First, a light starts to flash. Then a high-pitched siren starts to blare. Then come the sounds of nearby doors being flung open, and the frantic footsteps of doctors and nurses rushing toward a restroom at the end of a hallway. They’re in a hurry for good reason. These distress signals have a specific meaning: Somebody in the bathroom is overdosing.
Thankfully, it’s a false alarm. But at Boston Health Care for the Homeless Program, a clinic that caters to Boston’s unhoused population in the heart of the city’s infamous “methadone mile,” bathroom overdoses are a near-daily occurrence. They happen so frequently, in fact, that the clinic has outfitted its restrooms with motion-sensor systems designed specifically for this purpose: to detect when people in bathrooms stop moving, allowing clinic staff to intervene before it’s too late.
Thanks to the “safe bathroom” technology, as the system is known, these scenes have been ending in relief, not tragedy. By notifying health workers of overdoses as they happen, alarms give them a chance to administer naloxone, the medication that reverses opioid overdoses, and employ rescue breathing techniques. In the roughly seven years since the clinic first installed these sensors, it has seen hundreds of bathroom overdoses — but not a single death.
“It gives you an early warning so the providers on site can bring everyone back,” said John King, the local electrician who the clinic tasked with creating a specialized motion-sensor system aimed at detecting overdoses. “It’s like going back in time — like I invented a time machine.”
The technology has helped BHCHP flip the script on an increasingly common phenomenon: overdoses in public restrooms. Across the country, bathrooms in libraries, coffee shops, health clinics, and even schools have become venues for drug use. Unwitting security staff or service workers, as a result, have effectively been drafted to serve on the frontlines of the nation’s fight against drug deaths. All too often, however, they learn of bathroom overdoses only by discovering people who are already dead.
Amid a drug crisis claiming roughly 110,000 American lives each year, and with ultra-potent fentanyl dominating illicit drug markets, opioid overdoses are only happening faster and more frequently.
But thanks to the “safe bathroom” systems, in Boston and at several dozen health care facilities across the country, overdosing alone in a locked bathroom is no longer a death sentence. Clinic staff have a routine: Once the alarm sounds, they’re prepared to force the door open, if needed, then administer naloxone and use a handheld ventilator until the overdose victim regains consciousness.
In one sense, clinics’ decisions to install overdose-prevention technology in public restrooms represents a grim concession: The U.S. drug epidemic is such that people will use drugs — and in all likelihood, experience overdoses — almost anywhere.
But in another, it represents a simple, pragmatic approach often lacking in U.S. drug policy. At Boston Health Care for the Homeless, clinic staff have long since accepted that some people will use drugs onsite regardless of how sternly the clinic admonishes them not to. At a certain point, they argue, it effectively became the clinic’s choice whether they lived or died.
“We are very clear in our rules: We don’t allow drug use in the building,” said Omar Marrero, the clinic’s operations director. “But saying that doesn’t necessarily prevent people from using. So it’s just recognizing that this is happening, and what we can do to respond to the needs of our patients.”
Officials don’t keep specific statistics on how many overdoses occur in public buildings — much less whether they occur in bathrooms. But one estimate from Vancouver, British Columbia, put bathroom overdoses at more than 50 per month. Bathrooms represent a logical spot for drug use, researchers have noted: There’s privacy, good lighting, and access to water for dissolving and preparing drugs.
In response, numerous coffee shops or retail chains across North America have either closed bathrooms altogether or installed blue lights inside, claiming that they deter drug use by making it harder for intravenous drug users to find a vein. One Vancouver university even developed a safer bathroom “toolkit” meant to help public buildings ensure their staff are equipped to detect and respond to overdoses.
In Boston, as overdoses mounted in the mid-2010s, security staff at BHCHP and at other health care facilities increasingly found themselves responding to bathroom overdoses — a role they hadn’t signed up for and weren’t trained for, either.
“We were drowning in overdoses,” said Jessie Gaeta, a Boston physician who served as BHCHP’s chief medical officer from 2015 to 2022. “We had several close calls, and the security guards were loud and clear: We can’t take on this responsibility.”
Enter King, the local electrician. At the clinic’s request, he spent months tinkering with existing motion sensor kits to build out a system that could detect when someone was still inside the restroom but had stopped moving.
After a lengthy trial-and-error process, King and the clinic settled on a specific interval — 2 minutes, 45 seconds — after which the alarm begins to sound if no motion is detected inside the bathroom. And while false alarms do occur, clinic staff say the system’s lifesaving benefits are well worth the occasional inconvenience.
So far, the results have been positive for security staff, for doctors and nurses at the clinic, and, of course, for people who’ve experienced overdoses. While it’s difficult to measure precisely how many lives the alarm systems are saving, security personnel reported in one study that they generally viewed the technology as a positive, and believed responding to overdoses was an appropriate part of their job description.
Despite the growing recognition of bathrooms as an overdose hot spot, the vast majority of hospitals and homeless shelters have no ability to detect overdoses happening in their restrooms. Nor has the technology caught on in coffee shops or train stations.
King’s reputation has spread via word of mouth, however, even though he hasn’t invested in marketing the “safe bathroom” setup. The technology is increasingly popular in the Boston area, especially, and King has now installed systems at nearly 100 sites nationwide, in cities including Chicago, Philadelphia, Baltimore, and others.
Increasingly, systems are how King makes his living: He estimates that more than 50% of his business comes from selling and installing “safe bathroom” kits, and he’s open to a future where he works on overdose-prevention technology exclusively.
“It’s very rewarding,” King said. “Once in a while, I’ll get a call from one of the clients, saying, ‘John, we saved someone today.’”
To some addiction experts, however, the program stands as a symbol of the country’s broader failure to prevent drug deaths — its short-term success in Boston notwithstanding.
Gaeta, the clinic’s former medical director, said that the safe bathroom technology actually represents an argument in favor of supervised consumption: the practice of allowing people to use drugs with medical professionals present, ensuring that even if they experience an overdose, they’ll receive naloxone and other emergency care immediately.
Supervised consumption remains illegal under federal law, though two sites are currently operating in New York City in Manhattan, and a third is set to open in Rhode Island next year. Neither of the New York locations has ever recorded an overdose death. Proponents of supervised consumption argue that beyond simply preventing death in the short term, the services can help connect people who use drugs to harm-reduction services and sometimes can provide a stepping stone to treatment.
Still, the strategy faces stiff resistance from several levels of government: The Biden administration has continued to pursue a federal case initiated by the Trump administration in 2018, which is preventing a supervised consumption site from opening in Philadelphia. Pennsylvania’s state legislature and the Philadelphia City Council have each expressed opposition to the practice, and California Gov. Gavin Newsom (D) has vetoed legislation that would have allowed a number of sites to open as part of a pilot program.
“Part of the story is that we don’t have the facilities that we need, and we’re creating workarounds in our bathrooms, like motion detectors and safety protocols,” Gaeta said, adding that anything short of supervised consumption is a half-measure.
“That’s what we need,” she said. “But we can’t do that. Our hands are really tied. So this is coming as close as we possibly can.”
STAT’s coverage of chronic health issues is supported by a grant from Bloomberg Philanthropies. Our financial supporters are not involved in any decisions about our journalism.