As service providers and public health professionals who work with people who use drugs, we know that sometimes people use drugs in our facilities. Particularly in the case of injection drug use, a bathroom or other private area at a trusted services agency may be the safest and most secure location when the alternative is using outdoors, in business bathrooms, or similarly problematic places.
Many programs, and even businesses, have taken steps to improve safety and hygiene in places where people might use drugs. The first goal is to protect clients and staff. When done thoughtfully, such strategies can also foster therapeutic relationships by promoting open and frank dialog with drug using clients.
Examples of steps that can be taken include:
- Training staff on overdose response including the use of naloxone, equipping spaces or individuals with overdose rescue kits, and adopting policies and procedures for overdose management.
This is a sample policy developed for on-site overdoses– it was created for pharmacies, but can easily be adapted to different venues.
- Collaborating with participants to develop policies for use of public facilities such as bathrooms or showers, including rules regarding allowed time for use, monitoring, cleanliness, or other issues.
- Installing sharps disposal containers, non-porous surfaces, mirrors, clearly displayed safety information, intercoms, or other items in places where people may use illegal or prescribed drugs.
In the U.S., programs in New York State have perhaps gone the furthest in formalizing practice in this area. Multiple public health agencies and numerous CBOs have adopted policies and procedures in the context of syringe exchange programs, but they may be easily adapted for use by any organization with public facilities where people might use drugs.
- EXAMPLE: Policies and Procedures for Service Providers
Adapted from P&Ps in use by organizations in New York City.
Policies and Procedures for Public Bathroom Management
This document provides guidance on managing public bathroom facilities or other private spaces in agencies serving people who use drugs.
Policies and Procedures for Overdose Response
Designed for use by health services staff working in locations where people may overdose, this document provides policies and procedures for managing drug overdoses or other medical emergencies and maximizing participant and staff safety.
- EXAMPLE: New York State Department of Health Syringe Exchange Policies and Procedures
The following guidelines have been issued by the New York State Department of Health in order to encourage syringe state-funded harm reduction programs to create safer spaces for people who might use drugs on their premises. They are excerpted from the September 2016 version of the Department of Health’s policies and procedures for syringe exchange programs (pp. 10-11, “Staying Safe at a Syringe Exchange Program”). The full document is available online.↓ click to expandPolicy: All staff, peers, volunteers and clients should follow the agency’s rules and procedures regarding personal and collective well-being to ensure a safe working and welcoming environment for anyone on the premises.
Procedure: All staff, peers, volunteers and clients should receive orientation and written guidance regarding SEP safety rules related to being on-site for work or receipt of services. A signed attestation of receipt of the written information should be included in staff/peer/volunteers’ personnel files and clients’ record.
A. Proper utilization and maintenance of agency facilities by clients, staff, peers and volunteers:
- All agency facilities and property should be well lit for safety purposes. All facilities should be treated with respect and care. This is especially important for shared facilities such as bathrooms, showers, washrooms, washers/dryers, and kitchen/break room equipment.
- The agency should have a first aid kit that is secured but accessible to staff.
- Fire extinguishers should be strategically placed throughout the SEP, especially in kitchen or cooking areas.
- The agency should have naloxone kits available at the site, and have staff trained as opioid overdose responders. The location of the kits should be clearly marked. Place decals or signs that can be easily seen on the places where the naloxone kits are kept.
- The agency should establish and post a schedule when special equipment or facilities, such as showers, washrooms, washers/dryers and kitchen equipment may be accessed.
- The frequency of participants’ use of these facilities and the maximum allowable time of use should be established and posted along with the staff person to speak to in special or emergency situations.
- Participants requesting to use these facilities should be directed to the sign-up or sign-in sheets.
B. Bathroom/washroom (see above) procedures to reduce incidences of overdose fatalities or other medical emergencies:
- Bathrooms and/or washrooms should be readily accessible to participants during SEP hours of operations. Hygiene is of critical importance to avoid injection site infections especially for homeless individuals who may need to access bathrooms and washrooms on a regular basis. Bathroom and shower tables should be made of a non-porous material so they can be thoroughly cleaned.
- The agency should post its bathroom/washroom policies in a conspicuous place and at a literacy level appropriate for agency participants.
- Participants should be made aware of any restrictions related to use of the bathroom and/or washroom.
- Participants’ dignity and privacy should be respected. There needs to be a reasonable expectation of privacy as the person could be in various stages of undress. For this reason, there should be a way to secure the bathroom door and individuals can expect not be disturbed for a reasonable time frame. If possible a flat surface such as a table or counter should be made available to avoid having participants place possessions on the floor. As previously stated, these need to be non-porous so they can be thoroughly cleaned. When space allows, there should also be a chair, to avoid chance of a participant falling and being injured.
- Internal agency response protocols should be established in the event of a possible emergency, including an overdose. This includes a means for staff to access the shower, bathroom, washroom, or restroom lounge if entry is deemed warranted.
- To improve the agency’s ability to respond to emergency situations, having a shower, washroom or bathroom door that swings out rather than into the space will maximize access to anyone experiencing an emergency inside.
- The agency should also consider having an intercom system so agency staff can communicate with participants using the bathroom, washroom, or showers.
- If feasible, a separate space that does not contain toilet facilities should be provided for individuals who need to administer an injectable medication (e.g. insulin) or as a quiet space to gather composure in the event of an incident (e.g. on-site altercation or overdose).
C. All communal areas, and especially showers, kitchens, washrooms and bathrooms, must have a regular cleaning schedule. The schedule should be posted at the supervisor’s workstation and signed by the employee when cleaning is done so cleanliness can be monitored and good sanitation practices followed.
D. SEPs may order locked sharps containers […] for installation in bathrooms. The sharps container will enable staff and clients who need injectable medications (e.g insulin) to discreetly dispose of their syringes.”