Public restrooms and the opioid epidemic

Risk factors for persistent fatal opioid-involved overdose clusters in Massachusetts 2011-2021: a spatial statistical analysis with socio-economic, accessibility, and prescription factors

BACKGROUND

Fatal opioid-involved overdose rates increased precipitously from 5.0 per 100,000 population to 33.5 in Massachusetts between 1999 and 2022.

METHODS

We used spatial rate smoothing techniques to identify persistent opioid overdose-involved fatality clusters at the ZIP Code Tabulation Area (ZCTA) level. Rate smoothing techniques were employed to identify locations of high fatal opioid overdose rates where population counts were low. In Massachusetts, this included areas with both sparse data and low population density. We used Local Indicators of Spatial Association (LISA) cluster analyses with the raw incidence rates, and the Empirical Bayes smoothed rates to identify clusters from 2011 to 2021. We also estimated Empirical Bayes LISA cluster estimates to identify clusters during the same period. We constructed measures of the socio-built environment and potentially inappropriate prescribing using principal components analysis. The resulting measures were used as covariates in Conditional Autoregressive Bayesian models that acknowledge spatial autocorrelation to predict both, if a ZCTA was part of an opioid-involved cluster for fatal overdose rates, as well as the number of times that it was part of a cluster of high incidence rates.

RESULTS

LISA clusters for smoothed data were able to identify whether a ZCTA was part of a opioid involved fatality incidence cluster earlier in the study period, when compared to LISA clusters based on raw rates. PCA helped in identifying unique socio-environmental factors, such as minoritized populations and poverty, potentially inappropriate prescribing, access to amenities, and rurality by combining socioeconomic, built environment and prescription variables that were highly correlated with each other. In all models except for those that used raw rates to estimate whether a ZCTA was part of a high fatality cluster, opioid overdose fatality clusters in Massachusetts had high percentages of Black and Hispanic residents, and households experiencing poverty. The models that were fitted on Empirical Bayes LISA identified this phenomenon earlier in the study period than the raw rate LISA. However, all the models identified minoritized populations and poverty as significant factors in predicting the persistence of a ZCTA being part of a high opioid overdose cluster during this time period.

CONCLUSION

Conducting spatially robust analyses may help inform policies to identify community-level risks for opioid-involved overdose deaths sooner than depending on raw incidence rates alone. The results can help inform policy makers and planners about locations of persistent risk.

Addressing overdose risks and fatalities in public bathrooms: insights from the development of a Safer Bathroom Toolkit in British Columbia, Canada

SETTING

In British Columbia (BC), over 11,000 people have died of an overdose since 2016. Recently, an all-party standing committee on health tabled a report identifying several gaps in BC's overdose response. Chief among these is the inequitable distribution of supervised consumption and overdose prevention services across BC and barriers to accessing services that are currently available. In this context, public bathrooms continue to act as consumption spaces and contribute to overdose-related risks and fatalities.

INTERVENTION

The Safer Bathroom project sought to address long-standing policy and practice gaps by developing a toolkit to improve bathroom overdose prevention and response. Activities included a literature review and cross-sectoral, province-wide consultation (Fall 2021), the creation and launch of the Safer Bathroom Toolkit (Fall 2022), and knowledge transfer activities (ongoing).

OUTCOMES

The toolkit meets four objectives. First, it provides a bathroom safety checklist that helps identify and, most importantly, mitigate safety risks. Second, it offers organizational guidance on developing a bathroom safety policy and procedure. Third, it includes practical resources such as staff training material and signs that communicate bathroom safety messages in a non-stigmatizing manner. Finally, it identifies bathroom architecture and design features that can increase or decrease overdose-related risks.

IMPLICATIONS

The Safer Bathroom Toolkit is a highly comprehensive resource developed in response to the overdose crisis. However, significant reporting, research, policy, and practice gaps remain. This paper concludes with an overview of recommendations for advancing overdose prevention and response efforts within and beyond the bathroom context.

A Radar-Based Opioid Overdose Detection Device for Public Restrooms: Design, Development, and Evaluation Study

BACKGROUND

The opioid epidemic is a growing crisis worldwide. While many interventions have been put in place to try to protect people from opioid overdoses, they typically rely on the person to take initiative in protecting themselves, requiring forethought, preparation, and action. Respiratory depression or arrest is the mechanism by which opioid overdoses become fatal, but it can be reversed with the timely administration of naloxone.

OBJECTIVE

In this study, we described the development and validation of an opioid overdose detection radar (ODR), specifically designed for use in public restroom stalls. In-laboratory testing was conducted to validate the noncontact, privacy-preserving device against a respiration belt and to determine the accuracy and reliability of the device.

METHODS

We used an ODR system with a high-frequency pulsed coherent radar sensor and a Raspberry Pi (Raspberry Pi Ltd), combining advanced technology with a compact and cost-effective setup to monitor respiration and detect opioid overdoses. To determine the optimal position for the ODR within the confined space of a restroom stall, iterative testing was conducted, considering the radar's bounded capture area and the limitations imposed by the stall's dimensions and layout. By adjusting the orientation of the ODR, we were able to identify the most effective placement where the device reliably tracked respiration in a number of expected positions. Experiments used a mock restroom stall setup that adhered to building code regulations, creating a controlled environment while maintaining the authenticity of a public restroom stall. By simulating different body positions commonly associated with opioid overdoses, the ODR's ability to accurately track respiration in various scenarios was assessed. To determine the accuracy of the ODR, testing was performed using a respiration belt as a reference. The radar measurements were compared with those obtained from the belt in experiments where participants were seated upright and slumped over.

RESULTS

The results demonstrated favorable agreement between the radar and belt measurements, with an overall mean error in respiration cycle duration of 0.0072 (SD 0.54) seconds for all recorded respiration cycles (N=204). During the simulated overdose experiments where participants were slumped over, the ODR successfully tracked respiration with a mean period difference of 0.0091 (SD 0.62) seconds compared with the reference data.

CONCLUSIONS

The findings suggest that the ODR has the potential to detect significant deviations in respiration patterns that may indicate an opioid overdose event. The success of the ODR in these experiments indicates the device should be further developed and implemented to enhance safety and emergency response measures in public restrooms. However, additional validation is required for unhealthy opioid-influenced respiratory patterns to guarantee the ODR's effectiveness in real-world overdose situations.

Overdose Detection Technologies to Reduce Solitary Overdose Deaths: A Literature Review

Drug overdoses were a leading cause of injury and death in the United States in 2021. Solitary drug use and solitary overdose deaths have remained persistent challenges warranting additional attention throughout the overdose epidemic. The goal of this narrative review is to describe recent global innovations in overdose detection technologies (ODT) enabling rapid responses to overdose events, especially for people who use drugs alone. We found that only a small number of technologies designed to assist in overdose detection and response are currently commercially available, though several are in the early stages of development. Research, development, and scale-up of practical, cost-effective ODTs remains a public health imperative. Equipping places where people live, learn, work, worship, and play with the necessary tools to detect and prevent overdose deaths could complement ongoing overdose prevention efforts.

Humans peeing: Justice-involved women's access to toilets in public spaces

Justice-involved women face myriad challenges as they negotiate the terms of community supervision and manage the long-term implications and stigma of living with a criminal record. Major tasks that women juggle include securing safe, affordable housing, finding and retaining employment, accessing physical and mental health care (including substance use treatment), and handling relationships with family, friends, children, and intimate partners. In addition to these responsibilities, women must meet their basic physiological needs to eat, sleep, and use the toilet. Women's ability to safely meet their personal care needs may impact their capacity to manage their criminal-legal challenges. This study uses qualitative methods to understand justice-involved women's lived experiences related to urination. Specifically, the study reports on a thematic analysis of 8 focus groups conducted with justice-involved women (n = 58) and the results of a toilet audit conducted in the downtown areas of the small city in the United States where the focus group participants were living. Findings suggest that women had limited access to restrooms and reported urinating outside. Lack of restroom access impacted their engagement with social services support and employment and their ability to travel through public spaces. Women perceived their public toilet options as unsafe, increasing their sense of vulnerability and reinforcing the idea that they did not have full access to citizenship in the community because of their criminal-legal involvement. The exclusion and denial of women's humanity that is perpetuated by a lack of public toilet access impacts women's psychosocial outcomes. City governments, social service agencies, and employers are encouraged to consider how lack of toilet access may impact their public safety and criminal-legal objectives and expand opportunities for people to access safe restroom facilities.

Integrating Harm Reduction into Outpatient Opioid Use Disorder Treatment Settings : Harm Reduction in Outpatient Addiction Treatment

Opioid use disorder (OUD) is increasingly recognized as a chronic, relapsing brain disease whose treatment should be integrated into primary care settings alongside other chronic conditions. However, abstinence from all non-prescribed substance use continues to be prioritized as the only desired goal in many outpatient, primary care-based treatment programs. This presents a barrier to engagement for patients who continue to use substances and who may be at high risk for complications of ongoing substance use such as human immunodeficiency virus (HIV), hepatitis C virus (HCV), superficial and deep tissue infections, and overdose. Harm reduction aims to reduce the negative consequences of substance use and offers an alternative to abstinence as a singular goal. Incorporating harm reduction principles into primary care treatment settings can support programs in engaging patients with ongoing substance use and facilitate the delivery of evidence-based screening and prevention services. The objective of this narrative review is to describe strategies for the integration of evidence-based harm reduction principles and interventions into outpatient, primary care-based OUD treatment settings. We will offer specific tools for providers and programs including strategies to support safer injection practices, assess the risks and benefits of continuing medications for opioid use disorder in the setting of ongoing substance use, promote a non-stigmatizing program culture, and address the needs of special populations with ongoing substance use including adolescents, parents, and families.

Using passive surveillance technology for overdose prevention: Key ethical and implementation issues

Passive surveillance technology has the potential to increase safety through monitoring spaces where people are at risk of overdose. One key opportunity for the use of passive surveillance technology to prevent overdose fatality is in bathrooms where people may be using drugs. However, uncertainty remains with regards to how to attain informed consent, implications for data storage and privacy and potential negative socio-legal ramifications for people who use drugs. In addition, there are issues regarding responsibility and liability for the devices. Transparency with regards to data privacy and security may also be needed before bathroom users will feel comfortable with such solutions. In this article, we discuss these issues and offer recommendations to provide a foundation for future research and policy development.

Spatiotemporal Trends in Discarded Needle Reports in San Francisco Over a 10-year Period, 2010-2019

BACKGROUND

To describe the geographic and spatiotemporal distribution of needle reports in San Francisco, and examine spatial relationships between needle reports and needle disposal boxes, needle disposal kiosks, and homeless shelters.

METHODS

We conducted multiple geospatial analyses of a crowdsourced database of non-emergency service requests. We describe changes in discarded needle and bulky item reports across San Francisco between 2010 and 2019, and compared changes in the reporting patterns of these items, while 200-meter Euclidean buffers captured needle reports in close proximity to needle deposit boxes, needle deposit kiosks, and homeless shelters in 2019.

RESULTS

34,912 needle reports were included. Yearly needle reports increased by 3827.1%, with a markedly different geospatial distribution from bulky item reports. 45.6% of needle reports originated in the five downtown neighborhoods with the highest needle report density, and 33.8% were identified within 200 meters of boxes, kiosks, or homeless shelters.

CONCLUSIONS

Reports of discarded needles in San Francisco increased dramatically over the last decade, and more than one third of 2019 reports were adjacent to harm reduction and homeless shelter locations. Needle reports provide an opportunity to understand changes in public injection drug use and target harm reduction services.

A Case Report of a Novel Harm Reduction Intervention Used to Detect Opioid Overdose in the Emergency Department

Introduction

As over 130 people die daily from opioid overdose in the United States, harm reduction strategies have become increasingly important. Because public restrooms are a common site for opioid overdose, emergency department waiting room restrooms (EDWRR) should be considered especially high-risk areas.

Case Report

We present the case of a patient found after a presumed opioid overdose in our EDWRR. Staff were alerted to his condition by a reverse motion detector (RMD), and rapidly treated him with naloxone.

Conclusion

The RMD is a novel intervention that can save lives and should be considered in EDs with a high incidence of opioid overdose.

The spatio-temporal distribution of naloxone administration events in rural Ohio 2010-16

INTRODUCTION

In 2017, Ohio had the second highest rate of drug overdose deaths in the United States. Current opioid related epidemiologic literature has begun to uncover the environmental level influences on the opioid epidemic and how the end results may ultimately manifest over space and time. This work is still nascent however, with most clustering research conducted at a spatial unit such as county level, which (1) can obscure differences between urban and rural communities, (2) does not consider dynamics that cross county lines, and (3) is difficult to interpret directly into strategic and localized intervention efforts. We address this gap by describing, at the Census block level, the spatial-temporal clustering of opioid related events in rural Ohio.

METHODS

We use the outcome of the administration of naloxone emergency medical service (EMS) calls in rural Ohio Census blocks during 2010-16 in a Poisson model of spatial scan statistics.

RESULTS

We found that naloxone event clustering in rural Ohio in the recent decade was widely dispersed over time and space, with clusters that average 17 times the risk of having an event compared to areas outside the cluster. Many of the larger spatial clusters crossed administrative boundaries (i.e., county lines) suggesting that opioid misuse may be less responsive to county level policies than to other factors.

DISCUSSION

Timely identification of localized overdose event clustering can guide affected communities toward rapid interventions aimed at minimizing the morbidity and mortality resulting from contagious opioid misuse.