This is the first quantitative study of business manager encounters with drug use which suggests overdose recognition and naloxone training, combined with the operation of supervised injection facilities, could save lives.

Business Bathrooms

Drug overdose death rates per year in the United States (U.S.) nearly doubled from 1999 to 2013. In New York City (NYC) alone, drug overdose deaths had a 43% increase between 2010 and 2014. The majority of these deaths in NYC involved opioids, with heroin being the most predominant.

A previous survey of 440 drug injectors in NYC conducted in 2015 by the Injection Drug Users Health Alliance found nearly two-thirds (60%) of active injectors surveyed reported using public locations, such as public bathrooms, in the last three months for injections.

“While there are a growing number of syringe exchange programs (SEP) across the U.S. that provide people who inject drugs (PWID) with sterile injecting equipment,” said Dr. Brett Wolfson-Stofko, PhD, the lead author and a post-doctoral fellow at the Behavioral Sciences Training in Drug Abuse Research (BST) program at the New York University Rory Meyers College of Nursing (NYU Meyers), “they are not authorized to offer a safe and sanitary space for injection. As a result, many tend to inject in public bathrooms.”

Public injection has been associated with a variety of health risks and risk behaviors such as syringe sharing, overdose, abscesses, endocarditis, rushed injection, incarceration, and the transmission of HIV, hepatitis C (HCV), and hepatitis B (HBV).

Dr. Wolfson-Stofko saw an opportunity for research, as a large number of NYC businesses provide public bathrooms. The results of the study were published in the International Journal of Drug Policy  and entitled, “Drug Use in Business Bathrooms: An exploratory study of manager encounters in New York City.” The study looked at the frequency of business manager encounters with drug use occurring in their business bathroom.

Eighty-six business managers participated in the survey with 58% (50 managers) reporting encounters with drug use in their business bathrooms in the past six months. Data was not used from the 36 managers who did not report encountering drug use.

The research team found that managers reported a median of three encounters with drug use per month. Fourteen percent (7 managers) called 911 due to encounters with unresponsive users. Nearly half of managers who called 911 requested both law enforcement and EMS, suggesting the calls were not solely made because of disruptive behavior, but out of concern for the individual's health. Additionally, over a third of managers found improperly disposed syringes in their business’ bathrooms, putting PWID, community members, and staff at risk of needle sticks and potentially HIV, HCV, and HBV infection.

“These managers, by default, are first-responders in the event of a drug overdose and thus of intrinsic interest during the current epidemic of opioid-related overdoses in the U.S.” said Dr. Wolfson-Stofko.

The survey found that only 10% of these managers reported some type of overdose recognition and naloxone training. Unsurprisingly, 64% thought this training would be useful and is something Dr. Wolfson-Stofko is currently pursuing.

The researchers also suggest the operation of supervised injection facilities (SIF)/drug consumption rooms (DCR), which are places where people are legally allowed to consume illicit drugs under the supervision of medical staff in order to prevent overdose mortalities, the spread of disease, and reduce the improper disposal of syringes and public injecting.

“Supervised injection facilities and drug consumption rooms are practical, cost-effective strategies that would more than likely reduce public injecting and overdose mortality in New York City and assist in linking this population to health services and drug treatment just as they have in other cities throughout the world,” said Dr. Wolfson-Stofko.

“These facilities would also help reduce the burden placed on business managers and staff whose bathrooms act as de facto injection sites,” continues Dr. Wolfson-Stofko. “These individuals are not typically trained to handle these types of situations on the job.”

The authors argue that implementing multiple SIF/DCR throughout the city would be the best strategy to address public injection and the current overdose epidemic.

In the long term, the researchers hope to help reduce the dangers of public drug injection and improve the overall health of people who use drugs and their communities. Dr. Wolfson-Stofko is expanding upon this research by conducting interviews with staff, managers, and owners of businesses about their perspectives on drug use and overdose as well as well as offering them free naloxone and training through the NDRI opioid overdose prevention program.


Researcher affiliations:  Brett Wolfson-Stofko, a,c, Alex S. Bennett, a,c, Luther Elliott a,c; Ric Curtis, b,c

a National Development & Research Institute, Institute for Special Populations Research, 71 W. 23rd St., 4th Fl., New York, NY 10100, United States of America

b John Jay College of Criminal Justice, City University of New York, Department of Law, Police Science and Criminal Justice Administration, and Department of Anthropology, 524 W. 59th St., New York, NY 10019, United States of America

c Center for Drug Use and HIV/HCV Research, Rory Meyers College of Nursing, New York University, 433 First Avenue, New York, NY 10100, United States of America

Acknowledgements:  The authors wish to thank the staff and participants at BOOM! Health, Washington Heights CORNER Project, New York Harm Reduction Educators and SIF NYC for their feedback and support. In particular, Maria Caban, Ed Manchess, Adrian Feliciano, Adriana Pericchi Dominguez, Evelyn Silva, Tara Larsen, Terrell Jones, Taeko Frost and Sarah Deutsch. We would also like to thank all the student research assistants from John Jay College of Criminal Justice that assisted in data collection, Jonathan Broker for data management, NDRI BST fellows for our discussions, and M. Dot Fullwood for his assistance with SPSS.

This research was supported by the Ruth L. Kirschstein National Service Award (5T32DA007233) and by R01DA03675402 awarded to Alex S. Bennett.

Conflict of interest: The authors of this paper declare no conflict of interest. The opinions of the authors do not necessarily reflect those of National Institutes of Health, National Institute on Drug Abuse, National Development & Research Institutes, Inc., New York University, or City University of New York.

About the Behavioral Sciences Training in Drug Abuse Research (BST) program:

BST’s training program prepares social scientists for careers in research on drug abuse and HIV/AIDS through intensive training—fellows participate in seminars and workshops all day on Mondays—and hands on research on NIDA grants. The program comprises 16 fellows (9 predocs and 7 postdocs) from the various behavioral disciplines and includes both qualitative and quantitative researchers working in a mutually supportive milieu to conduct research, build their publication records and write grants for outside funding. Fellows specialize in a wide range of topics (e.g., drugs among college students, doping in sports, drugs and crime, HIV risk factors and interventions, drug treatment, politics and drug policy, international research). Gregory Falkin, PhD, Program Director; George De-Leon, PhD, Co-Director

About the NYU Rory Meyers College of Nursing

NYU Rory Meyers College of Nursing is a global leader in nursing education, research, and practice. It offers a Bachelor of Science with a major in Nursing, a Master of Science and Post-Master’s Certificate Programs, a Doctor of Nursing Practice degree and a Doctor of Philosophy in nursing research and theory development.


The mission of the Center for Drug Use and HIV Research (CDUHR) is to end the HIV and HCV epidemics in drug using populations and their communities by conducting transdisciplinary research and disseminating its findings to inform programmatic, policy, and grass roots initiatives at the local, state, national and global levels. CDUHR is a Core Center of Excellence funded by the National Institute on Drug Abuse (Grant #P30 DA011041).  It is the first center for the socio-behavioral study of substance use and HIV in the United States and is located at the New York University College of Nursing. For more information, visit

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