Naloxone in the School Setting
It is the position of the National Association of School Nurses (NASN) that the safe and effective management of opioid-related overdoses in schools must be incorporated into the school emergency preparedness and response plans. The registered professional school nurse (hereinafter referred to as school nurse) provides leadership in all phases of emergency preparedness and response. When emergencies happen, including drug-related emergencies, proper management of these incidents at school is vital to positive outcomes. The school nurse is essential to the school team responsible for developing and implementing emergency response procedures. School nurses in this role should facilitate access to naloxone for quick response in the management of opioid-related overdoses in the school setting.
BACKGROUND AND RATIONALE
Opioid overdose deaths are a public health crisis according to the National Institute of Health (NIH) due to increased opioid misuse (NIH, 2019). According to the Centers for Disease Control and Prevention (CDC), drug overdose deaths are the leading cause of injury-related deaths in the United States. In 2017, more than 70,000 people died from prescription or illicit opioid misuse (CDC, 2017). In response, the US Department of Health and Human Services (HHS) is focusing its efforts on five priorities: access to treatment and recovery services, promoting overdose reversing drugs, strengthening understanding of the epidemic through better public health surveillance, providing support for cutting edge research on pain and addiction, and advancing better practices for pain management (NIH, 2019).
Deaths from opioids include those caused by prescription medications such as oxycodone, morphine or hydrocodone, and illegal drugs such as heroin or the synthetic opioid fentanyl (CDC, 2018). A crucial contributing factor regarding drug overdose deaths involves the nonmedical use of prescription painkillers—using drugs without a prescription or using drugs to obtain the "high" produced. Between 2016 and 2017, deaths from synthetic opioids increased significantly in 23 states (CDC, 2019). Many of these opioid-related deaths by overdose were due to opioids which contained fentanyl, perhaps the most dangerous synthetic opioid (CDC, 2019). In 2018, the CDC stated that deaths related to opioids consisted of over two-thirds of all overdose deaths (CDC, 2018).
According to the Substance Abuse and Mental Health Services Administration’s (SAMHSA) National Survey on Drug Use and Health, in 2017 there were 2.2 million adolescents ages 12 to 17 who were current illicit drug users. The CDC recognized the magnitude of this crisis in 2018 (SAMHSA, 2018) when overdoses were named as the most pressing health concerns and added to its list of top five public health challenges.
Naloxone is an opioid antagonist that will temporarily reverse the potentially deadly respiratory depressive effects for legal and illicit drugs. It is available as intramuscular or subcutaneous injection and nasal spray. When administered quickly and effectively, naloxone has the potential to immediately restore breathing to a victim experiencing an opioid overdose. Additional doses can be administered every 2-3 minutes (Selekman, 2019).
The use of naloxone as an opioid overdose reversal agent by laypeople and first responders has doubled from 2017-2018 and has proven to be an effective strategy in preventing overdose opioid deaths. The CDC (2019) estimates a co-prescribing ratio for opioids and naloxone as 70:1. For every 70 high dose opioid prescriptions written, there is only one naloxone co-prescription written, with rural areas having a much lower rate than metropolitan areas.
Schools are responsible for anticipating and preparing to respond to a variety of emergencies. The school nurse is often the first health professional who responds to an emergency in the school setting. The school nurse possesses the education and knowledge to identify emergent situations, manage the emergency until relieved by emergency medical services (EMS) personnel, communicate the assessment and interventions to EMS personnel, and follow up with the healthcare provider. Thus, school nurse access to naloxone as part of their school’s emergency preparedness will improve opioid overdose response, response preparation, and harm reduction and avoid horrific outcomes such as death. With naloxone as part of an emergency protocol, a school nurse can quickly administer it to prevent overdose deaths by reversing life-threatening respiratory depression. Ensuring ready access to naloxone at schools aligns with one of the SAMSHA’s five strategic approaches to prevent overdose deaths (SAMHSA, 2018).
Naloxone saves lives and can be the first step toward opioid use disorder (OUD) recovery. Opioid overdose-related deaths can be prevented when naloxone is administered in a timely manner. As a narcotic antagonist, naloxone displaces opiates from receptor sites in the brain and reverses respiratory depression that usually is the cause of overdose deaths (SAMHSA, 2018). Emergency protocol for any suspected overdose should include administering Naloxone and transporting the individual for emergency care. The access to emergency treatment can be the first step toward a much larger course of treatment of OUD.
School nurses should be familiar with the legal implications in their state when implementing naloxone as part of their school district’s emergency response plan. Laws vary from state to state in terms prescribing, supply maintenance and who can administer naloxone in the school setting. Since 2017, every state and the District of Columbia have laws that provide protection from criminal liability for naloxone administration by laypersons or first responders (SAMSHA, 2019).
Community prevention education is key when addressing the public health crisis of opioid-related deaths. School nurses have a crucial role to play with research-based, primary prevention strategies within their school communities. Through community outreach with prescription opioid abuse, misuse and overdose awareness programs, school nurses can provide valuable education and be a useful resource for K-12 students and their families. Furthermore, school nurses can assist families in recognizing the signs and symptoms of substance abuse, support and guide them in locating resources for care, counseling, and even refer students for appropriate treatment of OUD.
Centers for Disease Control and Prevention. (2018). Drug overdose deaths. https://www.cdc.gov/drugoverdose/data/statedeaths.html
Centers for Disease Control and Prevention (2018). Opioid overdoses treated in emergency departments. https://www.cdc.gov/vitalsigns/opioid-overdoses/
Centers for Disease Control and Prevention (2018). Opioid basics. https://www.cdc.gov/drugoverdose/opioids/index.html
Centers for Disease Control and Prevention. (2018). 2018 in review: CDC looks back at the year’s most pressing health concerns. https://www.cdc.gov/media/releases/2018/p1221-2018-year-review.html
Centers for Disease Control and Prevention (2019). Synthetic opioid overdose data. https://www.cdc.gov/drugoverdose/data/fentanyl.html
Center for Disease Control and Prevention. (2019). Life Saving Naloxone from pharmacies. https://www.cdc.gov/vitalsigns/naloxone/index.htm
Johnson, K., Selekman, J. (2019). Students engaging in high risk behavior. In J. Selekman (Ed.) School nursing: A comprehensive text (3rd ed.), pp. 826-835. Philadelphia, PA: F.A. Davis Company.
National Institute of Health (NIH): National Institute of Drug Abuse. (2019). Opioid. https://www.drugabuse.gov/drugs-abuse/opioids
National Institute of Health (NIH): National Institute On Drug Abuse. (2019). Opioid overdose crisis. https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis
Substance Abuse and Mental Health Services. (2018). Opioid overdose prevention toolkit (HHS Publication No. [SMA] 18-1472). Rockville, MD: Author. https://store.samhsa.gov/system/files/sma18-4742.pdf
U.S. Department of Health and Human Services (HHS). (n.d.). About the Epidemic webpage provides information from HHS on the opioid epidemic. https://www.hhs.gov/opioids/about-the-epidemic/
Acknowledgment of Authors:
Suzanne Levasseur MSN, APRN, CPNP, NCSN
Lynn Nelson MSN, RN, NCSN
Doreen Crowe, MEd, BSN, RN, NCSN
Keisha ES Major MSN-Ed, RN, NCSN
Adopted: June 2015
Reviewed: July 2019
Revised: June 2020
Suggested citation: National Association of School Nurses. (2020). Naloxone in the school setting (Position Statement). Author.
“To optimize student health, safety and learning, it is the position of the National Association of School Nurses that a professional registered school nurse is present in every school all day, every day.”
All position statements from the National Association of School Nurses will automatically expire five years after publication unless they have been renewed, revised, or retired at or before that time.