor Training 
 
 

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Written Controlled Substance 
Use Policy 
 
 
Drug Testing 
 
 
Healthcare Insurance and 
Pharmacy Coverage 
 
Member or Employee 
Assistance Program 
 
Legal Concerns for ADA 
 
 
 
14.6 PROGRAM RESOURCES AND TRAININGS 
Employee Education 
• A Dose of Reality for Employees 25-30 minutes: Educates Employees on a 3 point 
prevention strategy to prevention opioid misuse 
https://www.odjfs.state.oh.us/tutorials/OWD/WorkforeProf/Dose-of-
Reality/story_html5.html  
• The Hartford: Shatter Proof Addiction video modules: A series of videos on Stigma, 
Addiction, Risks, Support, Recovery 
https://www.thehartfordisshatterproof.org/open-access/ 
• Nevada DHHS: 45 minute Lunch and Learn Outline to educate employees (pg.16): 
Lunch and Learn Outline on risk of opioids, addiction, treatment, and recovery friendly 
workplace https://www.nevadaworksitewellness.org/wp-
content/uploads/2019/04/Nevada-Recovery-Friendly-Workplace-Toolkit.pdf  
• NSC: Opioids at Work Employer Toolkit “Employee Education” section: Education 
tools on videos such as 5 minute safety talks and videos 
https://www.nsc.org/pages/prescription-drug-employer-kit 
• 
CPWR: Opioid Awareness Training Program 
https://www.cpwr.com/research/research-to-practice-r2p/r2p-library/other-
resources-for-stakeholders/mental-health-addiction/opioid-resources/opioid-
awareness-training-program/ 
• CDC: Opioids in the Construction Industry 

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3 part educational videos series released by CDC to raise awareness on the 
issue of opioids in the construction industry 
Part 1: https://www.youtube.com/watch?v=XqOlAyEuqpQ  
Part 2: https://www.youtube.com/watch?v=inQu1WqAPII  
Part 3: https://www.youtube.com/watch?v=gsgbUQ2nKsE&t=1s  
 
Supervisor Training 
• NSC: Impairment Recognition and Response Training for Supervisor 
https://www.nsc.org/impairmenttraining 
• Kentucky Comeback: Reasonable Observation Checklist 
https://kentuckycomeback.com/wp-content/uploads/2020/08/Kentucky-
Comeback-Reasonable-Observation-Checklist-1.pdf   
• NAHB Supervisor Training: Addressing Opioid Misuse at the Worksite (pg.14): trains 
supervisors on signs workers may be misusing opioids, Talking to Employees about 
performance issues due to drugs, and using a performance checklist 
https://www.nahb.org/-/media/NAHB/advocacy/docs/industry-
issues/safety/opioid-resource-page/supervisor-training-opioid-misuse-
intervention.pdf 
Human Resources/Employers 
• Kentucky Comeback: Employer Inventory Form: This inventory exercise will 
help an employer recognize programs that need to be developed to support 
prevention, treatment, and recovery for their employees. 
https://kentuckycomeback.com/wp-content/uploads/2020/08/Kentucky-
Comeback-Employer-Inventory-Form-1.pdf  
• 
Kentucky Comeback: Policy and Procedures Samples: Samples documents for 
different policies and procedures when employers are developing written policy for 
their workplace substance use and opioid programs 
https://kentuckycomeback.com/policies-procedures/  
• Minnesota Department of Health- Opioid Epidemic Response: Employer Toolkit 
offers pre made social media posts and communication tools 
https://www.health.state.mn.us/communities/opioids/communities/employertool
kit.html#Example1  
 

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Employee Engagement Surveys 
• The Boston Medical Center: Employer Survey on Employee Support for Substance 
Use and Mental Health Disorders 
https://www.bmc.org/sites/default/files/addiction/1-employer-survey_v2.pdf 
• The Boston Medical Center: Focus Group Discussion Questions: Questions for Focus 
Group on mental health and substance use 
https://www.bmc.org/sites/default/files/addiction/1-focus-group-discussion-
questions.pdf 
• 
NSC: Sample Employee Engagement Survey: A survey to understand 
employees knowledge and attitudes on Opioids in the workplace. 
https://www.nsc.org/getmedia/c2d74fc8-1027-4c29-afab-
5cedfc07c3a1/sample-employee-engagement-survey.pdf.aspx  
 
Naloxone Training 
• NSC Opioids at Work: Naloxone in the Workplace: Guides employers on how to 
develop a Naloxone workplace program https://www.nsc.org/getmedia/2b1616a1-
c8a6-4c8c-b56b-1aa32f395bd5/naloxone-in-the-workplace.pdf.aspx  
• Reverse Overdose Oregon: Naloxone Training: Documents and training videos that 
train individuals on how to use Narcan "Naloxone" and what to do in the situation of 
an overdose https://www.reverseoverdose.org/training-video 
NOTE: State Specific Employer Resources may be found on page 41. 
15 PROGRAM CONTENT GUIDE:  
Essential Elements for a Workplace Opioid Prevention Program 
 
1. BUILD A CULTURE OF CARE 
Building a culture of care starts with a company or union organization clearly stating in their 
core values a commitment to the well-being of their employees.  This commitment is woven 
into the mission, and must be consistently demonstrated though policies, practices, 
communications, and education. Companies and organizations that display and implement 
empathetic policies and practices are able to build trust with their employees.  Trust leads to 

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better employee engagement and utilization of employer- or union-sponsored benefits, which 
enhances well-being and prevents the development of poor health.  Figure 4 shows a positive 
feedback loop created by consistent communication from organizational leaders to employees. 
The feedback loop shows higher levels of employee engagement, improvements in 
productivity, reduction in absences, reduced burnout, and higher innovation [18].   
 
An organization with a culture of care is capable of supporting employees with varying degrees 
of mental health conditions. Most workers will struggle with mental health issues at some time 
during their work, but they will 
cope better and remain more 
productive if they work in an 
environment that is 
empathetic to their health 
condition. Employees who are 
in recovery from addiction or 
opioid use disorder may have 
challenges maintaining sobriety 
yet they will have greater 
success if they work in a caring environment [19].  
Here is a short list of tangible action items an organization can do to move towards a culture of 
care [20]. 
o Coach leaders to model caring values with consistent follow-up and reinforcement 
o Share stories that highlight acts of caring within the organization 
o Provide job descriptions, especially for those involved in risk management or 
safety, that explicitly include protecting the well-being of employees 
 
Culture of Care and Stigma 
Social stigma is the negative attitude and behaviors of employees toward people with a specific 
characteristic that sets them apart from others. Even though opioid use disorder is recognized 
as a treatable brain disease, employees with opioid use disorder are often intentionally or 
unintentionally mistreated by coworkers and managers. Mistreatment from social stigma can 
increase an employee’s risk of having a relapse or of isolating themselves from their coworkers.  

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Educating all employees and supervisors to use destigmatized language and behaviors, and 
educating them about opioid dependence can help change attitudes, reduce stigma, and foster 
a caring culture [21].  
 
STRATEGIES: CULTURE OF CARE [33] 
1. Ensure organizational policies and programs are in place to prevent and treat opioid 
misuse, and support those in recovery from opioid use disorder (OUD). 
2. Communicate with care.  The words you choose are important as well as how the 
messages are conveyed. Provide consistent destigmatized messaging about mental 
health and substance use disorders and resources available into company and union 
organization communications [34]. 
3. Provide education to all employees in the workplace on the cause of opioid use disorder 
and how it can be effectively treated. 
Cause and effects of stigma 
 
Workplace stigma is prevalent in many companies and organizations, primarily caused by 
“unsupported assumptions, preconceptions, and generalizations” of employees [22].  Stigma 
implies social disapproval and can lead unfairly to discrimination against and exclusion of the 
individual [23]. 
 
Stigma presents itself in three ways: self, social, and structural.  Self-stigma is an individual’s 
negative feeling towards them self, based on a negative social reaction from a characteristic or 
health condition. Social stigma is other people’s negative attitudes and behaviors exhibited 
towards a stigmatized group or person that reinforces the stereotype.  Structural stigma is 
caused by institutional policies and practices that restrict the rights and opportunities for 
individuals of a stigmatized group [24].  Stigmatized conditions are usually associated with 
high-perceived levels of control and fault of the individual (e.g. “It is their fault they chose to 
take drugs and if they really wanted to, they would stop”).  People living with stigma lose 
hope, don’t believe in themselves, and subsequently become less productive and less engaged 
[25, 26]. 
 
Allowing stigmatized attitudes and behaviors in the workplace causes employees to suffer 
from feelings of shame and social alienation, reinforces isolation, and discourages the 
stigmatized employee from getting help when needed [27, 28].  Stigma can be reduced by 
changing the way people talk about addiction, using positive and supportive terms rather than 
negative labels, and educating employees about opioid dependency, effective treatment for 
chronic pain, and mental health conditions and resiliency [29-32].  

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a.  Successful strategies to reduce OUD stigma include: [27] 
i. Sharing success stories 
ii. Educational programs including participation from individuals in recovery 
b. Off-the-shelf Resource:  Shatter Proof Just Five Training Modules 
4. Offer information and help to find professional resources. Participate in mental health 
and substance use prevention campaigns with materials developed by trusted 
organizations like SAMHSA and American Psychological Association (APA). 
Connecting peer-based recovery supports to employees in need 
 
Employees in recovery and those who desire help for opioid or substance misuse often 
struggle with trusting others to seek help. For employees in recovery, this struggle may lead to 
relapse following return to work. Relapse does not mean that the person or treatment has failed 
– rather, it means that the treatment regimen in place is not the correct treatment for the person 
[35]. Peer-based recovery supports can help to improve trust among employees, increase 
feelings of inclusion, and increase help seeking for individuals at risk.   
 
Union or Employer Peer program (internal to organization):  A formal peer program may be 
created by a union or employer and include individuals in recovery from substance use or 
others interested in providing support to employees with substance use issues. These peers 
should be formally trained. Their primary role is to guide or help navigate co-workers in need 
toward accessing services from trained professionals. These peers do not provide counseling 
or other treatment themselves. Often organizations integrate their peer program with their 
EAP/MAP who also provide oversight for the trained peers to insure encounters with 
employees in need are handled appropriately.  Trained peers may assist with onsite trainings 
on related topics and be identified through posters or by wearing a special hard hat sticker to 
indicate they are trained and willing to help others [36].  
 
Peer Based Recovery Supports in the community: There are several ways that community-
based peer recovery services can provide assistance and support to a local company or union.  
These local programs can help connect employees with established peer support groups (e.g. 
Alcoholics Anonymous (AA), Narcotics Anonymous (NA)).  Some community programs 
employ peer-support coaches who can provide one-on-one peer coaching to others, and these 
services may be recommended to employees in need (Listen to NAHB’s Podcast, A 
Constructive Response to The Opioid Epidemic, Opioid Intervention in the Workplace 
to learn how GE Johnson integrated third party peer-support coaches within their 
organization). 
 
Example Programs 
• The Road Home Video, International Union of Operating Engineers Peer Program 
https://www.youtube.com/watch?v=P-PxdTlXpDs 

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2. EMPLOYEE EDUCATION  
Increasing employee’s knowledge of the risks of opioids, their role in having an impact on 
prevention of opioid misuse in the workplace, and awareness of policies and employer benefits 
related to prevention requires a communication and educational plan.  Comprehensive 
employee education involves presentation to all employees either in person or virtually. The 
goal of employee education is to decrease inappropriate use of prescription opioids and other 
substances by workers and to reduce stigma by increasing knowledge and empathy toward 
workers with addiction and opioid use disorders.  Communication strategies depend on the 
type of work, the size of the organization, culture, and employer resources (See FAQ “How do I 
communicate with my workforce effectively”).   
A comprehensive general employee opioid education may include the following topics:  
• What are opioids? 
• Risks of taking opioids 
• Treatment myths and facts  
• Signs and behaviors of opioid use disorder 
• Opioid overdose and naloxone for prevention 
• How to get help 
• Stigma reduction 
• Effects of opioids on job performance and workplace safety 
• Non-opioid pain management options 
• Talking to providers about non-opioid pain management options 
• Home safety practices (safe storage, safe disposal or take back opportunities, don’t 
mix with other drugs, don’t share) 
• Workplace expectations/policies and prevention strategies 
• Laborer’s Health and Safety Fund of North America, LEAN Program 
https://www.lhsfna.org/tackling-opioid-addiction-one-liuna-member-at-a-time/ 
 
National Peer Support Trainings 
https://www.mhanational.org/how-become-peer-support-specialist 
https://www.naadac.org/ncprss 
https://www.laborassistanceprofessionals.com/ 

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• Workplace supports and benefits for accessing help and treatment related to opioid 
use 
For more info on employee education on these topics, visit the National Safety Council’s 
Opioids at Work Employer Toolkit. Other employee education resources are located in the 
Program Resources and Training section in these guidelines. 
15.1.1 
STRATEGIES: EMPLOYEE EDUCATION 
1. Training may be delivered by human resources, occupational health, or a representative 
from the EAP/MAP. Trainings may be offered using online or virtual options. 
2. The large number of topics that should be included in a comprehensive opioid education 
program may not be adequately covered or well-understood if delivered in a single 
session. Provide single topic or short training sessions and repeat trainings on various 
topics regularly throughout the year. 
3. General opioid education can be part of the new hire onboarding process and should be 
regularly included in team/staff meetings, and other trainings or briefings such as 
toolbox talks. 
4. Educational materials and promotional information may be posted throughout the 
workplace and through other communication channels (i.e. newsletters, email, texts). 
 
Resources: 
CPWR Opioid Awareness Training Program for Employees 
Nevada Recovery Friendly Workplace Toolkit- “Lunch and Learn” 
Shatter Proof Educational Video Modules on Addiction 
A Dose of Reality for Employees Video Training Module 
 
Other special considerations for employee education: 
• Provide employees a means to dispose of excess opioids safely to reduce potential for 
opioid misuse (Resource: FDA Drug Disposal Locations Website, contact your local 
hospital or pharmacy, Stericycle drug disposal envelopes). 
• Order “Warn Me Labels” from National Safety Council to place on insurance cards 

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• Implement a Workplace Naloxone Program (Resource: NIOSH Using Naloxone to 
Reverse Opioid Overdose Factsheet, Reverse Overdose Oregon Naloxone Training 
Program) 
• 
Use destigmatized language to grow a caring culture toward substance use disorders 
(Resource: NIDA Words Matter- Terms to Use and Avoid When Talking About 
Addiction) 
• Special topics such as Naloxone training may be offered by a qualified person from a local 
hospital, first responder, police department, or community organization for recovery or 
drug use (Resource: NIOSH Using Naloxone to Reverse Opioid Overdose) 
 
3. TRAIN SUPERVISORS ON MANAGING WORKPLACE SUBSTANCE MISUSE 
Identifying and addressing substance use problems in the workforce can prevent greater 
problems for employers and unions, and can help support the health of the workers. 
Supervisors know each employee’s job tasks and typical performance at work so they are often 
the first to recognize unusual or a change in employee behavior suggestive of substance 
misuse. Supervisors can play a critical role in early intervention of substance misuse if they are 
properly trained on recognizing behaviors and how to manage the situation of an employee 
under the influence. Their training should include general information about risks of opioid use 
described in the employee education section (p.18). But it is important for supervisors to 
develop the knowledge and skills about how to help manage an employee in need. Companies 
or union organizations that already provide supervisor training on other topics may add 
information on opioid-related issues as part of ongoing training.   
 
THE FOLLOWING IS A LIST OF BEHAVIORS THAT OFTEN INDICATES AN EMPLOYEE IS 
STRUGGLING WITH A PERSONAL ISSUE (THAT MAY OR MAY NOT BE RELATED TO 
SUBSTANCE USE):  
• Regular tardiness  
• Unplanned absenteeism and excessive use of sick days  
• Ongoing performance issues (frequent disappearances at work, failure to complete 
assignments or meet deadlines) 
• Less engagement (signs of confusion, memory loss, greater mistakes) 

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• Behavioral concerns (greater conflicts with co-workers, deterioration in personal 
appearance, increasing isolation) 
 
Supervisors should not make assumptions about the reason for the behavior but should follow 
their employer policies and training or seek advice from human resources or management. 
 
The following is a list of the critical components of supervisor training [37, 38]: 
• how to recognize behaviors and observable signs of impairment   
• how to talk to an employee 
• how to recognize a medical crisis is due to a substance overdose and how to 
respond  
• know the employer policies for managing an employee with an opioid or 
substance use condition 
• which jobs performed by their employees involve safety sensitive activities 
• how to make a return to work accommodation for an employee after treatment 
• how and when to use Naloxone 
• the company’s critical incident response plan and procedures 
 
The supervisor has the most direct contact with employees after a critical incident, so should be 
able to gauge how well the employees are mentally coping with the situation.   
 
15.1.2 
STRATEGIES: SUPERVISOR TRAINING 
1. Train supervisors to encourage a culture of care, discourage the use of stigmatized 
language and behaviors, and provide fair and equitable treatment of all employees. 
2. Train supervisors in how to manage employees with substance use or in recovery, 
before being assigned this responsibility [22].  
3. Train supervisors in how to talk to employees under reasonable suspicion, employees in 
need of help, and employees in recovery using respectful and appropriate language. 
4. Supervisors should receive training on reasonable suspicion behaviors and 
organizational and procedures to manage these situations. 
5. Supervisors should be trained on how to engage with workers after a critical incident 
and how to provide resources and referrals to treatment as appropriate.  

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6. Supervisors managing return to work for employees in recovery should know how to 
communicate clearly defined expectations, timelines to complete tasks, and 
consequences for non-adherence to the return to work agreement.  
Resources: 
Supervisor Training From SAMHSA   
Supervisor training from NSC  
Intervention training for Supervisors from NAHB 
 
4. WRITTEN CONTROLLED SUBSTANCE USE POLICY 
Employers and unions each carry responsibility for the health and safety of employees, and 
therefore should each have a written controlled substance policy. The policy should include the 
organization’s goal for the workforce, be clearly stated and include the purpose, workforce 
expectations and prohibitions, substance use program elements, and policy consequences and 
appeals.  The policies may be designed to meet the minimum drug use requirements mandated 
by law or may cover policies more broadly.  Legal counsel, human resources, and employee 
relations should be involved with developing the policy to ensure it includes protections for risk 
management, injury prevention, and liability.  
The policy statement may include the following:  
• Specify who is covered  
• Drug testing and consequences for violations  
• Training to identify substance use behaviors for employees and supervisors 
• Employee education on substance use risks and how to get help for those in need 
• Assistance for employees who voluntarily seek help for impairment issues 
• Meeting the requirements of the law 
The substance use policy may include specific information related to the use of prescription 
opioids at work, and restrictions from safety sensitive work tasks while taking prescriptions 
opioids.  
The union’s policy is often part of the collective bargaining agreement.  The goal of the 
employer or union policy is designed to maintain a drug free workplace. There are several 

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guidance documents with examples of employer policies available for creating written 
workplace policies (links below). These documents may be a useful reference to create a 
union’s policy. 
 
Resources: 
SAMHSA’s Guide on Developing a Policy for a Drug Free Workplace  
NSC’s Sample Policy for a Drug Free Workplace Program  
Kentucky Comeback’s Sample Policies for a Drug Free Workplace  
 
Return to Work, Job Accommodations, and Recovery Treatment 
 
Return to work policies define the functional level an employee must meet to be eligible for 
returning to work after an injury, illness, or progressive health condition that limits function. A 
“fit for duty” determination means the employee is able to perform all of the essential duties of 
their assigned job, as outlined in the job description. For employees with medical or cognitive 
concerns, a fit for duty determination should be made by a medical provider knowledgeable 
about occupational tasks and workplace risks, such as an occupational medicine physician or 
person with similar training. Physical or mental impairments may be caused by work-related 
or personal injury or illness or substance use problems. Return to work policies for employees 
with substance use problems usually require a negative drug screen and documentation by a 
qualified physician approving fit for duty.  
 
Drug addiction may interfere with a person’s mental health processing shown as problems 
with attention, memory, ability to organize, and ability to control behaviors. Employees with 
substance use disorders (SUD) who complete recovery treatment may return to work if they 
can perform their regular job duties without placing themselves or others at risk of harm. An 
employee with as SUD may qualify for a job accommodation if their SUD has caused a 
disability as outlined in the American’s with Disability Act (See Legal Concerns, p. 34). 
Accommodations must be provided for all employees with the same or similar disability. 
Information for accommodating employees is provided by the U.S. Department of Labor’s 
Office of Disability Employment Policy and the Job Accommodation Network (JAN) [39, 40]. 
 
The goal of return to work policies for employees with SUDs is to create a system of support 
within the workplace and accountability of the returning employee to resume their usual work 
activities. There are several strategies employers can use to support employees in recovery 

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including the following: flexible leave of absence policies to allow time to receive outpatient 
treatments; having modified duty options if needed; having EAP/MAP services available and 
encourage its use; and having a healthy workplace culture that does not tolerate stigma and 
discrimination for people with substance use conditions [31]. (See the section on Build a 
Culture of Care, p. 16) 
 
Critical Incident Response Plan 
 
Every company should have an established plan for how to respond to a critical incident in the 
workplace.  A critical incident is defined as an event that caused an actual or perceived threat 
to an employee’s well-being or someone close to that employee.  Common examples of a 
workplace critical incident includes a major accident, workplace violence, employee suicide, 
or employee overdose.  The response plan should include the immediate action taken for the 
health and safety of the victim and all other persons at risk. The employer should have a plan 
for each type of critical incident.  
 
In the event there is an opioid overdose in the workplace, the employer plan may include 
having the lifesaving drug Naloxone available in the workplace, and trained persons to 
administer the treatment. In high doses, opioids will significantly slow breathing which can 
quickly lead to death if not reversed.  Emergency responders carry Naloxone to reverse an 
opioid overdose. However, an employer may consider implementing a workplace naloxone 
availability and use program, as having the life-saving drug available in the workplace 
improves the chance for reversing the overdose successfully.  If considering a workplace 
Naloxone program review the NIOSH Using Naloxone to Reverse Opioid Overdose 
Factsheet. A Naloxone program should include a written plan for how to respond to an 
overdose, training on how to administer Naloxone, clear expectations on who should be 
trained and how often, and insure Naloxone is available at the workplace.  Naloxone training 
may be considered as part of employee education and/or supervisor training. 
 
Addressing co-worker’s psychological response to a critical incident 
A critical incident response plan must consider the residual impact the incident might have on 
bystanders’ and co-workers’ psychological response and mental health. This is important for 
anyone who witnessed the event, or who was a friend or long-term co-worker to the victim(s) 
of the event.  Supervisors and frontline managers should monitor how well the employees are 
coping after a critical incident occurs in the workplace, and should know when to act if one or 
more employees shows signs of mental stress (see Supervisor Training). If the employees are 
members of a union, the union representative or business agent should be notified about the 
incident so union support resources may be provided for the union employees. EAPs/MAPs, 
mental health agencies, and other medically trained support services may be brought into a 
workplace to provide mental assistance for the employees after the critical incident. 

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Postvention strategies might include a formal critical incident debriefing session or an 
informal safety huddle debriefing with affected employees.  These debriefings often include 
behavioral specialists or EAP/MAP representatives.  Acknowledging the overdose and 
providing support in the immediate aftermath is a way to humanize your workforce and help 
individuals cope together and heal [41].  
 
Resources for Employers: 
NSC Naloxone in the Workplace 
Optum training on responding to traumatic events in the workplace 
International Critical Incident Stress Foundation’s Primer on Critical Incidents  
HRIA: Promising Policies for Overdose Prevention, Response, and Postvention 
 
5. DRUG TESTING POLICY 
A policy addressing workplace testing for illegal drugs outlines circumstances in which job 
applicants and employees will be tested, testing procedures, and consequences of violating the 
policy.  The goal of a drug testing policy is to deter employees from misusing drugs, identify 
employee’s under the influence of substances who may be a safety risk to themselves or 
others, and to identify employees who may have drug and/or alcohol problems and need 
treatment.  
A drug testing policy may be subject to the limits or requirements of state laws where the 
employer or union operates. Therefore, employers and unions should check with legal counsel 
to insure all policies comply with the state laws.  
The following sections provides general steps to create a drug testing policy:   
• Research applicable state (and federal) legal requirements 
• Establish drug testing procedures  
• Inform affected applicants and employees of the testing policy 
• Select an appropriate lab to conduct testing 
• Investigate rehabilitation and treatment options 
Special considerations: 
 
• Investigate federally defined regulations for safety sensitive jobs (see Safety 
Sensitive Activities, p. 27)  

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• Employers required to or who choose to follow the Federal Drug-Free Workplace 
Act (DFWA) must follow a standard protocol (Drug Testing Laboratory 
Protocols) [42]  
• All drug testing results should be treated as confidential medical information 
following Health Insurance Portability and Accountability Act (HIPAA) [43]  
• Employees with a first time offense should be offered a “second chance” to retain 
employment after completing treatment (see Second Chance Policy in a Drug-Free 
Workplace Program, p. 25) [44] 
• Create a Recovery Friendly Workplace that aligns with Culture of Care and 
demonstrates support across the full continuum of care from prevention, to 
treatment, and to recovery (see Recovery Friendly Workplace, p. 27) 
 
Resources: 
National Safety Council: Drug Testing and Opioids  
ACLU State-by-State Workplace Drug testing Laws  
 
 
Second Chance Policy in a Drug-Free Workplace Program 
 
A second chance is intended for employees who show a sincere desire to attain and maintain a 
drug-free state upon returning to work. Employees unwilling to follow the steps for treatment 
and return to work plan or who fail to abide by the return to work contract may need to be 
terminated. Many employees who misuse substances want to stop, but are unable to do it alone. 
A second chance policy provides employees a chance to receive the treatment and support they 
need to get into recovery. Second chance policies are a cost effective way for employers and 
unions to retain employees, save replacement costs to hire and train new employees, gain 
employee trust for early reporting and reduce fear of termination, save on healthcare costs, 
decrease absenteeism, and increase loyalty of employees following treatment [45].   
 
The expectations in the policy typically includes: 
 An assessment and treatment plan by a certified substance use professional   
 Completion of a substance use treatment program (inpatient or outpatient) 
 Employees agree to a return to work plan determined by the employer/human resource 
representative and supervisor 
 Completion of follow-up outpatient treatment to monitor progress after return to work   
 

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An employer may use an external provider or their EAP (or MAP) to guide the employee 
through the steps of the policy, to monitor compliance with treatment, and to serve as a liaison 
between the employer and healthcare providers. Often, there is a return to work contract that 
states the expectations of the employee and is signed by the employee and employer [40, 46]. 
Employees assigned to jobs involving safety sensitive activities may be given modified duty 
(other duties or another job) until they are deemed “fit for duty” to return to their usual work 
duties [31]. (See the sections on Safety Sensitive Activities (p. 27), and Return to Work, Job 
Accommodation, and Recovery Treatment (p. 23)) 
 
The return to work agreement may include the following items: 
• Monitor sobriety by submitting to random and/or regular drug tests. 
• Positive drug test may result in termination 
• Refusal to take a drug test may result in termination 
• Compliance with outpatient or other aftercare program 
• Statement about recourse for excessive use of sick or vacation time if illness is not 
verified by a physician’s note 
• Expectation to maintain standards of performance and failure may result in corrective 
action 
Since relapse is more common in the early stages of recovery or when an individual is in a 
stressful and demanding situation [47], it is important these employees be given support and 
flexibility with their work schedule to allow for adherence to prescribed medication and 
attendance to outpatient behavioral treatments [33]. Supervisors should be trained to recognize if 
employees are struggling and encourage the employees seek help from their counselor and 
human resource personnel before they fail a drug test from a relapse. The return to work contract 
and continued behavioral treatment are ways to support the employee during the early stages of 
recovery [48]. 
 
 
Safety Sensitive Activities 
 
Employees who perform safety-sensitive activities may need to be restricted from performing 
their usual duties while taking opioid prescriptions or related medications. According to the 
American College of Occupational and Environmental Medicine (ACOEM), safety sensitive 
tasks are activities that require high levels of cognitive function and judgment that can cause 
harmful or fatal events if the worker is impaired from substance use [49, 50]. Examples of 
safety sensitive activities include operating motor vehicles, forklift driving, overhead crane 
and other heavy equipment operations, or operators of other modes of transportation (i.e. 
airplane pilot, train conductor).  

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Employers should identify all jobs involving safety sensitive tasks, and document them 
consistently in written job descriptions. Employers may provide the treating physician and 
medical review officer (MRO) with a copy of the job description and a return to work letter 
template. The return to work letter may ask the physician if there are any safety concerns that 
must be accommodated in returning the employee to usual duties. The job description provides 
the physician the information necessary to make a “fit for duty” determination for workers.  
There is specific guidance on the topic of safety sensitive activities and return to work offered 
by the Department of Transportation (DOT) and Department of Defense (DOD) that can guide 
an employer’s return to work program  [51-56].   
 
 
 
Recovery Friendly Workplace  
 
Opioid use disorder is a brain disease that causes individuals to experience intense cravings for 
opioids, but with treatment, employees in recovery can be fully employed and productive 
workers in the workplace. Recovery is a process that helps the individual resist drug use, and 
improve resiliency and mental stability over time. Current evidence-based treatment includes a 
combination of medication to reduce the cravings and behavioral counseling to help the 
individuals learn positive behavioral approaches and how to avoid situations that expose them 
to reusing drugs [57, 58]. The workplace environment can improve the success of recovery by 
having a strong support team, a structured work schedule, and providing the employee 
meaningful activities [22, 59]. The workplace organization must be prepared to support an 
employee in recovery with a positive environment, as relapse is more common when the 
individual is immersed in stressful situations. With ongoing treatment and greater personal 
success, the employee in recovery will progress to a more stable mental state.  
 
What should a recovery friendly workplace include? 
Recovery Friendly Workplaces can increase the chance of successful return to work by 
offering jobs with manageable workloads and responsibilities, having a caring culture that 
promotes empathy for individuals in recovery and address stigmatizing attitudes, and 
promoting wellness as part of a “sober” lifestyle. Policies should allow the employee in 
recovery a flexible work schedule and/or time off to continue to receive treatment, a return to 
work plan with jobs based on the skill and mental stress tolerance of the employee, a 
structured work environment with clearly established expectations, and ongoing social and 
organizational support. Employees in recovery may benefit from having access to peer support 
specialist and support groups either at the worksite or accessible in a community setting [60].  
Some employers create “sober crews” of workers so they can support each other and avoid 
social discussions involving drug and alcohol use.   
 

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Steps employers (and unions) should take to become a recovery friendly workplace [22, 60] 
• Leadership openly communicates support for a culture of care 
• Educate employees to understand and prevent opioid use disorder  
• Supportive workplace policies for employees in recovery  
• Health insurance and pharmacy benefits to cover substance use treatments 
• Training supervisors to appropriately communicate with employees in recovery 
• An EAP/MAP program tailored to help employees with substance use needs 
• Workplace policies to confront stigmatized behaviors 
 
Resources  
Recovery Friendly Workplace Toolkit 
https://www.peerrecoverynow.org/ResourceMaterials/RFW_Toolkit_v6.pdf 
 
Recovery Community Organization Directory 
https://www.peerrecoverynow.org/field/rco.aspx 
 
6. HEALTHCARE INSURANCE AND PHARMACY COVERAGE 
Providing insurance coverage for comprehensive medical and behavioral healthcare, and 
appropriate forms of pharmaceutical treatments can insure employees have access to the best 
treatments to curb employee risk for developing opioid misuse and opioid use disorder [61].  
 
Comprehensive healthcare benefits should include coverage of both medical and behavioral 
health treatments across the substance use continuum from prevention to recovery. Although 
employees with opioid use disorder (OUD) may be successfully treated, current evidence 
suggests they generally require intense medical (detox), pharmaceutical management using 
medication for opioid addiction treatment (MAT) to reduce the strong cravings often 
experienced by individuals with opioid dependence, and extensive behavioral health counseling 
[62, 63].  
 
Collaborative Care Model (CCM) is an integrative approach to provide effective mental health 
care healthcare team, and is often led by the primary care provider with involvement from a 
behavioral health provider, a psychiatrist, and the patient [62]. Information is shared through 
the electronic health record (with patient permissions), and allows for greater knowledge about 
the patient’s health situation to be considered in all treatment decisions. There are specific 

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Current Procedural Terminology (CPT) codes available to cover charges of services and time 
related to CCM. 
Pharmaceutical Coverage and Pharmacy Benefits Manager (PBM) 
The health plan’s covered pharmacy generally include opioid formularies to treat painful 
medical conditions, but the condition, medication dosage, and duration of the prescription 
should limit the risk for developing opioid dependency. The Center for Disease Control and 
Prevention (CDC) provides guidelines on prescribing opioids for chronic noncancer pain 
management [64], and for combining opioids with other medications including benzodiazepines 
[65]. CDC guidelines recommend using immediate-release opioids, starting with low dose, 
limiting supply to address acute pain, avoiding extended-release long-acting opioids for acute 
pain, and re-evaluating pain by the physician before giving additional prescriptions [41]. 
Encourage physicians and pharmacies to consult the Prescription Drug Monitoring Program 
(PDMP) before filling new prescriptions [66].  The PDMP are state-run electronic databases 
used to track the prescribing and dispensing of controlled prescription drugs to patients, and 
are intended to avoid suspected abuse or diversion of controlled substances.  
 
Worker’s Compensation 
Workers’ Compensation insurers provide medical benefits, compensation for lost wages, 
retraining, and return to work assistance of occupational injury and illness.  Many workers’ 
compensation plans follow the CDC guidelines to carefully monitor the use of prescription 
opioids to decrease the risk of the employee using chronic opioids that may lead to the 
development of opioid use disorder. 
 
Using Data to Drive Decisions 
Data on employee health metrics such as the number of employees prescribed opioids and 
types of claims for these prescriptions are useful for showing the overall substance use patterns 
and problems of misuse in the workforce. However, this data is protected by privacy rules (such 
as the Health Insurance Portability and Accountability Act of 1996) that restricts the sharing of 
data. Using health claims and pharmacy data is a valuable way to show if a substance use 
program is effective and if there are gaps in coverage of benefits that may contribute to opioid 
misuse.  Recommendations and guidance on data analytics may be found at the Kentuckiana 
Health Collaborative. Other types of data, often called leading indicators, are useful to 
document the roll-out of a prevention program (similar to delivery of a safety program). These 
metrics may include the number of positive drug screens (annual or for return to work), the 

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number of employees or supervisors attended opioid training or reasonable suspicion training, 
or the number of employees used EAP/MAP services.   
 
Resources: 
NSC’s Guide on Navigating Benefits and Health Care Data 
Optum’s 5 opioid Risk Management Strategies 
 
15.1.3 
STRATEGIES: HEALTHCARE INSURANCE AND PHARMACY 
COVERAGE 
1. Verify medical providers follow evidence-based practices for prescribing opioids (per the 
CDC guidelines for chronic noncancer pain and alternative non-opioid treatments when 
appropriate for acute or chronic pain).  
2. Minimize early exposure to opioids by offering non-opioid and non-pharmaceutical pain 
management options such as physical therapy, chiropractic, acupuncture, cognitive 
behavioral therapy, and/or mindfulness. 
3. Offer behavioral health services to employees (and their dependents) for treatment of 
mental illness and substance use disorders and follow mental health parity 
requirements. 
4. Insure behavioral counselors and providers are accessible to employees’ physical 
location for in-person sessions, offer a telehealth option, insure treatment hours 
accommodate the employee’s work hours, and offer crisis management hotlines for 
emergencies.  
5. Insure the behavioral health provider has an adequate number of counselors available 
to minimize wait times for appointments for treatment and work with your provider if 
they need to expand their network.   
6. Consider expanding insurance coverage for screenings, brief intervention, and referral 
to treatment (SBIRT) for substance use and prescription drug problems through a third 
party behavioral health or primary care provider in your health system. Visit SAMHSA’s 
website for more detail on SBIRT. 
7. Provide coverage (with reasonable copay) for inpatient and outpatient recovery services 
and behavioral counseling for those with opioid use disorder.  

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8. When possible, integrate medical, behavioral, and pharmacy services and health records 
to improve communication and a collaborative care model.  
9.  Use NSC Warn Me Labels on insurance cards 
 
Pharmacy coverage:  
10. Insure employee education on risks of opioid prescriptions, and provide safe disposal for 
unused medications (either a disposal bag or location). 
11. Monitor the supply of prescription opioids as recommended by the CDC minimal 
number of days (3 to 7), monitor dosage (maximum of 50 morphine milligram 
equivalent (MME)), and require reauthorization by provider regardless of the reason for 
the medication [67]. 
12. Check with your PBM to see if they offer an opioid management program (Example: 
Express Scripts).  
13. Coordinate with the physician to consult the Prescription Drug monitoring program 
(PDMP) before prescribing an opioid to avoid multiple opioid prescriptions [66]. 
14. Offer coverage for medication for opioid addiction treatment (i.e. buprenorphine) as 
this may be a treatment for employees with opioid use disorder. 
 
Prescription Opioids and Pain Management 
 
Opioids are highly effective to control acute pain but high doses and long-term use of 
prescription opioids quickly leads to addiction and the diagnosable condition called opioid use 
disorder [68, 69].  Prescription opioids should be judiciously prescribed for short-term acute 
pain, and carefully monitored by a physician [64]. Health plans, whether sponsored by the 
employer or union, should seek information from their insurance company and health system 
to learn about their in-network providers’ treatment approach of using prescription opioids for 
pain management to insure opioids are prescribed appropriately. 
 
Even though opioids are effective for treating acute pain, often non-opioid treatments are 
equally or more effective for managing pain [70-72]. Alternative treatments may include 
nonsteriodal anti-inflammatory or non-pharmaceutical treatments like physical therapy, and 
cognitive behavioral therapy [64, 67].  Employers and unions should consider providing 
alternative pain treatments as covered services in their benefits plan. 
 

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Treatment and Recovery from Opioid Use Disorder 
 
Employees dependent on opioids suffer from a brain disorder that creates strong cravings to 
seek more opioids [79, 80]. Current evidence suggests using medication can effectively treat 
cravings from opioid addiction so the employee can begin to recover and focus on normal 
activities including work [62, 70, 81]. These employees generally need to go through a detox 
program to eliminate opioids from their body before initiating medication for addiction 
treatment (MAT). There are three FDA-approved medications effective for preventing relapse 
and facilitating recovery (Buprenorphine, Naltrexone, Methadone). The provider should work 
with the employee to find the appropriate medication and dose, and the health plan sponsor 
(employer or union) should cover the cost of MAT as part of the pharmacy benefit. 
 
Employees with opioid use disorder may have experienced a dependency to opioids for many 
years, so treatment and recovery may require receiving inpatient and/or outpatient treatments. 
In addition to detox and medication for addiction, employees should receive behavioral health 
counseling to learn how to manage their substance use within the context of their life [82]. 
This process will take time. Risk of relapse is lessened with ongoing treatments and support 
[57] and if the cost of treatment is covered by their health plan [83]. The employee would also 
benefit from having a flexible work schedule and if necessary, paid time off to allow them to 
attend outpatient treatment. 
 
 
Opioids are not effective for treating long-term chronic pain [73, 74]. Patients with long-term 
pain often receive escalating doses of prescription opioids in an attempt to achieve effective 
pain reduction overtime. Yet there is low therapeutic benefit and increased risk of other health 
problems with long term opioid use [75, 76]. Patients with a dependency on opioids suffer 
from strong cravings and fear experiencing symptoms of withdrawal if opioids are abruptly 
stopped or opioid tapering is poorly controlled [77]. Before a health plan sponsor initiates an 
opioid prevention program with more strict opioid prescription policies (to follow the CDC 
guidelines), the health plan must first decide how they will manage employees who already 
receive opioids to manage pain [64]. An abrupt stoppage of opioids may cause patients to 
resort to misusing other’s prescriptions or to using illicit drugs [77, 78]. The health plan 
sponsor (employer or union) should work with their healthcare system and providers to tailor a 
plan to each employee who uses chronic opioids [73, 77, 78].  Patients with severe chronic 
pain may benefit from treatment through a pain management center as there are a growing 
number of non-opioid alternative treatments that can help patients manage high pain levels 
[70].  
 

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7. EMPLOYEE OR MEMBER ASSISTANCE PROGRAMS  
An employee assistance program (EAP) is an employer-provided benefit intended to help 
employees improve work life balance due to mental health, substance use, and personal and 
workplace issues primarily through short-term solution-focused counseling.  Unions offer a 
similar program through a member assistance program (MAP). EAPs or MAPs should offer easily 
accessible and confidential services.  
 
EAP/MAP services related to opioid misuse prevention should span the continuum of care from 
prevention to intervention to recovery services. EAP/MAPs may help with prevention support 
by providing employee education trainings; intervention support through counseling and 
referral to services; and recovery support through intensive treatment and return to work [33]. 
More information for each of these topics can be found in other sections: Drug Testing Policy p. 
24; Healthcare Insurance and Pharmacy Coverage p. 28; Return to Work, Job Accommodations, 
and Recovery Treatment p. 23; Critical Incident Response Plan p. 23. 
EAP/MAP services may be provided by clinicians employed in-house or contracted by local or 
national vendors [84]. Services should be provided by trained or certified clinicians (licensed 
psychologists, master’s level social worker, licensed professional counselor, licensed substance 
abuse professionals, or a certified employee assistance professional). The type of service, 
whether in-person by a local vendor or via telehealth from local or national providers, often 
affects the hours of operation. Many national call centers and telehealth sessions are available 
24 hours per day, 7 days per week. In-person sessions may be limited to weekday, daytime 
hours. There may be a trade-off in costs and type of services offered by a local versus national 
provider. Less cost does not always provide your employees the services they need (see FAQs).  
Many EAPs and MAPs are poorly utilized by employees. A behavioral health survey with 
employees from 2020 showed 39% of employees reported struggling with mental health issues 
[85] suggesting that many of these employees would benefit from EAP/MAP services. Yet 
utilization of these services has remained consistently below 10%, even during the pandemic 
[86]. Most health plans provide employees only the contact information for their EAP/MAP and 
leave it up to the employee to initiate contact. Some EAP/MAPs fail to have a person answer 
the call by limiting in-person coverage to standard 9:00-5:00 business hours or using an 
answering service; many have an inadequate number of clinicians, so first available 
appointments are weeks or months after the call. Under-utilization may also be due to a lack of 

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awareness of available services, how to navigate the service, lack of trust in confidentiality, and 
the stigma that coworkers and supervisor will think less of the employee for using the service.  
There are many ways to optimize utilization of EAP/MAP [33, 84, 87]:  
• Cover the cost of employee sessions (for a specific number of sessions or all sessions) 
• Upper management demonstrates support for EAP/MAP and mental health 
• Increase awareness of services by regular promotion and simple description of services 
• Build employee trust with providers through in-person provider-delivered presentations 
on relevant topics  
• Emphasize respect for confidentiality in all communications 
• Encourage referral for services from human resource and supervisors (supervisor 
training on how to talk to employees about EAP services)  
• Insure the EAP/MAP has an adequate number of clinicians available for timely 
appointments that meets employee demand  
• Insure the location and available services are convenient (location of office, telehealth 
option, hours of operation, flexibility) 
Health plans should monitor the utilization of EAP or MAP services regularly, and make 
decisions to increase utilization by changing promotion, services, or providers. Refer to the 
section on Things to Consider When Selecting an EAP (p. 33) to find more guidance on selecting 
and strengthening an EAP. 
 
15.1.4 
STRATEGIES: EAP/MAP 
1. EAP/MAP providers may give education on opioid risks  
2. Know who is eligible to use your EAP/MAP 
3. Know the utilization rate of your EAP/MAP 
4. The EAP/MAP providers may organize and/or lead peer support groups 
 
Things to Consider when Selecting an EAP or MAP 
 
When seeking an EAP or MAP for eligible employees, you may send out a Request for 
Proposal to learn what each company has to offer. The following items can be used to guide 
questions for potential vendors [84] 
1. Verify the provider offers 24-hour coverage, accessible by telephone, and has an intake 
process. 

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2. Have them explain their clinical assessment process, short-term counseling offerings, 
and referral procedures. 
3. Ask about available services to support the company’s workplace substance abuse 
program such as ability to consult with supervisors on employee management issues, 
provision of training programs for supervisors and/or employees related to substance 
use, assist with development of human resource procedures and policy, and critical 
incident response services (Resources: Optum training on responding to traumatic 
events in the workplace, International Critical Incident Stress Foundation’s 
Primer on Critical Incident Stress Management)  
4. Describe their current network of EAP/MAP affiliates and contracted behavioral health 
providers, credentials or qualifications of the clinicians, and geographical locations of 
offices. 
5. Explain their data management plan, list of metrics monitored, and provide examples 
of utilization and other reports. 
6. Explain their account management, communication between and within contracted 
organizations, and promotional plan and methods of services. 
7. Ask for information about how data is utilized for quality improvement and evaluation. 
8. Describe roles and responsibilities of their staff, verify professional liability insurance, 
and describe any other enhancement services provided. 
9. Ask for a fee proposal with services itemized and explain fee structure. 
10. Ask them to describe their past experience working with employees in the same 
industry. EAPs should be familiar with the unique characteristics and challenges faced 
by employees in unique industries such as construction, mining, agriculture, and 
transportation among others. 
It is also a good idea to test out the customer service for yourself. Send a communication 
through the website, and make a test call to the 24-hour hotline. Make the call at a time similar 
to when an employee might call. Assess the time to get a response, number of transfers, and 
professional response of the counselor.  
 
 
8. LEGAL CONCERNS 
An employer or union opioid prevention program should consider the federal and state labor 
laws and regulations and the expectation that employees will be kept safe and free from harm 
while performing their work duties. These laws and regulations are related to medical 
management, labor laws and contracts, and employee rights for employment. An opioid 
prevention program should be developed with full knowledge of the laws and reviewed by a 

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legal counselor. Medical protections include protecting individual health privacy so 
communications of employee medical information maintains the privacy of the employee’s 
medical condition [43]. This includes information involving drug test results, and return to work 
plans following treatment. In addition, health plan sponsors should be aware of and follow the 
expectations in the Mental Health Parity and Addiction Equity Act of 2008 [17].   
There are several labor laws and regulations designed to protect the safety and health of the 
workforce. The Occupational Safety and Health Act of 1970 requires employers provide safe 
and healthy working condition for all workers [88]. Employers are expected to keep all 
employees safe from harm and from causing harm to others such as from the harmful influence 
of drugs while working. Federally-funded organizations and contractors must provide a drug-
free workplace (DFWP) which is free of illicit drug use and provides a safe workplace for all 
employees [89, 90]. The DFWP guidelines require the organization insures the workplace is free 
of drugs including employees under the influence of drugs. Private businesses may choose to 
follow some or all of the DFWP policies and procedures.  
Employment laws also prohibit discrimination of individuals with disabilities including those 
suffering from substance abuse (Americans with Disabilities Act of 1990, ADA). The ADA (and 
updated Americans with Disabilities Act Amendments Act ADAAA of 2008) requires employers 
to provide reasonable accommodations for employees who have a disability that may impact 
job performance [91]. An employee in recovery from substance use, including those taking 
prescription medication for substance use disorders or currently taking prescription opioids 
may qualify for an accommodation [92].  
15.1.5 
STRATEGIES: ACCOMMODATIONS FOR EMPLOYEE WITH OUD 
• Determine the limitations the employee is experiencing 
• Identify how these limitations affect the employee and their job performance 
• List specific job tasks that are problematic as a result of the limitations 
• Identify accommodations available to reduce or eliminate these problems 
• Once accommodations are in place, evaluation effectiveness and determine if 
modifications or additional accommodations are needed 
• Provide supervisors with appropriate training if needed 
 
Employers with 50 or more employees may be required to provide Family Medical Leave Act 
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insurance coverage [93]. Employees may be able to use their benefit to receive intermittent or 
short-term substance use and recovery treatments. Union requirements may differ from 
private employers.  
 
16 FREQUENTLY ASKED QUESTIONS (FAQS) 
1. Q: How do I communicate with my workforce effectively about opioids, risk of addiction 
and opioid use disorder? 
A: Using methods of communication that will reach everyone in your diverse workforce is 
important to increase knowledge of opioids among employees and benefits of using employer 
and union-sponsored resources. Communicate information and resources to employees through 
established employer or union organization communication channels such as e-mail, social 
media posts, and newsletters [94]. Using multiple communication channels is important to 
increase the reach and accessibility of the information. Here are some effective ways of 
communicating about opioids and risks of opioid misuse: 
 
• 
Having organization-wide training sessions in-person or on zoom can be effective ways to 
communicate information to employees and answer any questions they may have 
surrounding opioids and addiction.  
• 
Using appropriate testimonials within the organization when communicating about 
addiction and opioids can help employees better relate to the issues. 
• 
Enlist trusted employees to communicate messages that may be more readily acceptable 
to general employees.  
• 
Use infographics and signs to communicate key points, statistics, and tips about opioids 
that you want to emphasize. 
• 
The NSC has provided a helpful guide for communicating about opioids in the workplace. 
Visit the resources section for information and other resources to use when 
communicating with employees  
 
2. Q: How can I help employees with opioid related challenges feel comfortable seeking help? 

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A: It can be hard for employees to be open about opioid use issues due to the stigmatization 
around addiction, drug misuse, and fear of consequences. Employees delaying help and 
treatment for opioids misuse can allow drug use issues to worsen. Building trust with employees 
is key to increasing help seeking behaviors. Employers and unions can increase trust by: 
• 
Having top-down organizational buy in to create a culture of care starting with leadership 
(see section on Creating a Culture of Care). 
• 
Have open conversations about society’s opioid crisis and opioid use disorders in the 
workplace [51]. 
• 
Use non-stigmatizing language in all communications [44]. 
• 
If an employee is willing to share their recovery story they can be a source of support for 
others. 
• 
Provide EAP services to employees, and ensure and emphasize confidentiality (See section 
on EAP). 
• 
Have members of leadership (if willing) give testimonials or share stories about their own 
or other’s experience with opioid misuse and addiction. 
 
3. Q: How can I ensure employees who are seeking help for substance use problems have 
access to effective treatment quickly? 
A: The health plan sponsor (employer or union) should: 
• 
Communicate to employees a list of in-network providers for substance use treatment.  
• 
Ensure that in-network providers use effective evidence based treatments. 
• 
Provide EAP/MAP and telehealth resources to employees with 24/7 or flexible availability. 
• 
Provide employees with anonymous substance use emergency hotlines and ensure 
responsiveness. 
• 
Provide health care navigation services (EAP/MAP or Nurse Advocate). 
 
4. Q: How do I support my employees struggling with OUD if I'm a small employer? 
A: Smaller size employers may struggle with inadequate time and resources to be able to 
create an opioid prevention program.  Smaller employers may get group insurance rates offered 
through small business organizations or insurance plans (i.e. small business health option 
programs (SHOP)). Insurance benefits pooled across many companies can provide lower rates. 
Joining local or state opioid safety coalitions (i.e. NoMODeaths) to combat opioid abuse and 

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misuse in your community can show employees that you care and have a positive impact on the 
community [32]. Here are some resource for offering benefits and Insurance as a Small 
employer: 
• 
Small Business Health Options Program (SHOP)-  SHOP is an insurance marketplace for 
small employers (1-50 employees) who want to affordably provide health insurance to 
their employees.  
• 
Look to see what information and options on benefit plans your state’s chamber of 
commerce offers to small businesses. Chambers of Commerce in states like Missouri and 
California offer group benefit plans to small employers (1-50 employees). 
 
5. Q: If my business or employees are located in a rural area how can I offer a range of 
treatment & support options? 
A: While rural employers or union locals may have limited access to treatment facilities, rural 
employers or unions can still: 
• 
Provide telehealth for employees to access both behavioral and medical healthcare. 
Telehealth options allow employees in rural areas to receive certain treatments misuse by 
phone with flexible hours.  
• 
Use a local pharmacy that is a part of Community Pharmacy Enhanced Services Network 
(CPESN). Pharmacies a part of this network offer continuous patient care after visiting a 
health professional or being discharged from a hospital or other healthcare facility. 
Pharmacists work collaboratively with the patient’s other health care team members to 
provide coordinated care. 
• 
Locate and promote local peer support groups in the area to your employees. If there are 
not peer support groups near your area, try and connect employees to online peer support 
groups. 
• 
For more information and strategies on combating the opioid crisis in a rural community 
look at the Rural Community Action Guide: Building Stronger, Healthy, Drug-Free 
Communities 
 
6. Q: How do we improve EAP/MAP utilization? 
A: Promotion and implementation of an EAP/MAP should include a review of utilization rate 
report regularly. These reviews should set specific utilization goals and metrics to identify 

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specific targets for management focus. Management’s focus should be directed at areas that 
your company or union believes they can improve on with specific measurable processes and 
outcomes. These metrics should be reviewed regularly and used to create action plans and 
assess progress.   
For example, a company’s utilization report identified EAP counseling services as 
underutilized by field workers of the company.  The company sets a goal to increase 
utilization rates of field workers.  It measures the process or efforts made to promote 
and increase utilization by field workers (e.g., track number of toolbox talks given to 
promote EAP to field workers, the signs posted, emails sent).  Review results at next 
quarter’s utilization report to determine improvements and create new plans. 
EASNA has suggested the following strategies for promotion and implementation of EAP 
services [57]: 
• 
No cost to employees for a specific number of sessions or all sessions  
• 
Emphasize respect for confidentiality in all communications to employees  
• 
Insure there is an adequate number of providers for timely appointments to meet 
employee demand  
• 
Frequent written promotion and positive verbal promotion from managers in employee 
meetings  
• 
Manager training to encourage making both formal and informal referrals to employees  
• 
Have EAP representatives in the workplace build trust and foster relationships with 
employees  
 
7. Q: My EAP/MAP is not as responsive as I would like, what can I do?   
A: EAP/MAP services may not be available for a variety of reasons. If employees are 
experiencing challenges getting help, define the problem by taking the following step: 
• Review the EAP/MAP contract terms and agreement of services for your organization to 
determine if the expected services are covered.  
•  Make a call to the EAP/MAP to test their response and access to help. Conduct the test at 
various times of the day and night.  
• If there is a poor response to a call, notify your EAP/MAP and see if they can resolve the 
issue. If not, consider getting a different EAP/MAP provider. 
• Ask employees to share their experience about the responsiveness of calling the EAP/MAP. 
Give the employee the option to report anonymously. 

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8. Q: How can an employer integrate our EAP with business operations? 
A: EAPS should work collaboratively with internal organizational departments and other 
benefit providers (e.g. health insurance) who work in absence management, disability 
management, return to work programs, injury rehabilitation, and disease management 
programs.  EAP can work with these programs to improve treatment access and case 
management for chronic disease management programs. To get the highest value from an EAP 
purchasers will need to: 
• 
Request services that can be integrated into their business operations (see sections on 
Drug Testing, Supervisor Training) 
• 
Develop an action plan for EAP integration using EASNA’s EAP Purchaser’s Guide 
• 
Integration and maintenance of EAP integration will require HR staff time and resources.  
Staff responsibilities related to EAP integration could be explicitly included in the positions’ 
job descriptions.    
 
9. Q: What are the best options for ensuring treatment coverage if we have employees at 
multiple geographical locations? 
A: Health plan sponsors (employer or union) whose employees work at a variety of locations 
should make sure the treatment providers and facilities for “in-network” providers matches the 
geographical locations of the employees.  There is an increasing use of tele-health and virtual 
options by providers for a variety of health issues, which can be accessed in locations with 
reliable phone or internet. Employers may consider using health insurance with a national 
presence that cover providers in many locations. 
 
10. Q: How do I accommodate an employee at work who is taking prescription medication 
for opioid addiction treatment (MAT)? 
A: MAT is an evidence-based treatment for employees in recovery to manage strong cravings 
from opioid addiction. Consult with the employee’s prescribing physician to learn how long the 
employee may need to take MAT, although this treatment may be long-term. Employers should: 
• 
Educate employees, supervisors, and leadership about MAT 
• 
Develop written policy on how MAT and return to work will be handled  

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• 
Provide a wide range of evidence based treatment and recovery options for employees. 
MAT with safe and well managed dosages works best when paired with counseling and 
social support strategies [33] 
• 
Use an EAP/MAP to help track an employee's engagement with treatment services while 
an employee is in a return to work program 
 
11. Q: Are there concerns for employees using MAT in the workplace? 
A: Medication for Opioid Addiction Treatment (MAT) is an effective treatment for employees in 
recovery with opioid use disorder [95]. MAT is more effective when combined with behavioral 
therapy and counseling to help employees control strong cravings, and manage mental health 
issues after they have returned to work [63]. Educating employees, supervisors, and leadership 
on the facts around MAT can help dispel myths, misconceptions, and stigma around MAT in the 
company or union organization. While using the correct dosage of MAT does not have adverse 
negative effects on physical and mental functioning, employability, or intelligence, it may impair 
a person ability to perform safety sensitive tasks [96]. Being educated on how to accommodate 
employees prescribed MAT can be helpful in a return to work situation. For more info, look at 
“COB: Safety Sensitive Activities, p. 27.” 

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17 STATE LEVEL EMPLOYER RESOURCES 
State Resources: Focus of the Resource (Prevention= P, Treatment= T, Recovery= R) 
Alaska 
• Addiction and the Workplace- 
https://dhss.alaska.gov/osmap/Documents/WorkplaceAddiction.pdf (T,R)  
• Alaska 211- https://alaska211.org/search-our-database/ (T,R) 
Arizona 
• Treatment Options for Opioid Abuse, Misuse, and Dependence- 
https://www.pinalcountyaz.gov/sheriff/documents/gettinghelpforopioidmisuseabused
ependence.pdf (T,R) 
Arkansas 
• Arkansas 211- https://arkansas211.org/ (T,R) 
• Together Arkansas Resources- https://togetherarkansas.com/resources/ (P,T,R) 
Colorado 
• Colorado Opioid Treatment Programs-
https://drive.google.com/file/d/0B_Qu7DlYJwx7d0NzTE1yelBrVTQ/view?resourceke
y=0-zCDLXFeCptTz93qq0NxdfA (T) 
Connecticut 
• Connecticut Community for Addiction Recovery (CCAR)- https://ccar.us/ (R) 
• The Opioid Crisis and Connecticut’s Workforce: https://portal.ct.gov/-
/media/Departments-and-
Agencies/DPH/dph/environmental_health/occupationalhealth/Opioid-conference-
writeup_FINAL-FINAL_11_28_18-(2).pdf (P) 
Florida 
• 
Dose of Reality: Get Support (Business)- https://doseofrealityfl.com/businesses.html (P) 
Georgia 

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• 
Dose of Reality: Get Support (Business)- https://doseofrealityga.org/get-
support/business/ (P) 
Hawaii 
• 
Hawaii Opioid Initiative: (Business)- https://www.hawaiiopioid.org/business/ (P) 
• List of Hawaii Treatment Centers- https://www.hawaiiopioid.org/wp-
content/uploads/2019/07/2017-2019-Treatment-Providers-.pdf (T) 
 
Illinois 
• Illinois Helpline for Opioids and Other Substances: 1-833-2FINDHELP (T) 
Indiana 
• INConnect-  https://secure.in.gov/apps/fssa/providersearch/home (T,R) 
Kentucky 
• 
Find Help Now KY- 
https://findhelpnowky.org/?utm_source=Vimarc&utm_medium=display&utm_term=&utm_
content=ky-chamber-of-commerce&utm_campaign=ky-chamber-of-commerce (T) 
• 
Opioid in Kentucky Abuse- The Business Community’s Perspective- 
https://www.kychamber.com/sites/default/files/pdfs/Opioid%20Abuse%20in%20Kentucky
%202019%20-%20website.pdf (P,T,R) 
Maryland 
• Opioids in the Maryland Workplace: Challenges and Solutions- 
https://health.maryland.gov/phpa/OEHFP/EH/Shared%20Documents/Opioids%20an
d%20Work/MarylandOpioidWorkplaceReport_091619.pdf (P) 
• MDHope: Opioid-Related Text Message Support: https://211md.org/about/text-
messages/md-hope/ (T,R) 
Michigan 
• MDHHS: Get Help Now (Behavioral Health)- https://www.michigan.gov/mdhhs/keep-mi-
healthy/mentalhealth/drugcontrol/welcome/get-help-now-behavioral-health_1 (T) 

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Minnesota 
• Minnesota Opioid Epidemic Response: Employer Toolkit- 
https://www.health.state.mn.us/communities/opioids/communities/employertoolkit.ht
ml (P,T,R) 
• Minnesota Recovery Connection- https://minnesotarecovery.org/ (R) 
Mississippi 
Missouri 
• Recovery Friendly Missouri- https://recoveryfriendlymo.com/ (P,T,R) 
• NOMODEATHS- https://www.nomodeaths.org/ (P,T,R) 
Montana 
• Opioids in the Montana Workforce: https://erd.dli.mt.gov/_docs/work-comp-
research/Montana-Opioids-by-Industry-Occupation.pdf (P) 
New Hampshire 
• New Hampshire Works for Recovery- 
https://www.recoveryfriendlyworkplace.com/contact (P,T,R) 
• The DoorWay New Hampshire- https://www.thedoorway.nh.gov/ (T) 
New Mexico 
• Recovery Friendly Workplace New Mexico- 
https://www.recoveryfriendlyworkplacesnm.org/  
• New Mexico Crisis and Access Line- https://nmcrisisline.com/ (T,R) 
North Carolina 
• North Carolina Opioid Resources- https://opioidresources.ncdoj.gov/resources/ (P,T,R) 
North Dakota 
• Recovery Reinvented Workplace- https://recoveryreinvented.com/ (P,T,R)  
Ohio 

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• Ohio Chamber of Commerce: Opioid Toolkit- https://ohiochamber.com/opioid-toolkit/ 
(P,T,R) 
• Strategies for Helping Individuals Impacted by Opioid Use Disorder- 
https://jfs.ohio.gov/owd/WorkforceProf/Docs/OWDOpioidToolkit.stm (P,T,R) 
Oregon 
• Reverse Overdose Oregon- https://www.reverseoverdose.org/ (P,R) 
Pennsylvania 
• Pennsylvania Recovery Friendly Workplaces- https://recoveryfriendlypa.org/ (P,T,R) 
• PA Department of Drug and Alcohol Programs: Find Treatment- 
https://apps.ddap.pa.gov/gethelpnow/CareProvider.aspx (T) 
Rhode Island 
• Rhode Island Recovery Friendly Workplace Initiative- https://recoveryfriendlyri.com/ 
(P,T,R) 
• Prevent Overdose RI- Get Help- https://preventoverdoseri.org/get-help/ (P,T,R) 
South Carolina 
• Just Plain Killers: Find Help- https://justplainkillers.com/find-help/ (Treatment) 
 
 
South Dakota 
• Avoid Opioid: Resource Hotline- https://www.avoidopioidsd.com/find-help/resource-
hotline/ (Prevention, Treatment, Recovery) 
Tennessee 
• The Tennessee Redline- https://tntogether.com/resources/tennessee-redline/ (T) 
Texas 

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• Texas HHS Outreach, Screening, Assessment & Referral- 
https://www.hhs.texas.gov/services/mental-health-substance-use/mental-health-
substance-use-resources/outreach-screening-assessment-referral (P,T,R) 
Utah 
• Opidemic: Get Help- https://www.opidemic.org/get-help/ (Treatment/Recovery)  
Vermont 
• VT Helplink- https://vthelplink.org/ (T,R) 
Virginia 
• Resource Guide: Opioid Public Health Emergency- 
https://www.vdh.virginia.gov/content/uploads/sites/127/2017/12/Opioid-Resources-
VSP-Div-II.pdf (T,R) 
Washington 
• Stop Overdose: Crisis and treatment resources- https://stopoverdose.org/getting-
help/crisis-and-treatment-resources/ (T,R) 
West Virginia 
• West Virginia State Substance Abuse Response Plan- https://dhhr.wv.gov/office-of-drug-
control-policy/news/Documents/FINAL%20-
%20West%20Virginia%202020_2022%20Council%20Substance%20Use%20Plan_
January%2020%2C%202020%20%28as%20filed%29.pdf (T,R) 
Wisconsin 
• Dose of Reality Wisconsin- https://doseofrealitywi.gov/get-support/business/ (P)  
 
18 SPECIAL TOPICS/CALLOUT BOXES 
Employer Versus Union Health Plans (pg.12) 
Cause and effects of stigma (pg. 17) 

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Connecting peer-based recovery supports to employees in need (pg. 18) 
Return to Work, Job Accommodations, and Recovery Treatment (pg. 23) 
Critical Incident Response Plan (pg. 23) 
Second Chance Policy in a Drug-Free Workplace Program (pg. 25) 
Safety Sensitive Activities (pg. 27) 
Recovery Friendly Workplace (pg. 27) 
Prescription Opioids and Pain Management (pg. 31) 
Treatment and Recovery from Opioid Use Disorder (pg. 31) 
Things to Consider when Selecting an EAP (pg. 33) 
 
19 TERMS LIST 
Addiction 
A primary, chronic, neurobiologic disease with genetic, 
psychosocial, and environmental factors influencing its 
development and manifestation. Characterized by 
behaviors that include impaired control over drug use, 
compulsive use, cravings, and continued use despite 
harm.  
Behavioral Health Care (Mental Health Care) 
Health care service and delivery involved in 
psychological assessment and intervention by certified 
providers from several specialties (counselors, 
psychiatry, neurology, social work). This type of care 
includes but is not limited to psychological screening 
and testing, psychotherapy and family therapy, and 
neuropsychological rehabilitation.  
Behavioral Health Insurance 
Offers coverage of mental and behavioral health 
services. Plans ideally cover treatment for 
psychotherapy and counseling, mental and behavioral 
health inpatient services, and substance use disorder 
treatment. 
Chronic Pain 
 
MAT (Medication for Addiction Treatment) 
Medication used to treat substance use disorders as well as 
sustain recovery and prevent overdose. 
Mental Health Parity and Addiction Equity Act 
Enacted in 2008 and requires insurance coverage for 
mental health conditions, including substance use 
disorders, to be no more restrictive than insurance 
coverage for other medical conditions. 
MRO Medical Review Officer 
A physician who determines how drug test results will be 
reported to an employer or union in the context of all 
information including the test result and the donor 
interview. 
Substance Abuse 
A pattern of compulsive substance use marked by 
recurrent significant social, occupational, legal, or 
interpersonal adverse consequences 
Substance Misuse 
The use of a substance for unintended purpose or intended 
purpose (i.e. prescription) but in improper amounts or 
doses.  

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Pain that is experienced most days or every day, and 
has lasted three or more months. 
Collaborative Care Model 
An integrative approach for effective mental health 
care provided by a care team often led by the primary 
care provider and includes a behavioral health 
provider, a psychiatrist, and the patient. 
DFWA Drug Free Workplace Act 
States a drug-free workplace policy is required for any 
organization receiving a federal grant of any size or 
any organization that receives a federal contract of 
$100,000 or more. 
DFWP Drug Free Workplace Program 
Drug-Free workplace programs are comprehensive 
programs that address illicit drug use by federal 
employees and in federally regulated industries. 
 
Substance Use 
The use of tobacco, alcohol, prescription drugs, or illicit 
drug. 
Substance Use Disorder (opioid use disorder) 
The clinical term describing a syndrome consisting of a 
coherent set of signs and symptoms that cause significant 
distress and or impairment during the same 12-month 
period. When caused by use of opioids, defined as opioid 
use disorder. 
Tapering 
A practice in pharmacotherapy of lowering the dose of 
medication incrementally over time to help prevent or 
reduce adverse experiences as the patients’ body makes 
adjustments and adapts to lower and lower doses. 
Workplace Culture 
A set of beliefs, norms, and values that are apparent in the 
workplace. 
 
 
Authors This document was written and data collection for the content by Ann Marie Dale, PhD, Samuel Biver, 
MPH, and Sam Kurtz from Washington University School of Medicine, and Daisy Chang, PhD from Michigan State 
University. Other team members contributed to the design and execution of the project including Laura Beirut, 
MD, Bradley Evanoff, MD, and Brian Gage, MD from Washington University School of Medicine and John Gaal, EdD, 
Consultant. Alexandra O’Brien, Abigail Self and Candice Cho were students who substantially contributed to the 
work on the guidelines. 
Disclaimers These guidelines provide general information on the topic of addiction in the workplace but should not 
be taken as legal advice. Please consult an employment attorney to discuss the content of your substance use 
program. The content of the guidelines are solely the responsibility of the authors and do not necessarily represent 
the official views of the National Institute of Health. 
Acknowledgments Thank you to National Institute of Drug Abuse, National Institutes of Health for funding this 
project (Grant 1R34DA050044-01). We would like to thank all of the collaborators, external advisors, subject 
matter experts, stakeholders, and workers for their contributions. There were nearly 200 people who participated 
in this project. Here we recognize several key contributors (alphabetically): 
Jamie Becker, Laborers' Health & Safety Fund of North America 
Cal Beyer, Holmes Murphy & Associates 
Shawn Billings, Missouri Hospital Association 
Chris Cain, CPWR-The Center for Construction Research and Training 
Gary Franklin, Washington State Department of Labor and Industries 
Kristi Giles, Granite Construction 

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Karen Grear, International Union of Bricklayers 
Thomas Gunning, Building Trades Employers Association 
Sherrie Hall, Workers Rights Law Firm LLC  
Mike Hawes, Pacific Northwest Carpenters Institute 
Jim Hynes, Pipe Trades Services MN 
David Jaffe, National Association of Home Builders 
Marko Kaar, Bartlett Brainard Eacott 
Bob Kunz, Dimeo Construction Company 
Stephanie LaBanow, IBEW Health and Welfare Fund 
Diana Marburger,  Greater St. Louis Construction Laborers’ Welfare Fund 
Shawn Nehiley, Ironworkers International 
Steve O'Sick, New York Labor Health Care Alliance 
Mia Parham, Tilcon Connecticut, Inc. |CRH Company 
Travis Parsons, Laborers' Health & Safety Fund of North America  
Carolyn Perez, Carpenters' Regional Council 
Don Willey, Laborers Local 110  
Rachel Winograd, Missouri Institute of Mental Health 
Corey Wirth, IBEW Health and Welfare Fund 
Kyle Zimmer, Operating Engineers Local 478 
Archway Institute 
Healthier Workforce Center of the Midwest 
Preferred Family Healthcare 
Places for People 
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National Safety Council and National Opinion Research Center. Substance Use 
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E. Monthly Health Fund meeting script_followup 
Monthly Health Fund follow-up meeting: 
Date: _____________ 
Organization: ___________________ 
Participant: _______________ 
Notes from past Interview: 
 
 
1. Are you in the process of making any changes 
to your opioid prevention program? If yes 
please describe (date of adoption, 
 

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implementations strategies, how are you 
measuring effectiveness of the change, 
participation rates in programs for workers, 
adherence to and enforcement of policies, and 
methods for disseminating programs) 
a. Have you made any changes to existing 
opioid prevention programming? If so 
please explain 
 
2. Did you review the guidelines? If yes, what did 
you find useful and what do you think is missing 
from the guidelines? 
a. Did you complete the needs assessment?  
b. Did you follow the process guide, steps 1, 
2, and 3? 
c. 
What did you list on your inventory of 
resources? 
d. Did you make a plan? 
 
 
3. What are challenges or barriers are you 
encountering in trying to implement your 
program? 
 
 
 
G. Data management of Administrative Health Claims and Worker Surveys 
Data management of Administrative Health Claims and Worker Surveys 
a) Administrative Health Claims 
a. Inclusion 
i. Health plan member (as opposed to dependent or retired) at some point during 
study period (6/1/2019-5/31/2022), per census records 
1. Could transition to retired status during study period, but needed to 
start as  member 
b. Exclusion 
i. Missing eligibility or termination dates in census records 
ii. Cancer diagnosis 
1. Ever received ICD-10 code in medical claims data:  C00.x–C26.x, C30.x–
C34.x, C37.x– C41.x, C43.x, C45.x–C58.x, C60.x–C76.x, C77.x–C85.x, 
C88.x, C90.x–C97.x) 
c. Initial work 
i. Medical claims (“claims”), pharmacy claims (“fills”), census data was received 
“piecemeal” 
1. By timeframe (i.e, quarterly) and type (plan member, dependent, 
retired) 

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ii. Consolidate files into single datasets for claims, fills, census data and work 
histories 
iii. Create eligible/valids file—this is the list of members eligible for the study, 
based on above criteria 
iv. Limit all analysis data (claims, fills) to members in the eligible/valids list 
d. Opioid/claim linkage:  The process of linking opioid prescriptions (from pharmacy fills) to 
diagnoses (from medical claims) involves two main steps:  1) assign opioid fills to claims 
based on timing and acuity, and 2) assign opioid refills to claims  
i. Opioid/claim join using timing and acuity 
1. Create file of opioid fills from pharmacy fills data, using CDC file 
[“CDC_opioid NDC_oral MME conversion_update_2020.xlsx”] to 
identify opioids  
2. Split opioid claims into two groups based on refill status:  initial fills and 
refills (note this is using refill status indicated by the health fund.  Many 
members have serial initial fills and not refills in these data; those would 
be in the initial fills file) 
3. Assign diagnosis category for each claim, using ICD-10 and procedure 
codes.  Categories include “MSD surgery”, “Acute MSD injury”, “Chronic 
MSD”, and “Other diagnosis” 
a. If more than one diagnosis category is present on a single claim, 
assign claim to the highest acuity (MSD Surgery, then Acute 
MSD Injury, then Chronic MSD, then Other diagnosis)  
4. Join claims with initial fills by member ID (UID)—this generates a many-
to-many match 
5. Calculate time difference between claim date and fill date 
a. If fill<before claim, use this information to generate opioid 
naivety status for each claim 
6. If fill is 0-3 days after claim and the claim diagnosis category is not 
“Chronic MSD”, assign the opioid to the claim.  If more than one claim 
fits the criteria, assign based on order other diagnoses, then MSD 
surgeries, lastly acute MSD injuries.  If more than one claim is still 
eligible, use the smallest time difference between claim and fill to assign 
the fill 
7. Among the unlinked opioid fills, if fill is 0-30 days after a chronic MSD 
claim, assign opioid to that claim.  If more than one claim meets the 
criteria, assign based on time difference (i.e., smallest time difference 
between claim and fill date) 
ii. Assign opioid refills to claims 
1. Serial prescriptions (most common scenario) 
a. Start with all opioid first fills (including unlinked and linked with 
medical claims, using the process above) 

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b. Arrange all fills by UID and fill date 
c. Assign fills to claims that 1) occur after a claim with a linked 
opioid fill, and 2) opioid fill date is no more than 30 days after 
previous fill runout date (fill date + days supply) 
2. Refills specified in the pharmacy data 
a. Join opioid refills (from 1b above) with the first fills using 
prescription identifier (“RXNUM”).   
b. Assign claim information from first fills to linked refills 
Variable definitions 
e. Opioid-related variables.  These variables were generated using information from the 
medical claims and pharmacy fill data from the health fund and the CDC opioid file 
“CDC_opioid NDC_oral MME conversion_update_2020.xlsx”.  The CDC file was merged 
with health fund pharmacy fill data on NDC 
i. Medication assisted treatment (MAT):  Drug name contained “methadone” or 
“buprenorphine” in either file or drug description was “ANTIDOTES AND 
SPECIFIC ANTAGONISTS” in the pharmacy fill file 
1. This strategy picks up buprenorphine, suboxone, zubsolv, naltrexone, 
methadone, narcan, and vivitrol 
ii. Opioid:  pharmacy class was “opioid” in the CDC file, and the drug was not 
already identified as MAT (see above) 
iii. OUD:  ever ICD-10 code “T40x” or “F11x” on a medical claim or identified as 
MAT (see above) 
iv. Days supply > 7 days:  based on “days supply” as provided in fill data 
v. MME/day:  Instructions for calculation are in CDC file.  Formula is “strength per 
unit” * “average quantity per day” * “MME conversion factor” 
vi. Overlapping Rx:    Date opioid fill is within previous days supply (current fill date 
< previous fill date + days supply) 
1. When the previous prescription is a “short course” (the prescription 
window is encompassed by prescription before it), the prescription 
before the short course is used in evaluation 
vii. Chronic use (>60 days supply in a 90 day window) 
1. For each worker time is divided into 90 day “cycles”, starting with the 
date of the first opioid fill 
2. Days supply is totaled within the 90 day cycle 
3. If the individual had opioid fills later than 90 days after the first fill, a 
new cycle is started and the process starts over 
4. When workers have multiple opioids filled on the same day, use the 
longest days supply in calculations 
5. Indicator variable for total days supply in a cycle > 60 for any given cycle 
viii. Multiple Rx in a single visit:  multiple Rx filled on the same day and NPI is the 
same between fills 

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ix. Multiple Rx on same day, different provider:  multiple Rx filled on the same day 
and NPI between Rx different.  Could indicate doctor shopping 
x. Misuse:  “Overlapping Rx” OR “Multiple Rx on same day, different provider” 
f. Diagnoses.  These variables were generated from information in the medical (i.e 
diagnosis and procedure) claims.  Diagnoses are assessed at the claim level, and “rolled 
up” to the worker (i.e, has worker ever had a diagnosis for X) 
i. MSD surgery:  CPT codes 20005-21010; 21500-22900; 62263-63746; 64400-
64999 
ii. Acute MSD injury:  ICD-10 codes ranging S00-T14 
iii. Chronic MSD:  ICD-10  codes M.x, G54-G57 
iv. Recurring acute injury.  Acute MSD injuries that occur across multiple claims are 
recoded as “recurring injuries”.  These are combined with chronic MSD for our 
purposes 
1. ICD-10 codes for acute MSD injuries are identified on a given claim (see 
above) 
2. If the same ICD-10 code occurred on a previous claim more than 30 days 
before the claim in question, the acute MSD injury is recoded as 
“recurring injury” on the claim in question and will no longer be counted 
as an acute MSD injury 
3. Using this method, the first occurrence of a given acute MSD injury 
ICD10 code will be left as “acute MSD injury” 
v. Other diagnosis: Claims that do not fit into i-iv above are coded as “other Dx” 
vi. Acuity: claims can have multiple diagnoses associated with them.  Acuity is 
assigned as follows, regardless of other diagnoses associated with the claim:  
MSD surgery, Acute MSD Injury, recurring injury or chronic MSD, other 
diagnoses.   
1. So if a claim had codes for both MSD surgery and chronic MSD, the 
acuity is assigned to MSD surgery 
g. Description of the study sample [all data are in “claims eligibility_20230213.docx”, 
unless otherwise noted] 
i. Demographics and worker characteristics 
1. Gender 
2. Age in 2022 
3. Plan status (Active, COBRA, etc) 
4. Time worker eligible for benefits during study period 
5. Gaps in eligibility 
ii. Plan utilization 
1. Proportion of workers with a health claim, pharmacy claim, overlap of 
these 
iii. Distribution of diagnoses based on original order of acuity 
iv. Diagnoses.  Number of workers with: 
1. MSD surgery 
2. Acute MSD injury 

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3. Chronic MSD or recurring acute injuries 
4. Other diagnoses 
v. Opioid utilization.  Number of workers with: 
1. At least one opioid fill 
2. Ever days supply > 7 
3. Ever MME/day > 50  
4. Ever MME/day > 90  
5. Overlapping Rx 
6. Chronic use (>60 day supply in 90-day period) 
7. Multiple Rx on the same day, same provider 
8. Multiple Rx on the same day, different providers 
9. Misuse 
vi. OUD 
1. N by source (diagnosis, MAT fill, both)  
h. Medical claim/opioid linked data  
i. Distribution of opioid fills by diagnosis, as captured on linked claim 
b) Worker Surveys 
a. Worker surveys will be distributed to all members of each health fund at start of project, 
to collect a sample of 300 surveys. We will collect another sample of 300 surveys after 6 
months. 
b. We will examine the serial cross sectional data (baseline & 6mos) by comparing sample 
characteristics.  
 
Age, x  
 
gender, x 
 
race, x 
 
hisp, x 
 
unionbenefits, x 
 
employstatus, x 
 
time_construction, x 
 
months_construction, x 
 
constype;x 
c. We will examine the items related to each of the three outcomes of interest 
i. Opioid misuse- A “yes” response to either of the following two items: 
1. Did you use the pain medication more than prescribed, or for a longer 
period than prescribed?  [pnmed_longer]x 
2. Have you used prescription pain medications that were prescribed to 
someone else? [pnmed_othersrx]x 
ii. Proportion of workers with lost time- A “yes” response to either of the following 
two items: 

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1. Please refer to the last 12 months for the following questions:  Did you 
miss any days of work because of your pain or discomfort? 
[missday_pn]x 
2. In the past 12 months, have you gone to work intoxicated, high, or 
recovering from the night before? [missday_intox] [*possible reduced 
productivity]x 
iii. Proportion of workers who are willing to seek help 
1) their workplace 
1. If I was struggling with a substance use problem... I would be willing to 
seek help from my supervisor or someone in human resources  
[help_sup_hr]x 
2. If I was struggling with a substance use problem... I would be willing to 
seek help from a professional (MAP or behavioral health)  [help_prof]x 
3. If I was struggling with a substance use problem... I would be willing to 
ask a trusted coworker for help [help_coworker]x 
4. Have you attended Alcoholics or narcotics anonymous (AA/NA) group 
[aa_na_use]x 
5. Have you met with the specialist? [peer_supp_use]x 
2) professional help (employee assistance program or behavioral health)  
6. If benefit is available…. Union sponsored Member assistance program 
(MAP) [eap]x; Have you used these benefits? Member assistance 
program (MAP) [eap_use]x 
7. If benefit is available…. Behavioral health (counseling) [behav_health]x; 
Have you used these benefits? Behavioral health (counseling) 
[behav_health_use]x 
 
20.1 ABBREVIATIONS AND SPECIAL TERMS 
 
AE 
Adverse Event 
CFR 
Code of Federal Regulations 
CDC 
Centers for Disease Control and Prevention 
COC 
Certificate of Confidentiality 
COBRA 
Consolidated Omnibus Budget Reconciliation Act 
CPT 
Current Procedural Terminology 
DHHS 
Department of Health and Human Services 
DSMB 
Data Safety Monitoring Board 
Dx 
Diagnosis 
FDA 
Food and Drug Administration 

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HIPAA 
Health Insurance Portability and Accountability Act  
ICD-10 
International Classification of Diseases, Tenth Edition 
IRB 
Institutional Review Board 
MAT 
Medication Assisted Treatment 
MME 
Morphine Milligram Equivalents 
MSD 
Musculoskeletal Disorder 
NDC 
National Drug Code 
NIDA 
National Institute on Drug Abuse 
NIH  
National Institutes of Health 
OHRP 
Office for Human Research Protections 
OUD 
Opioid Use Disorder 
PI 
Principal Investigator 
QA 
Quality Assurance 
QC 
Quality Control 
Rx 
Prescription 
SAE 
Serious Adverse Event 
SAP 
Statistical Analysis Plan 
UID 
Union member ID 
UP 
Unanticipated Problem 
US 
United States 
 
20.2 PROTOCOL AMENDMENT HISTORY 
There were no changes made to the IRB-approved versions of the protocol. 
 
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