The criminalization of drug users means that every day, people addicted to drugs are forced to make difficult decisions, often choosing not what’s good for them, but what will hopefully result in the least harm.

Marilou Gagnon, president of the Harm Reduction Nurses Association (HRNA), offered an example: “In the absence of a safer space to use, the default becomes a washroom,” she told the Straight.

“A washroom is safe because you can get away from cops,” the University of Victoria (UVic) associate professor explained. “It is safe because you are by yourself, because you cannot be the target of law enforcement. But most washrooms are not designed to facilitate an entry and rapid action in the event of an overdose....So these washrooms become extremely dangerous."

Last year in B.C, there were 54 fatal overdoses that occurred indoors in a location that was not someone’s residence. Of those 54 deaths, 23, or 43 percent, happened in a public washroom, according to B.C. Coroners Service statistics released in response to a freedom-of-information request.

Public-washroom overdoses only constitute a small minority of the 1,533 illicit-drug overdose deaths that B.C. suffered in 2018. But they represent instances where it might have been relatively easy to prevent an overdose from ending as a fatal one.

In 2018, 87 percent of fatal overdoses occurred in a person’s private home or in another residence such as a hotel or homeless shelter. Those sorts of overdose are especially difficult to prevent. That’s because the victim is often by themselves, using drugs in isolation. With the 23 fatal overdoses in 2018 that occurred in public washrooms, there are specific actions that authorities and private-business could have taken to reduce deaths.

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Dr. Patricia Daly is chief medical health officer and vice president of public health for Vancouver Coastal Health (VCH). She told the Straight that washroom overdoses initially came on the care provider’s radar via reports from hospitals, but that it quickly became apparent the bigger concern was washrooms in public spaces such as shopping malls and coffee shops.

“We want to work with municipalities,” Daly said in a telephone interview. “There are strategies that governments can use with businesses owners to make modifications to their washrooms that might be a benefit.

“Strategies could include giving tax breaks to businesses that might be willing to change their washrooms,” she suggested.

VCH developed guidelines for how best to monitor and reduce washroom overdoses in 2016 and, earlier this year, revised and added further detail to those documents.

“Announcing that, ‘drug use is not allowed in the washroom,’ may be part of an agency’s internal policy; however, this can deter people from using the washroom space & using somewhere even more isolated & dangerous,” reads one of the 2019 notices.

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Included is a checklist of “safer washroom protocol suggestions” divided into three categories of effort and cost.

“Ensure all staff have access to key, fob &/or device to open all washroom locks,” reads one item in the “minimal effort/cost” category.

“Install washroom/stall external facing washroom doors that swing outward,” reads a suggestion in the “moderate” category.

And in the “maximum effort/cost” category, VCH recommends installing timer-lock mechanisms, intercoms, and motion detectors that alert facility staff when someone inside a toilet stall fails to move for a certain length of time.

Shannon Riley is a clinical educator with VCH’s overdose emergency response and prevention team. She previously worked at a homeless shelter in San Francisco, a city where people using drugs are generally stigmatized worse than they are in Vancouver, and therefore where they are more likely to hide drug use in isolated locations such as public washrooms. Riley told the Straight she responded to many washroom overdoses during the 10 years she worked in San Francisco, and brought that experience with her to VCH.

“There are some really easy things that people can do,” Riley said. She noted that any business interested in learning how to reduce the risk of a fatal overdose occurring on their property can contact VCH for a free consultation.

“A system of checking is something that needs to be established,” Riley said. “With fentanyl, where someone can overdose in five minutes, you really have to step up checking.”

There were 538 illicit-drug overdose deaths in B.C. during the first six months of 2019 and 1,533 the year before. More than 85 percent of them involved fentanyl or carfentanil, dangerous synthetic-opioids that can cause overdoses to occur much faster than is the case with similar but less-potent drugs like heroin and OxyContin.

In response to more overdoses occurring in public washrooms, some B.C. businesses have installed neon-blue lights, which make it extra challenging for people injecting drugs to see their veins. The lights are designed to make it so difficult for people to inject drugs safely that they’ll choose to go elsewhere. But, as an August 2016 paper published by UVic's Centre for Addictions Research of B.C. explains, where health authorities decline to make available designated locations for intravenous drug use, public washrooms become “de facto” injection sites.

"Almost half (43%) of the 80 people interviewed in the Victoria High Risk Populations Monitoring Study survey in 2015 reported using substances in the washroom of a social service agency in the past 12 months,” it reads. “The number of people reporting substance use in agency washrooms nearly doubled between the first and second waves of data collection in 2015 from 11 (28%) to 23 (58%).”

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Downtown Vancouver's St. Paul's Hospital sees a lot of patients with addictions issues. In response, its Rapid Access Addition Clinic installed a motion detector that alerts staff if no movement is detected for several minutes.

Another way that St. Paul's responded to bathroom overdoses is by integrating an overdose-prevention site (OPS) into its property on Burrard Street.

"We’re the first hospital in North America with a peer-staffed OPS right on site," Ann Gibon, a spokesperson for the hospital's operator, Providence Health Care, told the Straight. "Since the OPS opened in 2018, there have been no incidents of washroom overdoses."

Daly suggested the entire issue of washroom overdoses leads back to stigma.

“It’s very sad,” she said. “People are taking these [harm-reduction] supplies that we’re giving them and then using their substance in a public washroom at risk of death. This is a very unfortunate situation that shows the stigma associated with drug use, that people end up having to consume their substances in a washroom like this.

“If they have a home…are they trying to hide their substance use or addiction and therefore go into a washroom to do that?” Daly continued. “It’s a real symbol of the stigma associated with substance use.”