Shannon Riley spent nearly a decade in survival mode, responding when people overdosed in the bathroom and showers of a San Francisco drop-in centre where she worked as a nurse.
“We often had to crawl underneath the stall doors and pull people out,” said Riley, now a clinical educator for Vancouver Coastal Health’s overdose emergency response and prevention team.
“And we didn’t have enough time to think that there were other ways we could take care of ourselves and our clients to improve our response times.”
But after a close friend died of a toxic drug overdose in a bar bathroom in 2007, Riley realized that simple design changes could save lives.
No one knew her friend, who was active in harm reduction, was using at the time. And when others at the bar realized he was missing and called for help, first responders couldn’t open the door to the small bathroom because his fallen body blocked the inward-swinging door.
“If someone can’t get on their hands and knees and pull them out, that chance of survival goes down,” said Riley.
With British Columbia’s increasingly potent and unpredictable drug supply flooded by fentanyl, carfentanil and benzodiazepines, whether someone lives or dies after a drug poisoning can be decided in a matter of a few minutes.
A Safer Bathroom Toolkit aims to help organizations make lifesaving changes to their washrooms in the midst of B.C.’s toxic drug crisis.
The toolkit, co-developed by Riley, walks businesses through assessing their washrooms’ safety features and ensuring staff are prepared to respond to toxic drug incidents.
Riley said bars and clubs are effectively safe consumption sites for alcohol, but there are “not enough [safe consumption sites] for people who use drugs.”
“And in the meantime, we need to be creating safer bathrooms.”
About 50 people overdose in public bathrooms every month in B.C., according to 2018 data from BC Emergency Health Services, though not all of these overdoses are fatal.
Data from the BC Coroners Service shows that 16 people have died in public bathrooms so far this year.
That’s about one per cent of 2022’s 1,644 poisoned drugs deaths to date. The number is higher this year than last year.
But physical and technological changes can cut response times and make bathrooms safer for everyone.
Enclosed sharps containers for needles and doors that swing outwards are essential, Riley said. A panic button people can use to call for help, and measures to block the space between the toilet and the wall, where people can become wedged if they lose consciousness, can also save lives.
Businesses and organizations should ensure everyone on staff has a universal key to the bathrooms and knows where the naloxone kits are kept and how to use them, she added.
Tech solutions can also help. Staff can be automatically notified if someone is in the washroom for an unusually long period of time and intercoms can allow staff to check on someone.
Riley and a team of peer and research colleagues released the toolkit online last month and it has already been viewed more than 2,000 times.
“There are lots of important reports and stories, but we haven’t equipped people and businesses to respond,” said Marilou Gagnon, a harm reduction expert at the University of Victoria school of nursing who collaborated with Riley on the project.
“People want to help but they just don’t know what to do.”
Many people opt to use drugs in public bathrooms because they are quiet spaces away from the risk of being arrested, Gagnon said.
A 2016 paper from the University of Victoria found public washrooms effectively become consumption sites when designated sites are not accessible.
Supervised consumption and overdose prevention sites are mainly concentrated in a few locations in Vancouver and Victoria and aren’t available to people living elsewhere in the province, Gagnon noted.
During the years Kali Sedgemore was experiencing homelessness, public washrooms offered the only privacy they could find.
If Sedgemore couldn’t get access from staff, they would be forced to use in alleys, which increases the risks of injuries like infection or botching the injection due to exposure to the elements and stress around being seen and arrested.
“A washroom is a private place to be alone and to be my own person,” said Sedgemore, who now works as a peer harm reduction worker with Vancouver Coastal Health and co-developed the toolkit. “To be alone with yourself is important, and everybody deserves dignity and access to a washroom.”
Bathroom access in Vancouver plummeted during the pandemic, and many businesses see keeping them closed as a way of avoiding people using drugs and overdosing inside.
It is frustrating that people and organizations complaining about public drug use or public urination and defecation but don’t consider how few public washrooms are available in Vancouver, says Sedgemore.
“It’s a perfect storm for leaving people with nowhere to go,” said Gagnon.
Some businesses have even installed neon blue lights inside their bathrooms, which make finding a vein more difficult, to deter people from using drugs inside. That drives people to less safe locations and makes it more difficult to clean the bathrooms, Gagnon explained, and can also make it difficult for people who are visually impaired or disabled to navigate the bathrooms.
“It’s a knee-jerk reaction, it’s not supported and not safe,” said Gagnon. “It’s a good example of what happens when people don’t know what to do.”
Riley acknowledged overdose response is not in the job description for many employees at these businesses, but said employers have a responsibility to equip and support their staff to respond to the reality of the toxic drug crisis.
“How do we give our staff all the tools they need to be resilient and survive these challenging situations?” asked Riley. “We need to be sharing what they can do instead of standing outside a locked door feeling helpless after they call 911.”
And substance use in bathrooms isn’t going to increase because it is made safer, said Sedgemore.
“Our toolbox doesn’t attract drug users,” they said. “It’s more about showing care for people who use drugs.”