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A Piece of My Mind
June 25, 2019

A Pitiful Sanctuary

Author Affiliations
  • 1Boston Health Care for the Homeless Program, Boston University School of Medicine, Boston, Massachusetts
JAMA. 2019;321(24):2407-2408. doi:10.1001/jama.2019.7998

I never anticipated spending so much of my clinical time in bathrooms. But drug overdose is the leading cause of death among the homeless individuals I take care of at a health center in Boston—and without homes or access to supervised consumption sites, people who are homeless frequently inject drugs behind the closed doors of public bathrooms, including ours.

Despite the housekeeping staff’s relentless efforts to keep them clean, these bathrooms can be desolate spaces. I try to imagine what it might be like for a person as he or she approaches the restroom; it’s painful to think that this bleak space could be a person’s only sanctuary. A trail of desperate attempts at patient education and clinician preparation lines the hallway: a fentanyl alert poster several doors down; an overdose prevention fact sheet a little closer; another sheet asking, “Do you know what to do if a friend overdoses?” I imagine people shuffling past these warnings and pleas. As they enter, the bathroom door clicks decisively behind them. Escaping from the bustling clinic lobby, they are alone, finally hidden to do what their mind and body are demanding: dissolve the pain and stem the symptoms of withdrawal.

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    3 Comments for this article
    Washroom Safety is Essential!
    Shannon Riley, RN, MPP | Vancouver Coastal Health
    I agree with the writer that, "(w)e must be able to create cleaner, safer spaces for people to consume drugs and be connected to help." In Vancouver, BC we have 9 places for the public to consume drugs under supervision to prevent overdose morbidity and mortality. We also have 25+ places in housing for residents to consume drugs in a safer area than using alone in their room. However, people will still use drugs in bathrooms. We know this because we still see evidence of people using in these spaces, e.g. used harm reduction supplies and people overdosing.

    following checklist is a document we have been working on in Vancouver Coastal Health, and improving on over the last 2 years, to recommend safer ways to operate bathroom facilities. Thank-you for raising awareness on this issue!:

    A Recent Video
    Lora Burke-Mulkey, Registered Nurse | FQHC Indiana
    In an animated video I saw (1) the author spoke about addiction and theorized that the cure was connectivity. I was perplexed by what he meant but as I watched I totally got it. We ignore, shun, shame, and avoid people with addiction. In reality if we actually connected, showed them they matter and we want to help them, understand them yet hold them accountable for their actions, make them feel they ARE part of our community, not invisible, they may slowly begin to see they are still part of "us," still worthy of human interaction, conversation, compassion, kindness, help...real help. Maybe they will begin to value themselves and their lives enough to keep trying to get a  better grip on their substance abuse and to keep asking for help until the right help is found. They often feel unheard, unseen, unworthy, better off dead, and certainly less than everyone else they see. Connecting, being a part of a community, this might be the wisest theory I have heard regarding addiction and those lost in its web of lies, pain, suffering, and secrecy. 


    1. https://youtu.be/C8AHODc6phg 
    Washroom drama points to need for long-term solutions.
    Robert Beech, MD, PhD | Yale University, Department of Psychiatry
    Thank you Dr. Gaeta for your vivid description of the repeated overdoses at your facility and your heroic efforts to both help and humanize the victims of the opioid epidemic. Sadly, your comment that, "often, the terrified, revived person walks out our door before we can even learn his or her name," speaks to the ongoing failure of our healthcare and legislative systems to adequately address this problem. Someone who has just overdosed on narcotics should not be walking out of the emergency room, whatever their stated wishes. Arguably, such a person lacks the capacity to make medical decisions for themselves precisely because of their addiction, and has just demonstrated that they are a threat to themselves. Last year, during a particular noteworthy week in New Haven, where I practice, there were over 100 overdoses involving 47 people on the New Haven Green in one day. This means that most victims were poisoned at least twice by the same substance. Some reportedly went back and used 3 or 4 times, being taken to the emergency department each time for potentially life threatening symptoms. Connecticut has a statute (CGS § 17a-685) that allows a person to be involuntarily committed for treatment if, as a result of their addiction to drugs or alcohol, that person is dangerous to themselves or others. However, this law is seldom, if ever, used in an ER setting. There are 2 main reasons for this. The first involves obstacles built into the commitment law. The statute requires a formal hearing by a probate court judge "within 7 days of filing of the application" (which would require the ER to hold that person for up to 7 days before the hearing could be held) and a letter from the proposed treatment center indicating that a bed is available before the application can even be filed. The second reason this law is seldom used is that even if these procedural hurdles could be ironed out with an improved statute, we simply have no beds to put all of the people who need treatment into. If this crisis is going to be addressed in more than an ad hoc way, we must commit adequate resources to provide long-term treatment for all of the people suffering from addiction. If not, we will continue to see them gasping for breath in the ERs and on the bathroom floors.