Should Emergency Naloxone Be in Schools?
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.
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
Other Points to Consider
- 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.
