At an unassuming storefront on a busy Brooklyn street, people sign up to use a bathroom outfitted to try to curb an overdose crisis.
Waiting his turn, a man named Robert is frank about why he's there, instead of one of the stairwells, parks, rooftops or porches where he has used heroin in the past.
"It keeps us safe. It keeps us from getting arrested. You feel secure here," says Robert, who discussed his drug use on condition that his last name not be used because he fears arrest and damage to family relationships. "You know that someone's paying attention if you fall out in there. ... You know they're not going to let nothing happen to you."
As communities debate trying to stem overdose deaths by allowing safe havens for people to take heroin and other narcotics, places like this needle exchange program are quietly providing a model of sorts: bathrooms monitored by intercom, so someone can intervene to stop an overdose.
Officially, they aren't the more full-fledged and controversial facilities — often called safe injection sites — that cities including New York, Philadelphia, San Francisco and Seattle are seeking to open and that already operate overseas. At the same time, some counties and cities have pre-emptively banned injection sites, and federal officials have said they're illegal.
While the discussion plays out, Robert and about a dozen other people turned up on a recent afternoon to use the bathroom off the green-and-orange drop-in room at VOCAL-NY, where work includes needle exchange, support groups and advocacy campaigns.
A sign on the bathroom allows 10 minutes "to take care of business." But every three minutes, a staffer checks in by intercom. If there's no response, the staffer will release the door lock and come in, ready to administer anti-overdose medication. In eight years, a few people have overdosed but all have been rescued, VOCAL says.
If not official, the restroom isn't exactly underground, either. State Health Department policies suggest that needle exchange programs bathrooms have such safeguards.
"This bathroom is literally a response to hundreds of overdose deaths in bathrooms and streets across the city," Jeremy Saunders, VOCAL's co-executive director. "You can say we're enabling people, but what we would say is: At what point do you want us to stop caring?"
Opioid drugs — including pain pills, heroin and the heavy-duty painkiller fentanyl — have spawned the deadliest epidemic of drug overdoses in U.S. history. It has killed over 47,000 people nationwide in the 12 months that ended in November, the most recent federal data.
About 100 supervised injection sites have opened in Canada, Australia and Europe over the past 30 years. At least one has been operating under the radar somewhere in the U.S. since 2014, according to a research paper .
The mayor of the college town of Ithaca, New York, proposed a supervised injection space in 2016. Now New York is seeking state and community approval for a one-year test of four "overdose prevention centers" at privately run syringe-exchange programs, and Philadelphia is looking for organizations interested in running or funding injection sites.
San Francisco initially hoped to open two sites this summer or fall but now isn't setting a timeframe while working through legal issues. Seattle has budgeted $1.3 million this year to work toward launching a site, while opponents have been trying for a public vote on banning it.
A typical site would go well beyond VOCAL's bathroom, offering a space with tables or booths set up with sterile syringes, alcohol swabs and other accoutrements.
As people injected themselves, staffers would watch for trouble signs and jump in with overdose-reversing drugs if needed. Workers would look for opportunities to discuss treatment, and advocates argue the caring-but-not-coercive approach helps people make changes. But the main goal is simply survival.
"You can't detox if you're dead. You can't treat someone if they're dead," says Kassandra Frederique, New York state director of the Drug Policy Alliance, which advocates for less restrictive drug laws.
There has never been a reported overdose death at a supervised injection site, according to studies that say the facilities also reduce HIV infections and 911 calls for overdoses, among other problems. Researchers estimated New York's City's proposal could prevent 130 deaths and save $7 million in health care expenses per year.
"The evidence is absolutely clear that (the concept) has these great benefits," says injection-site researcher Alex Kral, a researcher at the RTI International research institute. "Once people understand it, I have a hard time understanding how anyone could be against it."
Tell that to Snohomish County Councilman Nate Nehring, who recently spearheaded a safe injection site ban in his county north of Seattle; they're also prohibited in some Snohomish cities and Pierce County , south of Seattle.
"I don't see where the compassion is in just handing someone a needle so they can shoot up heroin for the rest of their lives," says Nehring, a Republican. "True compassion is saying, 'We're not going to let you live this way. ... We're absolutely willing to help you with our resources, but you've got to get clean.'"
Members of a Colorado General Assembly committee had similar qualms when they recently nixed a proposal to allow a site in Denver.
And in Baltimore, Health Commissioner Dr. Leana Wen says taking steps toward an injection site without federal approval could jeopardize funding that the city can't afford to lose.
U.S. Surgeon General Dr. Jerome Adams has called the facilities illegal. While the Justice Department declined to comment on injection sites, Vermont U.S. Attorney Christina Nolan's office has said injection site staffers could face criminal charges and landlords forfeiture under a federal law against operating a place for narcotics use.
In New York, city special narcotics prosecutor Bridget Brennan fears injection facilities would stoke neighborhood resentment, risk legal problems and send misleading signals that drug use can be "safe." But Police Commissioner James O'Neill says the sites are worth trying, though the city's five district attorneys are divided on the issue.
There's no such debate at VOCAL-NY, where reminders of the dangers of drug use are as close as a framed artwork by a 28-year-old who died of an overdose.
Or as close as VOCAL activists and newlyweds Levele and Nilda Pointer, sitting beside each other.
Nilda, 46, survived three overdoses and three strokes related to her former heroin use. Levele, 50, says he'd have "kicked the door in" to get to a safe injection site, rather than the underpasses, condemned buildings and other locales where he used to take heroin, crack and marijuana.
He remembers times when he knew he'd gone too far and thought his heart was about to stop or burst. He felt "total fear that I was about to die."
"Those are moments that I would never want anyone else to live," he says, and chokes up.
"It's OK, baby," Nilda says. "You're OK today."
