The Call for a School-Based Approach to Opioid Overdose Prevention

Drug overdose is the third leading cause of death among children and adolescents in the United States.¹ Although youth substance use, including opioid use, decreased in recent decades, there was a 121% increase in adolescent overdose deaths from 2010 to 2021.^2,3 This dramatic increase is driven by a toxic drug supply, with synthetically manufactured opioids like fentanyl contributing to the majority of adolescent deaths.^2,4 Among youths who died from an overdose from 2019 to 2021, 65% did not have a history of opioid use, 89% had never received substance use disorder treatment, and naloxone was used only 33% of the time.⁴ These trends emphasize the inadequacy of current responses to adolescent overdose. In the current context, adolescent substance use is increasingly risky, and it is insufficient to focus only on primary prevention strategies. It is clear that we need an urgent public health strategy to provide youths with overdose prevention education and information about how to use naloxone. Although this article emphasizes adolescent-focused public health strategies, reducing adolescent opioid overdose deaths will also require engaging families, school staff, providers, and other adults who care for youths.

An efficacious prevention strategy would universally teach individuals how to recognize and respond to an overdose with naloxone administration, which is foundational to opioid overdose response. Naloxone is an opioid antagonist and Food and Drug Administration–approved opioid overdose reversal medication. Two versions (4 mg and 3 mg nasal sprays) were approved for over-the-counter sale in 2023.⁵ Public health strategies to improve naloxone utilization, including state laws providing access without a prescription (before naloxone became over the counter) and provision of civil liability protection to laypeople administering naloxone, have helped decrease opioid overdose mortality and have not been associated with an increase in nonmedical opioid use by adolescents or adults.^6,7 However, adult-focused implementation strategies to improve access to naloxone are not reaching youths. Per capita dispensing of naloxone remains lowest among those aged birth to 19 years,⁸ and a review of Centers for Disease Control and Prevention 2019–2021 data found that naloxone was not administered in 70% of fatal overdoses in those aged 10 to 19 years despite the presence of a potential bystander in 67% of the cases.⁴

Overdose education with naloxone distribution (OEND) is a proven public health strategy that reduces opioid overdose deaths in adults and may be one way to improve youth naloxone access.⁹ However, there are currently limited models for implementing OEND content in youth-focused and accessible settings. Schools offer public health education on a number of youth-specific risk behaviors. Naloxone implementation in schools offers an opportunity for universal youth education and prevention of fatal overdose in a space where youths spend substantial time. An open letter published by the US Department of Education and Office of National Drug Control Policy in October 2023 called for schools to develop plans to educate students and personnel on overdose response, noting that “there is no time to waste when responding to an overdose, and it is critical that youth and school personnel can access naloxone on school grounds during and after school.”^10–13 However, there are limited evidence-based interventions to educate school personnel and students on overdose prevention, recognition, and intervention.

In this essay, we review barriers to youth naloxone access, describe legislative efforts to improve access in schools, and discuss potential opportunities for youth-focused opioid overdose prevention education.

BARRIERS TO YOUTH NALOXONE ACCESS

Adolescent access to naloxone is likely influenced by inadequate youth overdose education, pharmacy barriers, insufficient provider prescribing, limited data on adolescent overdose risk factors, and stigma surrounding adolescent use. As a result of insufficient adolescent education, college students report limited knowledge of naloxone use (30%) and administration (14%).¹⁴

Pharmacy barriers include the high cost of over-the-counter naloxone and prevalent incorrect pharmacist assumptions about minimum age requirements.¹⁵ Adolescents also worry about pharmacist or provider judgment, feel embarrassed, and misunderstand the need for parental consent when accessing stigmatized medications.¹⁶

Pediatric providers are also not meeting the needs of youth naloxone prescribing. Insufficient pediatrician and provider education persists, which may limit naloxone prescribing and further contribute to poor adolescent naloxone access.¹⁷ Although pediatricians feel that overdose prevention is their responsibility and they can identify at-risk youths, very few pediatric trainees (10%) report ever prescribing naloxone, and only 14% of pediatric emergency room physicians report providing naloxone after an opioid-related visit.^17,18 Prescribing patterns are likely influenced by limited naloxone knowledge, lack of education on addressing overdose risk with patients, and provider stigma around who is at risk for overdose.¹⁷

Recent data show that most adolescents who died of an overdose had no history of an opioid use disorder. This suggests a need to reconceptualize prior data identifying youth overdose risk factors such as injection drug use, prior opioid use, and sedative use as risk factors for youth opioid overdose. If youths are overdosing on fentanyl-contaminated pills the first time that they try substances, focusing on improving naloxone distribution to youths already known to use substances will be insufficient in preventing overdose deaths.

LEGISLATIVE EFFORTS TO IMPROVE NALOXONE ACCESS IN SCHOOLS

Schools offer a promising opportunity to provide universal prevention through OEND in a setting where many youths already receive education on public health topics and risk behaviors. Making naloxone available in the case of an emergency is an important component of such a strategy. US schools have adopted response programs for a range of potentially fatal emergencies, including opioid overdose. As of 2017, 17 states required the installation of automated external defibrillators for use in sudden cardiac arrest, and as of 2018, all 50 states and the District of Columbia enacted laws facilitating the use of undesignated epinephrine in the case of anaphylaxis.¹⁹ Currently 36 states allow schools or school employees to store, possess, or administer naloxone on school campuses.²⁰ However, requirements differ by state; only two states (Illinois and Rhode Island) require all private and public schools (kindergarten to 12th grade) to stock opioid antagonists, whereas Arkansas, Maryland, Minnesota, New Jersey, and Oregon require all public high schools to stock opioid antagonists.²⁰

Access to naloxone in US schools may improve with the passage of the recently proposed School Access to Naloxone Act of 2023 (S.2946, H.R.3065) or the proposed Stop Overdose in Schools Act (H.R.5652), which would incentivize schools to maintain opioid overdose reversal agents that can be administered by trained personnel under civil liability protection law.^11,12,21 The Helping Educators Respond to Overdoses (HERO) Act (H.R.6251) would establish grants to fund the development and implementation of overdose prevention curricula for students and community members in addition to the purchase of opioid overdose reversal agents.¹³ The School Access to Naloxone Act of 2023 is supported by the National Association of School Nurses, which recommends that opioid overdose management plans be incorporated into school emergency preparedness and response plans,²² and by the American College Health Association, which recommends that college health centers be prepared to respond to an opioid overdose and add naloxone to emergency kits.²³

YOUTH-FOCUSED OVERDOSE PREVENTION EDUCATION

Improving naloxone availability and training in schools is a promising development, with the potential to save lives. However, the School Access to Naloxone Act misses an opportunity to improve universal prevention of overdose deaths outside of school by not requiring youth overdose education. Classroom-based interventions are a common primary substance use prevention strategy, yet existing programs do not generally incorporate overdose education, including use of naloxone. As naloxone is potentially introduced into more schools, there is an urgent need to implement overdose prevention curricula in schools. Although the HERO Act recognizes this need, it does not emphasize the equally urgent need to develop outcome measures and evaluate curricula to ensure that youths are receiving efficacious and youth-focused messages. Previously, non-evidence-based substance use prevention curricula (e.g., Project DARE) were widely adopted in US schools and received substantial government support despite an absence of proven efficacy.²⁴ Curricula should present evidence about opioids, overdose risk, and appropriate response while addressing common myths—for example, that topical fentanyl exposure causes overdose, or that fentanyl is present in nicotine or cannabis vapes—that may make youths reluctant to respond and may perpetuate stigma related to drug use.²⁵

Opioid overdose education and prevention curricula currently implemented in limited high school settings include Safety First, which uses thirteen 55-minute sessions to discuss signs of problematic substance use, harm reduction strategies, and overdose response, and the Rx for Addiction and Medication Safety program, which includes two to three interactive education sessions on opioid safety, misuse, and overdose.^26,27 In pilot studies of participating ninth graders, these curricula are associated with improved confidence and skills in understanding harm reduction strategies, identifying overdose, utilizing naloxone, and educating friends and families on opioid overdose response.^26,27 Neither study evaluated postintervention use of naloxone.

On college campuses, interventions combining free naloxone distribution with naloxone education are well-received by students and are associated with improved knowledge of opioid overdose risks and readiness to respond to an overdose. They are also linked to increased access to naloxone on campus, which can lead to successful overdose reversals.^28,29 These college programs are currently opt-in, and it is unknown how effectively they could be universally applied in a high school setting.

Opioid overdose curricula have also been piloted in juvenile detention centers, where youths may be at particularly high risk of overdose.³⁰ In these settings, the combination of overdose response education and distribution of naloxone kits on release was associated with increased naloxone knowledge, confidence managing an opioid overdose, and, in one evaluation of postrelease follow-up, willingness to share knowledge.^30,31 Youths engaged in these interventions did report concerns about legal repercussions of overdose response (e.g., arrest for being at the scene of opioid use), suggesting that education on civil liability protections when appropriate may improve readiness to respond.³¹ Despite these promising results, it is unknown how applicable these interventions may be in high school settings, where youths may have less familiarity with overdose preintervention.

CONCLUSION

Adolescents are dying at an increasing rate from opioid overdose. Most of these youths have no history of documented opioid use or treatment of other substance use disorders. Reliance on overdose strategies targeting youths with previously described overdose risk factors such as injection drug use or prior opioid use is insufficient. Instead, a universal public health overdose prevention strategy is needed to save lives when there is an increasingly toxic drug supply. Overdose deaths are preventable when youths can access naloxone and overdose prevention education that is evidence-based and acceptable to youths. Yet public health efforts to expand naloxone access focused on adults and patients with a history of opioid use have not addressed gaps in provider knowledge, pharmacy access, and understanding of overdose risk factors that limit youth access. There is a desperate need for new public health strategies targeting youths to prevent further adolescent deaths.

The School Access to Naloxone Act of 2023 and related proposed legislation are a promising opportunity to improve naloxone availability for youths. However, to universally address overdose risk and prevent fatal overdoses, we need evidence-based naloxone education for youths that can be implemented in diverse school settings alongside accessible naloxone. Promising studies suggest that interactive, case-based interventions improve youth knowledge of overdose risk and naloxone use, but curricula implementation remains limited. As members of the public health community, we must advocate for the inclusion of evidence-based educational interventions alongside improved naloxone access to address opioid-related risk, prevent further deaths, and improve health for all youths.