This article is from\u00a0Kaiser Health News\u00a0(KHN), a national health policy news service. It is an editorially independent program of the\u00a0Henry J. Kaiser Family Foundation. PORTLAND, Oregon \u2014 Jimmy Sullivan prepared for his job as a bricklayer the same way every morning for years: injecting a shot of heroin before leaving his car. The first time he overdosed on the job, in 2013 at a Virginia construction site, a co-worker who is his cousin stealthily injected a dose of Narcan, an opioid antidote, into Sullivan\u2019s leg. He woke up and went straight back to work. The second time, in 2014, his cousin revived him again, and after resting for an hour in his car, Sullivan was back on the job. His boss told him not to let it happen again. But within a month, Sullivan had again overdosed on the job site. This time, another worker called 911. After a few hours at the hospital, he went back to work. As the opioid epidemic continues to rage across the country, with a record 72,000 drug overdose deaths estimated in 2017, the fallout is increasingly manifesting itself at construction sites, factories, warehouses, offices and other workplaces. A stunning 70 percent of employers\u00a0reported\u00a0that their businesses had been affected by prescription drug abuse, including absenteeism, positive drug tests, injuries, accidents and overdoses, according to a 2017 survey by the\u00a0National Safety Council, a research and advocacy organization. At least 217 workers died from an unintentional drug or alcohol overdose while at work in 2016, up 32 percent from 2015, according to the\u00a0Bureau of Labor Statistics. Workplace overdose deaths have been increasing by 25 percent or more a year since 2010. Those numbers don\u2019t include the many more overdoses that don\u2019t end in death, like Sullivan\u2019s, or accidents caused primarily or partly by drug impairment. Incident reports\u00a0from the Occupational Safety and Health Administration paint a grim national picture of workplace overdose deaths: a mechanic at a Fiat Chrysler Automobiles plant in Michigan, a construction worker on a barge in Rhode Island, a crawfish fisherman in Louisiana and a Sam\u2019s Club worker who died while stocking shelves in a Texas warehouse. But despite the growing problem, many employers have turned a blind eye to addiction within their workforce, ill-equipped or unwilling to confront a complicated issue they do not know how to address, according to researchers and business executives. The National Safety Council survey, which was based on interviews with 501 managers at businesses with 50 or more employees, found that fewer than 1 in 5 companies felt extremely well-prepared to combat the opioid crisis. Just 13 percent were very confident they could identify risky use. And a little more than half said they screened all employees for drugs, but 40 percent of those had failed to screen for synthetic opioids like oxycodone and fentanyl. \u201cEmployers have been asleep at the wheel,\u201d said Dave Chase, co-founder of Health Rosetta, a company that certifies employer health benefits, and author of \u201cThe Opioid Crisis Wake-Up Call.\u201d Some companies are \u201ckey, unwitting enablers,\u201d he added. It is not that businesses are unaware of the toll the crisis is taking. Large employers spent $2.6 billion on treating opioid abuse and overdoses in 2016, up from $300 million 12 years earlier, according to the\u00a0Peterson-Kaiser Health System Tracker. Those numbers do not include the cost of lost productivity. Workers who misuse pain medication miss an average of\u00a029 days a year, compared with 10\u00bd days for other employees. Yet, many managers are unwilling to acknowledge drug use at their businesses. \u201cIf you ask them if they believe they have an opioid problem within their population, a very high percentage of them would say, \u2018No, we don\u2019t,\u2019\u201d said Pat Sullivan, executive vice president of employee benefits at Hylant, a large insurance broker in Indiana that manages benefit plans for more than 19,000 businesses. \u201cAnd yet we have access to prescription reports that are absolutely telling me there\u2019s abuse happening\u201d among their workers. Pain comes with the job Jimmy Sullivan, now 39, is slender and serious. He wears a heavy silver cross around his neck and has a half-finished tattoo of two barracudas, teeth gnashing, on his arm. A bricklayer for more than two decades, he is proud of his skills. \u201cI love my job. All over the city I drive around and say, \u2018Hey, I built that,\u2019\u201d he said over lunch in Portland, where he grew up and now lives. \u201cIt\u2019s really tough work and not too many people can do it.\u201d The construction industry has the\u00a0second-highest rate\u00a0of pain medication and opioid misuse after the entertainment, recreation and food business. About 1.3 percent of construction workers are thought to be addicted to opioids, or nearly twice the addiction rate for all working adults, according to data from the 2012-14 National Survey on Drug Use and Health. Construction workers had the highest proportion of heroin- and methadone-related overdose deaths from 2007 to 2012, according to the\u00a0Centers for Disease Control and Prevention. In Massachusetts,\u00a0a recent report\u00a0found that 1 in 4 opioid deaths involved construction workers. On-the-job injuries are common in that industry, and many workers begin their addiction with a prescription intended to help get them back to work. In 2016,\u00a0two in five workers\u2019 compensation\u00a0claims for prescriptions included an opioid. Laborers tend to come and go on job sites, meaning employers often don\u2019t know much about their workers. Sullivan said he worked nonstop as a bricklayer in Portland during the 2000s, despite a serious drug habit \u2014 in those days, crystal meth. By 2011, he was a father of three girls and often so strung out that he didn\u2019t recognize himself. Alarmed by his descent, he moved across the country to Newport News, Virginia, where he would be far from his dealers and drug-using friends. Though he readily found a job in Virginia, he also quickly got hooked \u2014 this time to opioids. That part of the country was awash in cheap heroin, which he augmented with Dilaudid, a semi-synthetic opioid prescribed by a doctor for back pain. He\u2019s certain that several of his employers knew he was using, but they seemed not to care as long as he didn\u2019t get caught. \u201cI was so productive that a lot of crews just swept it under the rug,\u201d he said. His employers did not respond to requests for comment. At times he contemplated going into rehab at the suggestion of his family, but he did not seek treatment. Employer intervention Sullivan said no employer asked him to take a drug test, even though he had a criminal history that included arrests for drug possession and distribution in Portland. It was an open secret on job sites that many workers were using drugs, he said. They were the ones who disappeared for long lunches, isolated themselves and occasionally nodded off. \u201cIf you drug-tested everyone, you wouldn\u2019t find many people to work with you,\u201d Sullivan said. In theory, employers are in a unique position to confront opioid misuse, through random testing and spotting erratic behavior or absenteeism, said Chase, the author of \u201cThe Opioid Crisis Wake-Up Call.\u201d They could change their health insurance policies to limit opioid prescriptions to five days and waive deductibles for addiction treatment \u2014 an option that is often not available to construction firms because they typically do not provide health insurance. But many employers have been slow to act. On-the-job injuries are common in construction, and many workers begin their addiction with a prescription intended to help get them back to work. The Nord Family Foundation, a charity in northern Ohio, hosted an event in May in Elyria, near Cleveland, that was designed to teach employers how to identify and treat employees with substance use problems. Dr. Donald\u00a0Sheldon, a trustee at the foundation and a former hospital president, advertised in local newspapers and reserved a room at the local community college that would seat 200. Just 30 people showed up, he said. Of the 10 companies whose employees\u2019 suspected opioid overdose deaths were detailed in OSHA reports since 2014, most did not respond or refused to address specific incidents. Sam\u2019s Club, a division of Walmart, said in a statement that it provided mental health and substance abuse coverage to employees and offered an employee assistance program. Fiat Chrysler said in an email that it had adopted more stringent opioid prescribing guidelines in its health plan and supported the use of medication-assisted addiction treatment. Just one employer, Giovanna Painting in Spencerport, N.Y., agreed to an interview. Alan Hart, the company\u2019s president, said he was shocked when one of his employees was discovered dead from a heroin overdose in a port-a-potty on a job site in 2017. A recovered addict himself, Hart said he tries to be sympathetic and help workers get into rehab, though he does not provide health insurance. \u201cWe\u2019re much, much stricter now,\u201d since the 2017 overdose death, he said. \u201cWe\u2019re doing a lot more drug testing. I\u2019m on the sites a great deal more. I\u2019m walking and talking, and I pull the guys aside and look in their eyes.\u201d This summer, Hart fired 12 of his 50 employees for suspected drug abuse. It pained him to do it, he said, and it was difficult to lose so many workers in his busiest season. But he said the risk of keeping someone on who was using drugs was too high. The Association of Union Constructors recently devoted the\u00a0spring issue of its magazine\u00a0to the opioid epidemic. The group says an increasing number of union contractors provide naloxone, the opioid antidote, on job sites. Clusters of tents line the streets of downtown Portland. A lifesaving union benefit After his third overdose on the job for the same contractor in Virginia, Sullivan was fired. In 2015, he returned to Portland, which was in the throes of its own heroin crisis. Amid clusters of homeless encampments that dot downtown Portland, users can be spotted leaning against buildings, heads nodding back, needles in arms. Back in his hometown, enticed by union retirement benefits, Sullivan joined the Bricklayers and Allied Craftworkers Local 1, Oregon, in 2016, which turned out to be a turning point for him. Shortly after he joined the union, Sullivan was laid off for erratic behavior and his local learned he was abusing drugs. But unlike his previous employers, the union had a plan to get him back to work. Having seen many of its members struggle with addiction, officials at the International Union of Bricklayers and Allied Craftworkers had over several years come up with a suite of programs to prevent substance abuse, to identify affected workers and to steer them into treatment. This year, labor leaders at the North America\u2019s Building Trade Unions (NABTU), a coalition of 14 unions in the building trades, set up a task force to address the opioid crisis. \u201cWe\u2019re all facing almost the same identical problem,\u201d said Karen Grear, who runs the member assistance program for the bricklayers union. At a recent presentation to local union chiefs, Grear asked whether anyone had lost a member to opioids. Three-quarters of the participants raised their hands. One reported that five apprentices had died in the past few months. In Portland, Matthew Eleazer, the president of Sullivan\u2019s local, said at least 10 of his approximately 650 members had recently struggled with opioid use disorders, some with lethal outcomes. One was a single father prescribed opioids for a back injury who accidentally took too many pills. Another was a promising young apprentice found by the side of the road with a needle in his arm on his way to a wedding. Eleazer said the union tests all members when they join and randomly after that; he often gets reports from employers when a member doesn\u2019t show up for work or is repeatedly tardy. At a time of labor shortage, he said, contractors have mostly adopted a don\u2019t-ask-don\u2019t-tell attitude. \u201cThey just want guys to put material on the walls,\u201d Eleazer said. \u201cThey just want the building to go up.\u201d The union told Sullivan he could return to work if he went into rehab, but there was a problem: He had an arrest warrant out for violating parole from a prior arrest, and the treatment centers would not accept him until he served his jail term. Sullivan was unwilling to go to jail and disappeared. Union officials tracked him down and called the police to arrest him when he was passed out in his car. The union persuaded a parole officer who helped convince a judge to let him serve his time at a drug treatment facility instead of jail, and union representatives called him several times a week. As promised, they found him a job when he was released in 2017, but this year he was laid off at the end of a construction project and relapsed again. Weeks later, Sullivan called to say he was living in his two-door Honda, claiming to have been clean for a couple of weeks. \u201cDo you remember what I told you to do when you were in that situation? That I was your first phone call?\u201d Mike Titus, a union official, said to him when they met up at a bar. \u201cCould you pass a drug test right now?\u201d If so, the union had a job for him and he could shower at the union hall, until he arranged for a home. \u201cMatt and Mike were the first ones who cared enough,\u201d said Sullivan. \u201cNone of my employers gave a shit enough to even ask.\u201d A month later, Sullivan was back to work on a union job, living in a new home and sober once again.