Evaluation of Occupational 

Exposures to Opioids, Mental 

Health Symptoms, Exposure to 

Traumatic Events, and Job Stress 

in a City Fire Department

HHE Report No. 2018-0015-3384 

August 2021
Authors: Sophia Chiu, MD, MPH

Douglas M. Wiegand, PhD

Kendra Broadwater, MPH, CIH

Jessica F. Li, MSPH

Desktop Publisher: Jennifer Tyrawski

Editor: Cheryl Hamilton

Medical Field Assistance: Marie de Perio, Guadalupe (Pita) Gomez, Reed Grimes, Laurel Harduar 

Morano, Sean Lawson, Sara Luckhaupt, Miriam Siegel, Loren Tapp, Shawna Watts

Data Support: Denise Giglio

Keywords: North American Industry Classification System (NAICS) 922160 (Fire Protection), 

Ohio, Firefighter, Emergency Medical Services, Illicit Drug, Opioid, Fentanyl, Job Stress, 

Mental Health, Trauma

Disclaimer 

The Health Hazard Evaluation Program investigates possible health hazards in the workplace under 

the authority of the Occupational Safety and Health Act of 1970 (29 U.S.C. § 669(a)(6)). The Health 

Hazard Evaluation Program also provides, upon request, technical assistance to federal, state, and 

local agencies to investigate occupational health hazards and to prevent occupational disease or 

injury. Regulations guiding the Program can be found in Title 42, Code of Federal Regulations, 

Part 85; Requests for Health Hazard Evaluations (42 CFR Part 85).

Availability of Report

Copies of this report have been sent to the employer (city and fire department) and fire department 

union. The state and local health departments and the Public Employment Risk Reduction Program

have also received a copy. This report is not copyrighted and may be freely reproduced.

Recommended Citation

NIOSH [2021]. Evaluation of occupational exposures to opioids, mental health symptoms, 

exposure to traumatic events, and job stress in a city fire department. By Chiu S, Wiegand DM, 

Broadwater K, Li JF. Cincinnati, OH: U.S. Department of Health and Human Services, Centers for 

Disease Control and Prevention, National Institute for Occupational Safety and Health, Health 

Hazard Evaluation Report 2018-0015-3384, https://www.cdc.gov/niosh/hhe/reports/pdfs/2018-

0015-3384.pdf. 
Table of Contents

Main Report

Introduction....................................................................................................................................................... 1

Request .......................................................................................................................................................... 1

Background ................................................................................................................................................... 1

Our Approach ................................................................................................................................................... 1

Our Key Findings.............................................................................................................................................. 2

The majority of firefighters reported opportunities for exposure to opioids. Two firefighters 

reported symptoms, which were nonspecific, after contact with suspected opioids.......................... 2

Some firefighters reported symptoms consistent with accepted case definitions of post-traumatic 

stress disorder, depression, and generalized anxiety................................................................................ 2

Our Recommendations.................................................................................................................................... 3

Supporting Technical Information 

Section A: Fire Department........................................................................................................................ A-1

Section B: Methods, Results, and Discussion .......................................................................................... B-1

Methods: Questionnaire .......................................................................................................................... B-1

Results: Questionnaire............................................................................................................................. B-4

Discussion ............................................................................................................................................... B-10

Limitations............................................................................................................................................... B-14

Conclusions............................................................................................................................................. B-15

Section C: Tables.......................................................................................................................................... C-1

Section D: References.................................................................................................................................. D-1
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1

Introduction

Request

In October 2017, a city in Ohio requested a health hazard evaluation (HHE) concerning possible 

unintentional exposure to opioids among police officers and firefighters during first responder activities. 

As one part of the overall HHE request, city and fire department officials were concerned about how 

responding to the opioid epidemic might affect the mental health of firefighters, who also provide 

emergency medical services (EMS) for the city.

Background

Ohio experienced 4,162 opioid-related overdose deaths in 2017, a 19% increase compared with 2016. 

The number of emergency department visits for suspected opioid overdose in Ohio has also increased

in 2016–2017. These trends suggest that firefighters-EMS providers might face increased call volumes 

during the current opioid epidemic, which may lead to increased and/or different kinds of workplace 

stressors on responders. This component of the HHE focuses on a questionnaire designed to gather 

information about firefighters and their involvement in opioid overdose responses. A previous interim 

report focused on evaluations of incidents where police officers developed symptoms after potential 

exposures to suspected opioids. 

To learn more about the workplace, go to Section A in the Supporting Technical Information

Our Approach

We invited all on-duty firefighters during our visits to fire stations to complete an anonymous written 

questionnaire in May 2018. We then analyzed the questionnaire responses. The questionnaire included 

questions about 

• Potential exposure to opioids

• Personal protective equipment availability and use

• Health effects related to opioid exposure

• Job stress and potentially traumatic events related to opioid overdose responses

• Mental health symptoms and perceived stigma, barriers, and use of resources for coping with 

stress and mental health symptoms

To learn more about our methods, go to Section B in the Supporting Technical Information
2

Our Key Findings

The majority of firefighters reported opportunities for exposure to opioids. Two 

firefighters reported symptoms, which were nonspecific, after contact with 

suspected opioids. 

• Of the 189 firefighters who participated in the questionnaire, 173 (92%) reported that they 

participated in an opioid overdose response in the past 6 months.

• In total, 118 firefighters (62%) reported that suspected opioids were visible during the course of 

their work in the past 6 months. 

• Approximately 19% of firefighters reported one or more potential routes of exposure to 

suspected opioids in the past 6 months. 

• All firefighters reported gloves were available when suspected opioids were visible, and 

92% reported wearing them.

• In contrast, most firefighters reported never using a respirator (90%) or eye protection (79%) 

when suspected opioids were visible, even though more than 90% of firefighters reported that 

they were available. Commonly cited reasons for not wearing personal protective equipment 

when suspected opioids were visible included “I did not think it was necessary” and “It was not 

required.”

• On the questionnaire, two firefighters reported health symptoms after coming into contact with 

suspected opioids. The symptoms reported, headache and numbness or tingling, were 

nonspecific and relatively mild. They were not consistent with severe (life-threatening) opioid 

toxicity. It was not possible to definitively say if they were related to exposure to opioids or 

other drugs, or other causes. 

Some firefighters reported symptoms consistent with accepted case definitions of 

post-traumatic stress disorder, depression, and generalized anxiety. 

• Overall, screening thresholds were met for

o Post-traumatic stress disorder (PTSD)—by 3% of those surveyed;

o Moderate to severe depression—by 5%; and

o Moderate to severe anxiety—by 5%. 

• In general, firefighters did not report a perception of stigma or barriers to seeking mental health 

care, although only 11% indicated they had sought mental health care for work-related stress.

• Most firefighters (97%) reported experiencing one or more potentially traumatic events while 

responding to an opioid overdose in the past 6 months.

To learn more about our results, go to Section B in the Supporting Technical Information
3

Our Recommendations

The Occupational Safety and Health Act requires employers to provide a safe workplace.

Benefits of Improving Workplace Health and Safety:

 Improved worker health and well-being  Improved image and reputation 

 Better workplace morale  Better products, processes, and services

 Better employee recruiting and retention  Could increase overall cost savings

The recommendations below are based on the findings of our evaluation. For each recommendation, 

we list a series of actions you can take to address the issue at your workplace. 

We encourage the city and the fire department to use a health and safety committee to 

discuss our recommendations and develop an action plan. Both employee representatives

from the local chapter of the International Association of Firefighters and management 

representatives should be included on the committee to set priorities and assess the 

feasibility of our recommendations for the specific situation at the fire department. Helpful guidance 

can be found in Recommended Practices for Safety and Health Programs: 

https://www.osha.gov/shpguidelines/index.html. 

NIOSH has issued interim guidance on how to protect emergency responders from exposures to illicit 

drugs. We believe the current NIOSH guidance is applicable to this evaluation because fentanyl is 

increasingly being found mixed with illicit drugs. As a result, responders should assume fentanyl to be 

present in situations involving powders suspected to be illicit drugs. Current NIOSH guidance is 

intended to apply to a range of emergency responders. Recommendations provided below in some 

cases expand upon the current NIOSH guidance. 

Recommendation 1: Provide periodic training to firefighters on how to prevent 

occupational exposures to illicit drugs. Training topics should include standard safe 

operating procedures, personal protective equipment, and decontamination.

Why? Fentanyl and other drugs pose a hazard to responders (such as firefighters, EMS personnel, 

and law enforcement officers) who come into contact with these drugs while working. Possible 

exposure routes to fentanyl and other drugs can vary based on the source and form of the drug. 

Responders are most likely to encounter fentanyl and its analogues in powder (including compressed 

powder), tablet, and/or liquid form. Potential exposure routes of greatest concern include inhalation, 

mucous membrane contact, ingestion, and percutaneous exposure (e.g., needlestick). Any of these 

exposure routes can potentially result in toxic effects. Brief skin contact with powdered fentanyl or its 

analogues is not expected to lead to toxic effects if any visible contamination is promptly removed. 
4

Most firefighters in our questionnaire reported being in situations where suspected opioids were 

visible during the course of their work in the past 6 months. About 20% of reported one or more 

potential routes of exposure to suspected opioids.

How? At your workplace, we recommend these specific actions:

Follow guidance in the NIOSH Topic Page entitled Preventing Emergency 

Responders’ Exposures to Illicit Drugs

Specific recommendations that are most relevant to this fire department include

• Do not touch the eyes, mouth, and nose after touching any surface that might be 

contaminated with illicit drugs.

• Avoid tasks or activities that may make illicit drugs airborne.

• Wash hands with soap and water immediately after a potential exposure and after 

leaving a scene where illicit drugs are known or suspected to be present to avoid 

potential exposure and cross-contamination. Do not use hand sanitizers or bleach 

solutions to clean contaminated skin when fentanyl or its analogues are suspected to be 

present because it might increase absorption through the skin. 

• Wear nitrile gloves when illicit drugs are suspected to be present. Train responders 

(1) on how to remove gloves safely and (2) to change gloves and properly dispose of 

gloves when they become contaminated as soon as practical during response activities. 

Gloves should be changed periodically during response activities even without evident 

contamination.

Recommendation 2: Work with 911 dispatch coordinators to identify possible 

improvements in information gathering and communication before emergency 

responders arrive at scenes where illicit drugs are suspected. 

Why? Receiving information from dispatchers about the possible presence of illicit drugs before 

arriving on the scene can help first responders prepare accordingly and protect themselves, before 

conducting their own on-scene risk assessment.

Recommendation 3: Encourage firefighters to report possible exposures to illicit 

drugs and any potential health effects that result to their supervisors. 

Why? The city and fire department can periodically review this information to help determine 

whether changes in current procedures are needed. They can use this information along with forensic 

testing results to look for trends affecting the risk of unintentional work-related exposure to illicit 

drugs and the associated health effects.
5

How? At your workplace, we recommend these specific actions: 

Reinforce to firefighters that exposures can occur through inhalation, 

mucous membrane contact (eye, nose, or mouth), ingestion, and skin. 

Emphasize to firefighters that reporting potential exposures and 

symptoms contributes to a healthy and safe workplace.

Recommendation 4: Continue to provide firefighters with mental health resources 

and encourage their use.

Why? Research shows that mental health treatment helps to lessen job stress and other mental and 

behavioral problems. Research also shows that workers who receive mental health treatment reduce 

their overall need for other health services over time. Inform firefighters of the resources available to 

them through their workplace (i.e., employee assistance program) and their community (e.g., local 

practitioners, religious leaders, support groups) so they may seek care if experiencing symptoms of 

depression, anxiety, or stress. 

How? At your workplace, we recommend these specific actions:

Provide annual training by a mental health professional on topics like 

suicide prevention and recognizing and managing signs of stress. 

• Consult with the city’s employee assistance program to see if these services are 

available or can otherwise be developed.

• Supplement training with information from the Suicide Prevention Resource Center at 

http://www.sprc.org. 

• Provide firefighters with suicide prevention resources from the National Institute of 

Mental Health at http://www.nimh.nih.gov/health/topics/suicideprevention/index.shtml. 

• Teach firefighters how to recognize and manage stress using information from the 

American Psychological Association’s topic page on stress found at 

http://www.apa.org/topics/stress/index.aspx. 
6

Encourage employees to seek help from a qualified health professional if

they are experiencing symptoms of depression, anxiety, stress (including 

PTSD), or other mental health disorders that interfere with the social, 

occupational, or other areas of their lives.

• Remind firefighters that the city’s employee assistance program is available to them. 

• Reassure firefighters that the mental health symptoms they may be experiencing are 

not their fault, are reversible, and will improve with proper treatment. 

Include mental health assessments as part of the medical evaluation and 

follow-up when firefighters experience a work-related needlestick injury. 

• Provide mental health assessments by a trained physician or mental health professional.

• Consider using brief screening tools or interviews (structured or unstructured) to probe 

for additional details during mental health assessments when deemed necessary by the 

physician or mental health professional.
Supporting Technical Information

Evaluation of Occupational Exposures to Opioids, 

Mental Health Symptoms, Exposure to Traumatic 

Events, and Job Stress in a City Fire Department 

HHE Report No. 2018-0015-3384 

August 2021
A-1

Section A: Fire Department

Fire department management and union representatives, along with city management representatives, 

expressed concerns that led to this evaluation as part of the overall HHE request. At the time of this 

evaluation, the fire department had approximately 800 full-time, uniformed firefighters. Of these, 

193 were on duty at any given time at 26 fire stations. Firefighters were organized into companies. Some 

fire stations had more than one company. In general, firefighters were scheduled to work a 24-hour 

shift every third day. Most firefighters had one assigned primary company, but some firefighters rotated 

between different fire stations as “travelers.” Firefighters could work overtime, possibly at a different 

fire station.
B-1

Section B: Methods, Results, and Discussion

The objectives of this component of our evaluation were to

• Assess whether firefighters were exposed to drugs including opioids and whether such 

exposures were associated with any health effects. 

• Evaluate firefighters’ use of personal protective equipment (PPE) on responses where 

substances suspected to be opioids were visible. Determine if PPE use patterns were consistent 

with NIOSH guidance for preventing exposure to illicit drugs. 

• Determine whether firefighters reported exposures to suspected opioids to the fire department. 

If not, identify barriers that prevented firefighters from reporting exposures.

• Assess firefighters’ perceived job stress as related to opioid overdose responses. 

• Screen for symptoms of post-traumatic stress disorder (PTSD), depression, and anxiety using 

case definitions based on validated screening tools. 

• Assess whether having a positive screen for PTSD, depression, and anxiety was associated with 

experiencing various types of potentially traumatic events while responding to an opioid 

overdose. 

• Determine firefighters’ perceptions of stigma and barriers to seeking mental health care.

• Recommend ways to improve working conditions and practices associated with firefighters’ 

safety and health. 

Methods: Questionnaire 

On May 16–17, 2018, we visited 16 fire stations to invite all on-duty firefighters at the time of each visit 

to complete an anonymous written questionnaire. We arranged for on-duty firefighters from the 

10 stations that we did not visit to gather at the visited stations. We invited the equivalent of one shift 

of on-duty firefighters, or approximately one third of the department’s firefighters, to complete the 

questionnaire.

The questionnaire consisted of validated scales as well as questions developed specifically for this 

evaluation. It included questions on job and demographic characteristics, possible exposure to opioids, 

PPE availability and use, health effects related to opioid exposure, job stress, exposure to potentially 

traumatic events during opioid overdose responses, mental health symptoms, resources used to address 

mental health symptoms and stress, and perceived stigma and barriers to seeking care for psychological 

problems. The questionnaire also included a list of local and national resources for suicide prevention 

and mental health care. Sections of the questionnaire are described below. 

Possible Exposure to Opioids and PPE Availability and Use 

We asked firefighters whether they had been in situations where suspected opioids (powders or liquids) 

were visible during the course of their work in the past 6 months. If so, we asked about the frequency 
B-2

of being in such situations and the potential routes of exposure to suspected opioids. Potential routes of 

exposure to suspected opioids included contact with uncovered skin, gloved hands, eye or mouth, or 

through airborne substances. 

Firefighters were asked about PPE availability and use when suspected opioids were visible. If PPE was 

available but not used, we asked about reasons why PPE was not used. 

Health Effects Related to Opioid Exposure 

We asked firefighters if they had come into contact with suspected opioids during the course of their 

work in the past 6 months before asking them about possible health effects. On the questionnaire, 

we specified that “come into contact” corresponded to the potential routes of exposure. This question 

was posed to all participants, whereas in the previous section, we had only asked participants who 

reported that suspected opioids were visible during the course of their work about potential routes of 

exposures. For the purposes of this report, we defined opioid exposure as a “yes” or “not sure” 

response to this question. If firefighters reported opioid exposure, they were asked about health effects, 

types of medical evaluation and treatment received, and whether they reported the exposure to the 

fire department. 

Some firefighters gave discordant (i.e., conflicting) answers to questions in this section. For example, 

eight firefighters who reported no opioid exposure during the course of their work provided responses 

to the subsequent questions. We excluded this pattern of responses from the analysis. 

In addition, some firefighters gave discordant answers to questions about coming into contact with 

suspected opioids when they were visible versus more generally during the course of their work in the 

past 6 months. If a firefighter responded “yes” to one or more potential routes of exposure to 

suspected opioids (uncovered skin, gloved hands, eyes or mouth, or airborne) but “no” or “not sure” to 

opioid exposure, we included the responses about potential routes of exposure and excluded responses 

to health effects, medical evaluation and treatment, and reporting. There were 17 firefighters with this 

pattern of responses. 

If a firefighter had one or more “not sure” but no “yes” responses to potential routes of exposure to 

suspected opioids and “no” to opioid exposure, we included the responses about potential routes of 

exposure and excluded responses to health effects, medical evaluation and treatment, and reporting. 

There were 16 firefighters with this pattern of responses. 

Job Stress and Exposure to Potentially Traumatic Events During Opioid Responses 

We asked firefighters to rate their overall level of job stress with the following survey item: “How would 

you rate your level of job stress caused by responding to opioid overdoses over the past 6 months?” 

They were asked to use a rating scale from 0 (as low as it can be) to 10 (as high as it can be). Responses 

of 0–3 indicated low job stress, 4–6 indicated moderate job stress, and scores of 7 or greater indicated 

high job stress [Clark et al. 2011]. 

We asked firefighters to indicate “yes” or “no” to a list of potentially traumatic events that they may 

have experienced while responding to an opioid overdose in the past 6 months. We also asked whether 

someone close to them (e.g., family or friends) had experienced an opioid overdose. This was intended 

to be an indicator of personal impact beyond the firefighters’ job duties.
B-3

Mental Health Symptoms 

Post-traumatic Stress Disorder 

We used the U.S. Department of Veterans Affairs’ PTSD Checklist for the Diagnostic and Statistical 

Manual for Mental Disorders, 5th Edition (PCL-5) [Weathers et al. 2013] screening tool for PTSD. 

A PCL-5 score of 31–33 has shown a sensitivity of 88% and a specificity of 69% for PTSD [Bovin et al. 

2015].

Firefighters were asked to rate how much they were bothered by each symptom in the past 4 weeks 

using the following frequencies: not at all (+ 0), a little bit (+ 1), moderately (+ 2), quite a bit (+ 3), and 

extremely (+ 4). We calculated a total symptom severity score (range 0–80) by summing the scores of 

the 20 items in the measure, using the recommended cut point of > 33 as a positive screen for PTSD. 

Depression 

We used the Patient Health Questionnaire-9 (PHQ-9) [Kroenke and Spitzer 2002] to screen for 

depression. A PHQ-9 score of > 10 (moderate to severe depression) has shown a sensitivity of 88% 

and a specificity of 88% for major depression [Kroenke et al. 2001]. 

Firefighters were asked to rate how often they were bothered by each symptom in the past 4 weeks

using the following frequencies: not at all (+ 0), several days (+ 1), more than half the days (+ 2), and 

nearly every day (+ 3). We calculated a total symptom severity score (range 0–27) by summing the 

scores of the nine items in the measure, using the recommended thresholds of 5 (mild), 10 (moderate), 

15 (moderately severe), and 20 (severe) depression. 

Anxiety 

We used the General Anxiety Disorder-7 (GAD-7) [Spitzer et al. 2006] to screen for anxiety. A GAD-7 

score of > 10 has shown a sensitivity of 89% and a specificity of 82% for generalized anxiety disorder 

[Spitzer et al. 2006].

Firefighters were asked to rate how often they were bothered by each symptom in the past 4 weeks 

using the following frequencies: not at all (+ 0), several days (+ 1), more than half the days (+ 2), and 

nearly every day (+ 3). We calculated a total symptom severity score (range: 0–21) by summing the 

scores of the seven items in the measure, using the recommended thresholds of 5 (mild), 10 (moderate), 

and 15 (severe) anxiety.

Use of Resources to Cope with Mental Health Symptoms and Stress 

We listed a variety of resources that firefighters could use to manage stress or improve their mental 

health and asked them to indicate whether they had used each resource. 

Perceived Stigma and Barriers to Care for Psychological Problems

We included two validated scales to assess the stigma of psychological problems in the work 

environment [Britt 2000] and the barriers to seeking mental health care [Hoge et al. 2004]. We asked 

firefighters to rate their level of agreement with each item on a scale from 1 (strongly disagree) to 

5 (strongly agree). Scores of 3 were considered neutral, scores of 1 or 2 indicated disagreement, and 

scores of 4 or 5 indicated agreement.
B-4

Statistical Analysis 

We summarized the descriptive statistics for responses about demographic and job characteristics, 

possible exposure to opioids, PPE availability and use, health effects related to opioid exposure, job 

stress, exposure to traumatic events at work, and perceived barriers, stigma, and use of resources to 

manage mental health symptoms and stress.

We compared the distribution of primary company or traveler status in firefighters who reported at least 

one potential route of exposure to suspected opioids to the overall distribution of primary company or 

traveler status using the χ2 goodness-of-fit test. We compared the characteristics of firefighters who 

reported at least one potential route of exposure to suspected opioids and firefighters who did not 

report any potential routes of exposures using the Mann-Whitney U test for continuous variables and 

Fisher’s exact test or the χ2 test for categorical variables. 

We estimated the prevalence of symptoms consistent with PTSD, depression, and GAD using the 

standard case definitions presented [Kroenke and Spitzer 2002; Spitzer et al. 2006; Weathers et al. 2013]. 

We used Fisher’s exact test to determine whether exposure to potentially traumatic events, potential 

exposure to opioids, visibility of suspected opioids during response, and working overtime were 

associated with a high level of reported job stress or positive screenings of PTSD, depression, 

and anxiety. 

Statistical tests were two-tailed, and statistical significance was set at P < 0.05. Statistical analyses were 

performed using SPSS version 18 and R version 3.3.2 software programs.

Results: Questionnaire

Characteristics of Participating Firefighters 

Of the 190 firefighters working during the 2 days we visited the fire stations, 189 (99%) completed a 

questionnaire. Table C1 describes the demographic characteristics of the participants. Most were male 

(95%). The most common age category was 36–45 years. Table C2 summarizes the job characteristics 

of the participants. The most common job tenure of those who completed the questionnaire was 

1–5 years.

Potential Exposure to Opioids 

Of the 189 respondents, 173 (92%) participants reported that they participated in an opioid overdose 

response in the past 6 months. In total, 118 firefighters (62%) reported having been in situations where 

suspected opioids were visible during the course of their work over the past 6 months. The most 

frequently reported category was 2–5 times in the past 6 months (Table C3). 

Of the 118 firefighters who reported suspected opioids were visible, 35 (30%) indicated “yes” to one or 

more potential routes of exposure to suspected opioids (Figure 1). This corresponds to 19% of all 

firefighters who participated in the survey. Some firefighters reported more than one route of exposure. 

Gloved hand contact was the category with the highest number of “yes” responses (n = 33). None 

responded “yes” to having their eyes or mouth coming into contact with suspected opioids.

The distribution of primary company or traveler status among firefighters who reported one or more 

potential routes of exposure to suspected opioids was similar to that among all respondents (P = 0.96). 
B-5

In addition, firefighters who reported one or more potential routes of exposure to suspected opioids 

were similar to firefighters who did not report any potential routes of exposure in terms of job tenure 

(P = 0.06), whether they worked overtime or not (P = 0.31), total number of hours worked per week 

(P = 0.28), and current highest EMS training level (P = 0.21). 

Figure 1. Number of firefighters reporting “yes” to various potential routes of exposure to suspected 

opioids (n = 118). 

PPE Availability and Use 

The percentage of firefighters who reported that PPE was available when suspected opioids was visible 

was 63% for wrist/arm protection (uniform with long sleeves, sleeve covers, gowns, or coveralls), 

91% for respirators, 92% for safety glasses or goggles, and 100% for gloves. None of the respondents 

reported that all these types of PPE were available when suspected opioids were visible at a response 

site as recommended by current NIOSH guidance. 

Figure 2 shows the proportion of firefighters who reported that various PPE components were used 

when suspected opioids were visible by frequency. All respondents reported “always” or “sometimes” 

wearing gloves. Even when available, most respondents reported never wearing respirators, safety 

glasses, or goggles when suspected opioids were visible at a response site. Wrist/arm protection use was 

more variable. Three respondents reported always wearing all the forms of PPE available to them. 

Figure 3 summarizes the reasons given for not wearing PPE when suspected opioids were visible 

among 111 respondents who reported “sometimes” or “never” wearing PPE when it was available. The 

most commonly reported reasons were “I did not think it was necessary” (66%), “it was not required” 

(28%), “I initially did not have enough information to suggest that suspected opioids were present” 

(11%), and “I was too rushed at the scene” (11%). 

0

4

6

33

0 10 20 30 40

Eyes or mouth

Uncovered skin

Airborne

Gloved hand

Number of firefighters

Route of exposure
B-6

Figure 2. Frequency of PPE use reported by firefighters who reported each type of PPE was available 

when suspected opioids were visible (n = 74–114). Percentages might not sum to 100% because of 

rounding. 

Figure 3. Reported reasons for not wearing PPE when suspected opioids were visible at response scenes 

(n = 111). 

*Respondents wrote in this reason. 

1%

5%

7%

96%

54%

17%

4%

4%

45%

79%

90%

0%

Wrist/arm protection (n = 74)

Safety glasses or goggles (n = 109)

Respirator (n = 105)

Gloves (n = 114)

Frequency of PPE use

PPE type

Always Sometimes Never

4%

5%

8%

11%

11%

28%

66%

0% 20% 40% 60% 80% 100%

PPE was unavailable,* problems with fit, or other

Temperature/weather*

It impaired my ability to perform job duties

I was too rushed at the scene

I initially did not have enough information to suggest that

suspected opioids were present

It was not required

I did not think it was necessary

Percentage of firefighters who reported not wearing PPE

Reason for not wearing PPE when suspected opioids 

were visible
B-7

Health Effects Related to Opioid Exposure 

Excluding 41 discordant answers among the 189 survey participants left 148 responses to the question 

about opioid exposure included in the analysis. Of these 148 participants, 25 (17%) reported opioid 

exposure. Of these 25 firefighters, two reported health effects after coming into contact with suspected 

opioids, which they did not report to the fire department. None of the 25 firefighters reported someone 

else telling them that they had small or pinpoint pupils after the exposure. 

Regarding health effects, one firefighter described headache and numbness or tingling in an unspecified 

body part. This firefighter responded “not sure” to suspected opioids coming into contact with 

uncovered skin, with the eyes or mouth, or through the air. There was no response to whether there 

was contact with suspected opioids with gloved hands. The other firefighter reported numbness or 

tingling in the fingertips. This firefighter reported suspected opioids coming into contact with gloved 

hands and uncovered skin. These two firefighters who reported health effects stated that they did not 

receive naloxone or evaluation or treatment in an emergency department. 

Two of the 25 firefighters who reported contact with suspected opioids responded that they informed

the fire department—these were not the two firefighters who reported health effects discussed in the 

previous paragraph. Among the 23 firefighters who did not report their opioid exposure to the fire 

department, reasons for not reporting are summarized in Figure 4. The most common reason cited for 

not reporting opioid exposure was “I wasn’t sure that I was exposed” (n = 15). Among firefighters who 

cited this reason, contact with gloved hands was the route of exposure with the highest number of 

“yes” responses (n = 8), and airborne had the highest number of “not sure” responses (n = 9). Two 

firefighters who cited “I wasn’t sure that I was exposed” reported only coming into contact with 

suspected opioids with gloved hands. When the responses of these two firefighters were excluded, the 

ordering of reasons for not reporting did not change.

Of the two firefighters who reported health effects from opioid exposure, one cited “I did not think 

anything could be done to fix the problem” as the reason for not reporting exposure. The other 

firefighter endorsed all of the reasons on the questionnaire except for “other” (Figure 4).

Figure 4. Reasons given for not reporting opioid exposure to the fire department (n = 21–22).

4

6

8

12

15

0 5 10 15 20

I did not want to go through the follow-up interviews and

questions (n = 21)

I did not think anything could be done to fix the problem

(n = 21)

I took care of the problem myself (n = 21)

I did not think it was that serious or important (n = 22)

I wasn't sure that I was exposed (n = 22)

Number of responses

Reason for not reporting opioid 

exposure
B-8

Job Stress and Exposure to Potentially Traumatic Events During Opioid Responses 

The average job stress score for the 189 participating firefighters was 2.9, indicating low job stress 

caused by responding to opioid overdoses over the past 6 months. On the basis of individual stress 

scores, 124 (66%) firefighters indicated low job stress, 40 (21%) indicated moderate job stress, and 

25 (13%) indicated high job stress as a result of responding to opioid overdoses in the past 6 months. 

Table C4 shows the frequency and percentage of firefighters who reported experiencing a potentially 

traumatic event while responding to an opioid overdose in the past 6 months. Most (97%) firefighters 

reported experiencing one or more potentially traumatic events, with the most common being 

administering naloxone/Narcan (87%), seeing dead adults (75%), and seeing neglected or 

unaccompanied children (69%). Thirteen firefighters (8%) reported in the questionnaire that they 

received a needlestick injury while responding to an opioid overdose in the past 6 months. According to 

the city’s database of work-related injuries and illnesses, there were no reported needlestick injuries or 

other types of bloodborne pathogen exposure among firefighters during this time period. 

Firefighters who reported a high level of job stress were more likely than those reporting 

mild/moderate job stress to have experienced the following potentially traumatic events during an 

opioid overdose response 

• Seeing neglected or unaccompanied children (90.9% vs. 65.6%; P = 0.015) 

• Being physically attacked/assaulted (50% vs. 14.6%; P < 0.001) 

• Being in a situation where they believed they would be killed by another person (27.3% vs. 5.3%; 

P = 0.003) 

• Being injured by a needlestick (22.7% vs. 5.3%; P = 0.014) 

• Reviving the same person(s) from an opioid overdose on more than one occasion (90.9% vs. 

64.0%; P = 0.013) 

• Being in a situation where suspected opioids were visible (83.3% vs. 59.9%; P = 0.04) 

Firefighters who reported a high level of job stress were similar to those reporting mild/moderate job 

stress in terms of whether they had opioid exposure (P = 0.46) and whether they worked overtime or 

not (P = 0.14). 

As a measure of the personal impact the opioid epidemic has had on firefighters, 49 of 189 (26%) 

participants reported that someone close to them (family member or friend) had overdosed on an 

opioid in the past. This item was not associated with a high level of reported job stress.

Mental Health Symptoms 

Post-traumatic Stress Disorder 

In total, 187 firefighters completed the items necessary to screen for symptoms of PTSD. Of these, 

6 (3%) screened positive for possible PTSD. Firefighters who had been in a situation where they 

believed they could be killed by another person during an opioid overdose response had a significantly 

higher prevalence of positive PTSD screenings than those who had not been in a situation where they 

thought they could be killed (21.4% vs. 1.3%; P = 0.004). Firefighters who had been injured by a 
B-9

needlestick during an opioid overdose response had a significantly higher prevalence of positive PTSD 

screenings than those who had not been injured by a needlestick (15.4% vs. 1.9%; P = 0.047). No other 

types of potentially traumatic events experienced while responding to an opioid overdose response, nor 

personal impact of the opioid epidemic, were associated with a positive PTSD screen.

Depression

In total, 188 firefighters completed the items necessary to screen for symptoms of depression. Of these, 

149 (79%) screened negative, 30 (16%) met the screening criterion for mild depression, 5 (3%) met the 

screening criterion for moderate depression, 3 (2%) met the screening criterion for moderately severe 

depression, and 1 (< 1%) met the screening criterion for severe depression. Three firefighters (2%) 

reported having suicidal ideation. The questionnaire was anonymous, so we could not directly intervene 

with these individuals to ensure they received mental health care. However, we immediately alerted the 

district fire chief and the city’s office of risk management about the suicidal ideation responses, again 

providing local and national resources for suicide prevention and mental health. We encouraged the 

district fire chief and the city’s office of risk management to distribute information about these 

resources to all of the firefighters. 

Firefighters who reported experiencing the following potentially traumatic events during an opioid 

overdose response in the previous 6 months had a significantly higher prevalence of moderate to severe 

depression symptoms (as opposed to a negative or mild depression screening) than those who did not 

report experiencing the event 

• Being physically attacked/assaulted (55.5% vs. 17%; P = 0.013) 

• Being in a situation where they believed they could be killed by another person (33.3% vs. 6.7%; 

P = 0.027) 

• Being injured by a needlestick (33.3% vs. 6.1%; P = 0.022) 

• Opioid exposure (50% vs. 15%; P = 0.028) 

No other types of potentially traumatic events experienced while responding to an opioid overdose 

response, nor personal impact of the opioid epidemic, were associated with moderate to severe 

depression. 

Generalized Anxiety Disorder

Of the 187 firefighters who completed the items necessary to screen for symptoms of GAD, 161 (86%) 

screened negative, 17 (9%) met the screening criterion for mild anxiety, 8 (4%) met the screening 

criterion for moderate anxiety, and 1 (< 1%) met the screening criterion for severe anxiety. Firefighters 

who had been injured by a needlestick had a significantly higher prevalence of moderate to severe 

anxiety screenings (as opposed to negative or mild) than those who had not been injured by a 

needlestick (33.3% vs. 6.1%; P = 0.022). No other types of potentially traumatic events experienced 

while responding to an opioid overdose response, nor personal impact of the opioid epidemic were 

associated with moderate to severe anxiety.
B-10

Use of Resources to Address Mental Health Symptoms and Stress 

Twenty (11%) firefighters reported seeking mental health care for work-related stress. Table C5

describes resources firefighters may use to help them manage stress and mental health symptoms.

Among the 20 firefighters, the employee assistance program (7%) was the most frequently used 

resource for coping with stress and mental health, followed by a mental health professional (3%) and 

primary care physician (3%). 

Perceived Stigma and Barriers to Care for Psychological Problems

Table C6 shows the frequency and percentage of firefighters who responded at each level of agreement 

for the perceived stigma and barriers to care items. Most responding firefighters disagreed with the 

perceived stigma and barriers to care items. Of those that did perceive some stigma or barriers to 

seeking care, the greatest perceptions of stigma were concerns that they would “be seen as weak” (20%) 

or that “members in my unit might have less confidence in me” (15%). The greatest barrier reported to 

seeking mental health care was the cost of services (14%). 

Most firefighters (93%) indicated that completing the questionnaire was not at all upsetting to them, 

while 11 (6%) reported it was a little bit upsetting, 2 (1%) said it was somewhat upsetting, and 1 (< 1%) 

said it was extremely upsetting.

Discussion 

From 2015 to 2016, there was a 100% increase in the rate of overdose deaths involving synthetic 

opioids (which includes fentanyl and its analogues) in the United States [Centers for Disease Control 

and Prevention 2018a]. Ohio, a state severely affected by the opioid epidemic and where this fire 

department is located, experienced 4,162 opioid-related overdose deaths in 2017, a 19% increase 

compared with 2016 [Ohio Department of Health 2018]. The number of emergency department visits 

for suspected opioid overdose in Ohio has also increased in 2016–2017 [Centers for Disease Control 

and Prevention 2018b]. 

These trends have raised concerns about the possibility of unintentional work-related opioid exposure 

among firefighter-emergency medical service providers, as well as other emergency responders 

(e.g., law enforcement officers). Inhalation, mucous membrane contact, ingestion, and percutaneous 

exposure (e.g., needlestick) are primary potential routes of exposure. Brief skin contact with powdered 

fentanyl or its analogues is not expected to lead to toxic effects if visible contamination is promptly 

removed [Interagency Board 2017; Moss et al. 2018; NIOSH 2017]. 

In this city fire department, almost all firefighters (92%) responding to the questionnaire reported 

participating in opioid overdose responses in the past 6 months. This period roughly corresponds to the 

first half of 2018. During opioid overdose responses, 87% reported administering naloxone. 

Approximately 62% of firefighters reported work situations where suspected opioids were visible, 

which corresponds to at least a moderate anticipated level of exposure in the current NIOSH guidance 

[NIOSH 2017]. 

Approximately 19% of all respondents reported one or more potential routes of exposure to suspected 

opioids; however, we did not identify any work characteristics that were associated with exposure. No 

eye or mouth contact with suspected opioids was reported, but transfer from bare or gloved hands to 
B-11

the eyes or mouth is more likely to go unnoticed than direct contact. Because of this possibility, we 

asked about gloved hand contact with suspected opioids that might lead to mucous membrane exposure 

via subsequent inadvertent hand-to-face contact. The potential for exposure via gloved hand contact 

highlights the need for training about proper glove removal procedures and glove changes upon 

contamination or after tasks with potential for contamination. 

Two firefighters reported symptoms after opioid exposure. The low prevalence of symptoms after 

exposure to suspected opioids relative to the proportion of firefighters who reported work situations 

involving suspected opioids and potential routes of exposure in this questionnaire might indicate that a 

relatively high level of exposure is needed to develop symptoms. The symptoms reported, numbness or 

tingling and headache, were nonspecific and mild. Low-dose exposure to opioids may result in milder 

symptomatology. A continuum of signs and symptoms experienced upon exposure to opioids has been 

described, but does not specifically include headache, numbness, or tingling [Lynch et al. 2018; 

Suzuki and El-Haddad 2017]. None of the respondents reported signs and symptoms of severe 

(life-threatening or late-stage) opioid toxicity. These include profound lethargy or other indications of 

central nervous system depression; shallow, slow, or absent breathing; miosis (small or pinpoint pupils); 

slow heart rate; and low body temperature [Boyer 2012; Ropper et al. 2014].

Headache is an extremely prevalent symptom and has many other potential causes. Illicit fentanyl and 

its analogues are increasingly being mixed with other drugs, particularly cocaine [Centers for Disease 

Control and Prevention 2018c]. Cocaine has local anesthetic effects such as numbness and tingling 

[Aronson 2016], but we cannot conclude that the numbness or tingling reported in the survey was 

specifically related to cocaine or other drugs. We did not ask about the identity of substances 

firefighters might have come into contact with during the course of their work. Visual inspection does 

not confirm or rule out the presence of fentanyl or fentanyl analogues [Suzuki and El-Haddad 2017]. 

The low prevalence of symptoms after opioid exposure reported in this questionnaire is consistent with 

preliminary findings from studies of first responders in Virginia and Kentucky. Although methods 

differed from ours, approximately 3% of first responders in Virginia and Kentucky who responded to 

that survey reported health effects associated with exposure to opioids [Thompson et al. 2018; 

Tran 2018].

Ideally, the fire department would receive information about scenarios in which firefighters were 

exposed to hazardous substances and “near-misses.” This information can be incorporated into policies 

and work processes to prevent future incidents. Only two firefighters reported opioid exposure to the 

fire department, but 25 firefighters’ questionnaire responses indicated that they had opioid exposure. 

The firefighters who experienced health effects reported that they did not tell the fire department about 

their exposures and subsequent symptoms. 

Uncertainty about exposure was the most commonly cited reason for not reporting. Possible 

explanations include that some routes of exposures are harder to detect than others and uncertainty 

about what constitutes an exposure that should be reported. For example, it might be more difficult to 

know about substances being airborne as opposed to visible contamination on gloves or skin. In 

addition, firefighters who only had suspected opioids come into contact with their gloves might have 
B-12

not considered themselves exposed at the time of the contact; however, we instructed firefighters that, 

for the purposes of the questionnaire, exposure included contact with gloved hands. 

The ordering of reasons for not reporting did not change when we excluded firefighters with only 

gloved hand contact to address this potential difference in perceptions about being exposed. A 

perception that the exposure was not serious or not important was the second most commonly cited 

reason for not reporting. Specifying what constitutes an exposure to be reported and emphasizing the 

importance of reporting exposure to suspected opioids and other hazardous substances might 

encourage firefighters to report future incidents. 

All firefighters reported compliance with glove use when suspected opioids were visible, which is 

consistent with NIOSH guidance for situations with a moderate anticipated level of exposure. While 

more than 90% of firefighters reported respirators and eye protection were available when suspected 

opioids were visible, most reported never using these types of PPE. Reported wrist/arm protection 

availability was lower and use was more variable. These other types of PPE are also recommended for a 

moderate anticipated level of exposure [NIOSH 2017].

We did not ask about reasons for not wearing each specific type of PPE, but the two most frequently 

reported reasons for not wearing PPE in general were “I did not think it was necessary” and “it was not 

required.” Fire department guidelines on what types of PPE should be worn in various situations 

involving illicit drugs could help employees increase PPE use. Two common reasons (“I initially did not 

have enough information to suggest that suspected opioids were present” and “I was too rushed at the 

scene”) might be addressed through having more information available before firefighters arrive at 

scenes where illicit drugs might be present. 

Firefighting is an inherently stressful occupation. For example, the CareerCast [2017] annual report on 

stressful occupations lists firefighting as the second most stressful job in the United States, following 

active duty military personnel. Firefighters are in a high-risk occupation. Their lives are endangered 

regularly and they have a variety of life-saving duties beyond fire suppression. These include responding 

to medical crises, explosions, spills, and disasters. 

NIOSH [2011] defines job stress as the harmful physical and emotional responses that occur when job 

demands do not match the capabilities, resources, or needs of employees. Stress is complicated and 

multifaceted for firefighters. A mixture of traumatic experiences and daily working conditions such as 

administrative and organizational factors can affect firefighters’ mental health, job satisfaction, and 

morale [Beaton and Murphy 1993; Corneil et al. 1999]. 

As a group, the firefighters in our evaluation reported low job stress when asked specifically about 

responding to opioid overdoses. The overall level of job stress might have been different had we asked 

about job stress in general, perhaps because responding to opioid overdoses may represent a relatively 

low stress situation for those who experience death and other traumatic events regularly. We did find 

that a high job stress rating was associated with experiencing some of the potentially traumatic incidents 

we described in our questionnaire like administering naloxone and seeing dead adults. These findings 

indicate that it is important for firefighters to monitor their stress levels following opioid overdose 

responses and to engage in stress reduction techniques to improve psychological well-being.
B-13

In our evaluation, we found that 3% of firefighters screened positive for PTSD, 5% screened positive 

for moderate to severe depression, and 5% screened positive for moderate to severe anxiety. The 

12-month prevalence of these clinical disorders among U.S. adults is 3.5% for PTSD, 7% for 

depression, and 2.9% for anxiety [American Psychiatric Association 2013]. These rates, however, cannot 

be directly compared with our findings because they are based on actual diagnosed cases, whereas our 

findings were based on a screening tool. We did not assess how mental health symptoms influence 

functioning, which is an important consideration for a making a true clinical diagnosis for these 

conditions. Thus, it is possible that while firefighters may be experiencing symptoms of depression and 

anxiety, their performance at work or in social or other settings may be unaffected. 

In a similar HHE focusing on the opioid epidemic with firefighters in West Virginia (n = 53), we found 

higher percentages of positive screenings for PTSD (13%), moderate to severe depression (23%), and 

moderate to severe anxiety (25%) using the same screening tools [NIOSH 2017]. This was a relatively 

small community located in one of five states with the highest rates of death from drug overdose that 

experienced a mass overdose event involving 26 people at the same location over several hours. Other 

research using different screening tools with firefighters reported PTSD rates of 4%–37% [Bryant and 

Harvey 1996; Corneil et al. 1999; Meyer et al. 2012; Wagner et al. 1998]. In other studies, depression and 

anxiety findings have been similar to those found in this HHE. Carey et al. [2011] found a moderate to 

severe depression prevalence of 4.6%, and Meyer et al. [2012] reported a 3.5% prevalence of moderate 

to severe depression and a 4.2% prevalence of moderate to severe anxiety symptoms among firefighters 

serving large metropolitan areas of the United States.

Of the firefighters in this evaluation who reported experiencing a potentially traumatic event at work, 

most reported multiple events. PTSD symptoms usually do not begin until at least 3 months after the 

trauma, but in some cases, it may take many months or years after a trauma before a person experiences 

symptoms of the disorder [American Psychiatric Association 2013]. Therefore, firefighters should seek 

and give support and psychological first aid following any traumatic incident [Norwood and Rascati 

2012]. For example, our results showed that situations where a firefighter believed he or she could be 

killed by another person and experiencing needlestick injuries are specific traumatic events during an 

opioid overdose response that are each associated with PTSD symptoms. Firefighters who experience 

these types of events should speak with someone they trust shortly after the event and determine 

whether further assistance is necessary to help them mentally and emotionally process the event and 

begin to cope. 

Needlestick injury was a potentially traumatic event that was associated with high job stress and a higher 

prevalence of mental health outcomes. These findings were consistent with results from prior studies of 

health care workers who reported feeling symptoms of anxiety, depression, and PTSD following a 

needlestick injury [Cooke and Stephens 2017]. In this evaluation, although 13 (8%) firefighters reported 

a needlestick injury during an opioid overdose response in the past 6 months, no needlestick injury 

reports were recorded in the city’s database during that period. Similarly, a higher incidence of 

needlestick injuries was found in a survey of EMS providers [Alhazmi et al. 2018] than in another study 

based on incident reports [El Sayed et al. 2011]. 
B-14

Underreporting of needlestick injuries is common; one study estimated a 43.4% underreporting rate 

among U.S. health care workers [Panlilio et al. 2004]. Encouraging prompt reporting of occupational 

needlestick injuries and other bloodborne pathogen exposures is important because postexposure 

prophylaxis for human immunodeficiency virus infection and hepatitis B works best when it is started 

as soon as possible after exposure [Centers for Disease Control and Prevention 2001; Kuhar et al. 

2013]. In addition, mental health assessments related to the needlestick might be incorporated into 

medical evaluation and follow-up when firefighters experience a work-related needlestick injury. 

Most of the firefighters in our evaluation reported that they had not sought mental health care for stress 

or other psychological outcomes associated with their work. When a firefighter did seek help, of the 

potential mental health resources we listed, the most commonly used was the employee assistance 

program. Other studies have found that many people who experience psychological issues do not 

pursue treatment from a mental health specialist, mainly due to the stigma of mental illness and seeking 

treatment [Andrews et al. 2001; Corrigan 2004]. In our study, most of the firefighters reported that they 

did not believe workplace stigma exists associated with receiving mental health care. However, 

13%–22% of the firefighters gave neutral responses to these items, making it unclear as to whether they 

did not have an opinion or if they were unsure of how to respond. 

Future efforts should expand the focus to explore perceptions of stigma from society at large, from 

friends and family, from the firefighting or first responder community, and self-imposed stigma for 

receiving mental health care. Understanding potential stigma associated with receiving mental health 

care and support may lead to targeted interventions for improving perceptions and utilization of mental 

health services [Vogel et al. 2007].

This report completes the fire department evaluation portion of this HHE. A previous interim report 

for the HHE involved an evaluation of incidents in which police officers were potentially exposed to 

opioids [NIOSH 2018]. 

Limitations 

This evaluation was subject to several limitations. The greatest limitation was that questionnaire 

responses were self-reported, and we were unable to verify responses using records, such as emergency 

response logs. There is the possibility of recall bias from the self-reported responses. Second, because 

the questionnaire was anonymous, we were unable to clarify responses or ask follow-up questions once 

the responses were analyzed. For example, we were not able to follow up with firefighters who gave 

discordant responses. As a result, we excluded discordant answers from the analysis. In incidents where 

firefighters reported health effects after contact with suspected opioids, we were not able to obtain 

additional details.

A third limitation was that we only invited about one third of the department’s firefighters to participate 

in the questionnaire. However, firefighters who were on-duty during questionnaire administration were 

not expected to differ from firefighters working on different shifts in ways that would systematically 

bias the results. All but one invited firefighter participated in the survey. A fourth limitation was that the 

mental health screening tools used were not specifically validated for use with firefighters or first 

responders, but instead in general populations. The last limitation was that although responses were 
B-15

anonymous, firefighters may have felt the need to respond to the mental health questions in a socially 

desirable manner to avoid any questioning of their fitness for duty. 

Conclusions

Most firefighters in this city fire department reported being in situations where suspected opioids were 

visible during the course of their work in the past 6 months. Reported glove use was high during these 

situations. Approximately 20% of firefighters reported one or more potential routes of exposure to 

suspected opioids, although the frequency of PPE use other than gloves was low. While few firefighters 

developed nonspecific symptoms after opioid exposure, it is important to continue taking steps to 

prevent unintentional occupational exposure to opioids and other drugs. This includes educating 

firefighters on occupational safety and health topics related to the exposure to illicit drugs such as 

fentanyl and its analogues. 

Some firefighters reported symptoms consistent with case definitions of PTSD, depression, and anxiety. 

Firefighters should be educated and trained on mental health issues such as suicide prevention, 

psychological first aid, and recognizing signs of stress. Furthermore, they should be encouraged to seek 

help from a mental health professional when faced with a traumatic event while responding to an opioid 

exposure call. 
C-1

Section C: Tables

Table C1. Participant demographic information 

Demographic characteristic Number (%)

Male (n = 187) 178 (95)

Age in years (n = 187) 

18–25 4 (2)

26–35 45 (24)

36–45 65 (35)

46–55 54 (29)

55+ 19 (10)

Race (n = 187)* 

American Indian or Alaskan Native 7 (4)

Asian 2 (1)

Black or African American 59 (32)

Native Hawaiian or other Pacific Islander 3 (2)

White 131 (70)

Hispanic or Latino ethnicity (n = 189) 5 (3)

*Participants could choose more than one option
C-2

Table C2. Participant job characteristics (n = 189)

Job characteristic Number (%)

Years with this fire department 

< 1 0 

1–5 50 (26)

6–10 15 (8)

11–15 19 (10)

16–20 37 (20)

21–25 39 (21)

25+ 29 (15)

Supervisory position 51 (27)

Traveler 14 (7)

Current highest level of EMS certification 

Paramedic 85 (45)

Advanced emergency medical technician 1 (1)

Emergency medical technician 103 (54)

EMS = emergency medical services

Table C3. Frequency of being in situations where suspected 

opioids were visible during the course of work over the past 

6 months (n = 116)* 

Frequency Number† (%)

Just once in the past 6 months 17 (15)

2–5 times in the past 6 months 54 (47)

At least once per month 31 (27)

At least once per week 13 (11)

Once per shift 0 

More than once per shift 1 (1)

*Two responses about frequency were missing. 

†Percentages might not sum to 100 due to rounding.
C-3

Table C4. Number of firefighters who reported experiencing a potentially traumatic event while responding 

to an opioid overdose in the past 6 months (n = 173)

Potentially traumatic event Number (%)

Administering naloxone/Narcan to someone 151 (87)

Seeing dead adults* 129 (75)

Seeing neglected or unaccompanied children 119 (69)

Having to revive the same person(s) from an opioid overdose more than once* 116 (67)

Seeing a patient die 99 (57)

Being physically attacked 33 (19)

Being in a situation where you believed you could be killed by another person 14 (8)

Being injured by a needlestick 13 (8)

*n = 172

Table C5. Use of mental health resources for work-related 

stress (n = 188)

Resource Number (%)

Sought some form of mental health care 20 (11)

Employee assistance program 14 (7)

Mental health professional 5 (3)

Primary care physician 5 (3)

Religious leader 2 (1)

Support group 2 (1)
C-4

Table C6. Agreement ratings for stigma and barriers to receiving mental health care items (n = 188)

Stigma item Agree

Number† (%)

Neutral 

Number† (%)

Disagree

Number† (%)

I would be seen as weak 37 (20) 30 (16) 121 (64)

Members in my unit might have less confidence 

in me 

29 (15) 38 (20) 121 (64)

It would be too embarrassing 23 (12) 41 (22) 124 (66)

My unit leadership might treat me differently 23 (12) 36 (19) 129 (69)

It would harm my career* 14 (8) 33 (18) 139 (75)

My leaders would blame me for the problem 11 (6) 24 (13) 153 (81)

Barrier item Agree

Number (%)

Neutral

Number (%)

Disagree

Number (%)

Mental health care costs too much money 26 (14) 29 (15) 133 (71)

It would be difficult to get time off work for 

treatment 

14 (7) 18 (10) 156 (83)

I do not think mental health care would be effective 13 (7) 49 (26) 126 (67)

It is difficult to schedule an appointment 9 (5) 20 (11) 159 (85)

I don’t know where to get help 7 (4) 18 (10) 163 (87)

I don’t have adequate transportation 3 (2) 7 (4) 178 (95)

*n = 186

†Percentages might not sum to 100 due to rounding.
D-1

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D-2

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D-3

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