A man named Eddie threads through the mid-afternoon crowd in Cambridge, Mass. He's headed for a sandwich shop, the first stop on a tour of public bathrooms.
"I know all the bathrooms that I can and can't get high in," says Eddie, 39, pausing in front of the shop's plate glass windows, through which we can see a bathroom door.
Eddie, whose last name we're 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 service agency in this neighborhood have closed their restrooms in recent months, but not this sandwich shop.
"With these bathrooms here, you don't need a key. If it's vacant you go in. And then the staff just leaves you alone," Eddie says. "I know so many people who get high here."
At the fast food place right across the street, it's much harder to get in and out.
"You don't need a key, but they have a security guard that sits at the little table by the door, directly in front of the bathroom," Eddie says. Some guards require a receipt for admission to the bathroom, he says, 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 enters the restroom, then grab the door and enter as the customer leaves.
"For every 10 steps they use to safeguard against us doing something, we're going to find 15 more to get over on their 10. That's just how it is. I'm not saying that's right, that's just how it is," Eddie says.
Eddie is homeless and works at a restaurant. Public bathrooms are one of the few places where he can find privacy to inject heroin. He says he doesn't use the drug often these days. Eddie is on methadone, which curbs his craving for heroin, so he only uses the drug occasionally to be social with friends.
He understands why restaurant owners are unnerved.
"These businesses, primarily, are like family businesses; middle class people coming in to grab a burger or a cup of coffee. They don't expect to find somebody dead," Eddie says. "I get it."
Managing public bathrooms is "a tricky thing"
Many businesses don't know what to do. Some have installed low lighting — blue light, in particular — 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, Mass., 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's 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.
"We'd find needles or people's drugs," Gerber says. "It's a tricky thing, managing a public restroom in a big, busy square like Central Square where there's a lot of drug use."
Gerber and his staff have found several people on the bathroom floor in recent years, not breathing.
"It's very scary," Gerber says. His eyes drop briefly. "In an ideal world, users would have safe places to go [where] it didn't become the job of a business to manage that and to look after them and make sure that they were OK."
There are such public safe-use places in Canada and some European countries, but not in the U.S., at least not yet. 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 last week. Within 10 minutes he had about 25 replies.
"Mostly capital 'Yes' exclamation point, exclamation point, 'I'll be there for sure!' 'Count me in!' " Gerber recalls with a grin. "You know, [they were] just thrilled to figure out how they might be able to save a life."
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.
"I carry it on me every day, it's right here in a little pouch," says Ryan Curran, a police and security operations manager at Massachusetts General 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's team started carrying naloxone in the last 12 to 18 months.
"It's definitely relieving when you see someone breathing again when two, three minutes beforehand they looked lifeless," Curran says. "A couple of pumps of the nasal spray and they're doing better. It's pretty incredible."
Massachusetts General Hospital began training security guards after emergency room physician Dr. Ali Raja realized that the hospital's bathrooms had become a safe haven for some of his overdose patients.
"There's an understanding that if you overdose in and around a hospital that you're much more likely to be able to be treated," Raja says, "and so we're finding patients in our restrooms, we're finding patients in our lobbies who are shooting up or taking their prescription pain medications."
Many businesses, including hospitals and clinics, don't want to talk about overdoses within their buildings. Curran wants to be sure the hospital's message about drug use is clear.
"We don't want to promote, obviously, people coming here and using it, but if it's going to happen, then we'd like to be prepared to help them and save them and get them to the [Emergency Department] as fast as possible," Curran says.
Speed is critical, especially now, when heroin is routinely mixed with 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's no movement in the bathroom.
Limited public discussion
There's very little discussion of the problem in public, says Dr. Alex Walley, director of the Addiction Medicine Fellowship Program at Boston Medical Center.
"It's 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," he says.
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.
In the area around Boston Medical Center, wholesalers, gas station owners and industrial facilities are looking into renting portable bathrooms.
"They're very concerned for their businesses," says Sue Sullivan, director of the Newmarket Business Association, which represents 235 companies and 28,000 employees in Boston. "But they don't want to just move the problem. They want to solve the problem."
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.
"There are limits to better bathroom management," says Daniel Raymond, deputy director for policy and planning at the New York-based Harm Reduction Coalition. If communities like Boston start to reach a breaking point with bathrooms, "having 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."
Maybe. No business groups in Massachusetts have come out in support of such spaces yet.
ROBERT SIEGEL, HOST:
A public restroom is one of the few places where a drug user can find privacy. And that has meant businesses and communities are confronting the country's opioid crisis in an unexpected way. People who use drugs and sometimes overdose have been found in the restrooms of fast food restaurants, city buildings, even hospitals. WBUR's Martha Bebinger brings us this story which begins on Mass. Ave in Cambridge, Mass.
EDDIE: So we're going to go check out the place we talked about. It's this way.
MARTHA BEBINGER, BYLINE: A man named Eddie guides me through the mid-afternoon crowd toward a sandwich shop. We stop in front of big glass windows.
EDDIE: With these bathrooms here, you don't need a key. You just - if it's vacant, you go in. And then the staff just leaves you alone. I know so many people that get high here.
BEBINGER: At the fast food restaurant right across the street, it's much harder to get in.
EDDIE: You don't need a key, but they have a security guy that sits at the little table by the door directly from the bathroom.
BEBINGER: Some guards require a receipt for admission to the bathrooms, Eddie says, but you can grab one from the trash. Eddie, who's 39 and homeless, works in a restaurant himself. We're only using his first name because he's admitting to illegal drug use. Our next stop - a national restaurant chain.
EDDIE: You have to get the code to use their bathroom, but if you go in there and sit on that side by the bathroom, if you wait long enough, someone's going to use that bathroom. And then you'll say hey, hold the door for me. And then you're in.
BEBINGER: So you know which bathrooms you can...
EDDIE: I do. I do. I know all the bathrooms that I can and can't get high in. Even in the train station downstairs, you can use that bathroom most days and not be bothered. So...
BEBINGER: But that's not good in some ways, right?
EDDIE: It's not good at all. Who's keeping an eye on them? That's why you have to have somebody with you to make sure that you don't overdose. It's unfortunate that it's come to that, but that's the way it is.
BEBINGER: You can understand why the restaurants might be freaked out about this, right?
EDDIE: Absolutely. I mean, these businesses primarily are like family businesses, they don't expect to find somebody dead. So I get it.
BEBINGER: At one of those family businesses, the 1369 Coffee House, Joshua Gerber and his staff have found several people on the bathroom floor not breathing.
JOSHUA GERBER: And it's very scary, you know?
BEBINGER: Gerber has installed key codes on bathroom doors and metal boxes for needles, so users don't flush them and clog pipes.
GERBER: In an ideal world, users would have safe places to go that it didn't become the job of a business to make sure that they were OK.
BEBINGER: 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 to all employees. And within 10 minutes, he had about 25 replies.
GERBER: Mostly capital yes, I'll be there for sure, just thrilled to figure out how they might be able to save a life.
BEBINGER: Naloxone has become standard equipment for security guards at many Boston hospitals. At Massachusetts General Hospital, emergency room physician Dr. Ali Raja realized bathrooms had become a magnet for drug users.
ALI RAJA: There is an understanding that if you overdose in and around a hospital that you're much more likely to be able to be treated. And so we're finding patients in our restrooms. We're finding patients in our lobbies.
BEBINGER: Speed is critical, especially now when heroin is routinely mixed with fentanyl which is even more potent. Some clinics and restaurants knock on bathroom doors after five or 10 minutes. One clinic has installed an intercom and requires people to respond. Another designed a reverse motion detector that sets off an alarm when there's no movement in the bathroom. But Boston Medical Center's Dr. Alex Walley says no one wants to talk about their strategies in public.
ALEX WALLEY: It's against federal and state law to provide a space where people can use knowingly, so that is a big deterrent from people talking about this problem.
BEBINGER: As more libraries, city halls and businesses close their bathrooms to the public, drug users are moving to parks and city streets. But keeping bathrooms open by stocking naloxone and monitoring who goes in and for how long is a challenge for many businesses. For NPR News, I'm Martha Bebinger in Boston.
(SOUNDBITE OF DNTEL'S "PUMA")
SIEGEL: And that story is part of a reporting partnership of NPR, WBUR and Kaiser Health News.
(SOUNDBITE OF DNTEL'S "PUMA") Transcript provided by NPR, Copyright NPR.