It’s been more than a year since Iyisha Keller was found unconscious in a bathroom at the University of Texas Southwestern Medical Center’s Clements hospital in Dallas, a syringe labeled fentanyl in her arm.
Keller, 36, had been working in the neonatal intensive care unit. She was pronounced dead in the emergency room.
Denise Keller learned her daughter had bought the synthetic opioid a few times for an ex-boyfriend. Still, she couldn’t understand why her daughter had used it herself. Iyisha had dreamed of becoming a nurse from a young age.
The Dallas Morning News reported in September that while Southwestern initially said it had found no evidence that Keller’s death was related to hospital drugs, new evidence shows that the drugs may have, in fact, come from a patient. Southwestern had failed dozens of times from 2016-2018 to notify the Drug Enforcement Administration when drugs were lost or stolen, the newspaper said.
Keller’s death is part of a larger trend among health care workers falling victim to opioids, according to a 2018 study by the Centers for Disease Control. Health care practitioners have the third-highest rate of prescription opioid-related overdoses among 26 occupational groups, even when accounting for medications such as oxycodone and methadone.
Experts say the growing number of overdoses stems from intense physical on-the-job demands. The highest overdose rates are among construction workers and those in mining and oil and gas extraction.
The study, which analyzed more than 50,000 drug overdose deaths, examined the opioid crisis’ effect across 21 states. It compared overdoses from all opioid types and defined health care practitioners and technical occupations as including chiropractors, optometrists, pharmacists, dentists and registered nurses such as Keller.
Dr. Laurel Harduar Morano, the study’s lead author, said earlier studies had indicated that people in health care roles could be injured on the job, sometimes from lifting patients. Often, “these individuals end up working through the pain,” Harduar Morano said. Many substance-abuse addictions begin with prescription opioids used to treat such chronic discomfort.
Between 2012 and 2014, nurses and nurse assistants had the highest injury rates of all occupations examined.
A 2015 study by CDC’s National Institute for Occupational Safety and Health and the Occupational Health Safety Network found that one in five nonfatal occupational injuries reported in 2013 were among workers in the health care and social-assistance industries. Between 2012 and 2014, the study found, nurses and nurse assistants had the highest injury rates of all occupations examined.
Harduar Morano’s study didn’t look at specific on-the job-injuries and the correlation between injury and overdose. But according to another CDC report published earlier this year, the nation’s opioid epidemic was responsible for an estimated 68% of the 72,000 overdose deaths in 2017
In recent years, many hospitals and health care systems have implemented measures to combat the large number of on-the-job injuries that could lead to opioid use among their own employees.
The Washington Health System is one of the hospitals trying to reduce injuries by utilizing patient-lifting equipment at diagnostic centers and off-site locations, said Barbara McCullough, vice president of human resources.
The organization in Washington, Pennsylvania, also installed automated medication dispensing systems to circumvent the theft of narcotics by providing “a complete circle of accountability.” The system provides records filed from the initial receipt of the controlled-substance distribution request through documentation of the return to the pharmacy or waste, McCullough said.
While adding an automated medication dispensing system hasn’t completely eliminated misuse in the workplace, McCullough said, the inclusion of these technologies has “drastically reduced the ease of diversion” during the multiple stages of distributing medication.
Under the Washington Health System employee-assistance program, workers can refer themselves to a treatment program and managers can make mandatory referrals if they notice an increase in behaviors such as absenteeism, McCullough said.
Such changes and services are beneficial, but aren’t enough to halt the likeliness of addiction among health care employees, given the stressful workplace environment and physical demands most face, said Madeline Naegle, a professor emerita at the New York University College of Nursing.
Naegle, an expert in mental health and substance abuse, said measures already in place don’t deal with workplace culture among health care workers where stress and working long hours can make employees vulnerable.
“It’s the culture of the workplace that predisposes people to both stress strains and misusing prescriptions,” she said.
Continued education that highlights risk factors, including the ease of availability and accessibility of opioid analgesics, are especially important, Naegle said.
Working with pain isn’t new, said Jodi Sugerman-Brozan, executive director at the Massachusetts Coalition for Occupational Safety and Health. But while health care workers “used to take ibuprofen, now they’re using opioids.”
Sugerman-Brozan worked with health care practitioners across the state to understand workplace injury.
The marketing of opioids for chronic pain management moved health care workers toward a more dangerous, addictive drug, often unknowingly, Sugerman-Brozan said. Employees may not prefer opioids to ibuprofen, she said, but rather, the change is a result of how the drugs were marketed and prescribed.
Purdue and Johnson & Johnson are two of the major opioid manufacturers facing lawsuits filed around the nation by people who allege that companies used misleading advertising in the 1990s that encouraged doctors to prescribe the medication and patients to think the drugs were safe to use.
For Sugerman-Brozan, the shift underscores the health care industry’s heightened call for stricter workplace safety regulations to prevent problems before they occur.
“So much money and resources are going into helping people who are already addicted, but we need to look upstream, we need to see what’s causing this use,” she said. “If those who are working to stem the opioid epidemic are not also working to reduce workplace injury, they’re missing an entire strategy.”
Iyisha Keller would have been 38 this year and her mother said she’s planning to celebrate the day just as Iyisha would. She might go to Miami, a place she and her daughter had visited many times.
Officials at UT Southwestern told The Dallas Morning News that while they did not disclose cases to the DEA that involved errors in documenting drug usage, they did adhere to application regulations. Officials said they now follow “a more stringent interpretation” of federal law and that they’ve taken steps to better track the powerful drugs they give patients.