Why Are Opioid Users Overdosing in Libraries, and How Should Librarians Respond?

On an ordinary day last month, a scene played out at the McPherson Branch of the Philadelphia Public Library: Someone was having a medical emergency, and distressed onlookers struggled with how to help. Someone who knew what to do rushed to the scene. The event made headlines not because it was so unusual, but because Mike Newall, a Philadelphia Inquirer columnist, was there to witness what had become familiar to many who work there. Another overdose, another librarian at the ready.

Ben, a librarian at a Midwestern public library, sees such overdoses on a weekly basis. “[Someone will] come up to us and say something like, ‘We think someone is having a situation.’ Sometimes they know what’s going on, and sometimes not,” he says. “There are times it’s happening multiple times a day. Not too long ago, we had two in the same restroom at the same time. We call security, security calls paramedics. Of course they always find somebody lying there.”

Used appropriately, a prescription opioid works by attaching to receptors in the brain, effectively blocking the patient from feeling pain. The drugs also have a calming effect and tend to slow breathing. Historically prescribed for short-term pain treatment, opioids were often vastly over-prescribed. In an attempt to slow the progression of the addiction epidemic, prescription guidelines have tightened up. Addicts are often sold more potent forms of synthetic opioids (like carfentanil); others are increasingly turning to heroin, which can be cheaper and more accessible.

In 2015, there were more opioid-related deaths—33,000—than deaths from car crashes. Many of the people being asked to respond in the moment—to think clearly and decisively in a life-or-death situation, and sometimes even to administer life-saving treatment—are librarians. But do we have a right to expect that of librarians? Do we have any choice?

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In the United States, a person dies of an opioid overdose every twenty-four minutes. While they happen everywhere, it’s been impossible to miss the stories of overdoses happening in the restrooms of public libraries: Boston. Cleveland. Chicago. Curious as to why libraries have been so hard-hit, I reached out to librarians in several different cities, starting with Jessamyn West, a Vermont librarian and blogger who describes herself as a library activist.

“There are a lot of places that are de facto public meeting space because of how they’re used. People hang out at the baseball field, or the Cumberland Farms, the bar, the church,” West tells me. “But all those places have some sort of ‘You must be this tall to ride this ride’ kind of rules. The library doesn’t. It really strives to be available to everyone.”

The inclusivity of libraries tells part of the story. Libraries are quiet, private spaces you can stay for extended periods of time and not be questioned. Sociologist Roy Oldenburg called such destinations “third places,” neither home nor work; increasingly, fewer of these third places are free. While you might need an access code to use a Starbucks bathroom, that’s not a barrier you’ll encounter at a library.

In addition to offering privacy, Ben has another theory about why some addicts head to library bathrooms to use: “I think it’s also because they know if something happens, someone will alert the authorities. They know someone will have Narcan and help them out.” Narcan (also known as Naloxone) is an opioid antidote.

Without training, it’s unlikely most people would immediately recognize an overdose. Dr. Chad Brummett, Assistant Professor of Anesthesiology at the University of Michigan School of Medicine, says you might find patrons “acting in an erratic way . . . They might kind of nod out. They can have slurred speech and it can look just like any other kind of intoxication.” But it can be much more serious than intoxication, as opioids also affect the mid-brain—“your breathing center,” Dr. Brummett explains.

I ask him what happens without access to Narcan or knowledge of CPR. How much time do you have? “With oral pills, the onset might be much slower. Unfortunately, a lot of overdoses we’re seeing right now are from heroin, fentanyl, or carfentanil, and that can be incredibly fast, like minutes, a minute,” he says. “Fentanyl is something we’ve traditionally used in operating rooms, and it’s intentionally designed to be very quick in its onset. If somebody has just shot up fentanyl, your timeline might be incredibly short.”

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Within the library community, boundaries are always being discussed and redrawn around which services libraries can and should provide. Debate and dissent are common. While the American Association of Libraries states it is “crucial that libraries recognize their role in enabling poor people to participate fully in a democratic society,” that doesn’t mean every librarian will feel equally comfortable in that role.

“Being a librarian now implies being an expert in way too many fields: social work, child development, health care,” wrote one member of a Facebook group for librarians. As West points out, “There are a lot of rules . . . they’re not binding, but they are professional values. So when we [say] libraries are for everyone, it is because that’s how we’ve agreed to do it.”

A public librarian in Maine, a state hard hit by the epidemic, who spoke on the condition of anonymity shared that they “have found needles throughout the building (namely in the bathrooms, but not always).” While their director offered an education program on drugs for the library staff, not everyone could attend, and it was never repeated. Another librarian at an urban branch told me, “This happens with great regularity here. I doubt, however, that you will get anyone in authority to talk honestly about it. Most of the ‘incidents’ go down merely as a call for emergency services, no details mentioned.” When I reached out to the New York Public Library—my system, and the second-largest public library in the country—for word on how they’re dealing with the problem, they declined to comment.

Checking in with online librarian communities about opioid usage they’ve seen on the job was polarizing, with some commenters eager to vent (“I’ve been trying to get Narcan and the accompanying staff training for my library for months, and I keep getting shuffled from agency to agency. It’s incredibly frustrating”) and others annoyed by what they saw as an overblown problem (“Ooh yeah, we totally watch ’em shoot up right at the front desk . . . I checked out a needle and spoon to a gaggle of teen girls who wanted to shoot up together”).

Annoyed Librarian, an anonymous Library Journal contributor, spoke for many when they expressed concerns about stepping into a first responder role. “Is the goal just to make sure that people don’t die of overdoses in the library? Or is it to help them before they overdose?” they asked. “Or is that the social worker’s job? It’s hard to tell anymore.”

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Some libraries have taken decisive action. Between January and March of this year, the Denver Public Library’s Central Branch experienced six overdoses, including one death. In a move that’s made national headlines, its administration decided to stock Narcan and offer voluntary training to staff members who want to learn how to administer it.

“The [Narcan] we have looks just like a nasal spray,” says Chris Denning, a spokesperson for the Denver Public Library. “A concern we had is what happens if you administer it to someone who is not having an overdose. The great thing about it is, it does nothing.” Denning says that while the administration expected some public resistance, they’ve received only positive feedback.

One of the reasons Denver has had such success rolling out their program is that they’re among a growing number of libraries across the country employing on-site social workers. Aside from their other duties, social workers at their branches offer daily drop-in hours. Their primary customers are homeless people seeking help with shelter, medical issues, and veteran’s benefits.

Social workers are a strategic investment, one not all library systems can afford or are willing to make. But if Denver and Philadelphia are arming staff with Narcan and training (and recent reports suggest San Francisco is taking similar steps), should other cities follow their lead? Why wouldn’t they?

Based on what librarians shared with me, the most likely reasons are an admixture of bureaucratic inertia, ignorance of the true scope of the problem, and fear of negative publicity. “The administration seems [to have] turned a blind eye to it,” says Ben, of his city’s library system. “They don’t have to deal with it. We deal with it on a very personal level because we see it every day and they don’t.”

It’s worth noting that those heroic Philadelphia librarians in Newall’s article didn’t wait for Narcan training (or even permission from higher-ups), instead reaching out to a local a needle-exchange program to show them how to administer it. But even Narcan isn’t a one-stop fix: The antidote is effective at blocking the opioids only for a short time, typically less than an hour, so it’s critical to still get someone who has overdosed to a hospital so they can be properly treated. Dr. Brummett also stresses its limited efficacy: “If somebody goes a certain amount of time without oxygenation or circulation, the Naloxone won’t matter.”

Ultimately, even with training and better resources, libraries are not well equipped to address the root cause of the epidemic. And as long as they remain on the front lines, witnessing overdoses on the job, feelings of sadness and helplessness will weigh on some librarians.

“We’re expected to really care about the public that we serve,” says Ben, “and I would say we do . . . but none of us [are] trained social workers. To maintain a certain level of empathy when you’re seeing this day in and day out [is] taxing and difficult.”

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The complexity of the overdose problem puts pressure on library staff to not only advocate for themselves, but for their patrons, too. West points out that librarians might feel conflicted, caught “between the expectations of their job and the expectations of their heart.” As library doors are open to everyone by design, there will always be hot-button social issues debated—and dealt with—by library staff, whether it’s drug use, banned books, or the availability of pornography. And while the opioid epidemic is just one of the latest challenges for librarians, it’s fundamentally one that should affect us all.

Is it fair to ask librarians to step into the chasm between where the social safety net ends and their real job—or at least the one they went to school for—begins? After speaking with so many librarians, I still don’t know the answer. I’m not sure we have a choice. What I do know is that many librarians are willing to do their best to help in these frightening and sometimes tragic scenarios, and for that they deserve not just our support, but that of their administrators, too.

“[Opioid addiction is] a tragedy,” says West. “Everybody has to take partial responsibility for the fact that we have an overdose problem. The big thing is that librarians really care, and caring is hard when people are in pain.”

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