Above: In this film still from “Heroin(e),” members of the Huntington, W.Va., fire department tend to someone who overdosed in a c-store.
Photograph by Elaine McMillion Sheldon/“Heroin(e),” a Netflix Original
911 operator: Is he breathing?
Caller: Yes, barely. Holy s---, man. I’m just trying to keep him awake right now.
Operator: All right, hold on one second for me, OK? What did he take?
Caller: I’m not quite sure.
Operator: Do you know his drug of choice?
—911 call transcript from a Newark, Ohio, c-store
On a warm July night in 2017, a man overdosed on the bathroom floor of a convenience store in Newark, Ohio. In a panic, his friend called 911 and watched as paramedics attempted to revive him. The medics sprayed two doses of the opioid-reversing drug naloxone into his nose: no response. Next, they drilled a hole below the man’s knee to reach his bone marrow and inject the naloxone directly into his bloodstream. Success: He opened his eyes, sat up and told the emergency personnel that he’d just dozed off.
After paramedics loaded the man onto a gurney, a police officer searched his clothes and found a metal spoon with brown residue in his right front pocket. As they wheeled him out of the store, employees, who had taken a smoke break, asked if they could return to work.
This scene, reported by the Newark Advocate, is taking place in c-store restrooms and parking lots across the United States. The opioid epidemic does not discriminate between small and large retailers, those in big cities or those in farm country, players with sophisticated foodservice programs or those with more traditional smokes-and-Cokes offers. In the process, the crisis has turned the industry’s restrooms, one of its greatest assets, into a risk-management nightmare.
Nearly 94% of the respondents to a CSP retailer survey on opioids say they see evidence of drug use in their stores, and most of those retailers say the activity has increased in the past five years. (See “Quantifying the Problem,” below.) The Loss Prevention and Safety Networking Group (LPN), Phoenix, an organization of loss-prevention, security and safety professionals in the c-store industry, also surveyed its retailer members on behalf of CSP about opioids. Confirming the scope of the problem, all respondents, which included individuals representing a range of chain sizes and geographies, said they see evidence of drug use in their stores, mainly in restrooms. All said incidents have increased in the past five years.
Retailers who are witnessing the crisis firsthand include Lisa Dell’Alba, president and CEO of Square One Markets Inc. The Bethlehem, Pa.-based convenience-store chain has almost a dozen stores in five Pennsylvania counties, including in some towns that never fully recovered from the collapse of their manufacturing industries. At one Square One location, an employee administered CPR and saved the life of a person who overdosed on opioids. “After finding the overdose victim, our entire team that evening was very upset, and rightfully so,” Dell’Alba says. As a former mental-health professional, she worries about the effect of the drug crisis on her staff.
It’s not just customers who are bringing the opioid crisis into c-stores. A Midwestern fuel retailer, who asked to remain anonymous, found an employee passed out from an overdose in his travel center’s lounge.
“What was very shocking was the profile of the person,” the retailer says. “It was a young person, and they were innocent-looking. They’re not going to look like—if you ever watch those prison shows and you see tattooed faces—they don’t look menacing. They look like normal people in the initial stages of the addiction.”
In Boone County, W.Va., where Huntington is located, the opioid crisis costs each resident about $8,700 per year, according to The American Enterprise Institute.
Drug overdoses claimed more than 63,600 American lives in 2016, according to the National Center for Health Statistics. Opioids, including heroin, fentanyl and oxycodone, were to blame for about 66% of those fatalities. West Virginia, Ohio, New Hampshire, Pennsylvania and Kentucky had the highest rates of death due to drug overdoses in 2016, and the Midwest region saw a 70% increase in opioid overdoses from July 2016 to September 2017, according to the Centers for Disease Control and Prevention.
At the Wisconsin State Laboratory of Hygiene (WSLH), Madison, Wis., Lorrine Edwards has seen the opioid crisis reflected in the blood samples she tests at the lab, the results of which are often used in legal investigations associated with driving under the influence of drugs or alcohol.
Edwards, an advanced chemist, says the WSLH has tested several specimens from convenience-store overdoses. One took place at a c-store only a half-mile away from her lab. Wisconsin saw a 109% increase in emergency-room visits for suspected opioid overdoses from July 2016 to September 2017, according to the Centers for Disease Control and Prevention. In the past few years, the number of WSLH cases in which police officers list opioids as a suspected category of drugs involved in these incidents has been growing.
The epidemic was a long time coming. Edwards says this recent surge likely originated in the late 1990s, when pharmaceutical companies marketed some opioids as being nonaddictive, and doctors widely prescribed drugs such as oxycodone, hydrocodone and codeine for long-term use. Once those prescriptions ran out, some people who became addicted to the prescription painkillers turned to heroin. While oxycodone might be worth $25 to $50 per 5-milligram pill, $20 worth of heroin may last up to eight hours, depending upon frequency of use, tolerance and potency of the drug. But as demand for heroin outpaces production, synthetic opioids with up to 100 times the potency of morphine, such as fentanyl, have emerged, increasing the frequency and risk of overdoses.
“That response that a person gets is almost immediate,” Edwards says. “It’s described as a euphoria, but I’ve heard it described similarly to a sexual experience. We’ve had cases where someone passed out in a car at a convenience store, the car is on, their foot is on the brake and the car is in gear. It’s that quick.”
What Are Opioids?
According to the Substance Abuse and Mental Health Services Administration (SAMHSA), opioids include illegal drugs such as heroin, as well as prescription pain medications such as morphine, codeine, methadone, oxycodone, hydrocodone and fentanyl. Opioids work by binding to specific receptors in the brain, spinal cord and gastrointestinal tract, minimizing the body’s perception of pain.
The wide availability of opioids and staggering economic inequality in communities throughout the country have proved to be a dangerous—but increasingly common—combination. It’s difficult to find a c-store retailer that has not dealt with drug use at their sites on some basis.
“There’s no question that it has impacted us,” says Mike Thornbrugh, manager of public and government affairs for Tulsa, Okla.-based QuikTrip Corp. “In our industry, we see everything. A lot of things, we don’t want to see.”
Last February, a 27-year-old woman overdosed on heroin inside a Thorntons bathroom in Cincinnati. Her newborn baby was by her side, according to court documents. After the incident, Bob Hammond, Thorntons’ vice president of store operations, told WLWT-5 that because of incidents such as these, the Louisville, Ky.-based retailer does not lock its bathrooms.
“Our No. 1 concern is the well-being of our guests and our team members; therefore, we have regular comprehensive checks across all sections of the store, including our bathrooms, to ensure quality and safety,” he said. (Thorntons Inc. declined comment for this story.)
Quantifying the Problem
Finding hard numbers quantifying the frequency of drug use at c-stores is difficult. To get an idea of the scope of the problem, CSP in March conducted an online survey that asked retailers about their own experiences with drug use in their stores. While most respondents said they see evidence of it, including among employees, few said they are taking steps to address the problem.
Source: CSP survey
911 operator: What I need you to do—do you want to do CPR?
Caller: Uh, now he’s breathing again.
Operator: What I want you to do is tell me now each time he takes a breath in, OK?
Caller: OK. In. Out.
In. Out. In. Out. In. Out. —Continuation of transcript
Samantha Ruttan, a c-store retailer in British Columbia, where more than 1,400 people died from opioid overdoses in 2017, began stocking naloxone in her three Shell-branded stations after several overdose incidents. About 20 of Ruttan’s team members opted into training to learn how to use the drug to counteract an overdose. They also learned about how users might react to naloxone, which knocks the opioids off the receptors in the brain that affect breathing. A dose of the antidote can send recipients so quickly into withdrawal that they lash out in anger.
“I want them to have the training so they know what it is,” Ruttan told The Chilliwack Progress. “I think it is really important that my staff gets trained, not just for Shell but for their personal lives as well.”
In April, U.S. Surgeon General Jerome Adams said in a national public health advisory that naloxone must be available to the friends and family of those at risk to opioid overdose. “It is time to make sure more people have access to this life-saving medication,” he said, pointing out that 77% of opioid deaths occur outside a medical setting.
Training employees to be proactive about safety is a good first step, says Richard Jones, the police chief of Cleves, Ohio. In Hamilton County, where Cleves is located, the county coroner has reported that 373 people died from opioid overdoses in 2017—the third straight year of increases. “But the biggest thing is to keep calling 911 for the troublemakers,” Jones says. “Letting them grow roots and establish a safe environment for their drug usage will attract more.”
The safety implications at a c-store are massive, considering the gallons of flammable fuel surrounding the site. At one gas station in Jones’ jurisdiction, a tanker-truck driver overdosed in his vehicle while it was still running. Police found heroin and pills inside the truck’s cab.
Jones has instructed retailers in Cleves to stay alert about anything that might be suspicious, lock the bathrooms at night, call 911 for every incident and cut off power to exterior electric outlets, because users often wander town at night looking for places to charge their devices. He does not recommend attempting to administer first aid; instead, employees should wait for first responders.
“If you see a vehicle at the pumps for a long time, just call 911,” he says. “Don’t approach, as oftentimes the users wake up panicked, and the vehicle might still be in drive and suddenly take off.”
He also warns against CPR, because getting on the ground could make good Samaritans vulnerable to attack if the user is not alone, or it could accidentally expose them to opioids.
After a triple overdose last September at a Sheetz location in Johnstown, Pa., the convenience-store chain announced plans to work with law enforcement to combat the problem.
“Over the last several years, the number of opioid overdoses in public places has risen significantly,” the Altoona, Pa.-based company said in a press release. “Because Sheetz is open 24/7 and 365 days per year, we have definitely been affected by this nationwide epidemic. Sheetz is committed to being a good neighbor in every community we serve, and that includes working closely with local fire and police departments to aid in a quick response and ensure the safety of our customers and employees.”
As part of the commitment, Sheetz is willing to try tools that are relatively new to U.S. retailers. A Sheetz location in New Kensington, Pa., is testing blue lights in its restrooms to discourage drug use. The hue of the lights makes it harder for heroin users to see their blue veins and inject the drug. (Sheetz declined comment for this story.)
In Huntington, W.Va., where the overdose rate is 10 times the national average, Speedway is also trying out the technique. Huntington is also the setting of a 2017 Netflix documentary about the opioid epidemic, “Heroin(e).” A Speedway spokesperson said the blue lighting is an effort to provide a safe environment for customers and employees.
Osnabruck University in Germany uses the same blue lighting technique that some Sheetz and Speedway stores have adopted.
911 operator: OK, we have help on the way, OK? Stay on the line, and I’ll tell you exactly what to do next. I need you to get right back next to your friend for me, OK?
Caller: I can’t get in trouble for this, can I?
Operator: Our main concern right now is your friend’s life, OK? You need to stay right next to him for me, OK? —Continuation of transcript
When Dell’Alba of Square One Markets heard about Sheetz’s blue lights, she was encouraged. “It’s a conversation that people are embarrassed to have,” Dell’Alba says. “I was delighted that they were open to having that conversation, because, quite frankly, we should be talking about it.”
When Square One Markets remodeled its flagship store in 2008, the team aimed to design bathrooms that were welcoming for customers but also discouraged drug use. Aiming for the same effect as the blue lights, Square One installed cozy, low lighting. But Dell’Alba never expected heroin usage to become such a massive problem in her communities. Some of her stores lock their bathrooms at night; in most cases, they do not open them until managers return.
Dell’Alba is also working with an alarm company to design lights installed outside the restrooms that signal when they are occupied. However, the biggest piece of this problem is protecting employees, Dell’Alba says. Sometimes needles are left in the bathroom or thrown out in the trash. As part of their onboarding training, Square One staff learns how to properly dispose of needles, following Occupational Safety and Health Administration standards for workplaces to avoid blood, body fluids or other potentially infectious materials. Employees are taught to double-bag the garbage, and how to avoid accidentally sticking themselves or others with a needle. Square One Markets also removed the bathroom ceiling tiles at some locations so people could not hide drug paraphernalia above them. And employees are instructed to encourage known drug users to leave the store.
Some retailers are seeing employees succumb to the crisis. The Midwestern fuel retailer whose employee overdosed in his store has ratcheted up his screening methods for potential hires, including requiring more costly hair drug tests. Because such requirements tighten an already rigid labor market, c-stores have to be ready to pay for good help, the retailer says. According to Princeton University economist Alan Krueger, high opioid prescription rates might account for about 20% of a 6-point decline in the male labor force participation rate from 2014 to 2016.
The Midwestern retailer also watches for warning signs, such as people wearing long sleeves in extreme heat to cover up needle marks.
“If you’re selling fuel, you’re sitting on thousands of dollars of flammable liquid,” he says. “You should be very concerned about safety.” To the extent that a store owner is aware of opioid-addicted customers and employees, “they have the duty to take action and do something before someone gets hurt. As store owners, we can’t solve the problem, but we have to make sure we mitigate to the extent that problem shows up at our doorstop.”
Dick Hiers, owner of the Northeast Standard BP store in Sheboygan, Wis., has embraced this attitude wholeheartedly. Sheboygan is one of 28 Wisconsin counties that has filed lawsuits against pharmaceutical companies, alleging that the companies are to blame for the opioid epidemic. To fight back, Hiers has organized meetings with law enforcement and posted signs in his street about the dangers of heroin and other drugs.
The problem has become deeply personal for the retailer: Four of Hiers’ star workers were arrested and charged with manufacturing, selling or distributing drugs. Hiers felt blindsided.
“They hide it very, very well,” he says.
Samantha Ruttan, a c-store retailer in British Columbia, bought naloxone kits for her stores after several overdose incidents. Photograph by Jenna Hauck/The Chilliwack Progress
Signs of Opioid Use
- Slowed breathing
- Clumsiness or poor coordination
- Nodding off or loss of consciousness
- Constricted pupils
CSP contacted many retail and petroleum associations for comment about the opioid epidemic and its effect on their members. NACS said it does not have a policy recommendation on the issue. Other associations either declined comment or said they were not following the issue, highlighting how sensitive the topic is and how difficult it can be for retailers to get help dealing with it—especially when it comes to their own employees.
Seven in 10 employers are affected by prescription drug misuse, and one in 10 companies reported an employee overdose, according to a 2017 National Safety Council survey. Kelly Nantel, vice president of communications and advocacy for the National Safety Council, says drug-free workplace programs are cost-effective and help ensure that employees are safe.
“Many companies are updating the language in their drug-free-workplace programs to reflect the responsibility an employee has when it comes to potential impairment from a prescription drug,” Nantel says. She recommends working with healthcare providers, which can help employees avoid getting addicted to opioids in the first place. Retailers can demand conservative prescribing guidelines for pain treatment from all participating providers in their medical, occupational health and workers’ compensation programs. Ensuring coverage of physical therapy and substance-use treatment programs and providing employee assistance programs are also good preventive measures.
“Research shows that employer-initiated treatment programs are more effective than family- or friend-led interventions,” she says. “Simply said, employees who receive help from their employers often have a better chance of long-term recovery.”
Tim Dimoff, CEO and president of SACS Consulting and Investigative Services Inc., Akron, Ohio, recommends running a detailed background check on new employees’ criminal and civil pasts.
“It will tell you two things: if they have a past drug-abuse situation, and if they have a hard time handling money, which could lead them to theft or drug dealing,” he says. Open-ended interview questions can also save trouble down the road. For example, ask potential hires how they would handle someone who comes into the facility who wants to sell drugs to guests, and watch their reaction, Dimoff says.
“You’d be surprised how much information they will tell you if you just ask,” he says. Establishing and mentioning zero-tolerance drug policies in job listings and interviews will screen out many troubled applicants, he says.
As Dell’Alba watches some of her customers wrestle with opioid addiction, she feels a responsibility to help, but she wonders how she can get them the resources they need to recover.
“They’re all members of the community—these aren’t just people who you’re never going to see again,” she says. “How do we as a community member participate in the healing process?”
- Install blue or dim lighting to discourage intravenous drug use.
- Lock bathrooms at night or install “doorless” restrooms.
- Drug test job applicants and advertise drug-free workplaces.
- Conduct criminal and civil background checks on potential hires.
- Consider stocking the opioid antidote naloxone in stores and train employees on how to administer it.
- Cut power to exterior outlets.
- Encourage employees to call police at the first sign of opioid abuse and continue to call for repeat offenders.
- Demand conservative prescribing guidelines for pain treatment from all healthcare providers.
- Cover physical therapy and substance-use treatment programs.
- Provide employee assistance programs.