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. Author manuscript; available in PMC: 2025 Sep 9.
Published in final edited form as: J Workplace Behav Health. 2025 Aug 13;40(3):415–432. doi: 10.1080/15555240.2024.2390018

A Cross-Sectional Evaluation of City Firefighters’ Exposure to Potentially Traumatic Events During Opioid Overdose Responses and Mental Health

Douglas M Wiegand 1, Sophia K Chiu 1, Kendra Broadwater 1, Jessica F Li 1
PMCID: PMC12416402  NIHMSID: NIHMS2014187  PMID: 40927385

Abstract

Firefighters often serve as emergency medical services providers and face repeated exposure to potentially traumatic events (PTEs) while participating in opioid overdose responses (OORs), which may impact their mental health. A survey of 173 firefighters who had participated in an OOR in the previous 6 months was used to assess exposure to PTEs during such events, job stress, mental health symptoms, and resources used to address mental health symptoms. Most firefighters (97%) reported experiencing one or more PTEs while responding to an opioid overdose in the past 6 months. Associations between PTEs and mental health are reported. For example, there was a higher prevalence of high job stress (22.7% vs. 5.3%, p = 0.014) and meeting the screening definition of PTSD (15.4% vs. 1.9%, p = 0.047), depression (33.1% vs. 6.1%, p = 0.022), and anxiety (33.1% vs. 6.1%, p = 0.022) among those who experienced a needlestick injury during an OOR than those who did not experience a needlestick injury during an OOR. Seeking social support is recommended following PTEs; mental health care should be sought when symptoms interfere with personal, social, or occupational functioning. This survey identified important firefighter mental health characteristics which will assist fire departments in determining the appropriate mental health training, support, and services.

Keywords: opioid, overdose, firefighter, trauma, mental health, job stress, needlestick

Firefighters and Job Stress

Firefighting is an essential part of emergency response and an inherently stressful occupation. For example, the CareerCast (2019) annual report on stressful occupations lists firefighting as the second most stressful job in the United States, following active-duty military personnel. Firefighters are in a high-risk occupation where their lives are endangered regularly, and they have a variety of life-saving duties beyond fire suppression. These include responding to medical crises, explosions, spills, and disasters.

Work-related stressors for firefighters include psychosocial stressors such as interpersonal conflict, concerns over organizational fairness, and fatigue sensitivity (Igboanugo, Bigelow, & Mielke, 2021; Kaufffman, Manning, Zvolensky, et al., 2022). These stressors have been associated with various health outcomes including mental health symptoms, burnout, alcohol use disorders, sleep quality, and somatic disorders (Igboanugo et al., 2021). Job demands, job control, social support, and exposure to traumatic events are predictors of psychiatric distress in firefighters, with job control and social support moderating these relationships (Teoh, Lima, Vasconcels, et al., 2019). Additionally, there are various physical stressors (e.g., heat exposure, heavy equipment and personal protective equipment, long and/or irregular hours) that are inherent to the job (Kauffman et al., 2022; Meyer, Zimering, Daly, et al., 2012).

Much research on job stress of firefighters relies on general occupational stress scales that measure work organization and psychosocial factors such as work demands, decision latitude, and social support. While these instruments provide valuable insights into the overall stress experienced by firefighters, it is equally important to consider stressors specific to firefighting (Igboanugo, Bigelow, & Mielke, 2021; Lee, Lee, Kim, et al., 2017) and associated duties such as providing emergency medical services (EMS) (McGarry and O’Connor, 2023). These specific stressors can have a significant impact on the mental health and well-being of firefighters. For example, general measures of job stress do not account for stressors such as needlestick injuries, which are a source of significant fear, anxiety and emotional distress for firefighters and other healthcare workers (Lee, Botteman, Xanthakos, & Nicklasson, 2005).

Firefighters and Opioid Overdose Responses (OORs)

Firefighters are often the first responders to 911 emergency calls involving opioid overdoses. Opioid-involved overdose deaths in the U.S. increased from 49,860 in 2019 to 68,630 in 2020. This was followed by a further increase in 2021 to 80,411 overdose deaths (Spencer, Miniño, & Warner, 2022). Some studies have found that EMS encounters with naloxone administrations have increased in recent years. For example, a study of Baltimore, Maryland fire department records showed that the number of EMS encounters with naloxone administration doubled every two years between 2012–2017 (Dun, Allen, Latkin et al., 2022). An analysis of law enforcement officer naloxone administration increased 13.1% from 2019 to mid 2020 in New York State (Pourtaher, Payne, Fera, et al., 2022). A mixed methods study found that first responders reported increased workloads and emotional effects related to responding to opioid overdoses (Pike, Tillson, Webster, et al., 2019).

This increased workload of responding to more OORs may lead to increased and/or different kinds of workplace stressors on responders. For instance, Pike, et al. (2019) found that 95% of first responders believed that the opioid overdose epidemic affected their professions, and 56% reported that it made their jobs more difficult. Another study using qualitative methods reported themes of burnout, compassion fatigue, and hopelessness among firefighters with experience responding to opioid overdoses (Patch, Huang, Hendriks, et al., 2023).

Firefighters and Potentially Traumatic Events (PTEs) During OORs

Firefighters and other first responders are susceptible to the mental strain of witnessing and experiencing PTEs (examples may include seeing neglected or unaccompanied children, administering naloxone/Narcan®, handling human remains, being physically attacked) while responding to opioid overdose emergencies (Wagner, White, Buys, et al., 2021; Lee, Lee, Kim, et al., 2017; Myall, Roswell, Lund, et al., 2020).

There can be large numbers of opioid overdose emergencies in a short amount of time (i.e., mass overdose), and first responders may be called to intervene on the same individual(s) on multiple occasions, which can lead to stress and burnout (Pike et al., 2019). Such repeated experiences are associated with serious mental health issues such as post-traumatic stress disorder (PTSD), depression, and anxiety among first responders (Pinto, Henriques, Jongenelen, et al., 2015; Wagner, White, Randall, et al., 2020; Wagner et al., 2021). While a cause-and-effect relationship is difficult to determine, there is much to be learned about the types of PTEs firefighters experience during OORs and their association with mental health outcomes.

Firefighters and Mental Health

A recent review of the literature (Wagner et al., 2021) found elevated levels of mental health symptoms among firefighters compared to the general population. PTSD rates among firefighters ranged from 3.9%–54% (mean of 14.3%); depression rates ranged from 0%–33% (mean of 12.1%), and anxiety rates ranged from 1.4%–19.4% (mean of 8.9%). By recognizing the types of PTEs most associated with poor mental health, we can have a greater understanding of the impact of these occupational exposures, and interventions can be tailored and support systems developed to prevent or address poor mental health outcomes. The current work contributes to the literature by examining PTEs within the context of OORs and their association with mental health.

In May 2018, we conducted a survey with firefighters providing emergency services to a city in Ohio of 300,000 residents. The metro-sized department responded to approximately 66,000 incidents involving basic or advanced life support in 2017. Though the focus of the survey was broader in scale (NIOSH, 2017), the objectives for the analyses presented in this paper were to:

  1. Describe the prevalence of job stress related to OORs as indicated by selected PTEs

  2. Describe the prevalence of mental health outcomes

  3. Identify PTEs that are associated with increased prevalence of mental health outcomes

The results presented here are intended to inform future research that can further characterize these associations.

Method

Participants & Procedure

At the time of this survey, the fire department had approximately 800 full-time, uniformed firefighters who were represented by a union. Of these, 193 were on duty at any given time at 26 fire stations. In general, firefighters were scheduled to work a 24-hour shift every third day.

We visited 16 fire stations over the course of two consecutive days to invite all on-duty firefighters at the time of each visit to complete an anonymous written questionnaire. We arranged for on-duty firefighters from the 10 stations that we did not visit to gather at the visited stations. We explained the survey to all invited firefighters present which was equivalent to one third of the department’s firefighters. This sampling strategy was selected due to time constraints and available resources.

Participation was voluntary and anonymous in that no personal identifying information was collected on the questionnaire. No monetary incentive was offered for participation, though firefighters were told that participation would improve the quality of the evaluation and recommendations made for improving safety and health at their work. Surveys were completed during working hours. Informed consent was obtained verbally. This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.1

Questionnaire

The questionnaire consisted of validated scales as well as questions developed specifically for this evaluation and took approximately 20 minutes to complete. It included questions on job and demographic characteristics, job stress, exposure to PTEs during OORs, , mental health symptoms of posttraumatic stress disorder (PTSD), depression, and anxiety, and resources used to address stress and mental health symptoms. The questionnaire also included a list of local and national resources for suicide prevention and mental health care (including phone numbers and websites for the local employee assistance program, National Suicide Prevention Lifeline, Suicide Prevention Resource Center, the National Council for Suicide Prevention, and the Substance Abuse and Mental Health Services Administration). Sections of the questionnaire are described below.

Job stress and exposure to PTEs during OORs.

We asked, “During the past 6 months, have you participated in an opioid response?” to screen for inclusion in our analyses. We asked firefighters to rate their overall level of job stress with a single survey item: “How would you rate your level of job stress caused by responding to opioid overdoses over the past 6 months?” They were asked to use a rating scale from 0 (as low as it can be) to 10 (as high as it can be). Responses of 0–3 indicated low job stress, 4–6 indicated moderate job stress, and scores of 7 or greater indicated high job stress (Clark, Warren, Hagen, et al., 2011; Matthews, Pineault, & Hong, 2022).

We asked firefighters to indicate “yes” or “no” to a list of PTEs Figure 1 that they may have experienced while participating in an OOR in the past 6 months. We also asked whether someone close to them (e.g., family or friends) had experienced an opioid overdose. This was intended to be an indicator of personal impact beyond the firefighters’ job duties.

Mental Health Symptoms and Use of Mental Health Resources.

PTSD.

We used the U.S. Department of Veterans Affairs’ PTSD Checklist for the Diagnostic and Statistical Manual for Mental Disorders, 5th Edition (PCL-5) (Weathers, Litz, Keane, et al., 2013) screening tool for PTSD. A PCL-5 score of 31–33 has shown a sensitivity of 88% and a specificity of 69% for PTSD (Bovin, Marx, Weathers, et al., 2015).

Firefighters were asked to rate how much they were bothered by each symptom in the past 4 weeks (overall, not just within the context of OOR) using the following frequencies: not at all (+ 0), a little bit (+ 1), moderately (+ 2), quite a bit (+ 3), and extremely (score + 4). We calculated a total symptom severity score (range 0–80) by summing the scores of the 20 items in the measure, using the recommended cut point of ≥ 33 as a positive screen for PTSD (Weathers, et al., 2013). The PCL-5 had an internal consistency of α = .953.

Depression.

We used the Patient Health Questionnaire-9 (PHQ-9) (Kroenke & Spitzer, 2002) to screen for depression. A PHQ-9 score of > 10 (moderate to severe depression) has shown a sensitivity of 88% and a specificity of 88% for major depression (Kroenke, Spitzer, & Williams, 2001).

Firefighters were asked to rate how often they were bothered by each symptom in the past 4 weeks (overall, not just within the context of OOR) using the following frequencies: not at all (+ 0), several days (+ 1), more than half the days (+ 2), and nearly every day (+ 3). We calculated a total symptom severity score (range 0–27) by summing the scores of the nine items in the measure, using the recommended thresholds of 5 (mild), 10 (moderate), 15 (moderately severe), and 20 (severe) depression (Kroenke & Spitzer, 2002). Based on these scores, firefighters were categorized as having moderate to severe depression or other (none to mild). The PHQ-9 had an internal consistency of α = .854.

Anxiety.

We used the General Anxiety Disorder-7 (GAD-7) (Spitzer, Kroenke, Williams, et al., 2006) to screen for anxiety. A GAD-7 score of > 10 has shown a sensitivity of 89% and a specificity of 82% for generalized anxiety disorder (Spitzer et al., 2006).

Firefighters were asked to rate how often they were bothered by each symptom in the past 4 weeks (overall, not just within the context of OOR) using the following frequencies: not at all (+ 0), several days (+ 1), more than half the days (+ 2), and nearly every day (+ 3). We calculated a total symptom severity score (range: 0–21) by summing the scores of the seven items in the measure, using the recommended thresholds of 5 (mild), 10 (moderate), and 15 (severe) anxiety (Spitzer et al., 2006). Based on these scores, firefighters were categorized as having moderate to severe anxiety or other (none to mild). The GAD-7 had an internal consistency of α = .887.

Use of resources to cope with mental health symptoms and job stress.

We asked, “Have you sought mental health care for stress related to your job?”. We listed a variety of resources that firefighters could use to manage job stress or improve their mental health and asked them to indicate whether they had used each resource.

Data Analysis Plan

We summarized the descriptive statistics for responses about demographic and job characteristics, job stress, and exposure to PTEs at work. We used Fisher’s exact test to determine whether exposure to PTEs were associated with reported job stress.

We estimated the prevalence of symptoms consistent with PTSD, depression, and GAD using the standard case definitions (Kroenke & Spitzer, 2002; Spitzer et al., 2006; Weathers et al., 2013). We used Fisher’s exact test to determine whether exposure to PTEs were associated with positive screening results for PTSD, moderate to severe depression, and moderate to severe anxiety.

Statistical tests were two-tailed, and statistical significance was set at P < 0.05. No adjustment was made for multiple comparisons. Statistical analyses were performed using SPSS version 26.

Results

Characteristics of Participating Firefighters

Of the 190 firefighters working during the 2 days we visited the fire stations, 189 (99.5%) completed a questionnaire. Of the 189 participants, 173 (92%) indicated they had responded to at least one opioid overdose in the past 6 months. Our analyses henceforth are focused on these 173 individuals. Table 1 describes the demographic characteristics of the participants that completed those survey items. Most were male (n = 162; 94.7%). The most common age category was 36–45 years (n = 60; 35.1%). Table 2 summarizes the job characteristics of the participants. The most common job tenure of those who completed the questionnaire was 1–5 years (n = 45; 26.3%). In terms of highest level of EMS certification, most (53.8%) were paramedics, and the remainder were emergency medical technicians.

Table 1.

Demographic Information of Firefighters that Participated in an Opioid Overdose Response in the previous 6 months

Demographic Characteristic Number (%)
Male (n = 171) 162 (94.7)
Age in Years (n = 171)
 18–25 4 (2.3)
 26–35 43 (25.1)
 36–45 60 (35.1)
 46–55 49 (28.7)
 55+ 15 (8.8)
Race (n = 171)*
 Black or African American 54 (31.6)
 Asian, Native Hawaiian or other Pacific Islander, American Indian, or Alaskan Native 10 (5.9)
 White 120 (70.2)
Hispanic or Latino Ethnicity (n = 171) 5 (2.9)
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*

Participants could choose more than one option

Table 2.

Job Characteristics of Firefighters that Participated in an Opioid Overdose Response in the previous 6 months

Job Characteristic Number (%)
Years with this Fire Department (N = 171)
 ≤ 5 45 (26.3)
 6–10 14 (8.2)
 11–15 19 (11.1)
 16–20 32 (18.7)
 21–25 36 (21.0)
 25+ 25 (14.6)
Supervisory Position (N = 173) 47 (27.2)
Current Highest Level of EMS Certification (N = 173)
 Paramedic 93 (53.8)
 Emergency Medical Technician 80 (46.2)
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EMS = emergency medical services

Job Stress and Exposure to PTEs During OORs

The average job stress score for the 173 firefighters was 3.0, indicating low job stress associated with participating in OORs over the past 6 months. On the basis of individual stress scores, 111 (64.2%) firefighters indicated low job stress, 40 (23.1%) indicated moderate job stress, and 22 (12.7%) indicated high job stress associated with participating in OORs in the past 6 months.

Figure 1 shows the pattern of PTEs while responding to an opioid overdose in the past 6 months (N = 173). Most (97%) firefighters reported experiencing one or more PTEs. The most commonly reported PTEs were administering naloxone/Narcan (n = 151; 87.2%), seeing deceased adults (n = 129; 75%), and seeing neglected or unaccompanied children (n = 119; 68.8%). The most common combination of PTEs was that of administering naloxone, seeing dead adults, seeing neglected or unaccompanied children, reviving the same person from an opioid overdose more than once, and seeing a patient die (n = 34; 19.6%).

Figure 1. Pattern of potentially traumatic events (PTEs) reported by firefighters responding to an opioid overdose in the past 6 months (N=173).

Figure 1.

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The horizontal bars show the number of firefighters who reported experiencing each PTE. Each column of filled circles in the figure depicts a combination of PTEs reported by a firefighter. Each vertical bar in the figure shows the number of firefighters reporting the combination of PTEs depicted by the filled circles below. The frequency of PTE combinations reported are shown in decreasing order, from left to right. PTE combinations reported by fewer than 5 respondents are not shown.

Firefighters who reported a high level of job stress were more likely than those reporting low/moderate job stress to have experienced the following PTEs during an OOR than those who did not have these experiences during an OOR: seeing neglected or unaccompanied children (90.9% (20/22) vs. 65.6% (99/151); p =.015); being physically attacked/assaulted (50% (11/22) vs. 14.6% (22/151); p < 0.001); being in a situation where they believed they would be killed by another person (27.3% (6/22) vs. 5.3% (8/151); p =.003); being injured by a needlestick (22.7% (5/22) vs. 5.3% (8/151); p =.014); reviving the same person(s) from an opioid overdose on more than one occasion (90.9% (20/22) vs. 64.0% (96/150); p =.013); and being in a situation where suspected opioids were visible (83.3% (20/24) vs. 59.9% (97/162); p =.040).

Firefighters who reported a high level of job stress were similar to those reporting low/moderate job stress in terms of whether they worked overtime or not (p =.140).

As a measure of the personal impact the opioid overdose epidemic has had on firefighters, 46 of 173 (26.6%) participants reported that someone close to them (family member or friend) had overdosed on an opioid in the past. This item was not associated with a high level of reported job stress (p =.227).

Mental Health Symptoms and Exposure to PTEs

PTSD.

In total, 171 firefighters completed the items necessary to screen for symptoms of PTSD. Of these, 5 (2.9%) met the screening definition for possible PTSD.

Firefighters who had been in a situation where they believed they could be killed by another person during an OOR had a significantly higher prevalence of positive PTSD screenings than those who had not been in a situation where they thought they could be killed by another person during an OOR (21.4% (3/14) vs. 1.3% (2/157); p =.004). Firefighters who had been injured by a needlestick during an OOR had a significantly higher prevalence of positive PTSD screenings than those who had not been injured by a needlestick during an OOR (15.4% (2/13) vs. 1.9% (3/158); p =.047). Of those who reported experiencing a needlestick injury, five also reported being in a situation where they believed they could be killed by another person. Among those five firefighters, 2 (40%) had a positive screening for PTSD. No other types of PTEs experienced while responding to an OOR, nor personal impact of the opioid overdose epidemic, were associated with a positive PTSD screen.

Depression.

In total, 172 firefighters completed the items necessary to screen for symptoms of depression. Of these, 135 (78.5%) screened negative, 29 (16.9%) met the screening criterion for mild depression, and 8 (4.7%) met the screening criterion for moderate, moderately severe, or severe depression.

Firefighters who reported experiencing the following PTEs during an OOR in the previous 6 months had a significantly higher prevalence of moderate to severe depression symptoms (as opposed to a negative or mild depression screening) than those who participated in an OOR but did not report experiencing the event: being physically attacked/assaulted (15.2% (5/33) vs. 2.9% (4/140); p =.013); being in a situation where they believed they could be killed by another person (21.4% (3/14) vs. 3.8% (6/159); p =.027); and being injured by a needlestick (23.1% (3/13) vs. 3.8% (6/160); p =.022).

No other types of PTEs experienced while responding to an OOR, nor personal impact of the opioid overdose epidemic, were associated with moderate to severe depression.

Anxiety.

Of the 171 firefighters who completed the items necessary to screen for symptoms of anxiety, 150 (87.7%) screened negative, 14 (8.2%) met the screening criterion for mild anxiety, 6 (3.5%) met the screening criterion for moderate anxiety, and 1 (< 1%) met the screening criterion for severe anxiety. Firefighters who reported being injured by a needlestick during an OOR had a significantly higher prevalence of moderate to severe anxiety screenings (as opposed to negative or mild) than those who participated in an OOR but did not report being injured by a needlestick (23.1% (3/13) vs. 3.8% (6/160); p =.022). No other types of PTEs experienced while responding to an OOR, nor personal impact of the opioid overdose epidemic were associated with moderate to severe anxiety.

Any mental health concern.

Of the 173 participants, 27 (15.6%) reported high stress, met the threshold for a PTSD screening diagnosis, or scored moderate to severe on depression or anxiety screeners. In terms of comorbidity, 3 firefighters (1.6%; n = 187) met criteria for depression and anxiety and 3 (1.6%) met criteria for depression, anxiety, and PTSD.

Firefighters who reported experiencing the following PTEs during an OOR in the previous 6 months had a significantly higher prevalence of any mental health outcome than those who participated in an OOR but did not report experiencing the event: seeing neglected or unaccompanied children (20.2% (24/119) vs. 5.6% (3/54); p = .013); being physically attacked/assaulted (36.4% (12/33) vs. 10.7% (15/140); p = .001); and being in a situation where you believed you could be killed by another person (35.7% (5/14) vs. 13.8% (22/159); p = .047).

Use of resources to address mental health symptoms and stress.

Nineteen (11%) firefighters reported using mental health resources. The employee assistance program (EAP) (n = 14; 73.7%) was the most frequently used resource for coping with stress and mental health, followed by primary care physician (PCP) (n = 5, 26.3%), a mental health professional (n = 4; 21.1%), support group (n = 2; 10.5%), and religious leader (n = 2; 10.5%). Most employees only used their EAP (n = 12, 63%). Four firefighters used some combination of the EAP, a mental health professional, PCP, and religious leader for support. Of those reporting any mental health concern (positive screening for PTSD or moderate to severe screening for depression, and/or anxiety), 7 (25.9%) reported using at least one of the listed resources. Of those not reporting any mental health concern, 12 (8.2%) reported using at least one mental health resource. Those reporting any mental health concern were more likely to use a mental health resource on the list than those not reporting any mental health concern (36.8% (7/19) vs. 12.4% (19/153); p =.012).

Discussion

The National Institute for Occupational Safety and Health (NIOSH, 2013) defines job stress as the harmful physical and emotional responses that occur when job demands do not match the capabilities, resources, or needs of employees. Stress is complicated and multifaceted for firefighters. A mixture of PTEs and daily working conditions such as administrative and organizational factors can affect firefighters’ mental health, job satisfaction, and morale (Beaton & Murphy, 1993; Rajabi, Molaeifar, Jahangiri, et al., 2020).

As a group, the firefighters in our evaluation reported low job stress when asked specifically about responding to opioid overdoses. The overall level of job stress might have been different had we asked about job stress in general, perhaps because responding to opioid overdoses may represent a relatively low stress situation for those who encounter death and other PTEs regularly. This may be evidenced by our finding that administering naloxone was not associated with job stress. It may be that naloxone administration is common on the job and has become routine. This is supported by Patch et. al (2023), who did not identify naloxone administration as a stressor in qualitative research on first responders’ experiences with OORs. We did find that a high job stress rating was associated with experiencing some of the PTEs we described in our questionnaire like seeing neglected or unaccompanied children or being physically attacked/assaulted while on an OOR. These findings indicate that it is important for firefighters to monitor their stress levels following OORs and to engage in stress reduction activities to improve psychological well-being.

The 12-month prevalence estimates of the clinical disorders among U.S. adults is 3.5% for PTSD, 7% for depression, and 2.9% for anxiety (American Psychiatric Association, 2013). These rates, however, cannot be directly compared with our findings because they are based on actual diagnosed cases over a year, whereas we estimated point prevalence of symptoms using a screening tool. We did not assess how mental health symptoms influence functioning, which is an important consideration for making a true clinical diagnosis for these conditions. Thus, it is possible that while firefighters may be experiencing mental health symptoms, their performance at work or in social or other settings may be unaffected.

NIOSH completed a health hazard evaluation focusing on the opioid overdose epidemic with firefighters (n = 53) in another state and found higher percentages of positive screenings for PTSD (13%), moderate to severe depression (23%), and moderate to severe anxiety (25%) using the same screening tools as used here (NIOSH, 2017). This was a relatively small community that, in 2016, experienced a mass overdose event involving 26 people at the same location over several hours. Being in a relatively small community, the firefighters in this previous evaluation may have been familiar with the overdose victims or had to revive the same individuals they recognize on more than one occasion. In qualitative analyses, the firefighters expressed a main source of stress for them was a lack of resources, specifically being understaffed. These conditions may explain the differences in mental health screenings for these two populations (Igboanugo, Bigelow, & Mielke, 2021).

Of the firefighters in this evaluation who reported experiencing a PTE at work, most reported multiple events. PTSD symptoms usually begin within the first 3 months after the trauma, but in some cases, it may take many months or years after a trauma before a person experiences symptoms of the disorder (American Psychiatric Association, 2013). Therefore, firefighters should seek and give social support and psychological first aid following any PTE (Norwood & Rascati, 2012). For example, our results showed that situations where a firefighter believed he or she could be killed by another person and experiencing needlestick injuries are specific PTEs during an OOR that are each associated with PTSD symptoms. Firefighters who experience these types of events should be offered support/psychological first aid, including the option to speak with someone they trust who is trained to help or refer for further care if necessary (Feuer, 2021).

Needlestick injury was a PTE that was associated with high job stress and a higher prevalence of mental health outcomes. These findings were consistent with results from prior studies of healthcare workers who reported feeling symptoms of anxiety, depression, and PTSD following a needlestick injury (Cooke & Stephens, 2017). Similarly, a higher incidence of needlestick injuries was found in a survey of EMS providers (Alhazmi, Parker, & Wen, 2018) than in another study based on incident reports (El Sayed, Kue, McNeil, et al., 2011).

Needlestick injuries can result in the transmission of bloodborne pathogens such as hepatitis B, hepatitis C, and human immunodeficiency virus (De Laune, 1990; Higginson & Parry, 2013). Such injuries can cause distress and anxiety. In a study among healthcare personnel that had suffered a needlestick injury, more than 80% of respondents were concerned about consequences of the injury, and higher levels of anxiety were reported when the patient was known to have a chronic viral infection (Wicker, Stirn, Rabenau, et al., 2014). Green and Griffiths (2013) found that psychiatric illness (e.g., adjustment disorder, depression, PTSD) can result from needlestick injuries with severity similar to experiencing other psychological trauma.

Thirteen firefighters (7.5%) reported in the questionnaire that they suffered a needlestick injury while responding to an opioid overdose in the past 6 months. According to the city’s database of work-related injuries and illnesses, there were no reported needlestick injuries or other types of bloodborne pathogen exposure among firefighters during this time period. This should be explored further to determine why needlestick injuries are not being reported/recorded. One cross-sectional study found that unreported needlestick injuries are common in hospital workers, with 46% of workers suffering a needlestick choosing not to report it (Bahat, Hasidov-Fafni, Youngster, et al., 2021). Reasons for underreporting included the perception that the patient was not infected, believing it was a superficial injury, and thinking that the reporting process was too time-consuming. Training on needlestick injuries and simplifying reporting processes are recommendations for improving the underreporting of needlestick injuries (Bahat et al., 2021).

In addition, mental health assessments related to the needlestick might be incorporated into medical evaluation and follow-up when firefighters experience a work-related needlestick injury. Fire departments should have a formal health and safety officer that could ensure confidentiality when reporting injuries or mental health symptoms. Traditional methods of reporting injuries through the chain of command might discourage reporting if firefighters believe they may be disciplined or otherwise face negative social consequences.

Most of the firefighters in our evaluation reported that they had not used the mental health resources we listed for job stress or other psychological outcomes associated with their work. When a firefighter did seek help, of the mental health resources we listed, the most commonly used was the EAP. Some larger fire departments have the resources to have in-house behavioral health programs (e.g., having a mental health professional on site who specializes in helping firefighters), which may make it easier to seek help (Stanley, Boffa, Hom, et al., 2017). When resources allow, having EAPs or other easily accessible means for help-seeking behavior may improve mental health care uptake. Mental health care uptake may also be improved by promotion of peer support networks, such as that offered by the International Association of Firefighters (2022), where firefighters can discuss mental health issues with fellow firefighters, often anonymously, and receive referrals for local community resources and mental health professionals (Stanley et al., 2017).

Limitations

This evaluation was subject to limitations. This evaluation occurred in 2018 and in a specific city, so the conditions might not be generalizable. For example, differences in career versus volunteer status, union coverage, department size, pay, and geographic status might impact the generalizability of our findings. Since these data were collected in 2018 the opioid overdose mortality rates have increased and remain at historic highs in the U.S.(NIDA, 2024)

The second limitation was that questionnaire responses were self-reported and there is the possibility of recall bias and social desirability bias.

Third, It may also have been difficult for participants to distinguish between OORs and other types of emergency response (or emergency response overall) when describing their experiences and symptoms.

Fourth, we only asked about incidence of PTEs over the past 6 months, and did not take into account previous PTEs or gather information on PTE severity, frequency, and cumulative exposure. Future research looking at specific PTEs’ relation to firefighter mental health should measure these factors and look at interactions between PTE factors (Wagner et al., 2021).

Fifth, the number of firefighters who screened positive for each mental health outcome was low, leading to small numbers of firefighters who screened positive and either experienced or did not experience each PTE. Statistical results might not be stable with small numbers and should be interpreted with caution.

Conclusions

PTEs were frequently reported by firefighters who respond to opioid overdoses. For some PTEs, firefighters who reported experiencing them during OORs had a higher prevalence of meeting the screening definitions for PTSD, moderate to severe depression, or moderate to severe anxiety than firefighters who did not report experiencing the PTEs during OORs. Firefighters should be encouraged to seek social support following these PTEs or seek mental health care if symptoms interfere with personal, social, or occupational functioning. Fire departments should develop standard operating procedures for confidential reporting of injuries or mental health symptoms, and consider having a formal health and safety officer to receive reports instead of following the chain of command.

Acknowledgments

Authors would like to acknowledge Marie de Perio, Denise Giglio, Guadalupe (Pita) Gomez, Reed Grimes, Laurel Harduar Morano, Sean Lawson, Sara Luckhaupt, Miriam Siegel, Loren Tapp, and Shawna Watts for their field assistance and data support.

Footnotes

1

See e.g., 45 C.F.R. part 46, 21 C.F.R. part 56; 42 U.S.C. §241(d); 5 U.S.C. §552a; 44 U.S.C. §3501 et seq.

This manuscript is partially based on data used in a previously published report, NIOSH Health Hazard Evaluation 2018-0015-3384 (August 2021), yet presents new analyses not yet published elsewhere.

The authors report no conflicts of interest. The findings and conclusions in this manuscript are those of the authors and do not necessarily represent the official position of the National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention.

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