The battling the heroin and opioid addiction crisis. During

The opioid crisis and urban

is no secret that cities across the nation have been battling the heroin and opioid
addiction crisis. During the summer of 2017, national news media outlets
heavily covered the topic after the Philadelphia Inquirer featured a story
about the Free Library of Philadelphia’s McPherson Branch in which a reporter
witnessed library staff use Narcan to keep a patron alive after a suspected
opioid overdose (Newall, 2017). While not all libraries can stock Narcan and
train their staff to use it, there are other solutions that can be used to help
urban libraries combat the growing issue of opioid overdose.

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Census Bureau defines urban areas in two ways: Urbanized Areas that have 50,000
or more people, and Urban Clusters that contain at least 2,500 people but less
than 50,000 (2010 U.S. Census). While addiction and illegal drug use affects
all communities in some way, this paper will focus on ways in which opioid use,
specifically heroin and prescription opioids, has impacted public libraries in
urban communities.

The statistics

The Centers for Disease Control and Prevention report that heroin use has been increasing in recent years among
men and women, most age groups, and all income levels. Some of the greatest
increases have occurred in demographic groups with historically low rates of
heroin use: women, the privately insured and people with higher incomes. However,
as heroin use has
increased, so have heroin-related overdose deaths. Heroin-related overdose
deaths have more than quadrupled since 2010. From 2014 to 2015, heroin overdose
death rates increased by 20.6 percent, with nearly 13,000 people dying in 2015.
In 2015, males aged 25 to 44 had the highest heroin death rate. (CDC, 2017).

differences in drug use between urban and rural areas show how population
affects patterns of drug use. For example, states such as Florida and
Washington have relatively high rates of nonmedical prescription opioid
overdose and are largely urban (Keyes, Cerda, et. al., 2014, p. e55). Keyes,
Cerda, et. al suggest that a comprehensive understanding of why, for example,
rates of alcohol and drug use differ across time, across counties, and across
certain population subgroups should be explored and studied to better
understand the impact.

Library response to the epidemic

librarians in urban cities such as Philadelphia and Denver are learning how to
respond to overdose cases at their facilities and even becoming trained in
using Narcan. Narcan, or naloxone, is an FDA-approved medication for emergency
treatment of a known or suspected opioid overdose. Available as a nasal spray
or injectable, the drug was developed for first responders, as well as family,
friends, and caregivers. (Narcan, 2017). As many librarians can attest,
libraries are often used for illicit purposes, including substance abuse. The
San Francisco Public Library, for example, reports that some users shoot up in
the bathroom or in the stacks. Library officials are working with the San Francisco
Department of Public Health to increase library patrols during peak times in an
effort to combat the problem (Troknya, 2017).

urban library directly affected by opioid use is the Denver Public Library’s
Central Library. Although the library hired more security guards and installed
new security cameras, drug overdoses continued. After a patron died of an
overdose in the library in February 2017, staff were trained in using naloxone
and some carry Narcan kits. (Warburton, 2017, p. 18).

using Narcan and increasing security are not the only methods used by urban
libraries to deter suspected drug use. Public libraries are joining school
districts in an effort to provide educational resources and programming as part
of their roles as information professionals in the community. These programs
provide accurate and educational information about addiction and opioid use. In 2017, the Cleveland Public Library began a yearlong series
that provided patrons with information on opioid abuse, signs and symptoms of
addiction, and how to talk to children about drug abuse. The sessions allowed community
members to speak with a medical expert and learn about options for treatment. (Jacobsen
& Cottrell, 2017, p. 24).  Other
school districts are providing “social emotional learning programs” to support
students affected by addiction within their family (Jacobsen & Cottrell,
2017, p. 23).

is not clear exactly how many libraries have made Narcan available and trained
their staff in its use. The Denver Public Library’s Central Library has 13 staff
members trained to use it and library administrators believe that the cost –
$75 per kit – is a small price to pay to save someone’s life (Ford, 2017, p.
47). To the argument that administering Narcan falls outside the library’s
mission, library officials in Denver say the library is the de facto day
shelter so it is imperative that the library staff have the tools to deal with
this epidemic (Ford, 2017, p. 47).

San Francisco Public Library also has made it a priority to work with those who
have drug-use issues through the use of a social worker
and six formerly homeless health and safety associates who provide outreach to
those in need (Ross 2017). In addition, SFPL is considering training staff
members on how to administer naloxone through a voluntary training program. “City
police and emergency workers have long been trained how to administer naloxone,
which has been in use for decades. The overdose prevention project, operating
on a $245,000 annual budget, not only provides the drug, but also trains
participants to identify signs of overdosing and how to dispense the lifesaving
medication.” (Mark Troknya, 2017).

ways in which libraries have attempted to combat the rise in overdoses is by
monitoring restrooms. Philadelphia’s McPherson branch requires patrons who want
to use the restroom to show identification and enlisted the help of volunteers,
who sit by the bathroom, take identification, and time people … “no overdoses
have occurred since the new rules were implemented.” (Ford, 2017, p. 47). Restrooms
in urban public areas also have responded by installing key codes on bathroom
doors and metal boxes for needles so users don’t flush them and clog pipes
(Bebinger, NPR, 2017). But keeping bathrooms open, stocking naloxone, and finding
staff or volunteers to monitor bathroom usage can be a challenge for many
libraries and businesses.

In response to the growing opioid epidemic, the Public Library
Association and WebJunction collaborated on a virtual town hall meeting about the
opioid crisis in September 2017. During the 90-minute online
event, representatives from libraries and community organizations described ways
in which they are addressing this crisis, such as naloxone training, public
safety initiatives and securing funding for recovery programs.

some libraries have made it a priority to stock naloxone and train staff in its
use, there are others that do not. The Public Library of Cincinnati and
Hamilton County has seen a rise in overdoses but does not stock Narcan because
they are located close to a fire station. Having security patrol the building
more often also has helped deter negative behavior.” (Ford, 2017, p. 48). Pueblo
City-County Library District is not stocking kits but instead are monitoring
related circumstances (Severance, 2017). Some institutions have installed blue
lights in restrooms, while others have placed security cameras and signage
about video surveillance right outside the bathroom doors, while others have
installed secure needle-disposal boxes in restrooms, and adjusting doors so
they open outward rather than inward.” (Ford, 2017, p. 48).

Interacting with patrons in crisis

do library staff respond when someone is using drugs or may be overdosing? Some
libraries may have a security officer, social worker or peer navigator talk to
the person. The Denver Public Library Central Library staff works closely with
the Department of Environmental Health, and other community partners such as
the Harm Reduction Action Center and the Denver Police Department, to reach out
to affected individuals, as well as meeting regularly at the mayor’s office to
identify resources (Warburton, 2017, p. 18).

While it’s difficult to confront patrons who are hurting
the library experience for others, threatening other patrons or staff, or
otherwise creating discomfort or chaos, there are possible solutions to try,
such as partnerships with such outside groups as law enforcement, social
services, mental health and substance abuse counselors, city attorneys and county
counsels. (Albright, 2017, 39). Luis Herrera, a city
librarian at San Francisco Public Library, encourages libraries to train
staffers to identify “opiate narcosis,” or the signs that someone may be
overdosing: pin-dot pupils, hooded eyelids, sniffing, scratching, seemingly
asleep on their feet so that they know when it’s appropriate to call for help.
(Albright, 2017, 40).

Community response

Multnomah County Library in Oregon works with elected officials to discuss ways
to work more effectively with community agencies such as law enforcement and
the health department (WebJunction, 2017). The
WebJunction town hall provided information about resources available through
staff training and ways to partner with community organizations.

Hadi Sedigh from the National Association of Counties, noted the importance
of a strong local infrastructure, with participation across multiple community
agencies, including libraries. (WebJunction, 2017). “Using a
holistic approach, urban public libraries are creating community awareness
through forums, adopting social emotional teaching strategies to foster
resilience and empathy, and connecting people to resources to help bring
relief. They are doing what libraries do. In the process, they are innovating,
building partnerships, and leading with compassion.” (Miller, 2017, p. 6).

study found that 40 percent of people in San Francisco and 58 percent in New
York City who used opioids and attended an educational program in which they
received a naloxone kit had used it, “which resulted in a greater ability to
recognize an overdose and act appropriately after training” (Espelt,
Bosque-Prous, et. al, 2017, p. 10).


2015, journalist Sam Quinones published “Dreamland: The True Tale of America’s
Opiate Epidemic,” a book that details how sugar cane farmers in Mexico created
a distribution system that brought heroin to the United States, specifically
West Coast communities not typically associated with heroin use, and how a
pharmaceutical company created Oxycontin, a highly addictive pain medication
that affects the body in a similar way as heroin in that it binds to opioid
receptors to block pain signals and create feelings of euphoria. (Quinones,
2016). Since publishing his book, Quinones has been featured at community
events, including a public library presentation in October 2017 in Ohio. During
that presentation, Quinones suggested that the antidote to heroin is not
naloxone, but a community that is open to finding recovery solutions. “The
heroin and opiate epidemic is a community problem and the community is going to
come up with solutions. No one system, no one person is going to be able to
make an impact without collaborating,” he told those in attendance. (Lindstrom,

Kowalski, a librarian at the McPherson Square branch of the Free Library of
Philadelphia who has administered naloxone to save several patrons, told
National Public Radio that she believes the solution to the opioid epidemic is
“to dramatically change the way we treat addiction. We need to continue to
destigmatize mental health and addiction as well. I think what we can do right
now is to have more people be willing to train themselves on Narcan because it
really is a lifesaving tool.” (Scott, NPR, 2017.)  Mike Newall, a columnist at the Philadelphia Inquirer
who reported on the issue in 2017, told NPR that this epidemic is an opportunity
for communities to get outreach workers where overdoses are occurring to try
and get them into treatment (Scott, NPR, 2017).

the WebJunction town hall, Hadi Sedigh from the National Association of Counties
suggested the following actions for urban public libraries:

Encourage your county commissioners, your
mayors to become a champion of this issue and to inform them, if they are not
already aware, that libraries are becoming a front line for this epidemic, and
that you need their leadership and support.

Don’t underestimate the importance of
tailoring solutions. Get community input and know that what might work in a
rural area may not work in an urban area, and vice versa. For instance,
libraries that are 60 seconds away from first response may not need to have
naloxone on hand, versus a library that has incentive to keep a supply, because
they’re further away from first responders. And of course, what is politically
feasible in one place is not feasible in another.

Don’t lose sight of the importance of
prevention and education to stay focused on the ways in which you can help to
spread the message of drug prevention. “It goes without saying that the best
way to prevent someone from overdosing is to prevent them from becoming
addicted in the first place.” (WebJunction Town Hall. 2017).

is estimated that in the U.S., 90 people die each day from an opioid overdose (including
incidents involving prescription drugs and heroin) and that more than 1,000
people go to an emergency room for treatment for misuse of prescription opioids
(Jacobsen & Cottrell, 2017, p. 22-23). And the count of overdoses happening
in public libraries across the nation – Boston, Cleveland, Chicago and
Philadelphia – continue to rise. (Sanders, 2017).

to trustworthy information is easily accessible for urban public librarians. The National Library of Medicine has compiled resources to
assist librarians and other first responders to ensure that they understand the
complex legal and medical issues this crisis presents: Searching the Disaster
Lit database for “opioid” retrieves guidelines, training material,
reports, fact sheets, conference proceedings and congressional testimony. A
report by the RWJF Network for Public Health Law describes overdose Good
Samaritan laws in each state, as well as state laws about access to
naloxone. MedlinePlus has a good overview of opioid abuse and
addiction and links to many additional resources. The University of
Minnesota’s Bio-Medical Library is designated by the National Institutes of
Health National Library of Medicine/National Network of Libraries of Medicine to
provide free NIH and NLM resources on opioids and the opioid crisis. The U.S.
Department of Health and Human Services and the Centers for Disease Control
have both created resource guides to help inform the public about the opioid

deaths due to illicit drugs are caused by heroin and illicit opioids, with
overdose being a leading cause of death among people who use opioids. Training
programs in the prevention and management of opioid overdose have proven effective
in increasing the relevant knowledge among people those who inject opioids (Espelt,
Bosque-Prous, et. al, 2017, p. 2).

way to stem the issues associated with heroin/opioid overdoses in libraries is
to monitor restrooms. Libraries also should consider installing sharps
containers in restrooms so that needles can be placed there rather than flushed
down the toilet, which prevents plumbing issues. Even reinstalling bathroom
doors so they open outward rather than inward should be considered if someone
does overdose, then blocks the door when they fall, which could prevent help
from reaching them in time. (Ford, 2017, 44-49).

While the $75 per Narcan kit can be costly,
o is the staff training to learn how to administer it. This can make it
cost-prohibitive. By combining forces with other nonprofits in the community,
there may be a way to reduce costs, or find an organization willing to supply
Narcan kits. Even if a library does not want to incur the costs or liability
that comes with Narcan, it still must train staff in what to do in the event of
an overdose, as well as revamp security procedures and monitoring efforts.

“It’s important for us to talk more about
what the people in our communities are dealing with. We’re an information
profession. Why aren’t we sharing information with each other? Being open and
compassionate is the best thing we can do.” (Cottrell, 2017. p. 17).








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