When it's time to pour the concrete, a construction worker may suffer through a back strain and use prescribed painkillers to stay on the job. Same for an injured deckhand heading to Georges Bank to haul in nets filled with fish.
A path from injury to medication, and then to addiction and death, may explain why workers in these jobs — men in particular — have had in recent years fatal opioid overdoses far more often in Massachusetts than do workers as a whole.
Among fishermen, the death rate is more than five times higher. In construction and mining, workers die at a sixfold higher rate.
Those figures are in a report out Wednesday from the Massachusetts Department of Public Health (DPH). The authors say it's among the first in the United States to break down overdose deaths by industry and illustrate how risk varies from one job to the next.
Workers in the building trades and mining made up 24 percent of all opioid overdose deaths among Massachusetts workers between 2011 and 2015.
Farming, forestry and hunting, along with fishing, is the second most dangerous industry sector for men. For women, the report highlights the relatively high overdose death rates within health care support work and food services.
The report cites state and federal sources that show construction workers have higher rates of injury than most other occupations. Back pain appears to be the most common chronic ailment, at least among among older laborers.
The report does not make a direct link between occupational injuries and overdose deaths. It's possible, say the authors, that opioid use caused an on-the-job injury in some cases. But injuries certainly contribute to the overdose problem.
"Work-related injuries often serve as the initiation for opioid pain medication, which can subsequently lead to opioid misuse," state Public Health Commissioner Dr. Monica Bharel said in a statement. "Ensuring that jobs are safe, that the risk of injury is low and that workers have the time for rehabilitation and are not self-medicating to keep working are all key to decreasing opioid overdose death among workers."
Many of the jobs held by men and women who died after an overdose do not pay well; most of the workers who earned $40,000 to $49,000 in the chart below were in construction, according the DPH. Many workers were in temporary or contract jobs, and few included paid sick time.
Groups representing workers with dramatic overdose death rates say the report illustrates a troubling divide when it comes to employment benefits.
"There's a great need for society to take a look at the difference between the benefits received by workers who report to large corporations and independent workers," said J.J. Barlett, president of Fishing Partnership Support Services, which is based in Burlington. "It's very difficult for workers who have job insecurity and don't have benefit packages to get through illnesses."
Working at sea poses some unique risks for anyone addicted to opioids.
"Ambulances don't go where fishermen fish," Bartlett said, "and it's only recently that the Coast Guard has been allowed to carry Narcan, which reverses opioid overdoses."
For construction workers and fisherman who are in recovery, it can be particularly hard to stick to medication-assisted treatment.
Patients on methadone typically have to pick up their dose daily at a clinic. Those on buprenorphine may get a week's supply and be asked for random urine samples — which are common in union construction jobs — and may trigger a positive drug test and an employer alert. With all forms of MAT, patients are urged to attend counseling which, again, can be difficult with the hours required for construction work and time at sea.
Bartlett says the fishing partnership has stepped up efforts to prevent injuries with ergonomic training, teaching members to stretch well before starting work and trying to help fishermen keep up with routine medical care.
The report mentions several other efforts underway to reduce opioid use among blue collar workers. The state Department of Industrial Accidents is in the midst of a pilot program, the Opioid Alternative Treatment Pathway, and DPH is working with several community organizations on ways to prevent opioid misuse among high-risk workers.
Opioid prescribing rates for those hurt on the job may still be a problem.
The amount of opioids prescribed to injured workers dropped 24 percent in Massachusetts from 2013 to 2015, the most recent time period available. But the report found Massachusetts still had the fifth-highest amount of opioids for each worker, among 26 states DPH analyzed.