“Opening the door to somebody who has a chance.” – The experiences and perceptions of public safety personnel towards a public restroom overdose prevention alarm system

Abstract

Background
Opioid overdose deaths have surged due to fentanyl in the illicit opioid supply, which causes overdose more rapidly than other opioids. Public restrooms are venues where fentanyl overdoses commonly occur. In response, some organizations have implemented anti-motion alarm systems as a prevention approach. We aimed to describe the experiences and perceptions of public safety personnel after the installation of an anti-motion alarm system in public restrooms at an urban medical center.

Methods
From February to June 2019, we conducted semi-structured qualitative interviews to explore the experiences and perceptions of hospital public safety personnel who responded to overdoses in public restrooms with and without an anti-motion alarm system. We interviewed 11 personnel, with interviews lasting an average of twenty-six minutes. We conducted inductive thematic analysis to synthesize and identify salient themes.

Results
Ten participants were male; the average age was 40 with an average time employed by the hospital of 12 years. Four themes were identified: Public safety personnel 1) believe responding to overdoses is an appropriate responsibility; 2) focus on their training rather than individual emotions when responding to an overdose; 3) view the anti-motion alarm system as an acceptable tool for preventing overdoses, despite technological challenges; and 4) report concern for potential unintended consequences of the anti-motion alarm system.

Conclusions
Overdose response in public restrooms has been incorporated into the daily duties of public safety personnel at an academic medical center. Anti-motion alarm systems are an innovation with potential to improve overdose response and safety, though the technology warrants ongoing development and unintended consequences should be assessed. To optimize restroom safety in the midst of fentanyl use, more research is needed among first responders, people who use drugs in restrooms, and other restroom patrons.

Full text

International Journal of Drug Policy 88 (2021) 103038
Available online 21 November 2020
0955-3959/© 2020 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Short Report
“Opening the door to somebody who has a chance.” – The experiences and
perceptions of public safety personnel towards a public restroom overdose
prevention alarm system
Bradley M. Buchheit
a
,
b
,
*
, Erika L. Crable
c
,
d
, Sarah K. Lipson
c
, Mari-Lynn Drainoni
c
,
d
,
e
,
f
,
Alexander Y. Walley
g
a
Department of Medicine, Division of General Internal Medicine and Geriatrics, Section of Addiction Medicine, Oregon Health & Science University, 3181 SW Sam
Jackson Park Rd, Mail Code: L475, Portland, OR, 97239, USA
b
Department of Family Medicine, Oregon Health & Science University, 3303 S Bond Avenue, Mail Code: CH9F, Portland, OR, 97239, USA
c
Department of Health Law, Policy and Management, Boston University School of Public Health, 715 Albany Street, Talbot Building, T2W, Boston, MA, 02118, USA
d
Evans Center for Implementation and Improvement Sciences, Boston University School of Medicine, 801 Massachusetts Ave, 2nd Floor, Boston, MA, 02118, USA
e
Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
f
Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA
g
Grayken Center for Addiction, Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Boston Medical Center and Boston University
School of Medicine, 801 Massachusetts Ave, 2nd Floor, Boston, MA, 02118, USA
ARTICLE INFO
Keywords:
Fatal overdose
Opioids
Restroom drug use
Public drug use
Overdose prevention
Harm reduction
ABSTRACT
Background: Opioid overdose deaths have surged due to fentanyl in the illicit opioid supply, which causes
overdose more rapidly than other opioids. Public restrooms are venues where fentanyl overdoses commonly
occur. In response, some organizations have implemented anti-motion alarm systems as a prevention approach.
We aimed to describe the experiences and perceptions of public safety personnel after the installation of an anti-
motion alarm system in public restrooms at an urban medical center.
Methods: From February to June 2019, we conducted semi-structured qualitative interviews to explore the ex-
periences and perceptions of hospital public safety personnel who responded to overdoses in public restrooms
with and without an anti-motion alarm system. We interviewed 11 personnel, with interviews lasting an average
of twenty-six minutes. We conducted inductive thematic analysis to synthesize and identify salient themes.
Results: Ten participants were male; the average age was 40 with an average time employed by the hospital of 12
years. Four themes were identied: Public safety personnel 1) believe responding to overdoses is an appropriate
responsibility; 2) focus on their training rather than individual emotions when responding to an overdose; 3)
view the anti-motion alarm system as an acceptable tool for preventing overdoses, despite technological chal-
lenges; and 4) report concern for potential unintended consequences of the anti-motion alarm system.
Conclusions: Overdose response in public restrooms has been incorporated into the daily duties of public safety
personnel at an academic medical center. Anti-motion alarm systems are an innovation with potential to improve
overdose response and safety, though the technology warrants ongoing development and unintended conse-
quences should be assessed. To optimize restroom safety in the midst of fentanyl use, more research is needed
among rst responders, people who use drugs in restrooms, and other restroom patrons.
Introduction
Since 2000, the rate of US drug overdose deaths involving opioids
has increased 200% (Rudd, Aleshire, Zibbell & Gladden, 2016). Surges
in overdose deaths since 2013 have been driven by widespread
inltration of fentanyl into the illicit opioid supply (McKnight & Des
Jarlais, 2018). Fentanyl is rapid-acting compared to other illicit opioids,
such as heroin, so that the time window for responding and rescuing
someone overdosing is less than 5 min.
As supervised injection facilities are currently illegal in the US, there
* Corresponding author at: Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Mail Code: L475, Portland, OR 97239 USA.
E-mail addresses: buchheit@ohsu.edu (B.M. Buchheit), ecrable@bu.edu (E.L. Crable), sklipson@bu.edu (S.K. Lipson), drainoni@bu.edu (M.-L. Drainoni),
awalley@bu.edu (A.Y. Walley).
Contents lists available at ScienceDirect
International Journal of Drug Policy
journal homepage: www.elsevier.com/locate/drugpo
https://doi.org/10.1016/j.drugpo.2020.103038

International Journal of Drug Policy 88 (2021) 103038
2
are no safe places to use illicit opioids. Many who illicitly use opioids opt
to use in a restroom (Gaeta, 2019; Parkin, 2014). Restrooms typically
provide privacy, access to water to dissolve drugs, and good lighting for
injection preparation (Bebinger, 2017; Bever, 2016; Parkin, 2014;
Wolfson-Stofko, Bennett, Elliott & Curtis, 2017). Prior research suggests
that individuals who inject drugs frequently do so in public restrooms
(Bohnert, Hafezi & Pollak, 2001; Fozouni, Buchheit, Walley, Testa &
Chatterjee, 2019; Injection Drug Users Health Alliance, 2015; Sutter,
Curtis & Frost, 2019). Strategies to improve restroom safety or prevent
fatal drug overdoses in restrooms are urgently needed.
In 2018, a large urban academic medical center located in an area
with high rates of fentanyl use and overdose implemented an anti-
motion alarm system designed to prevent fatal overdoses in the hospi-
tal’s public restrooms. First responders, who serve as hospital public
safety personnel, do not carry rearms, and are trained in CPR, AED,
rst aid, naloxone administration, customer service and de-escalation
techniques. There is no research describing either the effectiveness of
anti-motion alarms or their impact on public safety personnel. This
study aimed to understand experiences and attitudes of public safety
personnel who responded to potential overdose alarms triggered by the
anti-motion alarm system by describing their perceptions of the instal-
lation and impact of the system on their daily workow.
Methods
Setting and context
The study took place at an urban academic medical center in the US
that primarily serves a safety-net population. Overdoses in public rest-
rooms at the medical center were common and increasing in the years
before the study. The medical center recorded 68 overdoses in 2016, 120
in 2017, and 169 in 2018, of which just over half occurred in single-
occupancy restrooms. The medical center reported one fatality related
to drug overdose in 2016, four in 2017, and two in 2018, all but one
occurring in single-occupancy restrooms, demonstrating the need for
improved restroom safety and overdose response. With the increase in
both public drug use and overdoses on the medical center campus,
public safety personnel began routine training in overdose response and
naloxone administration, serving as front-line staff in responding to
overdoses in the public restrooms.
The anti-motion alarm system
In 2018, in order to improve restroom overdose response and spare
public safety personnel from constantly monitoring the restrooms, the
hospital installed an anti-motion alarm system in three single-occupancy
restrooms where overdose fatalities had previously occurred. The sys-
tem detects lack of motion and is automatically activated when a rest-
room door is closed and locked. The alarm is triggered after four minutes
of motionlessness within a restroom. The system utilizes both visual and
audio alerts locally at the restrooms and at the building security desk,
with a remote electronic alert sent to mobile public safety personnel
(Fig. 1). A false alarm was dened as when the alarm sounded with a
patron in the bathroom that did not require medical attention, but for
whatever reason was not moving enough to trigger the device.
Sample
The study sample included English-speaking, public safety personnel
over age 18 who were employed at the hospital, had responded to an
overdose at the hospital within the previous year, and had responded to
at least one of the anti-motion alarms during the prior three months.
Participants were recruited via email and in person. Interviews began
three months after the anti-motion alarm system was installed.
Interview guide
The interview guide was developed through an iterative process with
input from experts in addiction medicine and qualitative methods. Semi-
structured questions asked public safety personnel to recall their expe-
riences responding to the anti-motion alarm, thoughts and emotions
during and after the response, and appropriateness of including over-
dose response and naloxone administration as a required task for public
safety personnel (see Supplemental Material).
Data collection, coding, and analytic methods
Interviews were conducted in-person. Participants also completed a
Fig. 1. Anti-Motion Alarm System.
B.M. Buchheit et al.

International Journal of Drug Policy 88 (2021) 103038
3
brief survey to obtain demographic information, including age, sex,
length of hospital employment, and history of overdose responses. The
study was determined to be exempt by the medical campus IRB (#H-
37686).
Interviews took place in a private space; each lasted approximately
30 min (mean =26 min). Interviews were audiotaped, professionally
transcribed with all identiers removed, and reviewed for quality.
Consistent with grounded theory methods (Glaser & Strauss, 1967),
thematic analyses were performed in multiple rounds of coding and data
analysis. The primary coder independently reviewed transcripts and
drafted qualitative memos to elucidate preliminary codes and develop
an initial codebook. Two trained qualitative researchers then indepen-
dently applied the initial codebook to ve transcripts and met to discuss
codebook revisions. Double-coding transcripts enabled the coders to
identify discrepancies and agreement in coding, and establish consensus
interpretations of the codes, thus enhancing study rigor. All discrep-
ancies were discussed with clarifying notes documented in the code-
book. The primary coder coded the remaining transcripts using NVivo
version 12 (QSR International Pty Ltd, 2019). Analysis was performed
on codes to synthesize and identify themes and form connections be-
tween data. Identication of nal themes was determined through team
consensus. Thematic saturation was reached after conducting 11
interviews.
Results
Participant demographics are presented in Table 1. Ten participants
were male and the average age was 40 years. Participants had been
employed at the hospital for a mean of 12 years. Two-thirds reported
having responded to a fatal overdose while employed by the hospital,
and 80% reported responding to at least ten anti-motion alarms over the
prior three months.
Four themes emerged: 1) public safety personnel believe responding
to overdoses is an appropriate responsibility; 2) public safety personnel
focus on their training rather than individual emotions when responding
to an overdose; 3) public safety personnel view the anti-motion alarm
system as an acceptable tool for preventing overdoses, despite techno-
logical challenges; and 4) public safety personnel report concern for
potential unintended consequences of the anti-motion alarm system.
Themes are described in detail below with illustrative quotes.
Theme 1: Public safety personnel believe responding to overdoses is an
appropriate responsibility
All participants agreed that responding to overdose was an accept-
able part of the duties of public safety personnel. Participants recognized
that they are often rst on the scene and the time it would take for
medical staff to respond could be the difference between the patron
living or dying. Personnel commented that the hospital’s location within
a high drug use and overdose area necessitated their being trained in
naloxone administration and overdose response. When asked how they
felt about responding to overdoses as part of their job description, one
participant stated: “Oh, 100 percent. It’s completely part of the job. There’s
no ifs, ands or buts.” Another ofcer commented on the importance of
being rst on the scene:
“I think it’s huge, ’cause you’re the rst… you’re probably
going to be the rst one there, so you have the best chance of…
hopin’-in saving somebody, and so… I think it’s huge. ’Cause we
get there so quick. I mean, by the time a call is made to [alert
medical staff] in this building or that building, it takes time,
that’s… precious time.”
“… the more medical training we have and things that we’re
allowed to do… is excellent… I think it’s a real need for us to be
able to do that… Rather than stay on the sidelines. I mean,
we’re here at a hospital, so obviously there’s amazing medical
staff here, but if we’re rst on the scene, you know, we gotta do
what we gotta do until somebody higher trained than us can
kind of get on the scene… and help us out.”
Theme 2: Public safety personnel focus on their training rather than
individual emotions when responding to an overdose
When asked about emotions felt during an overdose response, many
personnel reported they were focused on adhering to their training and
not personal emotions. It was not until after the overdose and trans-
ferring care of the patron to the medical team, that personnel described
feeling a tension between feeling accomplished and frustrated. Several
reported experiencing a sense of satisfaction, reward, and accomplish-
ment after being instrumental in saving a life. However, personnel re-
ported that when they responded to repeat overdose victims that they
felt “frustrated,” “angry,” “annoyed,” “disappointed,” and “unappreciated”
because “[those experiencing repeat overdoses] are putting themselves in
danger again and again and again… over and over and over…”
“I feel I have a duty to act. And not only that, but I want to help
this person. I want to… save that person. You know, I genuinely
want to do the job that I’m… trained to do… I always… I try to
stay calm. For the most part I feel calm because I feel condent. I
know what I’m doing.”
“It made me feel rewarded… that I’m able to save somebody…
‘cause it’s… it’s a human being.”
One participant described feeling frustrated after responding to the
same individual overdosing multiple times, sometimes even on the same
Table 1
Participant Demographics (N =11)
Average age (years) 40
Sex, n (%)
Male 10 (0.91)
Female 1 (0.09)
Average length of employment (years) 11.7
Lifetime number of overdose responses, n (%)
1-10 3 (0.27)
11-20 3 (0.27)
>20 5 (0.46)
Lifetime number of naloxone administrations, n (%)
1-10 7 (0.64)
11-20 1 (0.09)
>20 3 (0.27)
History of responding to fatal overdose, n (%)
Yes 7 (0.64)
No 4 (0.36)
Total number of responses to anti-motion alarm, n (%)
1-10 3 (0.27)
11-20 4 (0.36)
>20 4 (0.36)
B.M. Buchheit et al.

International Journal of Drug Policy 88 (2021) 103038
4
day.
“You get frustrated. You denitely get frustrated because… th-
there have been times that we’ve Narcan someone rst thing
in the morning, they’ve left, and by the afternoon, we’ve Narcan
them again in a different building.”
Theme 3: Public safety personnel view the anti-motion alarm system as an
acceptable tool for preventing overdoses, despite technological challenges
Public safety personnel did not perceive the alerts to be a burden,
despite reporting multiple occasions when no medical attention was
needed or the patron was not experiencing an overdose (e.g. false
alarms). They viewed responding to the anti-motion alarm system as just
another daily task - “it’s not a hassle… it’s not a convenience. It’s just a
different something to add on to the to do list.”
The increase in calls related to the anti-motion alarm system, most of
which were false alarms, were described as an acceptable alternative to
nding a dead body without warning. As one participant stated: “false
alarms is much better than going up to a cold body. For sure.” The preva-
lence of false alarms changed their expectations when they received a
potential overdose-related dispatch, but the expectation of high rates of
false alarms did not change response time or adherence to the response
protocol. Personnel said the alarm system provided some peace of mind
knowing that even if a patron overdosed immediately after entering the
restroom, only four minutes had elapsed by the time public safety
responded, which offered a much better chance of survival.
“And I shouldn’t think-I should treat every alarm like- I mean
treat everything like it’s the real thing. I actually feel better
about the situation knowing that it’s in the second oor, and it’s
the alarms going off in [building name], and then [the anti-
motion alarm system] quickly resets. [It] tells me that some-
body’s moving. Which means it’s-it’s probably gonna be okay,
but we’re gonna go up and check anyway.”
“I know that even if they overdosed… there’s still a very good
chance when I get up there, if I have to pop the door because
they’re overdosed, I have the Narcan on my hip. I’m hopefully
going to be breathing for them very quickly. I know if it’s only
been a max of four minutes, I’m not gonna open the door to
somebody in rigor or somebody… in dependent lividity. I’m
opening the door to somebody who has a chance.”
Although participants agreed with the installation of the anti-motion
alarm system, a major shortcoming was that the alarm was often trig-
gered by someone performing normal restroom activities within the
restroom and not someone who was sedated from drug use or overdosed
requiring medical attention. Recommendations to improve the system’s
accuracy varied. Potential solutions for improving the sensor included
not linking the timer to locking the door but to door closure, extending
the time before the alarm is triggered, and adding a warning alert before
the alarm is triggered to let the occupant know that if they do not move
an alarm would sound.
“I 100 percent understand why they’re there. I 100 percent
agree with why they’re there. I think the technology is… needs
some tweaking.”
“I would like to have a… a lesser margin of error, I guess? …or
know that it’ll work just as well as… the [motion sensors] that
sense-sense you in there and the lights turn on, you know?”
Theme 4: Public safety personnel report concern for potential unintended
consequences of the anti-motion alarm system
Although unintended consequences were not directly inquired about
in the interview, multiple participants raised concerns for unanticipated
outcomes related to the anti-motion alarm system. Potential conse-
quences focused on displacing drug use to other locations on campus and
the reduction in patrolling restrooms without the anti-motion alarm
system installed for fear of straying too far away from these restrooms
and missing an alarm.
“I’m also afraid that if I’m right, at least the cop side of me, the
overdoses in the area are gonna spike through the roof and not
be survivable ones, because we’re gonna… displace people to
tucking in where they’re not seen.”
“We tend to… be more stationary at the desk more, because if
you’re in the building, it take you even longer to go downstairs
to get to those restrooms, and… because of the frequency of the
alarms, you want to be closer to that-that oor. So… we nd
ourselves more isolated towards the desk in the lobby, antici-
pating an alarm going off.”
Discussion
We found that the role of public safety personnel as rst responders
to drug overdoses was supported by an anti-motion alarm system in
single-occupancy restrooms at a large urban medical center. Public
safety personnel reported this role was acceptable and appropriate.
Public safety personnel said they were well-trained to respond to over-
doses and felt both condent and calm during overdose response events.
These ndings build on prior research concerning overdose response
roles of law enforcement ofcers trained to administer naloxone. This
study is the rst to describe the role of an anti-motion alarm system in
supporting rst responders charged with public restroom safety. Previ-
ous studies showed that training community law enforcement ofcers in
naloxone administration resulted in increased condence to recognize
an overdose and administer naloxone (Purviance, Ray, Tracy, &
Southard, 2017; Wagner, Bovet, Haynes, Joshua, & Davidson, 2016). A
survey of police chiefs in Pennsylvania found most ofcers felt the
benets of carrying and administering naloxone outweighed the cost of
the medication, the administrative burden associated with equipping
ofcers with naloxone, and the risk of agitation of a victim after over-
dose reversal (Smyser & Lubin, 2018).
The anti-motion alarm system was perceived to have benets that
outweighed the cost of false alarms. In the US, many efforts have focused
on discouraging public restroom drug use through potentially harmful
strategies including: locking restrooms so that they are inaccessible to
the public, removing privacy doors from toilet stalls, and installing blue
lighting to make it more challenging for people who inject drugs to nd a
vein (Parkin & Coomber, 2010). Other strategies focused on supporting
safety include the posting of staff monitors to regularly check on people
(New York State Department of Health AIDS Institute Syringe Exchange
Policies & Procedures, 2016; Wallace et al., 2016). However, this
approach may not be feasible for many settings given that it requires
substantial stafng and training resources (Des Jarlais, 1995). The
anti-motion alarm system promotes privacy and respect of patrons by
maintaining access to public restrooms, while reducing fatality risk via
an alarm and a human response, which may be the difference between
life and death. Research is needed to assess the acceptability and
effectiveness of these devices in other settings, including syringe service
programs, homeless shelters, public libraries, and other public rest-
rooms. Additional details that warrant further research include the false
alarm rate and the impact of anti-motion alarm systems on the behavior
and perceptions of restroom patrons who do not use drugs.
We uncovered concerns about potential unintended consequences of
the alarms that warrant further study. Future research should assess
whether or not the alarm system results in displacing drug use, thereby
increasing overdose risk in other locations.
B.M. Buchheit et al.

International Journal of Drug Policy 88 (2021) 103038
5
Limitations
The study was conducted at a single academic medical center located
in an urban area with high rates of fentanyl use and overdose rates;
therefore, the results may not be transferable to other locations or set-
tings. Public safety personnel in this study may have more experience
and exposure to drug overdose than personnel at other hospitals. Those
individuals who agreed to participate in the study may have different
experiences or opinions than non-participants. Additionally, social
desirability is a factor; participants may have responded to questions
with answers that they perceived others would view favorably.
Conclusions
These accounts of public safety personnel responding to overdose
and their experiences with an anti-motion alarm system reveal that they
welcome their role as rst responders to drug overdose and perceive the
anti-motion alarm system as an effective tool to reduce overdose fatal-
ities. This has implications for reducing fatal overdoses in restrooms in
medical centers and other settings, as well as for training rst responders
at other institutions as the prevalence of opioid overdose increases. Anti-
motion alarm systems are promising tools for rst responders charged
with optimizing restroom safety in the midst of surging overdose deaths
from fentanyl use.
Declarations and Ethics
The authors have no competing interests. This study was determined
to be exempt by the medical campus institutional review board (IRB #H-
37,686).
Funding
HRSA grant #HP29243 “Preventive Medicine Residencies”
CRediT authorship contribution statement
Bradley M. Buchheit: Conceptualization, Methodology, Investiga-
tion, Formal analysis, Validation, Writing - original draft, Writing - re-
view & editing. Erika L. Crable: Conceptualization, Methodology,
Formal analysis, Validation, Writing - review & editing. Sarah K. Lip-
son: Writing - original draft, Writing - review & editing. Mari-Lynn
Drainoni: Conceptualization, Methodology, Formal analysis, Writing -
review & editing. Alexander Y. Walley: Conceptualization, Methodol-
ogy, Formal analysis, Writing - review & editing.
Declaration of Competing Interest
The authors declare that they have no known competing nancial
interests or personal relationships that could have appeared to inuence
the work reported in this paper.
Acknowledgements
All of the medical center public safety personnel, specically Connie
Packard and William Gibbons. James Moses and the medical center
quality and patient safety team who helped advocate for installation of
the anti-motion alarm systems.
Supplementary materials
Supplementary material associated with this article can be found, in
the online version, at doi:10.1016/j.drugpo.2020.103038.
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