Of all the provocative strategies to reduce harm from opioid addiction, the one that I am about to describe is near the top. Over the past several months, hardly anyone I spoke to about the abuse of opioids in the United States, including pain pills and heroin, had a neutral point of view about what is happening in a small but important corner of the larger epidemic. The place is where a former security guard named Hector Mata became an expert at reversing overdoses and probably saved 25 lives in the process. It is not a hospital or a clinic. Mata’s infirmary is the Corner Project, a syringe exchange program that began operating in the New York neighborhood of Washington Heights, which houses a bathroom where drug users can more safely inject heroin. On first glance, there is not much that is special about this bathroom except that there is someone checking in on an intercom every three minutes to make sure the user is still conscious. “A moral obligation” If a user doesn’t respond on the check-in, Mata, or someone similarly trained, will press a button to unlock the door and rush in, armed with a syringe full of naloxone, also known by the brand name Narcan, and hopefully reverse the effects of the opioid drugs. After seven years and at least 25 overdoses, he says he has never failed. While to some people, this sounds like a “consumption room,” or a safe injection site, the staff here say it is simply a bathroom. After all, injection sites aren’t legal under US law. I sat down with the Corner Project’s director, Liz Evans, and asked her just how a place like this legally exists. She told me that public bathrooms are the frontline of the opioid epidemic. “People are dying in those bathrooms, and so there’s an acknowledgment that as a syringe exchange provider, we have a moral obligation to make sure that people don’t die in our building.” And so, the Corner Project has implemented a safety net to make sure that people don’t die from overdoses in the bathroom in their building. Everything in this story is a murky gray. Perhaps the story of the Corner Project could have been predicted. A heroin addict goes to a needle exchange, obtains clean needles and immediately heads to the bathroom to inject drugs. After all, according to recent studies in New York City, nearly two-thirds of drug users visit places like abandoned buildings, cars, and public bathrooms to inject drugs. The Corner Project started out as a street based community outreach group in 2005. In 2009, when the Corner Project moved to its current brick and mortar location, the bathroom was just a matter of convenience for clients. Within a short time, however, there was an overdose in the bathroom, followed by another and so on. Without a system in place, the workers at Corner Project would hear a characteristic thud from someone passing out in the bathroom, make a mad scramble for the keys and then work to revive the person. Though they were mostly successful, it was always frightening. The Corner Project could have simply closed the bathroom or searched people before they used the facility, but the workers chose to do neither. Instead, they kept it open and put in safety measures, like an intercom system, timers, and naloxone to help prevent overdoses. They stayed open knowing that if they closed their doors addicts would simply find another public restroom to use their drugs, far from the people who might be able to save them. And with that, the Corner Project pushed the limits of harm reduction in the United States. Since last year, the New York State Department of Health has followed the Corner Project’s lead and instituted regulations and recommended procedures on how to best prevent overdoses in the places where users are likely to use: syringe exchange bathrooms. Criminalization vs. rehabilitation In the great debate of criminalization versus rehabilitation, many commonly held assumptions have been torn to shreds. For example, some believed the legalization of drugs like marijuana would lead to increased use. Yet in Colorado, which legalized recreational pot, teen marijuana use has dropped. When it comes to opioids, the number of people who overdose and die from legal prescription painkillers is about equal to the number of people who die from illicit drugs like heroin. Another commonly held belief is that a safe injection site would implicitly condone the use of drugs and lead to increased use. And yet we now know that theory starts to fray when we look at what has happened at the Corner Project and at a place called InSite in Vancouver, Canada, which Liz Evans also helped found. InSite started as a pilot project in 2003 and was the first legal supervised drug injection site in North America. To help manage the opioid crisis in Canada, Health Canada has approved more sites in recent months. Though the centers don’t provide any illicit drugs, the medical staff are there to provide first aid, including naloxone for overdoses, addiction counseling and mental health assistance. InSite has seen more than 3 million people since it opened, treated over 6,000 overdoses and not had a single person die. Furthermore, a 2011 Lancet study revealed that in the neighborhoods surrounding InSite, in the two years after it opened, there was a 35% reduction in overdose deaths from the two and a half years before it opened, compared with a 9% drop in the rest of Vancouver. Although it is unclear the impact of InSite on decreasing the total number of drugs users, it has led to increased admissions for addiction treatment and detoxification. And that also means cleaner communities. Streets and public restrooms aren’t littered with needles and other drug paraphernalia. In fact, a recent survey of drug users from an undisclosed safe injection site in the United States found that if they hadn’t used the site’s facilities, over 90% of the users would be using in public bathrooms or out on the street. These statistics are now the subject of dozens of studies in medical journals and were also recited to me as Mata showed me around the Corner Project’s bathroom. But he emphasized again, “It’s not a safe injection site,” he told me. He points out that unlike InSite, the Corner Project doesn’t have actual medical professionals monitoring the bathroom. In fact, if a doctor or nurse were to actually supervise its bathrooms, he or she could lose their license. He also doesn’t care for the term “consumption room,” which has been around in Western Europe since the 1990s. Instead, Mata insists I just call it a bathroom. Because unlike Canada or some countries in Europe, what I witnessed isn’t actually legal in the United States. At the front desk, a staff member monitored the clock and the intercom, checking to see whether any help was necessary. Considering the number of lives nearly lost in its bathroom, the mood in the Corner Project was calm and controlled. The soft music, brightly colored walls and chalkboards, and chestnut-colored tables with staff members casually engaged in small talk gave it the feel of a neighborhood coffee shop, more than a place where overdoses are prevented. A self-inflicted wound Mata said my tour needed to be quick because the bathroom is in use almost all the time, and there is a waiting list that often lasts more than an hour. One of the men in line was Taylor Prince, 35. Mata gave him a hug and then told me, “Taylor is a frequent flier.” I found out later that Mata saved Prince’s life on three occasions. We find ourselves in the middle of an opioid epidemic that is the worst drug crisis in American history. It is a self-inflicted wound and one that is predominantly made in America, as we consume more than 80% of the world’s supply of opioid pain pills, even though we are less than 5% of the world’s population. Many of those prescriptions have led to heroin use; three out of four new heroin users started with prescription narcotics. And there is no single strategy, as provocative or revolutionary as it may be, that is going to be the answer to turning those numbers completely around. Not even a controversial bathroom in the Washington Heights Corner Project could possibly do that, but in the meantime, Mata and others will work on saving as many lives as possible.