The troubling relationship between your job and your odds of drug overdose
Drug overdose deaths in America have doubled since 2015. They've more than quintupled since 2001. As we struggle to understand the risk factors, could we be overlooking jobs?
Overdoses killed 163 of every 100,000 people who usually worked in construction and extraction in 2020, whether they were on the job or not, making it by far the most dangerous major occupation, drug-wise. Restaurant jobs were second at 118 deaths per 100,000, according to new data from Rachael Billock, Andrea Steege and Arialdi Miniño at the Centers for Disease Control and Prevention, where the National Vital Statistics System collects state and local data on every death in the country.
This is the first time the CDC has published such comprehensive and detailed numbers linking jobs and overdoses, which the authors separately wrote was made possible by "funeral directors across the country who take time to speak with decedents' loved ones and record [industry and occupation] on the death certificate." This first release lacks data from D.C. and a few states (Iowa, Rhode Island, North Carolina, Arizona), but the data gaps should close in coming years.
The results are fairly startling: 1 out of every 5 people who died of an overdose in 2020 usually worked in construction or restaurants. These folks lived in a different universe from those who worked the safest jobs in the country: Education and computer work lost 6 and 9 people per 100,000, respectively. Combined, about 1 in 100 overdose victims nationwide worked those jobs. (This data set assigns jobs based on your usual occupation - meaning the one you held the longest, regardless of what you were doing at time of death.)
The substance most likely to cause a fatal overdose - no matter your occupation - is a synthetic opioid such as fentanyl. The category that includes meth usually comes next, then cocaine and heroin. The vast majority of deaths (92 percent) were deemed accidental rather than suicide or homicide.
What other factor ties them together? We guessed education. Occupations with a higher share of workers who earned only a high school diploma (or less) are more likely to rack up drug deaths, and construction has the lowest share of workers with at least a bachelor's degree (7 percent).
That matches other data showing a wide and growing education gap in overdose deaths. In 2015, less-educated women and men were seven and eight times as likely to overdose as their peers with bachelor's degrees. By 2021, less-educated folks of both sexes were 13 times as likely to die from drugs, according to a recent preprint analysis of the same federal data for people age 25 to 64, from Jay Xu, Marissa Seamans and Joseph Friedman at the University of California at Los Angeles.
From 2015 to 2021, the fatal overdose rate rose an alarming 52 percent among U.S. men with a bachelor's degree or higher, but it jumped an appalling 151 percent for men with a high school diploma or less. For women, the increase was 13 percent among college graduates and 101 percent for those without college degrees.
That observation dumps us square in the path of an onrushing freight train of academic research. Overdoses are often considered, along with suicide and alcoholism, to be deaths of despair. And since Anne Case and Angus Deaton set the train in motion in 2015, education (and its fellow traveler, income) has long been understood to be the fulcrum upon which your odds of an early death pivot.
Our colleagues on the Health desk just released an immense investigation into America's life expectancy crisis that explored this fact. And just a few days ago, Case and Deaton presented their latest research at the Brookings Institution, showing just how wide and pervasive America's education gap has become. If you didn't go to college, you're more likely to struggle with everything from colon, liver and pancreatic cancer to low odds of marriage, more mental distress and even difficulty socializing.
All of these cataclysmic outcomes seem to be deeply entwined with social problems that have accumulated over decades - and probably would take just as long to unpack. But UCLA's Friedman mentioned something about the jobs data we just couldn't shake: Well-off Americans also do drugs. They just aren't nearly as likely to die from them.
Less-educated folks are 13 times as likely to die of an overdose, but they were only three times as likely to have misused opioids in the past month in 2021 (0.6 percent for college grads, compared with 1.7 percent for high school dropouts), according to the National Survey on Drug Use and Health.
Why are drugs so much deadlier for the less educated?
We were at a loss. But our friend Haley Hamblin had a theory. Haley - a photo editor at The Post responsible for maintaining the Department of Data's supply of hilarious vintage photos - pointed to an obvious differentiator: insurance coverage.
She's absolutely right! The share of workers in an occupation who are uninsured correlates even more strongly with its overdose death rate than education. As Haley says, folks working blue-collar jobs could be both more likely to get injured than their white-collar peers and less likely to get that injury treated by the formal health-care system. That could lead many to self-medicate.
"Occupations with the largest rates of overdoses are also generally ones that require a lot of physical mobility/strength," University of Southern California health economist Rosalie Liccardo Pacula told us via email. "Many workers in these positions develop chronic pain conditions. Chronic pain is the leading reason why people use opioids long-term, and those with long-term use are now facing greater hurdles maintaining access to their opioid prescriptions in light of changing medical recommendations . . . so they may be more likely to turn to the illegal market."
This also explains what we saw when we looked deeper at detailed overdose data for construction jobs. The construction workers most likely to die from drugs are roofers, and roofing is super dangerous. It produced the third most work-related deaths overall of any occupation from 2019 to 2021, behind fishing and hunting, and logging.
When we looked more broadly at the individual, detailed occupations in which workers are most likely to die from drugs - whether work-related or not - we saw a similar pattern. Commercial anglers and sailors are even more likely to die of an overdose than roofers by this metric, and forest and conservation workers aren't far behind.
So, though the classifications differ slightly, the three occupations that are most dangerous overall are also among the jobs most likely to overdose.
But there's more to the story. UCLA's Xu points out that the education-overdose gap widened substantially in recent years, even though these jobs are not growing many times as dangerous.
To untangle what's really happening, we called two addiction specialists at the University of North Carolina School of Medicine. They explained that the overdose crisis in the area used to follow the classic model: Worker gets hurt, receives prescription opioids, runs out, turns to heroin, ends up with fentanyl.
That still happens, said Michael Baca-Atlas, a UNC family- and addiction-medicine specialist who also saw patients at a residential detox unit in Raleigh, N.C., until UNC's contract with the facility ended Sept. 30. But those classic patients are being replaced by "younger adults - late teens, early 20s, mid-20s - who are trying fentanyl for the first time."
These patients "haven't progressed their way from pain medicine. They're not following that traditional trajectory that we saw through 2010-2015," Baca-Atlas said. "We're seeing people just straight going to a pressed pill" of fentanyl that can be crushed and ingested easily, without the complicated steps needed for intravenous drug use.
These new patients don't have the same consistent occupational profile, said Joseph Williams, a psychiatrist and addiction-medicine specialist who treated patients at the detox unit.
"I can't identify any clear pattern where they've had a job that puts them at risk of physical injury or pain," Williams said. "It's skipping those steps."
So jobs aren't the defining risk factor they once were. These new patients often hail from poor, marginalized groups and have had mental health issues since childhood or adolescence. With little contact with the official health-care system - North Carolina's belated Medicaid expansion won't take effect until December - they turn to street drugs. Fentanyl's potency and availability has thus seized the existing fissures in American society and pushed them wider.
The opioid crisis is "the wound that exposes these inequities and how hard it is to make it in America when so much of health care and jobs and opportunity - all these advantages are founded for the wealthy," said Georgetown University's Emily Mendenhall, who conducted a large review of the drivers of the opioid epidemic with student Jake Lang and Adam Koon of Johns Hopkins University's Bloomberg School of Public Health.
The huge disadvantages faced by certain populations tend to compound one another, said UCLA's Friedman. That not only explains why overdoses kill less-educated Americans at higher rates, but also why they kill Americans more often than folks in comparably wealthy countries.
Consider naloxone, the active ingredient in the nasal spray Narcan, which can reverse an overdose in almost miraculous fashion. In a recent analysis of more than 700,000 pharmacy claims, Pacula, along with Evan Peet and David Powell of the Rand Corp., found that an American with private insurance paid an average of $28 for the drug in 2014. By 2018, it averaged $35. But if that American didn't have insurance? The average out-of-pocket cost of naloxone soared from $35 in 2014 to $250 in 2018.
Today, Narcan is finally available over the counter, but it costs $44.99 for a two-dose pack - a steep price to pay for struggling humans on the wrong end of America's education divide. Given that a regular fentanyl user can overdose a half-dozen times or more each week, and each overdose can require multiple doses of naloxone, the UNC doctors told us, the Narcan bill can really add up.
And that's just the cost to put out the immediate fire - the overdose. A lack of insurance also makes it more difficult to get the kind of coordinated mental and physical health treatment needed to control an addiction long-term. And a lack of insurance, often caused by the loss of a job, is just one of many causes behind the runaway feedback loop that drives disparities in overdose deaths.
According to almost every doctor we spoke with, these deaths are driven in part by the many holes in America's ragged social safety net - and the nation's deep economic inequality.
"These are basically deaths of structural abandonment," Friedman told us. "These deaths are occurring among the groups of Americans that the system is just not taking care of."
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