Julie Appleby/Elizabeth Lucas: Surgeons handed out far too many opiates
Two milligrams of the synthetic opiate Fentanyl. — a lethal dose in most people
“Prescribers should have known better”
— Andrew Kolodny, co-director of opioid policy research at Brandeis University, in Waltham, Mass.
As opioid addiction and deadly overdoses escalated into an epidemic across the U.S., thousands of surgeons continued to hand out far more pills than needed for postoperative pain relief, according to a KHN-Johns Hopkins analysis of Medicare data.
Search individual prescribing habits by doctor name or associated hospitals based on data analysis by Kaiser Health News and Johns Hopkins School of Public Health.
Many doctors wrote prescriptions for dozens of opioid tablets after surgeries — even for operations that cause most patients relatively little pain, according to the analysis, done in collaboration with researchers at Johns Hopkins School of Public Health. It examined almost 350,000 prescriptions written for patients operated on by nearly 20,000 surgeons from 2011 to 2016 — the latest year for which data are available.
Some surgeons wrote prescriptions for more than 100 opioid pills in the week following the surgery. The total amounts often exceeded current guidelines from several academic medical centers, which call for zero to 10 pills for many of the procedures in the analysis, and up to 30 for coronary bypass surgery.
While hundreds of state and local lawsuits have been filed against opioid manufacturers, claiming they engaged in aggressive and misleading marketing of these addictive drugs, the role of physicians in contributing to a national tragedy has received less scrutiny. Research shows that a significant portion of people who become addicted to opioids started with a prescription after surgery.
In sheer numbers, opioid prescribing in the U.S. peaked in 2010, but it remains among the highest in the world, according to studies and other data.
In 2016, opioids of all kinds were linked to 42,249 deaths, up from the 33,091 reported in 2015. The opioid-related death rate jumped nearly 28% from the year before, according to the CDC.
Yet long-ingrained and freewheeling prescribing patterns changed little over the six years analyzed. KHN and Johns Hopkins examined the prescribing habits of all U.S. surgeons who frequently perform seven common surgical procedures and found that in the first week after surgery:
Coronary artery bypass patients operated on by the highest-prescribing 1% of surgeons filled prescriptions in 2016 exceeding an average of 105 opioid pills.
Patients undergoing a far less painful procedure — a lumpectomy to remove a breast tumor — were given an average of 26 pills in 2016 the week after surgery. The highest-prescribing 5% of surgeons prescribed 40 to 70 pills on average.
Some knee surgery patients took home more than 100 pills in the week following their surgery.
Those amounts — each “pill” in the analysis was the equivalent of 5 milligrams of oxycodone — are many times what is currently recommended by some physician groups to relieve acute pain, which occurs as a result of surgery, accident or injury. The analysis included only patients not prescribed opioids in the year before their operation.
“Prescribers should have known better” based on studies and other information available at the time, said Andrew Kolodny, co-director of opioid policy research at Brandeis University, in Waltham, Mass., and director of the advocacy group Physicians for Responsible Opioid Prescribing.
While the dataset included only prescriptions written for patients on Medicare, the findings may well understate the depth of the problem, since doctors are more hesitant to give older patients the powerful painkillers because of their sedating side effects.
Surgeons’ prescribing habits are significant because studies show that 6% of patients who are prescribed opioids after surgery will still be taking them three to six months later, having become dependent. The likelihood of persistent use rises with the number of pills and the length of time opioids are taken during recuperation.
Also, unused pills in medicine cabinets can make their way onto the street.
Dr. Marty Makary, a surgical oncologist at Johns Hopkins, admits that he too once handed out opioids liberally. Now he is marshaling a campaign to get surgeons to use these powerful painkillers more consciously and sparingly. “I think there’s an ‘aha’ moment that many of us in medicine have had or need to have,” he said.
But old habits are hard to kick.
KHN contacted dozens of the surgeons who topped the ranks of opioid prescribers in the 2016 database. They hailed from small, community hospitals as well as major academic medical centers. The majority declined to comment, some bristling when questioned.
Look Up Opioid Prescribers: Search KHN Database By Doctor, Hospital
Some of those surgeons were critical of the analysis, saying it didn’t take into account certain essential factors. For example, it was not possible to determine whether patients had complications or needed higher amounts of pain medication for another reason. And some surgeons had only a handful of patients who filled prescriptions, making for a small sample size.
But surgeons also indicated that the way they prescribe pain pills was less than intentional. It was sometimes an outgrowth of computer programs that default to preset amounts following procedures, or practice habits developed before the opioid crisis. Additionally, they blame efforts in the late 1990s and early 2000s that encouraged doctors and hospitals to consider pain as “the fifth vital sign.” A major hospital accrediting group required providers to ask patients how well their pain was treated. Pharmaceutical companies used the fifth vital sign campaign as a way to promote their opioid treatments.
Makary, who oversaw the analysis of the Medicare dataset, said that, while opioid prescribing is slowly dropping, to date many surgeons have not paid enough attention to the problem or responded with sufficient urgency.
Dr. Audrey Garrett, an oncologic surgeon in Oregon, said she was “surprised” to hear that she was among the top tier of prescribers. She said she planned to re-evaluate her clinic’s automated prescribing program, which is set to order specific amounts of opioids.
KHN will analyze data for 2017 and subsequent years when it becomes available to follow how prescribing is changing.
Prescribing Patterns Highlight What’s At Stake
The analysis examined prescribing habits after seven common procedures: coronary artery bypass, minimally invasive gallbladder removal, lumpectomy, meniscectomy (which removes part of a torn meniscus in the knee), minimally invasive hysterectomy, open colectomy and prostatectomy.
Across the board, the analysis showed that physicians gave a large number of narcotics when fewer pills or alternative medications, including over-the-counter pain relief tablets, could be equally effective, according to recent guidelines from Makary and other academic researchers.
On average, from 2011 to 2016, Medicare patients in the analysis took home 48 pills in the week following coronary artery bypass; 31 following laparoscopic gallbladder removal; 28 after a lumpectomy; 41 after meniscectomy; 34 after minimally invasive hysterectomy; 34 after open colon surgery; and 33 after prostatectomy.
According to post-surgical guidelines spearheaded by Makary for his hospital last year, those surgeries should require at most 30 pills for bypass; 10 pills for minimally invasive gallbladder removal, lumpectomy, minimally invasive hysterectomy and prostatectomy; and eight pills for knee surgery. It has not yet published a guideline for open colon surgery.
The Johns Hopkins doctors developed their own standards because of a dearth of national guidelines for post-surgical opioids. They arrived at those figures after reaching a consensus among surgeons, nurses, patients and other medical staff on how many pills were needed after particular surgeries.
Hoping to reduce overprescribing, Makary is preparing to send letters next month to surgeons around the country who are among the highest opioid prescribers under a grant he received from the Arnold Foundation, a nonprofit group whose focus includes drug price issues. (Kaiser Health News also received funding from the Arnold Foundation.)
Even if the prescription numbers have fallen since 2016, the amounts given today are likely still excessive.
“When prescribing may have been five to 20 times too high, even a reduction that is quite meaningful still likely reflects overprescribing,” said Dr. Chad Brummett, an anesthesiologist and associate professor at the University of Michigan.
Brummett is also co-director of the Michigan Opioid Prescribing Engagement Network, a collaboration of physicians that makes surgery-specific recommendations, many of them in the 10- to 20-pill range.
“Reducing unnecessary exposure is key to reducing the risk of new addiction,” said former Food and Drug Administration commissioner Scott Gottlieb. In August 2018, when Gottlieb was at the agency’s helm, it commissioned a report from the National Academy of Sciences on how best to set opioid prescribing guidelines for acute pain from specific conditions or surgical procedures. Its findings are expected later this year.
“There are still too many 30-tablet prescriptions being written,” said Gottlieb.
Healers Sowing Disease?
Naturally, surgeons rankle at the idea that they played a role in the opioid epidemic. But studies raise serious concerns.
Transplant surgeon Dr. Michael Engelsbe, director of the Michigan Surgical Quality Collaborative, points to the study showing 6% of post-op patients who get opioids for pain develop long-term dependence. That means a surgeon who does 300 operations a year paves the way for 18 newly dependent people, he said.
Many patients do not need the amounts prescribed.
Intermountain Healthcare, a not-for-profit system of hospitals, clinics, and doctors in Utah, began surveying patients two years ago to find out how much of their prescribed supply of opioids they actually took following surgery.
“Globally, we were overprescribing by 50%,” said Dr. David Hasleton, senior medical director.
But Intermountain approached individual doctors carefully. “If you go to a prescriber to say, ‘You are overprescribing,’ it never goes well. A common reaction is, ‘Your data is wrong’ or ‘My patients are different than his,’” said Hasleton.
For the analysis, KHN attempted to contact more than 50 surgeons whose 2016 numbers ranked them among the top prescribers in each surgical category.
One who did agree to speak was Dr. Daniel J. Waters, who 13 years ago had his chest cut open to remove a tumor, an operation technically similar to what he does for a living: coronary artery bypass.
“So I have both the doctor perspective and the patient perspective,” said Waters, who practices in Mason City, Iowa.
In 2016, Waters’ Medicare bypass patients who filled their prescriptions took home an average of nearly 157 pills each, according to the KHN-Johns Hopkins analysis.
“When I went home from the hospital, 30 would not have been enough,” said Waters of the number recommended by the Hopkins team for that surgery.
But he said he has recently curbed his prescribing to 84 pills.
Nationally, the average prescription filled for a coronary artery bypass was 49 pills in 2016 and had changed little since 2011, the analysis shows.
Others who spoke with KHN said they had developed the habit of prescribing copiously — sometimes giving out multiple opioid prescriptions — because they didn’t want patients to get stuck far from the office or over a weekend with pain or because they were trying to avoid calls from dissatisfied, hurting patients.
In the KHN-Johns Hopkins data, the seven patients of Dr. Antonio Santillan-Gomez who filled opioid prescriptions after minimally invasive hysterectomies in 2016 received an average of 77 pills each.
A gynecologic oncologist, Santillan-Gomez said: “I’m in San Antonio, and some of my patients come from Laredo or Corpus Christi, so they would have to drive two to three hours for a prescription.”
Still, he said, since e-prescribing of opioids became more widespread in the past few years, he and other surgeons in his group have limited prescriptions to 20 to 30 pills and encouraged patients to take Tylenol or other over-the-counter medications if they run out. E-prescribing can not only help track patients getting opioids but also reduce the problem of patients having to drive back to the office to get a written prescription.
Dr. Janet Grange, a breast surgeon in Omaha, Neb., said that in her experience, opioid dependence had not been a problem.
“I can absolutely tell you I don’t have even 1% who become long-term opioid users,” said Grange.
The analysis showed that Grange had 12 opioid-naïve Medicare patients who had a lumpectomy in 2016. Eight of them filled prescriptions for an average of 47 pills per patient.
She called Johns Hopkins’ zero-to-10-pill pain-control recommendation following that procedure “miserly.”
The Pendulum Swings
Some of the higher-prescribing surgeons in the KHN-Johns Hopkins analysis reflected on their potential contribution to a national catastrophe and are changing their practice.
“That is a shocking number,” said oncologist Garrett, speaking of the finding that 6% of patients who go home with opioids will become dependent. “If it’s true, it’s something we need to educate physicians on much earlier in their medical careers.”
Garrett, in Eugene, Ore., said she has cut back on the number of pills she gives patients since 2016. The KHN-Johns Hopkins analysis showed that seven of her 13 opioid-naïve Medicare patients undergoing minimally invasive hysterectomies filled a prescription for opioids in 2016. Those patients took home an average of 76 pills each.
Johns Hopkins guidelines call for no more than 10 opioid pills following this procedure, while Brummett’s Michigan network recommends no more than 15.
Surgeon and researcher Dr. Richard Barth, once a heavy prescriber himself, said that his own experience convinced him that physicians’ preconceptions about how much pain relief is needed are often way off.
The analysis showed his lumpectomy patients in 2013 filled an average of 33 pills in the week after surgery. By 2016, that average had dropped to seven pills. Many patients, he said, can do just fine after lumpectomy with over-the-counter medications — and often no opioids at all.
The key, he said, is to set patients’ expectations upfront.
“I tell them it’s OK to have a little discomfort, that we’re not trying to get to zero pain,” said Barth, who is chief of general surgery at Dartmouth-Hitchcock Medical Center and has published extensively on opioid prescribing.
After lumpectomy, “what I recommend is Tylenol and ibuprofen for at least a few days and to use the opioids only if the discomfort isn’t relieved by those.”
Indeed, the data analysis showed that a significant number of patients given prescriptions for opioids never filled them because they don’t need that level of pain relief.
Between 2011 and 2016, for example, only 62% of lumpectomy patients in the analysis filled prescriptions, similar to hysterectomy patients.
In 2016, patients of Dr. Kimberli Cox, a surgeon in Peoria, Ariz., were prescribed about 59 pills in the week following lumpectomy, well above the recommendations from both Johns Hopkins and others.
But the KHN-Johns Hopkins analysis of that year’s data shows that half of her patients never filled a painkiller prescription — a fact she acknowledges has changed her thinking.
“I am now starting to prescribe less because many patients say, ‘You gave me too many’ or ‘I didn’t fill it,” she said.
Julie Appleby and Elizabeth Lucas are Kaiser Health News reporters.
Julie Appleby: jappleby@kff.org, @Julie_Appleby
Elizabeth Lucas: elucas@kff.org, @eklucas
Purdue Pharma played down OxyContin addiction danger
Side-effects of oxycodone, the generic name for OxyContin, the brand name of a controversial Purdue Pharma product.
By FRED SCHULTE
Two decades ago, Purdue Pharma, based in Stamford, Conn. {see headquarters below}, produced thousands of brochures and videos that urged patients with chronic pain to ask their physicians for opioids such as OxyContin, arguing that concerns over addiction and other dangers from the drugs were overblown, company records reveal.
Kaiser Health News earlier this year posted a cache of Purdue marketing documents that show how the pharmaceutical company sought to boost sales of the prescription painkiller, starting in the mid-1990s.
Purdue turned the records over to the Florida attorney general’s office in 2002 during its investigation of the company. Additional Purdue documents from the Florida investigation detail how the company targeted patients and allayed addiction worries.
“Fear should not stand in the way of relief of your pain,” a pivotal marketing brochure said.
Purdue said it handed out thousands of copies of the brochure, which emphasized consumer power in treating pain, as well as a videotape. “The single most important thing for you to remember is that you are the authority on your pain. Nobody else feels it for you so nobody else can describe how much it hurts, or when it feels better,” the pamphlet states.
More than 1,500 pending civil lawsuits, filed mostly by state and local governments, allege that deceptive marketing claims helped fuel a national epidemic of opioid addiction and thousands of overdose deaths.
Last week, the New York attorney general’s office filed another suit that accuses Purdue of operating a “public nuisance” in it sales tactics and marketing of opioids. Like many others, the suit demands compensation for addiction treatment costs and other problems. Purdue and other drugmakers have denied all allegations.
President Trump said last Thursday he wants the federal government to sue drugmakers in response to the addiction epidemic.
The Purdue brochure from the late 1990s spurred recent criticism from drug safety experts. Dr. G. Caleb Alexander, a physician at the Center for Drug Safety and Effectiveness at Johns Hopkins Bloomberg School of Public Health, said the sales pitch was “simply not true” and called it “a smoking gun.”
“We have learned the hard way that many patients develop opioid [addiction] when using these medicines as prescribed,” he said.
Alexander said other drugmakers also appealed to patients hoping to influence their doctors — a tactic that was relatively new in the late 1990s. But Alexander said he was “shocked” to hear that Purdue did so with OxyContin, given the risks posed by long-term use of the morphine-like narcotic.
“These drugs [opioids] are in a class of their own when it comes to the harms that they have caused,” Alexander said.
The internal Purdue documents, dating from 1996 to 2002, show that the company began marketing OxyContin to doctors in late 1995 for treating moderate to severe cancer pain. With modest sales of $49.4 million in 1996, Purdue posted a loss of $452,000 on the drug. In 1997, sales reached $146.5 million for a pretax profit of $16.5 million, the company records show.
In 1998, as Purdue hawked OxyContin for conditions such as arthritis and back pain, it decided to “increase communications” with patients, company records show.
The goal: “convince patients and their families to actively pursue effective pain treatment. The importance of the patient assessing their own pain and communicating the status to the health care giver will be stressed.”
Purdue’s six-page pamphlet for patients, provided to the Florida attorney general, was titled “OxyContin: A Guide to Your New Pain Medicine.” “Your health care team is there to help, but they need your help, too,” the pamphlet says. It says OxyContin is for treating “pain like yours that is moderate to severe and lasting for more than a few days.”
To patients or family members worried about addiction, Purdue’s pamphlet said: “Drug addiction means using a drug to get ‘high’ rather than to relieve pain. You are taking opioid pain medication for medical purposes. The medical purposes are clear and the effects are beneficial, not harmful.”
Asked to comment this week, Purdue spokesman Robert Josephson said the company “discontinued the use of this piece many years ago.”
Dr. Michael Barnett, a physician and assistant professor at the Harvard T.H. Chan School of Public Health, said that some of Purdue’s early marketing claims may have seemed reasonable to many doctors 20 years ago.
But he faulted the medical profession for not demanding scientific evidence that opioids were in fact safe and prudent for widespread use.
“I think a lot of physicians are coming to the realization that a lot of what we were taught about pain management was pure conjecture,” he said. “I feel foolish for believing it.”
In hindsight, he said, Purdue’s sales tactics seem “almost a satire of an unscrupulous corporation that really has no interest in understanding the implications and complications of people using their drugs.”
Dr. Art Van Zee, a physician in southwestern Virginia who was among the first to recognize the ravages of OxyContin misuse, said that some people who became addicted were already drug abusers.
But he added: “There clearly are people that I’ve taken care of who took it as directed orally and became opioid-addicted.”
Purdue also paid a New York City production company to shoot a videotape called “From One Pain Patient to Another,” featuring testimonials by seven patients from the Raleigh, N.C., area under the care of pain doctor Alan Spanos. Filming took place at the patients’ homes, places of work and other area locations on July 17, 1997, according to the documents.
Purdue did not pay the patients, though Spanos received $3,400 as a “physician spokesman” on that video and another, the company records state. Contacted recently by phone, Spanos would not comment. In the documents, Purdue said that the patients “participated willingly, wishing to speak out regarding the importance to them of being able to receive effective therapy for their chronic pain.”
Between January 1998 and June 2001, Purdue distributed 16,000 copies of the video to doctors, who showed them to selected patients.
The video did not mention OxyContin directly, but the Food and Drug Administration did balk at a claim in the video that fewer than 1 percent of people taking opioids became addicted. The FDA said that claim was not substantiated, according to a December 2003 General Accountability Office audit.
Purdue destroyed remaining copies of the video in July 2001, including 4,434 Spanish-language versions, according to the company records.
By then, annual OxyContin sales had topped $1 billion as Purdue pushed to “attach an emotional aspect to non-cancer pain so physicians treat it more seriously and aggressively,” according to the company’s marketing reports.
Asked about the video, Purdue spokesman Josephson said the drugmaker has not made that claim — regarding 1 percent addiction — “in more than 15 years.”
Purdue submitted the marketing records to the Florida attorney general’s office during its investigation of the company. The state settled the case in 2002 when Purdue agreed to pay $2 million to help set up an electronic prescription-tracking program.
Florida officials released the records to two Florida newspapers in 2003 after Purdue lost a court battle to keep them confidential. KHN posted some of those documents earlier this year for readers to review on its website.
Purdue's headquarters is in this building in downtown Stamford.
Public restrooms ground zero in opiate crisis
By MARTHA BEBINGER, WBUR
A man named Eddie threaded through the midafternoon crowd in Cambridge, Mass. He was 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,” said 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 services 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 said. “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 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 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 said.
Eddie is homeless and works at a restaurant. Public bathrooms are among 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, and he says he now uses the drug only 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 said. “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, 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 said. “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.”
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)
Gerber and his staff have found several people on the bathroom floor in recent years, not breathing.
“It’s very scary,” Gerber said. 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 recently. Within 10 minutes, he had about 25 replies.
“Mostly capital ‘Yes!! I’ll be there for sure!’ ‘Count me in!'” Gerber recalled 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,” 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’s team started carrying naloxone in the past 12 to 18 months.
“It’s definitely relieving when you see someone breathing again when two, three minutes beforehand they looked lifeless,” Curran said. “A couple of pumps of the nasal spray and they’re doing better. It’s pretty incredible.”
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)
Massachusetts General Hospital began training security guards after emergency room physician Dr. Ali Raja realized that the hospital’s bathrooms had become a 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 said, “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 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’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 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’t get high in.
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,” said 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,” said 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.
This story is part of a partnership that includes WBUR, NPR and Kaiser Health News.