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15 Articles in Volume 19, Issue #3
Analgesics of the Future: The Potential of the Endocannabinoid System
Buprenorphine: A Promising Yet Overlooked Tool
Chronic Pain and the Psychological Stages of Grief
Could a Personalized Approach to Therapy End the War on Pain?
Finally, A Systematic Classification of Pain (the ICD-11)
Hormone Therapy for Chronic Pain
How to Communicate with a Medical Marijuana Dispensary
Letters: Opioid Conversions; Scrambler Therapy for CRPS
MSK Pain: Time for an Enhanced Assessment Model
National Drug Use & Abuse Trends: Prescribed and Illicit
Neuroplasticity and the Potential to Change Pain Response
Should Emergency Naloxone Be in Schools?
Talking to Patients about Medical Cannabis
Utility of Pulsed Radiofrequency Ablation in Xiphodynia
When Opioid Prescriptions Are Denied

Should Emergency Naloxone Be in Schools?

With a looming rise in opioid use disorder, the authors look at the feasibility of placing naloxone in the hands of educators.
Pages 8-11

With the growing number of opioid overdose deaths associated with both prescription and illicit opioids, the sad truth remains that fatalities are affecting school-aged children ranging from elementary to high school. How do we prevent resulting morbidity and mortality in this vulnerable and mostly unprotested population? With the lifesaving drug naloxone available in multiple dosage forms, the next question is: should naloxone be available in schools? Herein, the authors attempt to separate fact from fiction regarding this ongoing debate and summarize the current legislation on the subject as well as related programs available across the United States.

Similar to EpiPens, emergency opioid overdose naloxone drugs are now being stored in school nurse offices across the country. (Source: 123RF)

Data & Directives

The range of policies and procedures around housing naloxone in schools is daunting. Not only do directives vary by school district, county, and state levels, but there are even a few at the individual school level. Similarly, there is limited data reported about the incidence of opioid overdoses in schools, as no federal agency seems to tracks this information.1 The US Substance Abuse and Mental Health Services Administration (SAMHSA) provides some data on the use of substances by children as young as 12 years old, however, this data includes all illicit substances (eg, cocaine, opiates).2 In the US, for example, from 2009 to 2010, illicit substance use among the 12-plus age group was 8.82% compared to 9.77% between 2013 and 2014. Until the opioid epidemic is fully controlled, one could assume that the associated use of these substances in those under age 12 may also rise.

The Surgeon General did issue a public advisory on naloxone encouraging widespread understanding and use of the medication, specifically noting that “too few community members are aware of the important role they can play to save lives.”3 In addition, the SUPPORT Act, passed by Congress in October 2018, requires the US Health and Human Services Department to develop best practices for overdose treatment, for the use of recovery coaches and care coordination, and for providing naloxone following an overdose. It also establishes grants for programs that provide care for individuals after an overdose.4 How quickly these efforts and training programs trickle down to the school level remains to be seen.


Current Programs at the Elementary and Secondary Level

Using the state of New York as an example, schools stock naloxone similar to other common medications, such as epinephrine auto-injectors, and a program provides the medication free to schools.3 Several other states, including Connecticut, Kentucky, Massachusetts, New Mexico, and Rhode Island have related legislation in place, however, there is no uniformity in policy. Rhode Island is perhaps the strictest as it requires all public middle, junior, and high schools to carry naloxone. Others allow their local school boards or superintendents to decide their naloxone fate.

Going back to New York as an example, each school district in the state is responsible for using one of the following three approaches, should they choose to participate in the state’s optional naloxone program.5

  • Providing Opioid Antagonists in Schools: Schools that have a medical director may register with the New York State Department of Health (NYSDOH) to become a Registered Opioid Overdose Prevention Program. The medical director of the school would be considered the Clinical Director of the program. Unlicensed school personnel may also become trained to administer emergency naloxone by completing a NYSDOH-approved training program. Unlicensed personnel may be trained to use intranasal naloxone, whereas only the school nurses may administer either intramuscular or intranasal naloxone. The school’s medical director would be the person responsible for prescribing naloxone and ordering rescue kits (through this option, the school may receive free naloxone kits).
  • Issuing a Non-Patient Specific Order: The school’s medical director may issue a non-patient specific order to school nurses for the administration of either intramuscular or intranasal naloxone. The medical director must obtain the naloxone for the school, and the school is not eligible to receive naloxone from NYSDOH.
  • Permitting Volunteers to be trained by a NYSDOH Registered Overdose Prevention Program: Unlicensed school personnel may become trained to administer intranasal naloxone through a NYSDOH approved training program. Through this option, the school may receive free intranasal naloxone kits. 

As of early February 2019, 106 school districts in New York State were participating in the naloxone program.5

Current Programs at the College Level
The proportion of college students using prescription drugs increased dramatically between 1993 and 20056 and opioid use has increased by 343%.6 The majority of college students (50%) are typically offered a prescription drug for nonmedical purposes by their sophomore year, indicating that opioids are becoming the college-age drug of choice.7 In fact, according to the American College Health Association (ACHA), college students reported using opioids for nonmedical reasons at 7 to 12%.6 The crisis seems to be more problematic in selective urban colleges.7
Students may embrace the misconception that prescription medications are safer than illicit opioids, but the death rate disproves this logic. Fatal overdoses, increasingly due to illicit fentanyl in most recent years, have overall more than tripled since 1991.7 There are also misconceptions that heroin and fentanyl are not present on college campuses. However, these substances are becoming more and more available and pervasive, including the availability of heroin in powder form, black tar heroin, and synthetic illicit fentanyl derivatives, 50 to 1,000 times more powerful than morphine.8 ACHA reports that 2 to 3% of college students using opioids for nonmedical reasons reported a change from using prescription opioids to heroin.9
College health groups are pushing for college prescribers to only prescribe opioids when benefit outweighs risk. These groups are also encouraging increased training to employees that treat overdoses and distribute naloxone.8,9 See Table I for specific examples. Unfortunately, due to existing denial, a lack of education/resources, and stigma, interventions for this type of substance use and abuse have been moving slowly at best.

Other Points to Consider

As schools and states consider implementing a naloxone program, the authors recommend the following:
  • Proper training for educators who may be carrying or expected to administer naloxone: this calls for a significant commitment to training (and re-training), time, and cost.
  • Safe storage of the medication: Schools should check with their state health department regarding whether a standing order to stock naloxone may be needed or whether the medication may be considered part of the school’s emergency stock. In addition, storage needs to be determined and may align with the school’s current epinephrine protocols (eg, in each classroom, the nurse’s office, the principal’s office, etc.)
  • Funding: Is the school able to partner with a pharmaceutical company to cover the cost of the drug or will it need to be purchased out of their operating budget. If the school is located in a state that has a naloxone distribution program, similar to New York State discussed above, they may be able to obtain naloxone at little to no cost.
  • Liability coverage: Coverage, and the individual state’s Good Samaritan legislation, should be reviewed.
Anecdotally, providers, patients, and school administrators have suggested to the authors that, if students know naloxone is being stored in their schools, they may be more likely to abuse drugs in the school setting as they may feel they have a “safety blanket.” Others have argued that, if naloxone has not been needed in a particular school yet, then there is no need to start stocking it now.
It is the opinion of the authors that both cases are myths at best and excuses that may cost the lives of young adults and children at worst. There is no valid reason for not stocking a life-saving medication.

In Summary

Even as the number of educational-institution programs around naloxone grows, the struggle of opioid use and potential overdose for school administrators, as well as peer groups and parents, remains. There are more gray than black or white areas related to naloxone access in schools. While having the emergency medication available in schools and any public area where defibrillators and epinephrine may also be available seems like an obvious smart choice to the authors, for others, naloxone access has been bogged down by purported ethical dilemmas, moral debates, cost concerns, time constraints, fund prioritization, and more.
Dialogue around this life-saving medication, in light of the current opioid epidemic, must continue. In the event that an overdose were to occur on school property, we as clinicians and Good Samaritans know there should be no question or debate as to whether the opioid antidote is on hand.
Read about FDA's review of improvised naloxone devices.
Last updated on: May 6, 2019
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