Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

THE DRUG TOXICITY CRISIS AND

ITS IMPACT ON FRONTLINE
HEALTH WORKERS
Jennifer Jackson

Ripple Effects: The Drug Toxicity Crisis and its Impact on Frontline Health Workers 1
Par k l an d I n s t i t ut e • Oc t ob er 2 0 2 5

THE DRUG TOXICITY CRISIS AND ITS IMPACT

ON FRONTLINE HEALTH WORKERS
Jennifer Jackson, PhD. RN
This report was published by Parkland Institute.
November 2025 © All rights reserved.

Acknowledgements��������������������������������������������������������������������������������������������������������������������iii
About the Authors�����������������������������������������������������������������������������������������������������������������������iii
About Parkland Institute�����������������������������������������������������������������������������������������������������������iii

Glossary��������������������������������������������������������������������������������������������������������������������1
Executive Summary�������������������������������������������������������������������������������������������������3
Recommendations ������������������������������������������������������������������������������������������������������������ 5
Photo credit on cover: HSAA Background��������������������������������������������������������������������������������������������������������������7

All Parkland Institute reports

Status of the Drug Poisoning Crisis in Alberta����������������������������������������������������������� 7
are available free of charge at Current Policy Landscape in Alberta����������������������������������������������������������������������������� 7
[Link].
Practice Implications for Alberta������������������������������������������������������������������������������������ 8
Your financial support helps us continue What We Already Know About Drug Poisonings and Their Impact on Health
to offer our publications free online. To Care Professionals from Other Areas���������������������������������������������������������������������9
find out how you can support Parkland
Institute, please visit ParklandInstitute. Included Literature������������������������������������������������������������������������������������������������������������� 9
ca/donate. Literature Review��������������������������������������������������������������������������������������������������������������� 9

To obtain rights to copy this report, Remaining Gaps in Knowledge������������������������������������������������������������������������������������ 10

please contact us: Research Questions�����������������������������������������������������������������������������������������������11
Parkland Institute Research Methods���������������������������������������������������������������������������������������������������������� 11
4-50 Arts and Convocation Hall
University of Alberta Results - Participants��������������������������������������������������������������������������������������������13
Edmonton, AB T6G 2E6 Results - Outcomes for HSAA Members��������������������������������������������������������������17

Phone: 780.492.8558 The Experiences of Health Care Professionals in the Drug Poisoning Crisis in
Email: parkland@[Link] Alberta are Influenced by Their Context������������������������������������������������������������������� 17
[Link].
Health Care Professionals Lack Knowledge About Responding to Drug
Poisonings��������������������������������������������������������������������������������������������������������������21
ISBN: 978-1-997612-00-1 Health Care Professionals are Facing Substantial Workplace Violence�������������� 23

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers I
Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

Health Care Professionals Face Consequences of Working During the Drug

Poisoning Crisis������������������������������������������������������������������������������������������������������25
There are Options to Make Things Better������������������������������������������������������������27
Local Strategies and Ability to Innovate������������������������������������������������������������������� 27
Comprehensive Benefits����������������������������������������������������������������������������������������������� 28
Manager Skills and Support are Critical�������������������������������������������������������������������� 28
Flexibility Helps People Stay���������������������������������������������������������������������������������������� 29
Informal Support and Grief Counselling�������������������������������������������������������������������� 30
Discussion��������������������������������������������������������������������������������������������������������������32
References��������������������������������������������������������������������������������������������������������������33
Appendix A: Data Extraction Table������������������������������������������������������������������������39
Appendix B: Survey Instruments��������������������������������������������������������������������������53
Appendix C: Interview Guide���������������������������������������������������������������������������������56

List of Tables
Table 1 Survey participant demographic and work characteristics (n=454)���������� 13
Table 2 Professional groupings for HSAA registered designations who
participated in the survey������������������������������������������������������������������������������������������������������ 15
Table 3 Demographic characteristics of interview participants��������������������������������� 16
Table 4 Summary of Scores by Profession for the Opioid Overdose Knowledge
Scale (OOKS) and Opioid Overdose Attitudes Scale (OOAS)���������������������������������������� 21
Table 5 The WVS frequencies by each category and frequency of incidents in the
past year������������������������������������������������������������������������������������������������������������������������������������ 23
Table 6 Summary of Scores by Profession for the ProQOL����������������������������������������� 25

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers II
Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

ACKNOWLEDGEMENTS
This report was created through the work of many people. Lindsay Whalen, an
Advanced Care Paramedic and doctoral scholar, conducted the statistical analysis
for the study. Nursing student Eron Muel conducted the literature searches,
with Jasjot Ghatore, as undergraduate research assistant. Samantha Perry, Peer
Support Worker and peer researcher, conducted interviews and provided lived-
experience consultation throughout the project. Undergraduate students Jinny
Choi, Shanique Sidhu, and Melody Choo all provided research assistant support.
Caitlin Stokvis, a social worker and a doctoral scholar, consulted on the policies
included in our analysis. Dr. Carla Ginn, RN, PhD, contributed her methodological
and subject matter expertise, as did numerous colleagues in Community Health
Sciences at the University of Calgary.

ABOUT THE AUTHOR

Dr. Jennifer Jackson, PhD, is a Registered Nurse and an Associate Professor in
the Faculty of Nursing at the University of Calgary. She has a joint appointment
in the Department of Community Health Sciences, Cumming School of Medicine,
University of Calgary. Dr. Jackson’s research focuses on supporting health care
workers in complex systems, primarily in community-based addiction treatment
services. Dr. Jackson has conducted research with supervised consumption site
professionals, outreach workers, municipal workers, and policy makers to support
better health care services for all Albertans. She was named Top 40 Under 40 by
Avenue Magazine in 2024.

ABOUT PARKLAND INSTITUTE

Parkland Institute is an Alberta research network that examines public policy
issues. Based in the Faculty of Arts at the University of Alberta, it includes
members from most of Alberta’s academic institutions as well as other
organizations involved in public policy research. Parkland Institute was founded in
1996 and its mandate is to:

• conduct research on economic, social, cultural and political issues facing

Albertans and Canadians
• publish research and provide informed comment on current policy issues
to the media and the public
• sponsor conferences and public forums on issues facing Albertans
• bring together academic and non-academic communities

All Parkland Institute reports are academically peer reviewed to ensure the
integrity and accuracy of the research.

For more information, visit [Link]

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers III
Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

GLOSSARY
T he language that is used around the drug poisoning crisis is fraught. While
we want to avoid stigmatizing language, we also do not want to get bogged
down in discussions about wording that produces a distinction, not a difference.
In our survey, there was debate about the wording we used, and participants
had contradictory sentiments. For example, some people wrote in our survey
that “drug poisoning” was the most accurate term, while others preferred
the term “overdose”. We recognize that any choice we make will not satisfy
everyone. However, we have worked with people with lived experience of drug
use as paid peer researchers in our research team and proceeded with our best
intentions. Where a participant has used a different word in their interview (such
as “overdose” instead of “drug poisoning”), we have retained the participant’s
wording in their quotes.

We have chosen to use the following:

• Clients: anyone with addictions and/or mental health issues that has been
affected by the drug poisoning crisis and accessed services provided by the
health care professionals who participated in this study.
• Drug(s): any substance that is either illegal and consumed illicitly, or legal
but consumed recreationally, outside of medical supervision, or for an off-
label purpose, rather than its prescribed purpose and/or dose. Drugs may
not consist of what a client expected (contained additives), as a result of
the toxic drug supply.
• Drug poisoning: includes any adverse reaction to consuming a drug,
synonymous with overdose, opioid overdose, drug reaction.
• Drug poisoning crisis: The rise in addiction and mental health crises that
began in the 2010s and continues as an ongoing public health emergency,
causing significant harm and mortality. This term covers overdose crisis
and toxic drug crisis.
• Homeless(ness): When someone does not have a consistent, safe place
to live. We do not assume a person who is homeless lacks community
or a geographically bound routine. This term includes houseless(ness),
unhoused, precariously housed, couch surfing, and people who use
shelters or temporary housing.
• Participants: Health Sciences Association of Alberta (HSAA) members, who
are health care professionals, who consented to participate in our research
study. In our study, these professionals were:

o Paramedic (Advanced/Primary)
o Emergency Communications
o Psychologist
o Mental Health Therapist

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 1
Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

o Addiction/Family Counselors
o Clinical Behavioural Specialist
o Social Worker
o Psychometrist
o Psychiatric Registered Nurse**
o Registered Nurse Mental Health Therapist**
o Cardiology Technologist
o Laboratory Technologist/Assistant
o Combined Laboratory X-Ray Technologist
o Medical Radiation Technologist
o Electroencephalogram Technologist
o Electroneurophysiology Technologist
o Computed Tomography Technologist
o Medical Laboratory Technologist /Assistant
o Medical Photographer
o Respiratory Therapist
o Dietitian
o Sonographer
o Tissue Specialist
o Pharmacist
o Pharmacy technologist
o Registered Nurse/Licenced Practical Nurse**
o Occupational therapist (OT)/Assistant
o Physiotherapist (PT)
o Recreation Therapists
o Speech-Language Pathologists (SLP)/Assistant
o Rehabilitation Practitioner
o Therapy Assistant

** Some nurses were included in this study, based on their workplace affiliation
with HSAA. Most nurses in Alberta are members of the United Nurses of Alberta.

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 2
Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

EXECUTIVE SUMMARY
D rug poisoning deaths in Alberta have reached record numbers, with the
province seeing 10,185 drug-related fatalities since 2016. While the
incidents of opioid-related deaths or medical emergencies have increased, the
resources and staff required to help the situation have not. Among those most
affected have been Alberta’s frontline health care workers, especially those
While the incidents of dealing with emergency situations.

opioid-related deaths The effects of this crisis reach beyond opioid-related deaths and affects all
or medical emergencies Albertans through increased wait times in emergency rooms, violence, loss of
loved ones, and a health care system losing vital workers due to burnout, stress,
have increased, the
and a lack of support from management and the government.
resources and staff
required to help the The provincial government’s response to this crisis has been to emphasize
abstinence-based and inpatient therapies to the exclusion of harm reduction and
situation have not. community services. Opposition by the community and health care workers to
this narrow approach has been significant but ignored by the government. The
resulting effect on health care workers and those at risk of harm via the poison
drug supply has been monumental. Providing Alberta’s health care workers with
fewer tools cannot result in a better outcome.

This study gauges how the drug poisoning crisis is impacting frontline health care
workers, their personal wellbeing, and their ability to provide care.

Previous studies have explored the experiences of doctors and nurses dealing
with the opioid drug crisis, but there has been limited research into the
experiences of other health care professionals. Our study focuses on Alberta
health care workers who are part of the Health Sciences Association of Alberta
(HSAA). In this study we asked the following questions:
• What has been the personal impact of the drug poisoning crisis for health
care professionals in Alberta in HSAA?
• How has the workload and nature of work changed for HSAA members
because of the drug poisoning crisis?
• What workplace supports do HSAA members need to continue working
during the drug poisoning crisis?

The impact on HSAA workers varied, with those working at street level
(paramedics, emergency department, in-patient, and specialty department
staff) being the most affected by the poison drug crisis. Our results show that
participants reported lower levels of knowledge and confidence to intervene
during a drug poisoning crisis, despite the high frequency of drug poisonings they
encounter in their daily work. Many health care professionals lack equipment and
treatment options to support clients. Participants in our study are expected to do
more with less as they face rationing of staff, equipment, space, and resources

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 3
Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

in order to reduce costs. Health care professionals also faced workplace violence,
which they felt was not taken seriously by their managers.

Respondents reported burnout, staff retention issues, and secondary traumatic

stress. Burnout was a notable problem among this study’s participants, especially
among emergency professionals. Exhaustion impacts the day-to-day experiences
of frontline health workers. Unaddressed professional quality of life issues can
lead to people leaving their jobs altogether, leading to increased strain on the
health care workers who stay. These factors all have the potential to affect all
Albertans needing health care.

The Covid-19 pandemic and policies around its management have had a profound
impact on the drug crisis in Alberta. One health care worker notes, “I would say
Covid has magnified it (the drug crisis) astronomically…the stresses of Covid
produced a lot of financial stress and depression, emotional anxiety. And I think
people turn to drugs to deal with a lot of that. And sadly, I think that’s when we
Effective services that saw a huge spike in a lot of cases.”

were closed during the Participants also pointed out that societal issues are also exacerbating the
Covid-19 crisis have not drug crisis and could be reduced by effective governmental intervention. One
been restored. Health participant said, “We have to try and house people.” The lack of housing is a
barrier for many people in accessing evidence-based addiction treatments in their
care workers interviewed communities.
report not being allowed
Participants don’t feel that the provincial government listens to or addresses
to provide clients with their concerns. Study participants are clear that governmental policies have
clean needles or other worsened the drug poisoning crisis. Effective services that were closed during the
supplies that would Covid-19 crisis have not been restored. Health care workers interviewed report
not being allowed to provide clients with clean needles or other supplies that
greatly improve a client’s
would greatly improve a client’s ability to mitigate harmful outcomes.
ability to mitigate
Adherence to a singular approach in terms of the drug toxicity crisis is exacting
harmful outcomes.
a toll in terms of both frontline heath care workers’ quality of life and loss of
life when it comes to those directly affected by the poison drug supply. HSAA
members face an uphill battle when there isn’t trust in the systems that are
supposed to support them.

If Alberta is to deal with this crisis effectively, health care workers need to have
the proper support and tools. Education, training, governmental and managerial
support, and policy based on the best available evidence are imperative,
especially in rural areas.

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 4
Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

Recommendations
Based on the results of this study, we recommend the following action items:

The Government of Alberta and Alberta Health/Recovery Alberta

• Address the drug poisoning crisis through evidence-based policies.
• Address system resource deficits in the Alberta health care and provide
additional funds for improved staffing.
• Offer comprehensive counselling, mental health, and pharmacare
programs to all Albertans to mitigate severe mental health difficulties.
• Support for harm reduction services. Supervised and safe consumption
sites (including smoking as well as injection and oral consumption) and
overdose prevention sites will reduce the volume of clients needing
emergency health care services, reduce emergency wait times, and
potentially decrease the risk of workplace violence faced by frontline
health care workers. This support could potentially also reduce the number
of fatalities among drug users.
• Provide comprehensive resources to people who use drugs: housing,
treatment options that aren’t exclusively abstinence-based, income
support, and access to mental health and addiction services.

Alberta Health Services

• Offer more flexibility in scheduling and work roles without a reduction in
benefits, pay, or pension.
• Offer more training, education, and resources for clinical managers to
ensure health care workers have support and strong leadership.
• Provide paid education and training regarding drug poisoning, harm
reduction, trauma-informed care, and addiction treatment to all heath care
professionals.
• Offer greater funding for counselling and mental health support for health
care workers, recognizing the need for external services.
• Create 24/7 accessible debriefing and crisis counselling systems for all
health care workers.
• Introduce Connect Care in emergency medical services.
• Empower health care professionals to make changes to their health care
services to address issues specific to their local area, especially in rural
areas.
• Reduce workplace violence by creating health care services that are
designed to meet clients’ needs in a supportive environment.

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 5
Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

The Public

Albertans can call on elected representatives and policy makers to implement

evidence-based, adequately resourced health care services that are
compassionate and effective, by:

• Writing MLAs and cabinet ministers to increase funding for health

care professionals and expand access to safe consumption/overdose
prevention sites.
• Challenging legislation and governmental policies that go against available
evidence and which demonstrate potential to cause harm.
• Challenging societal stigma about addiction and mental health issues.
Reducing the stigma faced by people who use drugs may result in
more compassionate and effective care and reduce moral injury to care
providers.
• Support job action by health care professionals.

• Bringing the issues illustrated in this report to the ballot box.

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 6
Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

BACKGROUND
T here have been unprecedented drug poisoning deaths in Alberta1, and
Canada2 since 2020. There has been a change in the work of health care
professionals across Canada to try and respond to the crisis, with increased
pressure on our health care systems1,2. The following sections provide context
for this report, outlining the consequences of drug poisonings in the policy
landscape in Alberta.

Status of the Drug Poisoning Crisis in Alberta

The drug poisoning crisis has had widespread impact across Canada, with 20
people dying per day in 20242. There have also been major impacts on Canadian
health care systems, with 67 emergency department and 99 emergency medical
responses per day2. In Alberta, there have been 10,185 recorded deaths since
20162. There has been a downward trend in drug poisoning deaths in Alberta in
In Alberta, there have 2024; however, this trend is seen across North America3 and annual death rates
been 10,185 recorded in 2024 remain higher than 2016-20191.

deaths since 2016. It is challenging to determine what drugs are being consumed in Alberta, as
there are widespread variations in substances and additives in the context of
an unregulated drug market. In Alberta in 2024, there were 1,053 confirmed
drug poisoning deaths, with 94% involving fentanyl and 65% involving
methamphetamine1. There were some variations across the province, but
in each region, fentanyl was involved in >90% of drug poisoning deaths, and
methamphetamine from 56-75% of deaths1. While other substances, like
cocaine, were identified, the vast majority of deaths in Alberta in 2024 were
associated fentanyl and methamphetamine, in both the general population1 and
These policies are among Indigenous populations4.

authored to paint drug

use as harmful for
Current Policy Landscape in Alberta
people and communities
The Government of Alberta, through both Alberta Health and Addiction and
and that the government Mental Health ministries, have advocated a policy of recovery, “including an
should respond to individual’s consistent pursuit of abstinence”5. The guiding documents for these
addiction with carceral policies include an impact assessment of supervised consumption services6, the
Alberta recovery model5, Compassionate Care legislation7, and other interim
practices, like involuntary reports (see [Link] These
admittance to inpatient policies are authored to paint drug use as harmful for people5 and communities6
treatment. and that the government should respond to addiction with carceral practices, like
involuntary admittance to inpatient treatment7. While these policy documents
state that the government recognizes that “services to reduce harm are
important in the overall continuum of care”5, there have been repeated attempts

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 7
Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

to close harm reduction services across Alberta8,9. The Government of Alberta

has attributed a decrease in drug poisoning deaths to their recovery policies10,
despite the fact that this trend has been observed across North America, in a
variety of policy environments3. Overall, the recovery policy approach decreases
the treatment options available to Albertans by prioritizing inpatient treatment
as the main addiction treatment option. In turn, there are increased pressures
on and limits to access for harm reduction services, which do not fit the recovery
policy approach. Inpatient treatment is also the most costly and resource-
intensive means of providing addiction health care, with community-based
options like supervised consumption sites being substantially cheaper11.

Practice Implications for Alberta

The policies in Alberta relating to drug poisonings have communicated a clear
vision for the future of addiction treatment in the province5. However, this vision
has not resulted in changes in the frequency of emergency department visits and
hospitalizations relating to substance use in Alberta1. There are data available
about the impacts of this crisis for Albertans who experience drug poisoning1,4,
but there is little known about the consequences of this crisis for health care
workers in Alberta. In this report, we present research where we investigated the
impact of the drug poisoning crisis for health care professionals in Alberta.

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 8
Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

What We Already Know

About Drug Poisonings and
Their Impact on Health
Care Professionals from
Other Areas
W e began our study with a literature review on the personal and workplace
outcomes of the drug poisoning crisis for health care professionals. While
we focused on the professions included in the HSAA (see Glossary), we also
considered research with nurses, physicians, and other professions that would
work in proximity to HSAA members. We conducted a comprehensive search of
five databases: APA PsycInfo, CINAHL Plus with Full Text, MEDLINE (R) ALL, Ovid
Healthstar, and Web of Science, from 1995-2025. A detailed accounting of our
search strategy and inclusion/exclusion criteria are available upon request.

Included Literature
We retrieved a total of 35 articles for our literature review. These health care
providers included in these studies were clinical care coordinators (n=1),
counsellors (n=5), nurses (n=7), paramedics (n=8), pharmacists (n=4), pharmacy
technicians (n=2), physical therapists (n=1), physicians (n=13), physician
assistants (n=2), social workers (n=2), and speech-language pathologists (n=1).
Most studies were from the U.S. (n=30), with a small number from Australia
(n=1), Canada (n=3), and France (n=1). A table presenting our data extraction from
these studies is available as Appendix A.

Literature Review
There was a consensus among these authors that the drug poisoning crisis has
gotten worse over time. These authors reported that health care professionals
were broadly and negatively impacted by the drug poisoning crisis. Clinical care
coordinators, counselors, nurses, paramedics, physicians, and social workers
reported an increase in clients who had experienced drug poisonings or sought
addiction health care as a result of the crisis12–17. Health care professionals
also experienced challenges with the increased complexity and time needed
to care for each client with addictions18–26. These authors have all indicated
that increases in workload were common among many of the health care
professionals.

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 9
Par k lan d I n s t i t ut e • Novemb er 2 0 2 5

Maintaining staffing during the drug poisoning crisis was a consistent issue.
Health care professionals reported that they did not have enough staffing to
meet the needs of patients during the opioid crisis12,16,18,20,24,27. Clinical care
coordinators, counselors, nurses, pharmacists, physician assistants, physicians,
and social workers also struggled with not having enough support from other
health care professionals to effectively care for clients12,20,22,28–31. Health care
professionals also reported that they did not have the needed equipment or
treatment options available to support clients16,17,25,32.

Many health care professionals experienced burnout during the drug

poisoning crisis14–18,21,25,28,31,33–37. A feeling of helplessness was also
caused by being unable to treat clients effectively and prevent future drug
poisonings14,15,17,21,25,34–36. Many health care professionals also experienced
violence from clients and people trying to access opioids from pharmacies
without a prescription15,16,19,21,28,30,32,38. There has been a broad, negative
effect on health care professionals’ wellbeing during the drug poisoning crisis.

Health care professionals also demonstrated resilience, with positive intrinsic

attitudes in their practices, such as hope for improvements, empathy or
compassion towards patients, responsibility for care outcomes, and personal
fulfillment12,14,16,17,20,22,36,38–41. Professional support was another
adaptive response to the effects of the drug poisoning crisis. Counsellors,
nurses, paramedics, pharmacy technicians, physicians, and speech language
pathologists reported receiving support from their health care team
members13,18,21,22,24,32,34,37,39. Health care professionals managed to
mitigate some of the personal effects of the crisis and improve treatment for
people with addictions13,18,21,22,24,32,34,37,39. In the absence of workplace
supports however, health care professionals were unable to manage the
significant adversity caused by the drug poisoning crisis. Consequences of this
adversity included health care professionals’ decreased job satisfaction, leaving
roles involving clients with addictions, and transferring to different practice
areas16,18,20,22,26,32,36,42.

Remaining Gaps in Knowledge

The lack of Canadian studies created an incomplete picture of the challenges
for Canadian health care professionals in addressing the drug poisoning crisis.
Nurses, paramedics, and physicians had an abundance of literature exploring their
experiences, but other professionals were largely excluded. We did not identify
any studies from the Alberta context, and we aimed to fill this gap with our
research.

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 10
Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

research questions
In our study, we addressed the following research questions:
• What has been the personal impact of the drug poisoning crisis for health
care professionals in Alberta in HSAA?
• How has the workload and nature of work changed for HSAA members
because of the drug poisoning crisis?
• What workplace supports do HSAA members need to continue working
during the drug poisoning crisis?

Research Methods
We conducted a sequential mixed-methods study about the experiences of HSAA
member health care professionals of their work during the drug poisoning crisis
in Alberta. Our study consisted of a survey, followed by qualitative interviews. We
sent a survey link to all HSAA members in August and September, inviting them
to participate in the study. Participants could complete an online survey about
their working experiences during the drug poisoning crisis. We asked people who
completed the survey if they would be willing to speak to us in an interview, to
gain more understanding about their experiences. We conducted interviews in
the fall of 2024. Our study received full ethical approval from the Conjoint Health
Research Ethics Board at the University of Calgary, approval number REB24-
0982. All participants provided informed consent to be part of this research.

We sent surveys to all HSAA members via email, inviting them to participate,
with two follow up reminders. There are approximately 29,000 HSAA members,
although there are members who would be on leave or other circumstances
where they would not be working at this time. Thus, it is difficult to say exactly
how many of these members were available for the study. The surveys included
questions about participants’ demographic backgrounds, their knowledge of
opioid drug poisonings43, attitudes responding to a drug poisoning43, their
professional quality of life44,45, and violence at work 46. The details of the survey
are presented in Appendix B: Survey instruments.

In the qualitative interviews, we spoke to participants across the province via

Zoom. All interview participants were recruited from the prior survey, where
participants provided their email address if they would be willing to complete an
interview. We asked people to tell us about how their work may or may not have
been affected by the drug poisoning crisis (see Appendix C). We used the features
in Zoom to transcribe these interviews, verified each transcript by hand, and used
NVivo v. 14 as our data management software.

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 11
Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

Our data analysis approach for the qualitative interviews was reflexive
thematic analysis47. Using this approach, researchers develop themes using a
systematic process of reading and coding qualitative data47. We used reflexive
thematic analysis to create a shared meaning from the individual experiences
of our participants, while being mindful of our own experiences and views that
influenced our analysis process47. We read the interviews to identify main ideas
from each participant individually, then looked at how these main ideas fit with
the experiences of others. Throughout the data analysis process, we wrote notes
about our coding and had regular debriefing discussions with the research team
to talk about the findings48. We bring together our results from the surveys and
our findings from the qualitative interviews in the following sections.

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 12
Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

results - participants
I n total, 534 participants responded to the survey, with 69% (n=374) reporting that
they have been affected by the opioid and drug poisoning crisis. 80 of the 534
people answered, “not sure”, and 80 of the 534 people responded “no” and were
prompted to the end of the survey and did not complete additional questions. 454
participants (“yes” and “not sure” respondents of the 534) completed the whole
survey. The demographic information for survey participants is presented in Table 1.

Table 1: Survey participant demographic and work characteristics (n=454)

CHARACTERISTIC FREQUENCY N (%)

PROFESSION

Emergency 104 (23%)

Mental health 84 (19%)

Health care technologist/specialists 104 (23%)

Rehabilitation 29 (6%)

No response/unknown 133 (29%)

GENDER

Cisgender male 103 (23%)

Cisgender female 312 (69%)

Non-binary 6 (1%)

Transgender 4 (<1%)

Two-spirit 26 (5%)

No response/unknown/in another way 3 (<1%)

RACE

White/European 377 (83%)

Indigenous (Inuit, First Nations, or Metis) 14 (3%)

East/Southeast Asian 26 (6%)

*Other 36 (8%)

MARITAL STATUS

Single 83 (18%)

Married 233 (51%)

Divorced/Separated/ Widowed 74 (16%)

Common-law 27 (6%)

In a relationship 37 (8%)

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 13
Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

AGE (years)

18-30 82 (18%)

31-45 247 (54%)

46-60

No response 108 (24%)

17 (4%)

ZONE

Calgary 162 (36%)

Edmonton 151 (33%)

Central 43 (9%)

North 52 (11%)

South

No response 45 (10%)

1 (<1%)

EMPLOYMENT TYPE

Full time 311 (69%)

Part time 108 (24%)

Casual 34 (7%)

No response 1 (<1%)

YEARS WORKED

<1 12 (3%)

1-5 88 (19%)

6-10 86 (19%)

11-20 164 (36%)

WORK HOURS

Day shift 180 (40%)

Night shift 12 (3%)

Both day and night shift 190 (42%)

9-5 working hours 72 (16%)

CLIENTS WITH DRUG POISONING IN THE LAST 30 DAYS

<5 305 (67%)

5-10 82 (18%)

11-20 31 (7%)

>20 33 (7%)

No response 3 (1%)

ADMINISTERS NALAXONE AT WORK

No 235 (52%)

Yes 208 (46%)

Unsure 11 (2%)

* Participants that reported their race as Latin American, Arab/West Asian, South Asian, and Black or
African American were included in the “other” due to their low numbers to protect their identities.

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 14
Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

HSAA contains many professional groups, and we created sub-categories of

professions to facilitate our analysis. A breakdown of how we grouped the health
care professions of survey participants is in Table 2 below.

Table 2: Professional groupings for HSAA registered designations who

participated in the survey

Emergency professionals Paramedic (Advanced/Primary)

Emergency Communications

Mental health professionals Psychologist

Mental Health Therapist
Addiction/Family Counselors
Clinical Behavioural Specialist
Social Worker
Psychometrist
Psychiatric Registered Nurse**
Registered Nurse Mental Health Therapist**

Health care technologist/ Cardiology Technologist

specialist/ Pharmaceutical Laboratory Technologist/Assistant
professionals Combined Laboratory X-Ray Technologist
Medical Radiation Technologist
Electroencephalogram Technologist
Electroneurophysiology Technologist
Computed Tomography Technologist
Medical Laboratory Technologist /Assistant
Medical Photographer
Respiratory Therapist
Dietitian
Sonographer
Tissue Specialist
Pharmacist
Pharmacy Technologist
Registered Nurse/Licenced Practical Nurse**

Rehabilitation professionals Occupational therapist (OT)/Assistant

Physiotherapist (PT)
Recreation Therapists
Speech-Language Pathologists (SLP)/Assistant
Rehabilitation Practitioner
Therapy Assistant

*The following professions were removed from analysis due to insufficient sample size for grouping
(n=9): Administrative staff, Analyst/Researcher, Clinical Educator, Clinical Information Resource Specialist
(poison), Clinical Supervisor, Public Health Inspector, Coding Specialist, Education Consultant, and Health
Information Manager.

**Most nursing professionals are members of the United Nurses of Alberta, but some nurses qualify for
HSAA membership instead, based on their practice setting and role professions were grouped into one
of the four categories: emergency professionals, mental health professionals, health care technologist/
specialist/pharmaceutical professionals, and rehabilitation professionals.

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 15
Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

In our survey, emergency and health care technologist/specialists had the highest
frequency of participants (23% each) followed by mental health professionals
(19%) and rehabilitation professionals (6%). Twenty-nine percent of participants
did not report their profession.

In our qualitative interviews, we spoke with 16 health care professionals, for

about 45 minutes each. We spoke with people from a variety of professional
backgrounds and work environments (illustrated in Table 3).

Table 3: Demographic characteristics of interview participants

CHARACTERISTIC FREQUENCY N (%)

Profession

Addiction Counsellor 3 (19%)

Medical Laboratory Assistant 2 (13%)

Paramedic 5 (31%)

Pharmacist 1 (6%)

Respiratory Therapist 1 (6%)

Social Worker 3 (19%)

Speech Language Pathologist 1 (6%)

Gender

Female 10 (63%)

Male 6 (38%)

Employment Length

3 Years or less 5 (31%)

4-10 years 6 (38%)

11+ years 5 (31%)

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 16
Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

results - OUTCOMES
FOR HSAA MEMBERS

I n the following sections, we present our results from the survey and our
interview findings grouped together, organized by the major themes that
we found in these data. We present the context for these results, the lack of
knowledge and education around drug poisonings, incidents of workplace
violence harming clients and participants, personal consequences for participants,
and recommendations from participants to make things better.

The Experiences of Health Care Professionals in the

Drug Poisoning Crisis in Alberta are Influenced by
Their Context
There are numerous contextual factors that influenced the experiences of health
care professionals who work with clients that experience drug poisonings.
Interview participants agreed unanimously that drug poisonings were a major
problem in all areas of Alberta. Addressing drug poisonings comprised a
significant part of their daily work. A participant, who worked across several
clinical areas, discussed the ubiquity of drug poisonings:
And just us seeing the number of cases go up in the last few years as
well. It's everywhere from the code room, where patients are completely
comatose and unconscious from a drug overdose, people who have
[been] arrested, to people who just come in because they're overly
Interview participants sedated or withdrawing. We see that every single day, and so I would
agreed unanimously that say it's definitely affected my job (P04).

drug poisonings were This participant highlighted how clients could be at varying stages of dealing with
a major problem in all a drug poisoning or addiction and need access to the health care system. This
understanding was coupled with the acknowledgement that while the problem
areas of Alberta.
had increased, the number of staff, services, and facilities had remained fixed.
One participant talked about the impact for a small, rural hospital:
[Name] hospital is one of the busiest hospitals in the zone. We are
actually very small- it’s a primary care hospital but we are really, really
busy. Our emergency is always full. So, what happens, especially during
the winter - sometimes the wait times can last from 6 to 8 h or 4 h to
8 h. Yeah, that's the case, because we have so many patients coming in
and not all patients a have primary physician (P06).

This participant discussed how the smaller facility was under resourced in both
beds and clinical staff, and that they were overwhelmed by increases in drug
poisonings.

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 17
Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

Participants were also unanimous that the drug poisoning crisis related to
COVID-19. They reported that the crises had occurred in tandem, complicating
their daily work.
I would say Covid has magnified it astronomically […] And I think that
when people were isolated and they had nothing else to do, you get
the kids who are just partying and trying something for the first time.
But then you also get the hard users who are really using a lot more.
And I think the stresses of Covid produced a lot of financial stress and
depression, emotional anxiety. And I think people turn to drugs to deal
with a lot of that. And sadly, I think that's when we saw a huge spike in
a lot of cases (P04).

Participants explained that COVID-19 and the drug poisoning crisis had
synergistic effects, increasing isolation among clients, decreasing access to
services, and creating financial problems. These conditions resulted in an
environment where people who were managing started to struggle, and people
who were struggling tipped into crisis.

Participants reported that drug use was not the same across the province, with
participants recognizing that while fentanyl was major issue, there were regional
complexities. This participant discussed the local nuances of the drug supply in
their rural area:
A lot of meth withdrawals or meth-use psychosis, that kind of thing.
And to be fair, we do see quite a few opiate overdoses. It's just not as
extreme as some other places, because, for whatever reason, the drug
culture just doesn't - the opiates just don't exist in quantity here (P13).

Participants reported that the drug supply was influenced by proximity to the USA
border and how rural their area was. These factors meant that the crisis existed
across the province, but local areas can have distinct challenges. Therefore,
participants’ experiences of the drug poisoning crisis were influenced by their
location and drug supply in their work areas.

Participants also highlighted the social problems that contribute to the drug
poisoning crisis. First among these problems was housing. There was a
consensus that a lack of housing was compounding the drug poisoning crisis. This
participant elaborated:
We have to try and house people. Well, it's impossible to house people
when they're on a fixed income because housing is so expensive. So
then it comes, all that frustration builds up. And then, oh, we need to
do more. I don't know what else we can do. I don't control the housing
market (P05).

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 18
Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

The participant explained that they recognized the need for clients to have
housing but could not overcome the systemic barriers related to cost. In turn, the
participant felt helpless because they were pressured to get people off the street,
The cost of housing but there were no appropriate homes available for clients. The cost of housing
represented an represented an insurmountable barrier for clients, which compounded their
insurmountable barrier difficulties.

for clients, which Participants reported that policies implemented by the provincial government
compounded their had worsened the drug poisoning crisis. Mental health services were closed
during Covid-19 and never restored. Participants also reported that they were not
difficulties. allowed to provide clients with new needles or other supplies like pipes, despite
a clear need. This participant reported that her work would not improve without
political intervention:
My day isn't going to get better until the Alberta Government sorts
out the f*cking income support system, and then until they make
investments in the health of people in this province, and until they start
putting money towards things that are actually going to help people
and start making it possible for us to build affordable housing (P12).

This participant recognized that she could not address clients’ real issues until
systemic problems were addressed. None of our participants verbalized optimism
that the current abstinence-based plan for care would be successful or address
the current crisis.

There were also universal concerns of asking to be doing more with less.
Participants reported rationing of staff, equipment, space, and other resources to
try and reduce costs. These changes resulted in poorer client care. One participant
described the micromanaging they faced at work:
Our butterflies [needles] are like our secret currency in the lab. It's your
most prized possession is your butterfly needle, because we only get
4 per shift. … That's management's way of keeping costs low because
butterfly needles are more expensive (P09).

This example illustrated how broad cost pressures are downloaded onto health
care professionals. Chronic under resourcing of the health care system was
evident at the individual level when participants had to adapt their work to things
like rationed equipment.

Outcomes for health care professionals were also influenced by their geographic
position in the health care system. It was broadly recognized that the drug
poisoning crisis was most acute at street level, where people who used drugs
and experienced homelessness were present. A lack of affordable housing meant
that clients occupied a liminal space on streets, outside of fixed addresses.
Participants experienced more exposure to the drug poisoning crisis the closer
they worked to street level health care services. For example, a paramedic
had to address the crisis more than someone in the emergency department,
who addressed the crisis more than someone in intensive care, and so forth. A
participant reported their experiences of working on an outreach team:

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 19
Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

We have a nurse that goes on their [outreach] walks with them, too. And
there's constantly people that are dropping. And it's more immensely
taxing on us (P05).

This finding is important because health care professionals experienced relative

degrees of exposure to the drug poisoning crisis, which could influence their
exposure to traumatic events like client deaths. Participants recognized their
relative levels of exposure:
I'm fortunate compared to a lot of maybe my other allied health
colleagues who might work in the community, is that the policy I have
to follow [if someone needs naloxone] is that I contact the nursing staff
and the health care staff, and they have all the equipment (P08).

The need for supports for health care professionals who work with clients
experiencing drug poisonings could be considered relative to their proximity to the
street level, and thus, their potential exposure to trauma. While support needs to
be available for all health care professionals in Alberta, our participants indicated
that proximity to clients at street level influenced their need for support.

In addition to these contextual factors, we found specific issues among health

care professionals in Alberta. These include a lack of knowledge about drug
poisonings, facing significant violence, and experiencing high levels of burnout.
Each of these issues is addressed in the following sections.

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 20
Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

HEALTHCARE PROFESSIONALS
LACK KNOWLEDGE ABOUT
RESPONDING TO DRUG
POISONINGS
W e assessed how much participants know about responding to drug
poisonings (Table 4). On a knowledge test about opioids (scored out of 45),
the mean scores were 21.55-25.75, indicating a moderate level of knowledge.
Participants’ competency to manage an overdose score averaged at 24/50. In
the section on readiness to respond to an overdose, the average score among
groups was 23/50. These scores indicate low to moderate levels suggesting
improvements for confidence and preparedness across professions is needed
when responding to an overdose.

Table 4: Summary of Scores by Profession for the Opioid Overdose Knowledge Scale (OOKS) and Opioid
Overdose Attitudes Scale (OOAS)

OOKS OOAS: Competency to OOAS: Concerns OOAS: Readiness

(Mean, SE) /45 Manage an Overdose About Managing an to Intervene in an
PROFESSION
(Mean, SE) /50 Overdose (Mean, SE) Overdose (Mean, SE)
/40 /50

Mental Health 25.75 (0.33) 24.00 (0.41) 29.07 (0.41) 20.21 (0.34)

Emergency 25.21 (0.35) 21.66 (0.24) 33.24 (0.39) 25.63 (0.49)

Health Care 23.53 (0.42) 26.06 (0.46) 27.23 (0.47) 23.20 (0.48)
Technologist/
Specialists

Rehabilitation 21.55 (0.78) 26.58 (0.78) 26.52 (0.77) 21.72 (0.53)

When we asked participants about their education around drug poisonings and
managing overdoses, they reported there had been little training available:

I've kind of watched the opiate crisis unfold. It moved a little faster than
the employer could even offer training … I'd say that we got trained on
how to use a naloxone kit and even got naloxone kits like quite late in
the game at our site. I don't recall much training, just how to reverse an
overdose (P14).

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 21
Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

We asked participants if they wanted more education on drug poisonings and

drug use and some indicated that the lack of training was symptomatic of a
bigger problem. This participant reported that they had been unable to access
education programs or time off:

Within the last year I just stopped asking. I've previously said, “Hey? I've
put in request for extra training on certain things. I've put in request for
extra time to learn or to have access to stuff,” we're always get kind of
get the same responses, it's, “We don't - there's no time, because you
have to go do this job.” So, you just stop asking (P10).

This participant perceived that they did not have support from their managers,
and so they stopped asking for opportunities to build their knowledge base. A lack
of options or support may be part of the reason for relatively low scores on drug
poisoning reversal.

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 22
Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

Health Care Professionals

are Facing Substantial
Workplace Violence
W e used the Workplace Violence Survey (WVS)49 to assess whether
participants had encountered any types of workplace violence from
patients or patients' relatives/friends in the past year50. WVS assesses
experiences of physical violence, different types of verbal abuse, bullying,
sexual harassment, and feelings of safety at work50. We found that health care
professionals reported high rates of emotional abuse, and moderate rates of
threats and feeling unsafe (Table 5). In this context, emotional abuse was defined
as the mistreatment to the professional through words (i.e. being disrespectful
and using curse words).

Table 5: The WVS frequencies by each category and frequency of incidents in the past year

CATEGORY 0 times (n, %) 1 time (n, %) 2-3 times (n, %) >3 times (n, %)

Physical abuse 246 (54.55%) 66 (14.63%) 70 (15.52%) 69 (15.30%)

Emotional abuse 73 (16.22%) 42 (9.11%) 112 (24.67%) 225 (50%)

Threats 159 (34.81%) 70 (15.52%) 94 (20.84%) 130 (28.82%)

Verbal sexual harassment 246 (54.22%) 74 (16.44%) 61 (13.56%) 71 (15.78%)

Sexual abuse 376 (83.30%) 40 (8.91%) 19 (4.23%) 16 (3.56%)

Felt unsafe at work 175 (38.58%) 75 (16.41%) 109 (24.17%) 94 (20.84%)

Sought help 378 (83.93%) 24 (5.36%) 25 (5.58%) 23 (5.13%)

Paramedic participants recognized that when clients experienced drug

poisonings, they may be in an alley or other public space, due to a lack of
supervised consumption sites. Clients could wake up to someone providing
medical interventions to them, which would understandably be frightening.
However, professionals like paramedics were there to resuscitate someone in an
unsupported environment, possibly working alone. Participants recognized that
this situation was problematic for both health care professionals and clients, with
both feeling unsupported.

Participants of all genders reported similar levels of workplace violence.

Participants reported that workplace violence came from clients, other health
care professionals, and members of the public. Participants attributed the
increased workplace violence directed toward emergency professionals to risks
outside of the hospital. When we asked a participant if they ever felt unsafe at
work, they replied:

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 23
Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

Yeah, all the time. So, you always have to be aware of your surroundings
and what's going on. Your safety isn't just violence, your safety is used
needles, weapons, all that sort of stuff. So, I've been in many, many drug
houses for many, many people that have overdosed with needles all
over the floor, whether they're needles from being given Narcan by their
friends, or needles from injecting medications. Houses with knives and
swords and guns and all that kind of stuff around you, and then there's
the violence piece where you wake somebody up and they're pissed off
that you've taken their high away, and they can get violent or threaten
violence or what have you. So, we're the only health care professional
that wears bulletproof vests for a reason (P15).

Despite these reports, very few survey respondents indicated that they sought
help to address these issues (Table 5). In the qualitative interviews, some
participants reported that they did not trust the support that was offered to
them:
We have no support, right? Like, EMS does not have a therapist. We do
not have a critical incident stress debrief team. We have peers, like, I can
be on the peer team to help my paramedic colleagues out. But I'm not
a professional, I'm not trained, I'm not licensed and registered. We need
monthly check-ins; we need a therapy team that's there and available
on call at least 24/7 for when we go to these crises (P16).

Some participants reported that they also avoided their employee assistance
program because they feared that their employer would use their participation
against them, and that there were no counsellors who specialized in debriefing,
post-traumatic stress, or the issues faced by health care professionals.

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 24
Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

Health Care Professionals

Face Consequences of
Working During the Drug
Poisoning Crisis
T he factors above have created difficult environments for health care
professionals in Alberta as they respond to the drug poisoning crisis. We
asked in our survey and interviews how participants were doing. We used the
Professional Quality of Life Scale (ProQOL), which measures the subscales of
compassion satisfaction, burnout, and secondary traumatic stress. We present
participant scores in Table 6.

Table 6: Summary of Scores by Profession for the ProQOL

Compassion Satisfaction Burnout Secondary Traumatic Stress

PROFESSION
(Mean, SE) /50 (Mean, SE) /50 (Mean, SE) /50

Mental Health 39.57 (0.69) 23.65 (0.66) 22.60 (0.73)

Emergency 35.12 (0.67) 27.27 (0.60) 25.04 (0.72)

Health Care Technologist/ 36.10 (0.56) 26.31 (0.54) 24.23 (0.62)

Specialist

Rehabilitation 38.10 (1.13) 25.14 (1.12) 24.14 (1.10)

Overall, we found that the average score for the ProQOL subscale on compassion
satisfaction for all participants was 37/50, indicating high job satisfaction and
feelings of making a positive contribution through one’s work. The average
participant score for the burnout subscale across all professions was 26/50,
indicating moderate burnout in the workplace. The average participant score
for secondary traumatic stress was 24/50 indicating moderate levels of stress
across all professions. Combined, these scales show an overall positive result,
with higher job satisfaction and lower burnout and secondary traumatic stress.

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 25
Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

However, in our interviews, participants reported that burnout was endemic

among Albertan health care professionals. Participants reported that either they
However, in our
experienced burnout, or they worked with people who did. This participant could
interviews, participants recognize burnout in her practice:
reported that burnout
Yes, there's definitely times where I know that the professional I want
was endemic among to be wants to go see this person and do more for them than I have.
Albertan health care But then I also have made the decision that I'm not doing that today,
professionals. because I just can't. Which is then, on the one hand, I feel good about,
because I know I'm setting up my own boundaries, and, on the other
hand, I feel terrible about, because that's not the type of professional I
want to be (P01).

This participant felt conflicted because they recognized that clients experienced
a high level of vulnerability, but that they could not sacrifice their own wellbeing
to support clients. There was a broad agreement that the drug poisoning crisis
had been hard on health care professionals, due to increased client needs and the
increased suffering among clients.

Notably, among all professional groups, emergency professionals had the lowest
compassion satisfaction and highest burnout and secondary traumatic stress in
the workplace. This result means that emergency professionals had the lowest
job satisfaction and the highest negative consequences of their work. Emergency
professionals reported that many structural elements made them feel like their
work was not valued. This participant discussed how emergency professionals
were excluded from province-wide electronic medical records:

We continue to fight for frontline to have access to Connect Care

[electronic medical record], and that's an ongoing fight that we're not
getting anywhere quick. I'll admit it was really frustrating. Launch 9 of
Connect Care just happened earlier this month, and the organization,
as a whole, got an email saying, “It was the final launch. Everybody's
finally on connect care. Everybody has access,” and EMS is sitting over
here saying, “Hello. We're part of AHS, and we don't have access to
Connect Care. What do you mean you're all done?” (P15).

The lack of access to Connect Care made emergency professionals feel like they
were not “part of the team” and that their work was not valued or appreciated
by other people in the health care system. Issues with managers, exclusion from
hospitals, and an ongoing staffing shortage all added to the burnout among
emergency professionals. The ProQOL scores for emergency professionals were
the lowest across all subscales, indicating that emergency professionals are
struggling more than their counterparts.

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 26
Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

There are Options to

Make Things Better
I n addition to these challenges, participants reported multiple ways that
structural supports could be implemented to improve working conditions.
Participants recommended concrete steps to support clients and people in the
community, recognizing that unless people with addictions got more support,
there would not be any change in demand for services.

I mean, we try our best to keep everybody alive, but you know, if there's
a toxic drug supply, you never know who's gonna go down (P07).

This participant highlighted that as long as the drug supply was not regulated
or reliable, clients would continue to face the drug poisoning crisis. There was
a strong sentiment among participants that the provincial government policies
around addiction needed to change, but that it was futile to expect any changes.
However, participants did make suggestions on intermediate measures that
could support health care professionals in Alberta, which included suggestions
for their immediate workplaces. These suggestions are detailed in the following
sections.

Local Strategies and Ability to Innovate

Participants reported that they had less burnout when they had the capability
to make changes at their workplace. These changes provided health care
professionals with both the opportunity to adapt to local issues and avoid
feelings of helplessness. One participant discussed how participating in a
department working group had helped to create changes that benefitted clients
and health care professionals:

Yes, so I have been invited to be part of a [department working group

on opioids]. And it's a super great committee that, I feel like I was doing
something useful with your frustration. This committee is really, is
a practical way to sort of deal with it … I have the space, and I have
the ability to share how I'm feeling about a situation or some of my
frustrations. It's shared. It's a shared frustration. And so, it's easy to
kind of talk about it with your colleagues and then, when you see
something practical like the committee being done and created to
manage some of [the issues]. It feels like, okay, we're actually also
dealing with it in a way (P04).

The participant reported that this group was effective because they had real
power to implement new strategies in their department, and it was led by
health care professionals who worked with clients daily. Providing groups with
resources and autonomy to make local-level changes has the potential to
improve client care and mitigate some of health care professionals’ burnout.

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 27
Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

Comprehensive Benefits
Participants recognized the need for increased benefits coverage, especially
relating to counselling. Participants preferred to access counsellors
independently, rather than utilize the employee assistance program. Services
offered by the employer were viewed with concerns about confidentiality or
whether the counsellors would be a fit. Counsellors outside the employer were
a major source of support for participants. However, the coverage limitations for
counselling prevented participants from getting the help they needed.

A lot of us have therapists that we talk to. That's one thing that we
push, especially for people who are joining up. I go to a therapist every
single week, which is - I never thought I'd be doing that as a kid or
as somebody who's entering this industry, and I wasn't even warned
about it, and I wasn't even told about it. You gotta spend a 3rd of
your paycheck on therapy, because you know nobody else is gonna
help you, right? And [the trauma] destroys yourself and destroys your
relationships around you, but I think everybody I know has a therapist
now that's been in this industry for more than five years (P16).

Counselling was identified as a vital part of participants continuing in their roles.

Increasing benefits coverage for counselling could promote staff retention and
support health care professionals to continue working during the drug poisoning
crisis.

Manager Skills and Support are Critical

Supportive managers were a critical part of health care professionals staying in
their roles. Participants reported better outcomes when they were listened to,
had their concerns taken seriously, and experienced empathy for the workplace
Participants reported difficulties of the drug poisoning crisis. This participant talked about the value of
better outcomes when supportive management:
they were listened to,
I have worked for really good people like the management teams
had their concerns that I've had. The leadership teams have largely been quite good and
taken seriously, and supportive, and I value that for sure. My team right now is awesome,
the leadership team is great. So that's the bonus. It's important to me
experienced empathy
for sure to have a good support like that and good mentorship (P12).
for the workplace
difficulties of the drug Providing additional training and support to managers would mean that there are
benefits for health care professionals, with relatively little expenditure. Targeting
poisoning crisis. clinical managers with more resources could potentially impact workers widely
across the health care system.

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 28
Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

Conversely, managers with poor leadership skills or lower autonomy had a toxic
effect on their employees. The importance of strong managers with adequate
resources was recognized clearly by participants. This participant spoke about
their lack of support:

Yeah, it's pretty horrible to be honest. A lot of the time, our management
is very dismissive of our concerns. And our supervisors are dismissive
of the concerns as well. For example, I told a story to one of the
supervisors, and he said, the reason why we almost got in a fight is
because we weren't smiling enough that day. I said, well, “You don't
know what I was going through that day. You definitely don't know what
the crew is going through on that day, and I don't think any amount of
smiling would have stopped that gentleman from trying to physically
hurt that young female paramedic, because he definitely could have if
he wanted to.” So, you know, it's just… our management is absolutely
horrible and it's part of the cause of why EMS is treated so poorly, and
why we don't get the support we need. And when we do try to report
things like violence, and these issues with opioids, they are just turn a
blind eye to the whole thing (P16).

This quote illustrates clearly how a lack of manager support has detrimental
effects for health care professionals. Factors like retention, job satisfaction, and
employee wellbeing become more pronounced without genuine support from
managers.

Flexibility Helps People Stay

Participants identified the street level as the center for the drug poisoning crisis,
and the place that they could experience the most potential trauma. To manage
their exposure to this trauma, some participants opted to work fewer hours in a
street-level clinical space. This participant reported how health care professionals
would use sick time to have a break if their schedule did not allow for flexibility:

I do see an increase in sick calls. But I don't know if that's secondary to

burnout, or if it's just the way the culture is shifting to the workforce. I'm
not sure, but that is something I've noticed (P02).

Other participants decreased their work hours or changed their shift schedule to
allow more days between shifts, so they had more time off for personal recovery.
Strategies that help health care professionals have more flexibility, or take on
multiple roles for fewer hours, may help to retain staff over the long term. Health
care leaders can promote options that allow health care professionals to change
jobs or have more than one role, and retain access to benefits, pensions, etc.

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 29
Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

Informal Support and Grief Counselling

Participants recognized the importance of confidentiality for clients but found
that the lack of closure could impair their ability to grieve client deaths. Not
knowing what had happened to a client made it difficult for participants to
process their experiences. For example, a participant talked about how clients
leave their clinical area:

We never hear about that end of the after they're admitted. We help to
wean them off the ventilator, and then they leave. And I'm just kind of
curious as to what happens after that (P03).

This participant discussed how it would help the health care team to know more
about a client’s journey to gain closure. Other participants wanted opportunities
to debrief about a client with their colleagues, especially when clients died.

And then we do things, for example, for people who have passed. We do
have little memory wall. So just trying to create that safe space where
you can talk and debrief about [the client] and have that as an option
(P08).

These examples highlight the value of having some knowledge of a client’s

outcomes for a health care professional. Things like the memorial wall provided
a way for health care professionals to remember clients after they died,
acknowledging that the client mattered to the participants. There may be ways to
protect client information and identities but provide limited follow up for health
care professionals to help prevent burnout and provide grief support.

Health care professionals told us about how important it was for them to have
support at work. Participants’ preferred source of support was their colleagues.
Participants reported that their colleagues understood their experiences and
knew the clients.

What is going well with my daily work life? I enjoy the people that I
work with. I enjoy patient interactions and making a difference (P11).

Informal support provided an opportunity for participants to talk about their work
with someone who shared their meaning. When asked about formal support, a
participant illustrated how they preferred to connect with their colleagues:

It's more the connection with the other people in your office and the
people that have experienced what you have gone through (P5).

This participant explained that they did not need to explain the whole situation to
a colleague; their shared understanding meant it was easier to privately debrief
after a difficult moment. Participants could give and receive support readily,
because of their shared context and understanding. This approach was preferred
by health care professionals over speaking to someone outside their context.

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 30
Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

Participants identified their colleagues as a strong factor that helped them

in their daily work. However, a participant reported that their communication
had been curtailed, because of concerns over client confidentiality. The lack of
communication created a gap for this participant:

There's very little like communication in between team members

allowed, [management has] shut down a lot of our- we used to have a
team chat. Every morning, somebody would start like a text group or
a chat group, so that, just even throughout the day, if you needed help
with something or say you needed a question like, “Okay, I'm doing this
lab work. And for the life of me I can't remember how to do this,” right?
And you would reach out and somebody would chime back and say, “Hi,
no problem. You just do this,” or “Hey, I'm not that far. I am free. I can
come, help you.” You know, there is a lot of that. They shut that down.
So that was just after Covid they shut - they took that away from us.
So, we're not allowed to communicate to our own team members … But
we're not allowed to talk to each other unless we're face to face, really.
So, it's really frustrating (P10).
The impression was
This participant felt that managers did not have valid reasons for implementing
that managers were
these changes. The outcome was that the participant felt that managers did
more interested in not take concerns seriously or recognize the need for support from coworkers.
following arbitrary rules The impression was that managers were more interested in following arbitrary
rules than addressing the need for health care professionals to access clinical
than addressing the
support from colleagues. Steps like these led participants to perceive that they
need for health care were losing one of their few resources for their daily work. One option could be
professionals to access increasing access to Connect Care, to provide health care professionals with a
clinical support from secure way to connect, while protecting client confidentiality.

colleagues.

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 31
Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

DISCUSSION
O ur work is similar to other authors, in that we found increases in workload for
health care professionals as they respond to the drug poisoning crisis12–17.
The outcomes for health care professionals were the result of systemic barriers
and a structural lack of resources, not a person’s individual difficulty coping with
the drug poisoning crisis. Participants felt they were blamed if they could not
manage system-level problems on an individual basis. In particular, our report
echoes the work of prior researchers in highlighting the issues with EMS in
Alberta51, and we found that workplace conditions have not improved since that
prior work. Our report adds to the evidence that the drug poisoning crisis has had
widespread impacts for workers in multiple sectors52.

The Government of Alberta, Alberta Health, and Alberta Health Services can
improve conditions for health care professionals in Alberta. Their primary
More supervised focus should be in providing resources to address the drug poisoning crisis and
consumption sites are implementing systemic strategies to provide people with access to housing and
needed, to decrease the treatment options. More supervised consumption sites are needed, to decrease
the workload on emergency professionals who are responding to drug poisonings
workload on emergency
after the fact. Supervised consumption sites could potentially prevent some drug
professionals who are poisonings and divert clients from other emergency services. There is also a need
responding to drug to offer comprehensive counselling and pharmacare coverage so Albertans can
access addiction treatment on their own terms.
poisonings after the fact.
Supervised consumption In the interim, health care professionals can be supported to adapt their work
sites could potentially at a local level to address the unique needs of their community. Additional
training can be provided across the health care system about drug poisonings
prevent some drug and intervention. Benefits, especially for counselling and psychological support,
poisonings and divert can be expanded. Managers can be offered additional training and resources
clients from other to better help their colleagues. Job structures can allow for flexibility, so that
health care professionals continue working in their clinical roles but mitigate
emergency services. burnout by having time off between shifts. Providing options for people to
work reduced hours in more than one role and retain benefits and pension
contributions could promote staff retention. More work to prevent and address
workplace violence against health care professionals is urgently needed, such as
expanding environments that prevent violence, supervised consumption sites,
and community-based addiction services. Additionally, managers can enhance
opportunities for health care professionals to support each other at work and
obtain closure around client outcomes. Changes like these are required to support
health care professionals as they address the ongoing drug poisoning crisis.

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 32
Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

REFERENCES
1. Alberta Health. 2025. Alberta substance use surveillance system.
[Link]
Uri=%2Freports%2Freports%2F1bbb695d-14b1-4346-b66e-
d401a40f53e6&sectionIndex=0&sso_guest=true&reportViewOnly=true&
reportContextBar=false&sas-welcome.

2. Government of Canada. 2025. Opioid- and stimulant-related harms in Canada.

[Link]
stimulants/.

3. Weiland, N. 2024. Drug overdose deaths are dropping. The reasons

are not perfectly clear. The New York Times. [Link]
com/2024/09/21/us/politics/[Link].

4. The Alberta First Nations Information Governance Centre. 2024. Alberta opioid
response surveillance report: First Nations people in Alberta. [Link]
[Link]/publications/alberta-opioid-response-surveillance-report-first-
nations-peoples-2024.

5. Alberta Mental Health and Addictions Advisory Council. 2022. Towards an

Alberta model of wellness. [Link]
alberta-model-of-wellness.

6. Alberta Health. 2020. Impact: A socio-economic review of supervised consumption

sites in Alberta. 190. [Link]
4d6b-a9c6-60d353ea87c3/resource/11815009-5243-4fe4-8884-
11ffa1123631/download/health-socio-economic-review-supervised-
[Link].

7. Government of Alberta. 2025. Compassionate intervention act. https://

[Link]/LADDAR_files/docs/bills/bill/legislature_31/
session_1/20230530_bill-[Link].

8. Jeffrey, A. 2025. Alberta looking into shutting down supervised consumption

site in Calgary: premier. [Link]
gondek-scs-chumir-1.7497204 CBC News Calgary.

9. Red Deer Advocate Staff. 2025. Court dismisses appeal for denied
injunction to keep Red Deer OPS open. Red Deer Advocate. [Link]
[Link]/local-news/court-dismisses-appeal-for-denied-
injunction-to-keep-red-deer-ops-open-7968175.

10. Tran, C. 2024. Alberta sees downward trend in opioid-related deaths. The
Edmonton Journal [Link]
deaths-april-2024.

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 33
Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

11. Filteau, M. R., Kim, F. L., & Green, B. 2022. “It’s more than just a job to
them”: A qualitative examination of patient and provider perspectives on
medication-assisted treatment for opioid use disorder. Community Ment
Health J 58, 321–327. [Link]
021-00824-7.

12. Beitel, M., et al. 2018. Experiences of burnout among drug counselors in a
large opioid treatment program: A qualitative investigation. Substance
Abuse 39, 211–217. [Link]
7.2018.1449051.

13. Pike, E., Tillson, M., Webster, J. M., & Staton, M. 2019. A mixed-
methods assessment of the impact of the opioid epidemic
on first responder burnout. Drug and Alcohol Dependence 205,
107620. [Link]
S0376871619303977?via%3Dihub.

14. Williams-Yuen, J., Minaker, G., Buxton, J., Gadermann, A., & Palepu, A. 2020.
‘You’re not just a medical professional’: Exploring paramedic experiences
of overdose response within Vancouver’s downtown eastside. PLoS ONE
15, e0239559. [Link]
[Link].0239559.

15. Won, N. Y., Palamar, J. J., Mike, S. A., Fitzgerald, N. D., & Cottler, L. B. 2023. A
qualitative analysis of emergency medical services personnel experiences
and perception responding to drug overdoses in the US during the
COVID-19 pandemic. Journal of Health Research 37, 270–279. https://
[Link]/jhr/vol37/iss4/10/.

16. Dhanani, L. Y., Harris, E. L., Mirto, J., & Franz, B. 2022. Barriers to working
with patients who misuse opioids and physician burnout: Implications for
medical education. Substance Use & Misuse 57, 1177–1184. [Link]
[Link]/doi/full/10.1080/10826084.2022.2069264.

17. Saunders, E., et al. 2019. “You can see those concentric rings going out”:
Emergency personnel’s experiences treating overdose and perspectives
on policy-level responses to the opioid crisis in New Hampshire. Drug and
Alcohol Dependence 204, 107555. [Link]
article/abs/pii/S0376871619303321?via%3Dihub.

18. Vadiei, N., Eldridge, L. A., Meyerson, B. E., & Agley, J. 2022. “The gatekeepers
in prevention”: Community pharmacist perceptions of their role in the
opioid epidemic. Substance Abuse 43, 319–327. [Link]
com/doi/10.1080/08897077.2021.1941516.

19. Dowdell, E. B., Alderman, S. E., Foushee, N., Holland, E., & Reedy, E. A. 2022.
Expressions of compassion fatigue by emergency department nurses
caring for patients with opioid and substance use disorders. Journal of
Emergency Nursing 48, 688–697. [Link]
S0099-1767(22)00178-7/abstract.

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 34
Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

20. Horner, G., et al. 2019. “You’re kind of at war with yourself as a nurse”:
Perspectives of inpatient nurses on treating people who present with a
comorbid opioid use disorder. PLoS ONE 14, e0224335. [Link]
[Link]/plosone/article?id=10.1371/[Link].0224335.

21. Reese, S. E., et al. 2021. Experiences of nursing professionals working with
women diagnosed with opioid use disorder and their newborns: burnout
and the need for support. Advances in Neonatal Care 21, 32. https://
[Link]/advancesinneonatalcare/abstract/2021/02000/
experiences_of_nursing_professionals_working_with.[Link].

22. Cooley, R., Venkatachalam, A. M., Aguilera, V., Olson, D. M., & Stutzman,
S. E. 2022. A Qualitative study of nurses’ perceptions of narcotic
administration after subarachnoid hemorrhage. Pain Management Nursing
23, 151–157. [Link]
9042(21)00121-1/abstract.

23. Carroll, J. J., Colasanti, J., Lira, M. C., del Rio, C., & Samet, J. H. 2019. HIV
physicians and chronic opioid therapy: It’s time to raise the bar. AIDS Behav
23, 1057–1061. [Link]
2356-2.

24. Shearer, R. D., et al. 2024. Providers’ experiences and perspectives in treating
patients with co-occurring opioid and stimulant use disorders in the
hospital. Substance Use Addiction Journal 45, 250–259. [Link]
[Link]/doi/10.1177/29767342231221060.

25. Webster, F., et al. 2019. An ethnography of chronic pain management in

primary care: The social organization of physicians’ work in the midst of
the opioid crisis. PLoS ONE 14, e0215148. [Link]
pone.0215148.

26. St. Louis, J., et al. 2022. Barriers to care for perinatal patients with opioid
use disorder: family physician perspectives. Family Practice 39, 249–256.
[Link]

27. Gimenez, L., et al. 2024. Barriers and facilitators to the involvement of general
practitioners in the prescription of buprenorphine. Journal of Substance
Use and Addiction Treatment 156, 209182. [Link]
josat.2023.209182.

28. Hadler, R. A., et al. 2024. Dangerous variation or patient-centered

care? Palliative care and pain providers’ comfort, experiences, and
approaches when treating cancer pain with coexisting aberrant
behaviors. The American journal of hospice & palliative care. [Link]
org/10.1177/10499091241259034.

29. Desveaux, L., Saragosa, M., Kithulegoda, N., & Ivers, N. M. 2019. Family
physician perceptions of their role in managing the opioid crisis. Annals of
Family Medicine 17, 345–351. [Link]

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 35
Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

30. Haggerty, T., Sedney, C. L., Dekeseredy, P., Capehart, K. D., & Pollini, R. A.
2023. “You didn’t have a choice, but to be on your train. The train was
moving”: West Virginia pharmacists’ perspectives on opioid dispensing
during the evolution of the opioid crisis. Journal of the American Pharmacists
Association 63, 863–872. [Link]

31. Hohmeier, K. C., et al. 2022. Exploring the frontline experiences of pharmacy
technicians during the opioid epidemic in community pharmacies. Journal
of the American Pharmacists Association 62, 1338–1343. [Link]
org/10.1016/[Link].2022.03.005.

32. Kinney, S. G. & Kiesel, J. D. 2023. Physical therapy professionals’ opioid

knowledge and attitudes in a midwestern state: A cross sectional survey.
Internet Journal of Allied Health Sciences & Practice 22, 1–10. https://
[Link]/ijahsp/vol22/iss1/23/.

33. Sable, P., Tang, F., Swab, J. A., Roth, S., & Rosen, D. 2023. EMS workers on
the frontline of the opioid epidemic: effects of sleep and social support
on depression. IJES 12, 306–317. [Link]
0037.

34. Baumgart-McFarland, M., Chiarello, E., & Slay, T. 2022. Reluctant saviors:
Professional ambivalence, cultural imaginaries, and deservingness
construction in naloxone provision. Social Science & Medicine 309, 115230.
[Link]

35. Patch, K. et al. 2023. “It’s pretty sad if you get used to it”: A qualitative
study of first responder experiences with opioid overdose emergencies.
Prehospital Emergency Care 0, 1–8. [Link]
gov/37436072/.

36. Maxwell, J., et al. 2022. Perceptions of speech-language pathologists’

service provision in the opioid epidemic: A focus group study. American
Journal of Speech-Language Pathology 31, 1672–1686. [Link]
org/10.1044/2022_AJSLP-21-00337.

37. Cernasev, A., et al. 2021. Pharmacy technicians, stigma, and compassion
fatigue: Front-line perspectives of pharmacy and the US opioid epidemic.
IJERPH 18, 6231. [Link]

38. Boulden, R. & Brown, C. 2022. “We’re kind of forgotten”: An initial

investigation of Appalachian school counselors’ lived experiences
responding to the opioid crisis. APA PsycNet. [Link]
record/2023-34193-006.

39. Hurstak, E. E., et al. 2017. The risks of opioid treatment: Perspectives of
primary care practitioners and patients from safety-net clinics. Substance
Abuse 38, 213–221. [Link]

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 36
Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

40. Oberleitner, D. E., et al. 2021. “Day-to-day, it’s a roller coaster. It’s
frustrating. It’s rewarding. It’s maddening and it’s enjoyable”: A qualitative
investigation of the lived experiences of addiction counselors. Psychological
Services 18, 287–294. [Link]

41. Hatch-Maillette, M. A., et al. 2019. Counselor turnover in substance use

disorder treatment research: Observations from one multi-site trial.
Substance Abuse 40, 214–220. [Link]
PMC6759413/.

42. Williams, A. V., Strang, J., & Marsden, J. 2013. Development of opioid overdose
knowledge (OOKS) and attitudes (OOAS) scales for take-home naloxone
training evaluation. Drug Alcohol Dependence 132, 383–6. [Link]
org/10.1016/[Link].2013.02.007.

43. Heritage, B., Rees, C. S., & Hegney, D. G. 2018. The ProQOL-21: A revised
version of the Professional Quality of Life (ProQOL) scale based on Rasch
analysis. PloS one 13, e0193478–e0193478. [Link]
[Link].0193478.

44. Stamm, B. 2010. The concise manual for the professional quality of life scale.
[Link]
[Link].

45. Xiao, Y., Chen, T., Zhu, S., Li, C., & Zong, L. 2024. Factors associated with
workplace violence against Chinese healthcare workers: an online
cross-sectional survey. Frontiers in public health 12, 1295975. [Link]
org/10.3389/fpubh.2024.1295975.

46. Braun, V. & Clarke, V. 2021. Thematic Analysis: A Practical Guide. Sage
Publishing. [Link]
book248481.

47. Morse, J. M. 2015. Critical analysis of strategies for determining rigor in

qualitative inquiry. Qualitative Health Research 25, 1212–22. [Link]
org/10.1177/1049732315588501.

48. Wang, P., Wang, M., Hu, G., & Wang, Z. 2006. Study on the relationship
between workplace violence and work ability among health care
professionals in Shangqiu City. Wei sheng yan jiu= Journal of hygiene research
35, 472–474. [Link]

49. Tian, Y. et al. 2020. Workplace violence against hospital healthcare workers in
China: a national WeChat-based survey. BMC public health 20, 1–8. https://
[Link]/articles/10.1186/s12889-020-
08708-3.

50. Corman, M. K. 2023. Lights and Sirens: The Critical Condition of EMS in Alberta.
[Link]

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 37
Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

51. Occupational Cancer Research Centre (Ontario Health) and Institute

for Work & Health. 2025. Opioids and work: Evidence, perspectives,
and looking ahead workshop report. [Link]
sites/opioids/files/opioids_and_work_workshop_report_2024.
pdf?utm_source=IWH+subscribers&utm_campaign=63bdac321e-
IWH_NEWS_2025_06&utm_medium=email&utm_term=0_-
63bdac321e-547579776.

52. Galiher, M. V. & Huffman, M. 2022. Attitude changes following short-form

opioid overdose video education: a pilot study. Harm Reduction Journal 19,
114. [Link]
s12954-022-00696-4.

53. Halmo, R. S., Sellers, C. M., Collin, C.-R. R., Chinamasa, G., & Putney, J. M.
2022. Changes in social work students’ attitudes and knowledge following
opioid overdose prevention training. Substance Abuse 43, 289–293.
[Link]

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 38
 Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

appendix a - Data Extraction Table

Author/Year Title Geographic Study Participants Question/ Method Themes/Outcomes
Location Design Aim

Baumgart- Reluctant Saviors: Midwest, U.S. Interviews 20 first Explore Qualitative, Disconnect between the
McFarland et al., Professional responders: opinions descriptive imaginary and professionals’
2022 ambivalence, police, about and lived experience resulted in a
cultural firefighters, experiences profound feeling of futility
imaginaries, and and emergency with naloxone
Naloxone was not addiction
deservingness medical provision
treatment, resulting in a feeling
construction in technicians/
of futility—frustration that
naloxone provision paramedics
their attempts to help seemed
fruitless
Naloxone was not addiction
treatment, resulting in a feeling
of futility—frustration that
their attempts to help seemed
fruitless
Participants paying their
frustration forward to the
patient and naloxone resulted in
less compassion for patients

Beitel et al., 2018 Experiences of Connecticut, Interviews 31 drug Explore Qualitative, Burnout reported by
burnout among U.S. counselors experiences of descriptive participants was due to clinical
drug counselors burnout and demands such as emergencies,
in a large opioid the strategies patient volume, and work pace
treatment used to
Burnout symptoms included not
program: A manage and/or
completing expected work tasks
qualitative prevent it
and becoming irritable with
investigation
colleagues
Counselors emphasized the
importance of supervision in
reducing stress, being goal
driven, and gaining perspective
Drug counselors already
employed a large array of coping
strategies to minimize the risk
of burnout
The stressful nature of the
job (e.g., managing patient
behaviors, paperwork demands)
was identified as a common
cause of counselor burnout

Boulden & Brown, “We’re kind of Appalachia, U.S. Interviews Five school Examine lived Qualitative, “I do a lot of self-care because
2022 forgotten”: An counselors experiences descriptive you just have to; I make sure I
initial investigation working in do stuff for me”
of Appalachian communities
For teachers and educators,
school counselors’ adversely
there was frustration because
lived experiences affected by the
they just want to teach
responding to the ongoing opioid
opioid crisis epidemic Participants advocated to
address student basic needs
Participants had moments that
instilled hope and belief in their
effectiveness
There was a lack of quality
training for school staff
centered on opioid use and
addiction

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 39
 Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

Author/Year Title Geographic Study Participants Question/ Method Themes/Outcomes

Location Design Aim

Carroll et al., 2019 HIV physicians U.S. Interviews 10 HIV care Explore Qualitative, A perceived lack of clinical
and chronic opioid physicians concerns and descriptive training resulted in a deep
therapy: It’s time perspectives frustration
to raise the bar related to
Developing trusting
chronic opioid
relationships in primary care
therapy
was key for the promotion of
patient health
Monitoring patients receiving
chronic opioid therapy added
to the list of tasks the clinical
team then needs to address in a
limited amount of time
There was anxiety that any
disruptions to chronic opioid
therapy would destabilize the
patient-provider relationship

Cernasev et al., Pharmacy Tennessee, Focus groups 46 pharmacy Characterize Qualitative, Negative interactions between
2021 technicians, California, New technicians stigma through descriptive pharmacy staff and patients
stigma, and Jersey, Florida, pharmacy displaying signs of addictive
compassion Georgia, and technicians car- opioid-use behavior occurred
fatigue: Front-line Alabama; U.S. ing for patients
Participants believed that they
perspectives of using opioids
have developed or needed to
pharmacy and
develop a thick skin to deal with
the U.S. opioid
patients
epidemic
Participants displayed
frustration in dealing with
patients who seek early refills
or who might be attempting to
“game the system”
Participants were referred to
as the “face” of community
pharmacy
Technicians expressed empathy
for patients’ conditions and
a feeling of responsibility for
providing high-quality care

Cooley et al., 2022 A qualitative U.S. Interviews Nine Understand the Qualitative, Nurses were frustrated with not
study of nurses’ neuroscience experiences descriptive having access to “as needed”
perceptions intensive care and processes orders for the patient or
of narcotic unit nurses of nurses when multiple agents for pain
administration administering
There was difficulty
after subarachnoid opioids
distinguishing between the lack
hemorrhage
of alertness cause by opioids or
worsening bleeding
There was stress of needing
to please family with pain
management plans
When patients were able to
participate in exams and in their
own care, it affected the nurses’
morale and confidence in pain
management

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 40
 Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

Author/Year Title Geographic Study Participants Question/ Method Themes/Outcomes

Location Design Aim

Desveaux et al., Family physician Ontario, Canada Interviews 22 family Explore Qualitative, Knowing their patients reduced
2019 perceptions physicians perspectives descriptive participants’ concerns about
of their role in on opioid aberrant behavior and the
managing the prescribing, the perceived need to implement
opioid crisis management enforcement measures
of chronic
Participants were frustrated
noncancer pain,
by an inability to effectively
and differences
address patient needs
that may
be potential Physicians are already
drivers of experiencing unprecedented
practice rates of work-related stress and
variation burnout
Tension adhering to guidelines
while attempting to effectively
manage patient symptoms
occurred
There was conflict between
their desired role as a healer
and the emerging expectation to
police opioid use and misuse

Dhanani et al., Revisiting the Ohio, U.S. Surveys 408 board- Examine Quantitative, Contact with patients with OUD
2021 relationship certified bias, burnout, cross- may heighten the effects of
between contact physicians and stress sectional bias, burnout, and stress
and physician as potential
The conditional negative
attitudes towards situational
effects of bias, stress, and
patients with and personal
burnout on willingness to work
opioid use characteristics
with patients with OUD were
disorder
the strongest when levels of
contact were high

Dhanani et al., Barriers to Ohio, U.S. Surveys 408 physicians Assess Mixed Growth of non-prescription
2022 working with experiences methods, opioid use among patients was
patients who working with cross- identified as “overwhelming”
misuse opioids patients who sectional,
Key barriers to providing quality
and physician misuse opioids descriptive
patient care were frustration
burnout: and barriers
and burnout from participants’
Implications for encountered
work
medical education
Physicians described providing
empathetic care only to have
the patient experience a
negative outcome, resulting in
“compassion fatigue”
Positive feelings were described
by some physicians and included
feeling gratified, fulfilled, and
hopeful
Practices that made them
more resilient to burnout and
frustration included better
understanding their patient or
creating alternatives to opioid
treatment
They often felt helpless
to connect patients with
affordable, accessible, and
evidence-based treatment
services

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 41
 Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

Author/Year Title Geographic Study Participants Question/ Method Themes/Outcomes

Location Design Aim

Dowdell et al., Expressions Philadelphia, Focus groups 55 emergency Gain insight and Qualitative, Frustrations about the time
2022 of compassion U.S. nurses understanding descriptive spent, resources, and energy
fatigue by about devoted to patients with OUD
emergency perceptions and/or SUD contributed to
department (ED) and feelings compassion fatigue
nurses caring of caring for
Negative job satisfaction was
for patients patients with
com mon and related to the
with opioid and OUD and/or
ED environment
substance use SUD
disorders (SUDs) Overstressed nurses often react
by leaving a position when they
believe they will not get relief
Participants talked about
having hope that change would
happen in the ED, with staffing,
management, and workload
Stressors included being
understaffed, having few
available professional
supports, and an absence of
recognition from management/
administration

Filteau et al., 2022 “It’s more the just Montana, U.S. Interviews Seven care Examine the Qualitative, Difficulty treating a full case
a job to them”: coordinators, constraints descriptive load of MAT patients occurred
A qualitative three clinical providers
MAT contributed to stress and
examination social workers, face as well
burnout
of patient seven program as patients’
and provider managers, 12 experiences Participants needed to create
perspectives prescribing with MAT for boundaries and manage
on medication- providers, five OUD expectations for patients and
assisted peer support staff to prevent burnout
treatment for specialists,
opioid use six licensed Providers and staff reported
disorder addictions challenges recruiting staff, high
counselors, burnout levels, and an inability
10 registered to meet demands for substance
nurses,15 use treatment services
executive staff Staff genuinely cared for their
(including CEOs patients and want to provide the
and COOs), and best treatment they can
25 patients

Gimenez et al., Barriers and France Interviews, 17 general Investigate the Qualitative, Adoption of motivational or
2024 facilitators to focus group practitioners obstacles and descriptive educational approaches seemed
the involvement (GPs) facilitators to to liberate GPs from their own
of general involvement considerations and objectives
practitioners in in the
Frequent renewal of
the prescription of prescription of
prescriptions required a great
buprenorphine buprenorphine
availability and a lot of time
despite GPs already being
overwhelmed
GPs described their ethical
difficulty in risking seeing their
prescriptions used for drug
trafficking or recreational use
Management of patients
with OUD seemed to disrupt
GP-patient relationships
and generated a feeling of
powerlessness
Patients’ knowledge could
exceed that of GPs and may
have destabilized them, leading
to their role being reduced to
that of a passive prescriber

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 42
 Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

Author/Year Title Geographic Study Participants Question/ Method Themes/Outcomes

Location Design Aim

Hadler et al., 2024 Dangerous U.S. Interviews Eight nurse Explore how Qualitative, Clinicians perceived themselves
variation or practitioners/ clinicians with descriptive as prescribers of last resort for
patient-centered PAs, 29 specialized patients with cancer pain and
care? Palliative physicians training in aberrant drug-related behaviors
care and pain palliative
Limited availability of addiction
providers’ comfort, care and pain
specialists was a significant
experiences, management
source of distress
and approaches approach the
when treating management Participants reduced opioid
cancer pain of aberrant prescribing in response to
with coexisting drug-related increasing administrative and
aberrant behaviors in medico-legal burden
behaviors clinical practice
Participants reported that their
access to social workers and
other specialists was limited by
time and caseload
Participants worried about the
repercussions of prescribing
medications that might be
abused, resold, or implicated in
an overdose

Haggerty et al., “You didn’t have a West Virginia, Interviews 10 pharmacists Understand Qualitative, Larger societal forces were
2023 choice, but to be U.S. the need for descriptive perceived to be at play,
on your train. The and impact contributing to a sense of
train was moving”: of restrictive powerlessness
West Virginia opioid
Pharmacists felt that their
pharmacists’ legislation on
employers did not “have their
perspectives on practice and
back” if they decided not to fill a
opioid dispensing patient care
prescription for a patient
during the
evolution of the Pharmacists who question
opioid crisis an opioid prescription were
occasionally met with hostility
from both patients and
prescribers
The opioid crisis has increased
the burden of patient counseling
and medication surveillance
They felt empowered by recent
policy changes to interrupt
individual prescriptions or act at
the individual patient level
They were aware of their
responsibility, but they felt
pressure from employers to
fill prescriptions despite their
suspicions about excessive
opioid prescribing

Hatch-Maillette et Counselor U.S. Surveys 64 counselors Provide a Quantitative, Accelerated turnover occurred
al., 2019 turnover in qualitative cross- due to increased productivity
SUD treatment description sectional expectations, increases in
research: of challenges caseload, and decreases in
Observations from related to administrative time
one multisite trial effectiveness
Counselors were asked to
research in
mount complicated evidence-
SUD treatment
based practices, resulting in
settings
performance pressure and
competing priorities
One of the barriers in the
behavioral health arena is staff
turnover

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 43
 Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

Author/Year Title Geographic Study Participants Question/ Method Themes/Outcomes

Location Design Aim

Hohmeier et al., Exploring Tennessee, Focus groups 46 pharmacy Explore Qualitative, Given the intensity of
2022 the frontline California, New technicians intentions and descriptive negative interactions with
experiences Jersey, Florida, motivations opioid dispensing, pharmacy
of pharmacy Georgia, and for serving technicians felt drained,
technicians Alabama; U.S. patients who fatigued, and numb
during the are receiving
Participants perceived bearing
opioid epidemic prescription
the brunt of the negative
in community opioid medica-
interactions with patients
pharmacies tions
receiving opioid medications
Patient-technician interactions
included participants being
patient advocates and
establishing rapport
Positive and supportive
coworker interactions and
time away from patient care to
“regroup” was felt to mitigate
emotional problems
Support from pharmacists was
suboptimal, with technicians
feeling underappreciated and
undervalued
There was a rising degree of
compassion fatigue

Horner et al., 2019 “You’re kind of at Boston, Interviews 22 nurses Understand Qualitative, Feelings associated with
war with yourself Manhattan, U.S. the attitudes, descriptive burnout were common
as a nurse”: perceptions among nurses, with several
Perspectives of and training expressing frustration and
inpatient nurses needs of nurses exhaustion working with a more
on treating people caring for “demanding” population
who present with patients with
Feelings of disappointment
a comorbid opioid OUD
stemmed from wanting to
use disorder
trust patients but often being
let down
Hostile interactions contributed
to a “cycle of problems” and
perpetuated stigma against
patients
There was a notion of offering
futile care to patients who may
not be willing or able to fully
recover
There was internal conflict over
medicating pain, worrying that
pain medicine would contribute
to addictions
There were attempts to reframe
addiction as a disease to
approach patient concerns as
genuine

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 44
 Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

Author/Year Title Geographic Study Participants Question/ Method Themes/Outcomes

Location Design Aim

Hurstak et al., The risks of San Francisco Interviews 23 primary care Analyze how Qualitative, Fear of overdose, misuse, and
2017 opioid treatment: Bay Area, U.S. providers (PCPs) clinicians and descriptive diversion had prompted shifts
Perspectives and 46 patients their patients in opioid prescribing, both at
of primary care with chronic the level of the clinic and the
practitioners and non-cancer individual clinician
patients from pain and past Fears about opioids are evolv-
safety-net clinics or present ing in the context of publicity
substance use of opioid risks, the issuing of
perceived the guidelines, clinician education
risks of opioids on opioid risk, opioid monitoring
policies, and reports of clinician
prosecution
PCPs had a sense of per-
sonal responsibility to prevent
overdose through “disciplined”
prescribing
PCPs worried that co-prescrib-
ing naloxone meant that they
were acknowledging the serious
risks of opioids while continuing
to prescribe them

Kinney & Kiesel, Physical therapy Indiana, U.S. Surveys 67 PT Determine Quantitative, Few PT professionals felt they
2023 professionals’ professionals opioid cross- had a role in an emergent opioid
opioid knowledge knowledge, sectional overdose
and attitudes in a attitudes Participants indicated a desire
midwestern state: towards opioid to help in emergent opioid
A cross-sectional use, and overdoses
survey knowledge on Participants indicated they did
managing an not have enough training to
opioid overdose manage emergent overdose
situations
Participants lacked confidence
in administering naloxone

Lofaro & Sapat, Occupational U.S. Surveys 2 722 EMS- Examine Quantitative, Indirect and direct personal
2024 and personal providers,1 the lived cross- experiences with addiction
challenges during 114 law experiences of sectional positively influenced first
the opioid crisis: enforcement first responders responders’ opinions
Understanding officers and opinions
Participants were often coping
first responders’ about clients
with multiple hazards and
experiences and with opioid use
stressors simultaneously
viewpoints of disorder
clients with opioid Participants were tasked
use disorder with responding to overdose
calls and reviving people from
overdose while coping with
addiction-related issues in their
personal lives

Louis et al., 2022 Barriers to care for U.S. Interviews 17 family Describe Qualitative, Implementation of a new
perinatal patients physicians experiences descriptive documentation method led
with opioid providing to less time scheduled for
use disorder: comprehensive counselors’ documentation and
Family physician care to paperwork
perspectives pregnant
Persistent negative interactions
people with
occurred between patients
OUD and the
seeking opioid medications
challenges
and “gatekeeper” health care
faced in
workers
providing such
care Providers described the time
and frustration of filling out
prior authorization forms to
ensure access to buprenorphine
products

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 45
 Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

Author/Year Title Geographic Study Participants Question/ Method Themes/Outcomes

Location Design Aim

Luckett et al., Risk of opioid New South Interviews 22 GPs Explore Qualitative, Compassion towards patients
2020 misuse in people Wales, experiences, descriptive with cancer caused GPs to be
with cancer Australian beliefs and slower to determine opioid
and pain and Capital Territory, attitudes misuse or addiction
related clinical Queensland, concerning
Discharge letters from cancer
considerations: and South the risk of
services were often delayed
A qualitative Australia; opioid misuse
and rarely included information
study of the Australia in people
about opioid therapy
perspectives of with pain and
Australian general cancer and Media attention and monitoring
practitioners related clinical in response to the opioid crisis
considerations led to reluctance among GPs to
prescribe, even when opioids
were indicated
The time required to engage in
high-quality, person-centred
pain management was
constrained by the business
model of contemporary primary
care
There were concerns that
patients might stockpile opioids
as a recourse for ending their
own life

Maxwell et al., Perceptions of West Virginia, Focus groups 20 SLPs Learn from Qualitative, Frustration occurred with
2022 SLPs’ service U.S. experiences descriptive other professionals, with
provision in the of working caregivers, with slow progress,
opioid epidemic: A with children with themselves, with lack of
focus group study with a history information, and so forth
or suspected
Many participants expressed
history of
that their primary role is
opioid exposure
advocacy, with a focus on
on a daily basis
establishing relationships
Participants had personal
initiatives to seek out additional
information on working with
children and increase their
ability to support students
Participants were concerned
for these children and felt
helplessness about how to best
meet their needs
There was uncertainty about
eligibility criteria and unclear
roles and responsibilities due to
complex needs of children
There were difficulties related
to providing assessment and
intervention services such as
lack of relevant information,
difficulty providing the one-on-
one services, and barriers to
service delivery

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 46
 Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

Author/Year Title Geographic Study Participants Question/ Method Themes/Outcomes

Location Design Aim

Oberleitner et al., “Day-to-day, it’s Connecticut, Interviews 31 addiction Exploration Qualitative, Counselors attempted to
2021 a roller coaster. U.S. counselors of addiction descriptive shape the reactions of others
It’s frustrating. counselors’ by emphasizing their clinical
It’s rewarding. It’s lived expertise and their positive
maddening and experiences contribution to the opioid crisis
it’s enjoyable”: by examining
Counselors find themselves
A qualitative their work
adopting the roles of educators
investigation roles, work
and advocates with others
of the lived motivation,
who often hold inaccurate or
experiences and perceived
pejorative views of their work
of addiction responses of
counselors others to their Counselors who treat clients
work with addiction also experienced
stigma
Counselors’ enjoyment of the
complexity, challenge, and the
witnessing of improvements
in their clients’ lives were
important intrinsic motivation
factors
Positive interactions with clients
were self-reinforcing

Patch et al., 2023 “It’s pretty sad if Ohio, U.S. Interviews 18 firefighters, Understand Qualitative, Participants reported becoming
you get used to it”: emergency experiences descriptive “numb,” “callous,” and
A qualitative study medical and attitudes “desensitized” in their response
of first responder technicians or toward
Perceived inefficacy seemed
experiences with paramedics treating opioid
to have a negative cumulative
opioid overdose overdose, as
effect over time, leading
emergencies well as the
to compassion fatigue,
emotional
hopelessness, demoralization,
effects, coping
desensitization to patients, and
strategies,
burnout in some participants
support
systems, Respondents coped with
and views on the stress of opioid-related
policies related emergencies by talking about
to the opioid calls with others, creating
epidemic boundaries between work and
home life, and practicing general
healthy habits and stress relief
Respondents expressed
compassionate views about
patients and said their beliefs
about opioid addiction had
evolved and led to increased
compassion
Respondents expressed
frustration with perceived
limitations on their ability
to affect long-term patient
outcomes
Respondents felt that it is not
their “job to solve this problem”
Some participants shared
that the cumulative emotional
effects of these and other
emergencies had led them to
seek temporary transfers to
lesser-affected areas

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 47
 Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

Author/Year Title Geographic Study Participants Question/ Method Themes/Outcomes

Location Design Aim

Pike et al., 2019 A mixed-methods Kentucky, U.S. Interviews and 196 first Examine Mixed Community opioid misuse was a
assessment of surveys responders: burnout by methods, significant problem that has led
the impact of the 151 law describing it cross- to burnout among participants
opioid epidemic enforcement among first sectional, and increased burdens on
on first responder officers, 36 responders, descriptive available services
burnout firefighters/ exploring how
Participants expressed
paramedics/ the opioid
helplessness to prevent future
emergency epidemic has
overdoses, particularly when
medical affected their
responding to calls for the same
technicians profession,
individuals
(EMTs), nine and examining
dispatchers; 12 how the effects Positive feelings demonstrated
first responder of the opioid a sense of job satisfaction or
interviews epidemic engagement with their job that
differed among is the opposite of burnout
their fields of
work Risks to personal safety further
increased stress and reduced
compassion among participants
The opioid epidemic affected
participants’ professions and
made it more difficult for them
to perform their job duties
There was a growing
indifference or a numbed
emotional response

Rao et al., 2021 Pharmacist views Pennsylvania, Surveys 50 community Explore Qualitative, Negative attitudes toward
regarding the West Virginia, pharmacists opinions, descriptive MAT seemed to stem from
prescription opioid and Ohio; U.S. experiences, a lack of knowledge of their
epidemic and beliefs effectiveness
relating to
Participants perceived their
the use and
current practice scope to be
misuse/abuse
limited and unsuitable for role
of prescription
expansion
opioids and the
prescription Personal experiences helped
opioid epidemic motivate participants to provide
in the U.S. better care
Personal experiences motivated
them to provide better care
Pharmacists were frustrated
and felt that prescribers will
view them as an interfering
Prescribers did not support their
clinical judgment

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 48
 Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

Author/Year Title Geographic Study Participants Question/ Method Themes/Outcomes

Location Design Aim

Reese et al., 2021 Experiences Utah, U.S. Focus groups 30 nurses Understand Qualitative, At times, participants
of nursing or nursing experiences descriptive experienced their work as
professionals assistants caring for rewarding and patients as
working with women pleasant and enjoyable
women diagnosed diagnosed with
Burnout led to a reduction in
with opioid use OUD and their
work satisfaction, a higher
disorder and newborns on
turnover rate, relationship
their newborns: a maternal–
stress, substance misuse,
Burnout and need newborn
depression, and suicide
for support and neonatal
intensive care Negative feelings toward
unit women with OUD may have
been related to the experience
of burnout—a constellation of
symptoms including “emotional
exhaustion, depersonalization,
and a diminished sense of
personal accomplishment”
Participants felt supported by
the team
Participants had concerns
for the welfare of newborns
and frustration with what
they perceived as disengaged
parents
Patients diagnosed with OUD
were more time- and labor-
intensive

Sable et al., 2023 EMS workers on Pennsylvania, Surveys 608 emergency Examine the Quantitative, Feelings of helplessness and
the frontline of the U.S. medical service impact of opioid cross- lack of capacity to help were
opioid epidemic: (EMS) workers overdose calls sectional associated with reported
Effects of sleep and attitudes emotional stress and feelings
and social support towards of burnout
on depression individuals
Improved sleep and social
with SUDs on
support significantly reduced
EMS workers’
the impact of frequent overdose
mental well-
calls on depression
being
Lack of treatment options
for individuals with OUD may
have contributed to feelings of
helplessness
Many workers would turn to
a colleague for work-related
stress
More negative attitudes about
opioid use and treatment were
associated with an increased
likelihood of experiencing
depression
Their concerns were not only
related to physical safety and
workload, as the epidemic
also affected their emotional
well-being
Workers favor harm
reduction policies, citing their
effectiveness as the main
reason for their support

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 49
 Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

Author/Year Title Geographic Study Participants Question/ Method Themes/Outcomes

Location Design Aim

Saunders et al., “You can see New Hampshire, Interviews 36 emergency Examine Qualitative, After overdoses occur,
2019 those concentric U.S. personnel: six emergency descriptive interactions between physical,
rings going out”: firefighters, six personnel’s economic, social, and policy-
Emergency police officers, experiences related factors create challenges
personnel’s six EMS, nine responding for responders
experiences physicians, five to overdose,
Coping mechanisms utilized by
treating overdose nurses, two including
participants included seeking
and perspectives ED medical the process
professional counseling, having
on policy-level directors/ of treating
informal conversations with
responses to the physicians, one overdoses,
colleagues and friends, utilizing
opioid crisis in paramedic, personnel’s
humor, or switching roles to
New Hampshire one PA knowledge
minimize time in the field
about illicitly
manufactured Frustration occurred due to
fentanyl, numerous physical, economic,
and the and policy-level barriers
personal and
professional Participants recognized
impact of symptoms of compassion
responding fatigue or posttraumatic stress
among themselves or their
colleagues, including symptoms
like fatigue, powerlessness,
fear, and intrusive recollections
of events
The burgeoning increase in
overdose-related encounters
took a significant emotional toll
on participants, who described
feeling burned out, exhausted,
and helpless at times

Shearer et al., Providers’ Midwest, West, Interviews 20 participants: Explore current Qualitative, Participants described unstable
2024 experiences and and Northeast 11 physicians approaches descriptive life circumstances and medical
perspectives in U.S. (trained in to addressing comorbidities that frequently
treating patients psychiatry, opioid and complicated care for patients
with co-occurring internal, stimulant co- with co-use
opioid and emergency, use; challenges
Participants had “less
stimulant use and family specific to
enthusiasm about treatment
disorders in the medicine), four co-use; and
success” and anticipated poor
hospital nurses, three opportunities
treatment outcomes
social workers, for improving
and two treatment of Participants reported difficulty
pharmacists patients with distinguishing between opioid
co-use in the and stimulant withdrawals
hospital setting
Without effective pharmacologic
options, providers felt that
treating stimulant use disorder
was futile and often ignored it
during patients’ hospital stays

Vadiei et al., 2022 “The gatekeepers Indiana, U.S. Surveys 214 Evaluate Qualitative, Burden of work was so high
in prevention”: pharmacists community descriptive that it prevented opioid-related
Community pharmacists’ consultation interventions
pharmacist perception of
Feelings of frustration were
perceptions of their role in the
derived from patients and
their role in the opioid epidemic
coworkers in respect to
opioid epidemic and assess
their many obligatory job
what barriers
requirements
they face in
fulfilling their Participants felt like a
perceived role “gatekeeper in prevention” for
opioid misuse in their patient
population
Structural barriers were
reported, such as burden of
responsibilities, minimal time,
lack of service reimbursement,
and limited consultation space

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 50
 Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

Author/Year Title Geographic Study Participants Question/ Method Themes/Outcomes

Location Design Aim

Webster et al., An ethnography Ontario, Canada Interviews 19 PCPs and Explore Qualitative, PCPs are often unable to
2019 of chronic pain eight nurses experiences of descriptive effectively facilitate treatments
management in providing care because their patients struggle
primary care: the to patients with with more pressing and
social organization chronic pain immediate concerns, such as
of physicians’ housing
work in the midst
Physicians described being
of the opioid crisis.
frustrated, worried and
distressed by their inability to
address their patients’ most
pressing needs
Providing care now frequently
revolves around restricting
and reducing opioid dosing in
patients with chronic pain
Stress, emotional exhaustion
and even depersonalization are
linked with treating patients
with low socio-economic status
The shifting nature of the work
performed by care providers
caused them frustration,
exhaustion and compromised
job satisfaction

Williams-Yuen et “You’re not Vancouver, Interviews 10 paramedics Explore Qualitative, Encountering repeat patients
al., 2020 just a medical Canada experiences descriptive who overdose was described as
professional”: during the an experience which often left
Exploring overdose crisis participants feeling helpless
paramedic
Increased call volumes which
experiences
paramedics responded to was
of overdose
cited as a source of stress
response within
Vancouver’s Participants addressed the
downtown lack of control and feelings
eastside. of frustration by trying to
understand patient perspectives
and adopting empathetic
attitudes
Participants described feeling
frustration and resentment
during patient encounters, with
one paramedic labeling their
experience as “compassion
fatigue”
Participants described feeling
frustration and resentment
during patient encounters
Participants often faced
difficulties when moving
overdose patients to different
levels of care
Participants prioritized patient
needs above regular protocols

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 51
 Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

Author/Year Title Geographic Study Participants Question/ Aim Method Themes/Outcomes

Location Design

Won et al. (2023) A qualitative U.S. Interviews 69 EMS chiefs, Explore Qualitative, “Compassion fatigue” resulted
analysis of 12 paramedics, perspectives on descriptive not only from large caseloads,
emergency 10 EMTs, and the substance use but also from aiding the same
medical services eight others crisis, overdose overdose patients “day in and
(EMS) personnel events, naloxone day out”
experiences administrations, Call volumes overall increased
and perceptions and burnout during the pandemic
responding to EMS personnel provided harm
drug overdoses reduction and outreach to
in the United patients
States (US) Increases in drug-related
during the emergencies placed great strain
Covid-19 on the full EMS system and led
pandemic to reported burnout among EMS
personnel
Participants continued to
reiterate the importance of not
disregarding the opioid epidemic
Participants reported reduced
personal time and vacation
Participants reported that due
to chronic exposure to assault
and dishonesty, their morale
was destroyed their views about
society overall were skewed
Repeated visits felt “like a waste
of resources,” or participants felt
that “overdose is irresponsible
and self-induced”
Strain related to the extra work
reportedly led to high turnover
rates with some EMS personnel
quitting to search for less
stressful jobs

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 52
Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

appendix b - Survey Instruments

Section A of the survey was a 12 question multi-dimensional survey with three
subscales: 1) Opioid-related factors, 2) Professional characteristics, and 3)
Demographics. The response categories are a mixture of nominal, ordinal, and
categorical. Question 2, “Have you been affected at work by the opioid/drug
poisoning crisis?” served as a screening question. If the participant answered
“no,” they were directed to the end of the survey and excluded from the study.
If the participant answered “unsure” they were included in our analysis since
participants had some level of effect regarding the opioid crises. These questions
were created by the research team to document the profile of the people
who completed the survey and ensure that survey participants had relevant
experience to the study.

Section B included the Opioid Overdose Knowledge Scale (OOKS)43,53 which is

a 45-item measure designed to assess knowledge related to opioid overdose
prevention, recognition, and response actions. The OOKS is a multi-dimensional
scale that has the following subscales: 1) Opioid Overdose Recognition, 2)
Naloxone Use Knowledge, and 3) General Awareness of Opioid Overdose
Prevention43. The OOKS items have the response selections yes/no or don’t
know and true/false or don’t know, where a correct answer scored the participant
a single point and don’t know or incorrect responses scored no points43. There
is an answer key that accompanies these questions, as they assess knowledge
about opioids. The possible range of scores for the OOKS is from 0 to 45, with
higher scores indicating greater knowledge about opioid overdose prevention43.

The OOKS has shown good reliability with a Cronbach’s Alpha score of 0.83
and test-retest reliability ICC total score was excellent (ICC = 0.90 total score of
subscales and varying range of subscales from 0.53 to 0.87)43. The OOKS was
compared to other scales like the Opioid Overdose Attitude Scale (OOAS) and
Brief Opioid Risk and Recognition Assessment (BORRA) to assess concurrent
validity43. The OOKS had a positive correlation with the OOAS (r = 0.51, p <
0.001)43.

The positive correlation indicates that higher knowledge on the OOKS is

associated with increased knowledge about opioid overdose treatment and
prevention43. In a previous study, health care professionals had a significantly
higher score on OOKS compared to their non-health care profession family
members43. The assessment of reliability and validity was assessed in other
studies that included health care professionals, similarly to our study43.

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 53
Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

Section C included the Opioid Overdose Attitude Scale (OOAS)43,53, a 28-

item multi-dimensional scale with three sections: competence, concerns, and
readiness43. The OOAS is designed to measure attitudes toward opioid overdose
prevention and response43. The OOAS uses a 5-point Likert scale with the
following response options:
o Completely disagree (1 points)
o Disagree (2 points)
o Unsure (3 points)
o Agree (4 points)
o Completely agree (5 points)43

The scores ranged from a low of 28 to a high of 140 where higher scores indicate
increased readiness and willingness to intervene in an opioid overdose53. Any
negatively worded items are reversed scored at data entry53. The OOAS has
shown good reliability with a Cronbach’s Alpha score of 0.90 and test-retest
reliability ICC total score was good (ICC = 0.82 total score of subscales and varying
range of subscales from 0.55 to 0.65)43. According to Williams et al43 the OOAS
is a valid tool that is suitable for assessing training on overdose management
and naloxone administration. Like the OOKS, health care professionals had a
significantly higher score on OOAS compared to their non-health care profession
family members43.

Section D used the Professional Quality of Life Scale (ProQOL version 5)45 is
a 30-item questionnaire using a multi-dimensional scale that includes the
subscales compassion satisfaction (CS), burnout (BO), and secondary traumatic
stress for professionals’ (STS)45). ProQOL uses a 5-point Likert scale, with the
response options:
o Never (1 points)
o Rarely (2 points)
o Sometimes (3 points)
o Often (4 points)
o Very often (5 points)45

Theoretical scores for each subscale range from 10 to 50 with a total score range
from 50 to 15045. Higher scores on the CS subscale indicate greater satisfaction
derived from work and higher scores on the BO or STS subscales suggest greater
levels of distress or negative outcomes45.

The ProQOL subscales measured by Cronbach's alpha has high reliability for
CS (0.88), an acceptable level of reliability for BO (0.75), and good reliability
with STS (0.81)45. The ProQoL is widely used and considered to have good
construct validity supported by over 200 published papers and widespread use
in research on compassion fatigue, secondary traumatic stress, and vicarious
traumatization45. Inter-scale correlations show minimal shared variance between

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 54
Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

CS and the BO and STS (r = -0.23, 2% shared variance with STS; r = -0.14, 5%
shared variance with BO)45. Burnout and STS share 34% variance (r = 0.58),
likely reflecting common distress45. However, the two scales remain distinct, as
burnout does not measure fear, which is central to STS45.

Section E included a modified version of the Workplace Violence Survey (WVS)49

to assess whether participants had encountered any types of violence from
patients or patients' relatives/friends in the past year50. The modified WVS is
a 7-item questionnaire that is multi-dimensional with the subscales physical
violence, verbal abuse, bullying/mobbing, sexual harassment, and psychological
violence50. Each subscale measures distinct forms of violence experienced in the
workplace using a 4-point Likert scale with the responses:
o None
o 1 time
o 2-3 times
o > 4 times50

The responses are reported in frequencies per category with higher frequencies
indicating a greater prevalence of workplace violence50. The WVS used in Tian et
al50 is a 5-item questionnaire shown to have acceptable to good reliability with
Cronbach’s coefficient of 0.75 and 0.92 among health care workers (similar to our
study’s population) in China46,50.

Section F consists of three open-ended questions developed by the research

team, allowing participants to elaborate on any issues covered in the survey.
Participants can also provide their contact information to be considered for an
interview, and a gift card draw. The entire survey including sections A through
F took most participants around 30 minutes to complete. Participants were
also invited to provide their email address to be contacted to learn more about
participating in a qualitative interview.

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 55
Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

appendix c - Interview Guide

We are planning to interview around 40 people across Alberta who are part of
HSAA. In these interviews, we hope to learn more about how your work may be
affected by the drug poisoning crisis.

Interviews will be conversational and open-ended; however, this interview

guide will give some structure to the conversation. Researchers will ask follow-
up questions, such as, ‘can you tell me more about what you meant when you
said…?’ or ‘can you expand on that?’

Introduction/Background
Please tell me about your professional role.
What got you interested in working in this position?

Drug Poisoning
What does your daily work look like? What is going well/ are the main challenges?
What kind of training or education have you had about opioids/overdoses/drug
poisonings?
How has your work been changed by the drug poisoning/overdose crisis?
Did COVID-19 also seem to influence the drug poisoning crisis?
How has your role been affected?
Do you feel confident to respond to a drug poisoning?

Impact
What impact have these work changes/the drug poisoning crisis had on you
personally?
What strategies do you use to manage these changes?
Have you been offered any formal support? Would you like any formal support? If
no, why? What form might this take?
What strategies do you use to manage the impact of drug poisonings on you/
your work?
If the participant responds to drug poisonings regularly: Do you feel differently
about clients after responding to repeated drug poisonings? (clients in general,
not a specific person)
If the participant is in the mental health professionals group (addiction
counsellors, psychologists, social workers): What resources are in place for you to
manage the impact of this work?

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 56
Par k l an d I n s t i t ut e • Novemb er 2 0 2 5

Safety
Have you felt unsafe at work relating to drug poisonings? If yes, could you give
me an example? Possible prompt about emotional or verbal abuse, if relevant
Have you sought out resources after experiencing abuse at work? Why/Why not?
We have talked about a lot of important things today, is there anything I missed
or that you would like to share with me?

Closing
Thank the participant for their time and for sharing their valuable knowledge and
experiences.

Ripple Effects: The Drug Toxicity Crisis and Its Impact on Frontline Health Workers 57
 4-50 Arts and Convocation Hall
University of Alberta
Edmonton AB | T6G 2E6
Phone: 780.492.8558
Email: parkland@[Link]
Website: [Link]

ISBN: 978-1-997612-00-1