A man named Eddie threaded through the midafternoon crowd in Cambridge, Mass. He聽was headed for a sandwich shop, the first stop on a tour of public bathrooms.
鈥淚 know all the bathrooms that I can and can鈥檛 get high in,鈥� said Eddie, 39, pausing in front of the shop鈥檚 plate-glass windows, through which we can see a bathroom door.
Eddie, whose last name we鈥檙e not including because he uses illegal drugs, knows which restrooms along busy Massachusetts Avenue he can enter, at what hours and for how long. Several restaurants, offices and a social services agency in this neighborhood have closed their restrooms in recent months, but not this sandwich shop.
鈥淲ith these bathrooms here, you don鈥檛 need a key. If it鈥檚 vacant, you go in. And then the staff just leaves you alone,鈥� Eddie said. 鈥淚 know so many people who get high here.鈥�
At the fast-food place right across the street, it鈥檚 much harder to get in and out.
鈥淵ou don鈥檛 need a key, but they have a security guard that sits at the little table by the door, directly in front of the bathroom,鈥� Eddie said. Some guards require a receipt for admission to the bathroom, he said, but you can always grab one from the trash.
A chain restaurant a few stores down has installed bathroom door locks opened by a code that you get at the counter. But Eddie and his friends just wait by the door until a customer goes into聽the restroom, then grab the door and enter as the customer leaves.
鈥淔or every 10 steps they use to safeguard against us doing something, we鈥檙e going to find 15 more to get over on their 10. That鈥檚 just how it is. I鈥檓 not saying that鈥檚 right, that鈥檚 just how it is,鈥� Eddie said.
Eddie is homeless and works at a restaurant. Public bathrooms are among聽the few places where he can find privacy to inject heroin. He says he doesn鈥檛 use the drug often these days. Eddie is on methadone, which curbs his craving for heroin, and聽he says he now uses the drug only occasionally to be social with friends.
He understands why restaurant owners are unnerved.
鈥淭hese businesses, primarily, are like family businesses; middle-class people coming in to grab a burger or a cup of coffee. They don鈥檛 expect to find somebody dead,鈥� Eddie said. 鈥淚 get it.鈥�
Managing Public Bathrooms Is聽鈥楢 Tricky Thing鈥�
Many businesses don鈥檛 know what to do. Some have installed low lighting 鈥� blue light, in particular 鈥� to make it difficult for people who use injected drugs to find a vein.
The bathrooms at 1369 Coffee House, in the Central Square neighborhood of Cambridge, are open for customers who request the key code from staff at the counter. The owner, Joshua Gerber, has done some remodeling to make the bathrooms safer. There鈥檚 a metal box in the wall next to his toilet for needles and other things that clog pipes. And Gerber removed the dropped ceilings in his bathrooms after noticing things tucked above the tiles.
鈥淲e鈥檇 find needles or people鈥檚 drugs,鈥� Gerber said. 鈥淚t鈥檚 a tricky thing, managing a public restroom in a big, busy square like Central Square where there鈥檚 a lot of drug use.鈥�
1369 Coffee House owner Josh Gerber opens the bathroom door, which has a combination lock given to patrons at the front counter. (Jesse Costa/WBUR)((Jesse Costa/WBUR))
Gerber and his staff have found several people on the bathroom floor in recent years, not breathing.
鈥淚t鈥檚 very scary,鈥� Gerber said. His eyes drop briefly. 鈥淚n an ideal world, users would have safe places to go [where] it didn鈥檛 become the job of a business to manage that and to look after them and make sure that they were OK.鈥�
There are such public safe-use places in聽聽and some European countries, but not in the U.S.,聽. So Gerber is taking the unusual step of training his baristas to use naloxone, the drug that reverses most opioid overdoses. He sent a training invitation email to all employees recently. Within 10 minutes, he had about 25 replies.
鈥淢ostly capital 鈥榊es!! I鈥檒l be there for sure!鈥� 鈥楥ount me in!鈥欌�� Gerber recalled with a grin. 鈥淵ou know, [they were] just thrilled to figure out how they might be able to save a life.鈥�
Safe Spaces And Hospital Bathrooms
Last fall, a woman overdosed in a bathroom in the main lobby of Massachusetts General Hospital in Boston. Luckily, naloxone has become standard equipment for security guards at many hospitals in the Boston area, including that one.
鈥淚 carry it on me every day, it鈥檚 right here in a little pouch,鈥� said Ryan Curran, a police and security operations manager at the hospital, pulling a small black bag out of his suit jacket pocket.
The woman who overdosed survived, as have seven or eight people who overdosed in the bathrooms since Curran鈥檚 team started carrying naloxone in the past 12 to 18 months.
鈥淚t鈥檚 definitely relieving when you see someone breathing again when two, three minutes beforehand they looked lifeless,鈥� Curran said. 鈥淎 couple of pumps of the nasal spray and they鈥檙e doing better. It鈥檚 pretty incredible.鈥�
Ryan Curran, the day-shift operations manager of police and security at Massachusetts General Hospital, stands in front of the bathrooms in the main lobby. (Jesse Costa/WBUR)((Jesse Costa/WBUR))
Massachusetts General Hospital began training security guards after emergency room physician聽聽realized that the hospital鈥檚 bathrooms had become a haven for some of his overdose patients.
鈥淭here鈥檚 an understanding that if you overdose in and around a hospital that you鈥檙e much more likely to be able to be treated,鈥� Raja said, 鈥渁nd so we鈥檙e finding patients in our restrooms, we鈥檙e finding patients in our lobbies who are shooting up or taking their prescription pain medications.鈥�
Many businesses, including hospitals and clinics, don鈥檛 want to talk about overdoses within their buildings. Curran wants to be sure the hospital鈥檚 message about drug use is clear.
鈥淲e don鈥檛 want to promote, obviously, people coming here and using it, but if it鈥檚 going to happen, then we鈥檇 like to be prepared to help them and save them and get them to the [Emergency Department] as fast as possible,鈥� Curran said.
Speed is critical, especially now, when heroin is routinely mixed with the much more potent opioid, fentanyl. Some clinics and restaurants check on bathroom users by having staff knock on the door after 10 or 15 minutes, but fentanyl can deprive the brain of oxygen and cause death within that window. One clinic has installed an intercom and requires people to respond. Another has designed a reverse-motion detector that sets off an alarm if there鈥檚 no movement in the bathroom.
Limited Public Discussion
There鈥檚 very little discussion of the problem in public, says聽, director of the Addiction Medicine Fellowship Program at Boston Medical Center.
鈥淚t鈥檚 against federal and state law to provide a space where people can use [illegal drugs] knowingly, so that is a big deterrent from people talking about this problem,鈥� he said.
Without some guidance, more libraries, town halls and businesses are closing their bathrooms to the public. That means more drug use, injuries and discarded needles in parks and on city streets.
I know all the bathrooms that I can and can鈥檛 get high in.
In the area around Boston Medical Center, wholesalers, gas station owners and industrial facilities are looking into renting portable bathrooms.
鈥淭hey鈥檙e very concerned for their businesses,鈥� said Sue Sullivan, director of the聽, which represents 235 companies and 28,000 employees in Boston. 鈥淏ut they don鈥檛 want to just move the problem. They want to solve the problem.鈥�
Walley and other physicians who work with addiction patients say there are lots of ways to make bathrooms safer for the public and for drug users. A model restroom would be clean and well-lit with stainless-steel surfaces, and few cracks and crevices for hiding drug paraphernalia. It would have a biohazard box for needles and bloodied swabs. It would be stocked with naloxone and perhaps sterile water. The door would open out so that a collapsed body would not block entry. It would be easy to unlock from the outside. And it would be monitored, preferably by a nurse or EMT.
There are very few bathrooms that fit this model in the U.S.
Some doctors, nurses and public health workers who help addiction patients argue any solution to the opioid crisis will need to include safe injection sites, where drug users can get high with medical supervision.
鈥淭here are limits to better bathroom management,鈥� said Daniel Raymond, deputy director for policy and planning at the New York-based聽. If communities like Boston start to reach a breaking point with bathrooms, 鈥渉aving dedicated facilities like safer drug consumption spaces is the best bet for a long-term structural solution that I think a lot of business owners could buy into.鈥�
Maybe. No business groups in Massachusetts have come out in support of such spaces yet.
This story is part of a partnership that includes , and Kaiser Health News.