National review of state laws on opioid antagonists in Kindergarten-12th grade schools across the United States

Abstract

Background

Opioid overdoses have surged among United States (US) youth, who face high risk of morbidity and mortality. Opioid antagonists (OAs), like naloxone, are life-saving medications that can reverse overdoses. For youth, schools can be key venues for harm reduction. As states enact laws governing OAs in schools, it is important to understand how states permit schools to manage and respond to emergencies with this medication. This study’s objective was to examine statutes on OAs in Kindergarten-12th grade schools to identify and compare key legislative components across states.

Methods

This national review analyzed US state laws on OAs in K-12 schools enacted by December 31, 2024. A search of statutes was conducted using Nexis Uni. Team members iteratively reviewed each statute to identify components and extract relevant language. Discrepancies were resolved through discussion. Findings were summarized and reviewed with experts in school health, addiction, and harm reduction for validity.

Results

Thirty-eight states have laws on OAs in K-12 schools. Nine states (24%) mandate a supply of OAs to be available in schools, while eight states (21%) require policies to be adopted for school systems to have OAs. State laws vary in terms of components. State laws commonly define OA (n = 24, 63%) and specify school types and/or levels (n = 35, 92%). Most states detail individual(s) who may administer OAs in school settings (n = 34, 89%) and training on OAs (n = 25, 66%). More than half of states detail acquisition (n = 22, 58%) and inventory logistics (n = 21, 55%). Few state laws include incident response post-administration (n = 9, 24%), reporting of administration (n = 8, 21%), and parental involvement (n = 5, 13%). Lastly, most states include immunity (n = 32, 84%) protecting school systems and/or individuals who provide or administer OAs.

Conclusion

This study found most states have laws on OAs in K-12 schools with variation in specific language. Such variability in state legislation contributes to varied implementation in school, which may affect accessibility to OAs and response to overdose emergencies in schools. If implemented effectively, such legislation has potential to promote harm reduction and reduce opioid overdoses among youth.

Background

Over 8.9 million individuals in the United States (US) reported opioid misuse in 2023 [1], including 12% of high school students [2]. This opioid crisis has had detrimental effects on younger populations with overdoses contributing to nearly 85,000 years of life lost and over 700 deaths annually among adolescents [3, 4]. Of these fatalities, males and American Indians/Alaska Natives account for the largest proportions, while rates among non-Hispanic Black, Hispanic, and urban youth have increased in recent years [5]. These statistics signal a critical need for tailored initiatives to support youth.

National guidelines for opioid use disorders (OUDs) among adolescents recommend evidence-based treatments including medications (e.g., buprenorphine, naltrexone, methadone) and clinical counseling [6–8]. Despite established recommendations, youth often do not receive treatment for OUD [9–12]. Factors include stigma, lack of awareness of affected youth, limited clinician preparedness, and high treatment costs [10, 12–14]. Without effective treatment, youth with OUDs face high risk of morbidity and mortality [15].

Given the prevalence of opioid use, along with the proliferation of illicit fentanyl in substances, one important harm reduction strategy is to ensure access to life-saving medication in case of an overdose among youth. Opioid antagonists (OAs), such as naloxone, are medications that are administered to individuals who show signs of an overdose to rapidly counteract the opioid’s effects and prevent fatal outcomes [16]. Naloxone can be administered intravenously by a medical professional. It is also available as an intramuscular injection and a prefilled nasal spray for use in the community and by bystanders [17–20]. Data suggests naloxone has an efficacy of 75–100% for reversing opioid overdoses by non-medical bystanders [21], thus making it an effective tool in reducing opioid overdose fatalities. Naloxone was first approved by the Federal Drug Administration (FDA) in 1971. It was exclusively used in medical settings and later became more broadly available in community-based harm reduction programs [22, 23]. To increase access to naloxone, the nasal form was developed and FDA approved as a prescription in 2015 and then as over-the-counter on March 29, 2023 [24, 25].

Efforts to address the opioid crisis include increasing public access to OAs [26], particularly through medication distribution. Such efforts can help reach people who are at-risk, which technically include all individuals, however specific factors increase the risk, for example substance use history, mental health conditions, and family history. Local harm reduction programs provide naloxone to at-risk individuals in community settings [27], while similar programs have been implemented in healthcare settings (e.g., hospitals, pharmacies) [28–31]. Other initiatives involve placing the medication in public spaces for broader access to at-risk persons and bystanders [32, 33]. Such efforts demonstrate accessible, community-based initiatives can mitigate the impact of the opioid crisis [21, 34], as evident by the recent national decline in overdose fatalities [35].

For youth, schools can serve as venues for harm reduction by having OAs readily available to respond to overdoses [36, 37]. One study of emergency medical services for youth opioid overdoses identified 128 encounters in schools between 2018 and 2022 [38]. Recognizing schools as critical sites for preventing and addressing opioid overdoses among youth, the majority of US states have enacted laws on OAs in Kindergarten to 12th grade schools. While having these laws is important, understanding the landscape of such laws is crucial to ensure broad access to this life-saving medication. The specific content of the laws can influence whether implementation of OAs is optimal in schools and if response to opioid-related emergencies is effective. To our knowledge, there has not been an in-depth analysis of each state’s law related to OAs in schools. To fill this gap, this study examined statutes on OAs in K-12 schools to identify components and determine similarities and differences across states. These findings can help optimize access to OAs, which can prove lifesaving for youth at risk of opioid overdose.

Methods

Study design

This national review analyzed state laws enacted as of December 31, 2024 that related to the access and administration of OAs in Kindergarten-12th grade schools across the United States.

Data collection

The research team (CC, HH, MK, AV) conducted a comprehensive search of state statutes between June 2024 and April 2025 using Nexis Uni, a legal database that provides access to cases and statutes across U.S. jurisdictions [39]. The team used two sets of search terms to identify relevant statutes: "‘opioid’ AND ‘school’" and "‘naloxone’ AND ‘school.’" Statutes were included if they were enacted in one of the 50 states or the District of Columbia by December 31, 2024 and had language pertaining to the use of OAs in schools. States were excluded if they did not address the use of OAs in schools. Identified statutes were cross-referenced and validated against a report from the Legislative Analysis and Public Policy Association [40].

Data analysis

The research team employed content analysis [41, 42] to examine components of the statutes, which are elements and provisions outlined in state laws regarding OA access and administration in K-12 schools. One researcher (CC) initially reviewed statutes of five US states to identify potential components related to OAs in schools, focusing on common language and statute structures. Then, research team members (CC, HH, MK, AV) independently reviewed statutes and met together to iteratively refine the list of components and the definition of each component, leveraging the expertise of team members in the areas of school health and stock medications at school as well as opioid use and opioid antagonists. The result was a framework for data collection, including components and subcomponents along with their definitions. Using this framework, research team members extracted language from all existing legislation and categorized the raw data within identified components. The research team discussed and refined subcomponents based on the language. A final review of the legislation was conducted by the research team. Each step, from identification of statutes to final review of the legislation, was performed by at least two team members. The research team discussed discrepancies at each step and consensus was reached for all discrepancies. Findings were summarized using descriptive statistics. Finally, to support external validity and interpretation, the framework and later the results were reviewed and clarified with a group of experts in school health, addiction, and harm reduction (SC, CD, CF, NG, AL).

Results

As of December 31, 2024, 38 states have statutes on OAs in K-12th grade schools (Fig. 1, Table 1). Of them, 25 (66%) were enacted after FDA approval of naloxone nasal spray as over-the-counter. Few states mandate supply of OAs to be available in schools (n = 9, 24%) or mandate policies (including guidelines or plans for implementation) about OAs to be established for school systems (n = 8, 21%). Across states, the OA-related laws vary in several components: definition of OA, school types and levels, individuals who may administer, training, acquisition, inventory logistics, incident response, reporting, parent/guardian involvement, and immunity (Table 2).

Fig. 1.

United States map depicting states laws on opioid antagonists (OAs) in Kindergarten to 12th grade schools, as of December 31, 2024 (n = 38)

Table 1.

State laws on opioid antagonists (OAs) in Kindergarten to 12th grade schools, as of December 31, 2024 (n = 38)

State—with citation for law	Law effective after FDA approval of over-the-counter naloxone spray	Law mandates supply of OAs in schools	Relevant law mandates policies for OAs in schools
AK—ALASKA STAT. § 14.30.145 (2024)	X	X
AZ—ARIZ. REV. STAT. ANN. § 15-341 (2023*), 36-2267 (2018*)	X		X
AR—A.C.A. § 6-18-723 (2023)	X	X
CA—CAL ED CODE § 49,414.3 (2017), 49,414.8 (2023), CAL BUS & PROF CODE § 4119.8 (2017)	X
CO—C.R.S. 22-1-119.1 (2024*)	X
CT—CONN. GEN. STAT. § 10-212a (2024*)	X		X
FL—FLA. STAT. § 1002.20(3)(o) (2022*)
GA—O.C.G.A. § 20-2-776.5 (2024)	X	X
IL—105 ILCS 5/22-30 (2024*)	X	X
IN—BURNS IND. CODE ANN. § 20-34-4.5-0.2 (2017), 20-34-4.5-0.4 (2023*), 20-34-4.5-0.6 (2020*), 20-34-4.5-0.8 (2017), 20-34-4.5-1 (2023*), 20-34-4.5-1.5 (2017), 20-34-4.5–2 (2017*), 20-34-4.5-3 (2023*), 20-34-4.5-4 (2023*), 20-34-4.5–5 (2017), 20-34-4.5-6 (2017)	X
IA—IOWA CODE § 135.190 (2023*)	X
KS—K.S.A. § 65-16,127 (2024*)	X
KY—KRS § 217.186 (2022*)
LA—LA. R.S. § 17:436.1 (2024*)	X		X
ME—20-A M.R.S. § 6307 (2023*)	X
MD—MD. EDUCATION CODE. ANN. § 7-426.5 (2019*)		X	X
MI—MCLS § 15.671 (2019), 15.673 (2019), 15.675 (2019), 15.677 (2020*), 333.17744b (2019)
MN—MINN. STAT. § 121A.224 (2023)	X	X
MS—MISS. CODE ANN. § 41-29-319 (2024*)	X
MT—20–5-426, MCA (2017)
NE—R.R.S. NEB. § 28-470 (2023*)	X
NV—NEV. REV. STAT. ANN. § 386.865 (2021), 386.870 (2021), 391.291 (2021), 388A.547 (2021), 394.1995 (2021*), 453C.105 (2021), 454.303 (2021), 639.2357 (2021*)
NJ—N.J. STAT. ANN. § 18A:40-12.23 (2018), 18A:40-12.24 (2021*), 18A:40–12.25 (2021*), 18A:40-12.26 (2018), 18A:40-12.27 (2018), S.N. 2082 (2013)		X	X
NM—N.M. STAT. ANN. § 24-23-1 (2016)
NY—N.Y. EDUC. LAW § 922 (2015)
OH—OHIO REV. CODE ANN. §§ 3715.50 (2023)	X
OK—70 OKL. ST. § 1210.242 (2023*)	X
OR—ORS. § 339.869 (2024*), 339.870 (2024*), 339.871 (2023*)	X
RI—R.I. GEN. LAWS ANN. 16-21-35 (2019)		X
SC—S.C. CODE ANN. §59-63-95 (2023*)	X
SD—S.D. CODIFIED LAWS § 13-33A-9 (2019), 13-33A-10 (2019), 13-33A-11 (2019)
TN—TENN. CODE ANN. § 49-50-1604 (2024*), 63-1-157 (2022*), 63-10-217 (2017*)	X		X
TX—TEX. EDUC. CODE § 38.221 (2023), 38.222 (2023), 38.223 (2023), 38.224 (2023), 38.225 (2023), 38.226 (2023), 38.227 (2023), 38.228 (2023)	X		X
UT—UTAH CODE ANN. § 26B-4-512 (2016)
VA—VA. CODE ANN. § 22.1-274.4:1 (2024), 54.1-3408 (2024*)	X		X
WA—WASH. REV. CODE ANN. § 28A.210.390 (2024*), 28A.210.395 (2024*)	X	X
WV—W. VA. CODE ANN. § 18-5-22d (2017)
WI—WIS. STAT. § 118.29 (2023*), 895.478 (2024*)	X
Total	25	9	8
*Year of latest amendment related to OAs in schools

Table 2.

Key components within state laws on opioid antagonists (OAs) in Kindergarten to 12th grade schools, as of December 31, 2024 (n = 38)

States	Definition of OA	School types and levels (n = 35)			Individuals who may administer medication (n = 34)			Training (n = 25)			Acquisition (n = 22)			Inventory logistics (n = 21)				Incident response	Reporting	Parental involvement	Immunity
		Type: public/ charter	Type: nonpublic	Level	School nurse	Other authorized personnel	Any employee	Under external agency purview	Training topic(s)	Training required	Prescription	Dispensing	Funding	Under external agency purview	Storage	Formulation	Inspection
AK	X	X						X	X	X					X						X
AZ		X					X					X									X
AR	X	X		X											X	X			X
CA	X	X	X	X	X	X		X	X	X	X	X	X			X	X	X			X
CO	X	X	X				X		X	X											X
CT	X	X			X	X		X		X				X						X	X
FL		X					X					X			X						X
GA	X	X					X								X			X			X
IL	X	X	X		X		X		X	X	X				X			X	X	X	X
IN	X	X	X		X		X		X	X	X	X			X				X		X
IA	X	X					X				X	X			X						X
KS	X	X			X				X	X											X
KY		X	X			X		X	X	X											X
LA		X	X		X		X			X	X	X						X			X
ME	X	X	X		X	X		X	X	X	X	X
MD		X			X	X							X						X		X
MI	X	X					X			X	X	X									X
MN	X	X						X							X	X
MS	X	X	X				X					X									X
MT	X	X	X		X	X			X	X	X	X			X			X		X	X
NE							X					X									X
NV	X	X	X		X	X			X	X	X	X	X		X			X	X		X
NJ	X	X	X	X	X	X		X	X	X				X							X
NM	X											X									X
NY		X	X				X			X
OH	X														X		X
OK	X	X			X	X		X	X												X
OR		X					X											X		X	X
RI	X	X	X	X	X					X				X	X						X
SC		X	X		X	X		X	X	X	X	X									X
SD		X	X				X		X	X											X
TN		X	X		X	X	X				X	X			X						X
TX	X	X	X	X		X			X	X	X	X	X	X	X	X	X		X		X
UT		X	X										X						X
VA		X		X	X	X		X		X	X			X		X	X				X
WA	X	X			X	X			X	X	X	X	X	X	X	X					X
WV		X	X		X	X		X	X	X				X				X	X	X	X
WI	X	X	X	X		X				X				X				X			X
Total	24	35	20	7	18	16	15	11	17	23	14	17	6	8	15	6	4	9	8	5	32

Definition of OA

More than half the states define OA in their law (n = 24, 63%) with a range in specificity. States commonly use various terms, including general terms (n = 23, 61%; e.g., “opioid antagonist”, “opioid overdose drug”, “opioid antidote”) and drug names (n = 17, 45%; e.g., “Narcan,” “naloxone”, “naloxone hydrochloride”). Sixteen states (42%) incorporate in their definition that the medication is FDA approved. Additionally, most states describe the purpose of the drug and/or its mechanism for reversing opioid overdoses (n = 23, 61%).

School types and levels

For school types, 35 states (92%) regulate public schools (including charter). Twenty states (53%) regulate non-public schools, including private schools (n = 11), parochial schools (n = 2; Kentucky, West Virginia), and tribal schools (n = 1; Wisconsin). Seven states (18%) detail certain school or grade levels in their laws (Table 3).

Table 3.

Detailed information from state laws on opioid antagonists (OAs) in Kindergarten to 12th grade schools, for a subset of components

Component/subcomponent	# states	Details by state
School levels	7
All school levels	1	Rhode Island—all school levels required to maintain OA, including public and private elementary, middle, junior high, and high schools
Elementary and secondary schools	3	California—elementary and secondary schools may decide whether to make OAs available
		Virginia—policies required for the supply and maintenance of OAs in elementary and secondary schools
		Wisconsin—immunity granted to public elementary and secondary schools if injuries arise from OA use
Schools serving adolescents	3	Arkansas—overdose rescue kit required on campus for public high schools
		New Jersey—OA maintenance required in schools with grades 9–12; other schools allowed
		Texas—school districts must adopt and implement OA policy on campuses with 6th-12th grades; may provide policies to other schools
Individuals who may administer—authorized personnel	16
Designated by school system	5	Nevada—charter schools designate staff to administer OAs
		New Jersey—board of education, board of trustees, or chief school administrator must designate staff to administer when school nurse not available
		South Carolina—governing authority of the school district/private school selects designated school personnel
		West Virginia—schools designate and authorize non-medical school personnel to administer OAs
		Wisconsin—employee of public or private school authorized in writing by administrator of school district or board/agency can administer OAs
Designated by school staff	4	Connecticut—school nurse or principal selects school employee to administer OAs
		Maine—school nurse (authorized by licensed physician/school health advisor) selects designated staff to administer OAs when nurse not present
		Nevada—school nurses in public or charter schools designate other staff to administer OAs
		Wisconsin—principal of public, private, or tribal school authorizes school employee to administer OAs
Designated by law	3	Oklahoma—public health nurse, licensed practitioners of healing arts, or contracted nurses authorized to administer OAs
		Tennessee—school resource officers may use supply of OAs to respond to overdose
		Wisconsin—school bus operator may administer OA for suspected overdose
Designated by other entities	3	Kentucky—approval from delegating physician or nurse required for school employees to administer
		Maryland—county board must establish policy authorizing school personnel to administer OAs
		Virginia—school board employee must be authorized by prescriber to administer
Acquisition—standing order	11
State agencies issue standing order	4	Indiana—state health commissioner or designee may issue statewide standing order for stock OAs for schools and school corporations
		Iowa—Chief Medical Officer of Department of Public Health may issue standing order to dispense OAs to person in position to assist
		South Carolina—Director of Public Health for Department of Health and Environmental Control authorized to issue standing order for prescription of OAs on schoolwide basis
		Washington—Secretary of Health or designee may issue standing order prescribing OAs to entity
School responsible for standing order	2	New Jersey—schools with grades 9–12 must obtain standing order for OAs
		Rhode Island—school physicians must prepare standing orders with procedures to respond to overdose in school setting
Prescribers must issue standing order	1	Texas—physicians or other prescribers required to provide school or school district with standing order for the administration of OAs
Standing order may be used to provide OAs to school	3	Iowa—licensed pharmacists may, by standing order, provide OAs to person in position to assist or secondary distributors (school districts)
		Mississippi—practitioner (licensed physician/healthcare provider authorized to prescribe) may by standing order prescribe OA to person at risk of overdose/in a position to assist
		New Mexico—licensed prescriber by standing order may prescribe, dispense or distribute OAs to person at position to assist
Immunity granted if standing order used	1	Kentucky—licensed healthcare provider (including pharmacists) who, by standing order, prescribes or dispenses OAs to person or agency will not be subject to disciplinary or other adverse actions
Authorization to administer OA regardless of standing order	1	Oklahoma—school nurse, public health nurse, licensed practitioner of healing arts, contracted nurse, or any person designated by school administration can administer OA in the event of a suspected overdose regardless of whether standing order in place
Acquisition—dispensing	17
OAs in schools dispensed by licensed health professionals or entities	13	Arizona—pharmacist may dispense, pursuant to standing order, OAs to community member in a position to assist
		Indiana—licensed pharmacists may dispense a valid prescription, drug order, standing order, or protocol for stock OAs for school/school corporation
		Iowa—licensed pharmacists may dispense OAs to school districts
		Louisiana—licensed pharmacists or physicians may dispense OAs maintained in schools
		Michigan—dispensing prescribers or pharmacists may dispense OAs to agency authorized to purchase, possess, and distribute OAs
		Mississippi—pharmacist may dispense OAs under prescription or standing order
		Montana—OA prescription for schools must be filled by a licensed pharmacy
		Nebraska—authorized health professional may dispense OAs to school personnel
		New Mexico—licensed prescriber may directly or by standing order dispense OAs to employee, volunteer, representative of community-based entity providing overdose prevention and education services (including schools)
		South Carolina—licensed pharmacists and physicians may dispense OAs in accordance with prescription issued to school
		Tennessee—licensed pharmacist authorized to dispenses OAs pursuant to a collaborative pharmacy practice agreement in which local education agency can utilize to obtain medication
		Texas—pharmacist may dispense OAs to school district, open-enrollment charter school, private school
		Washington—authorized healthcare practitioner may dispense OAs by prescription, collaborative drug therapy agreement, standing order, protocol to person/entity in a position to assist person at risk
OAs for schools from wholesale distributor or manufacturer	6	California—state agency, department of education, or public school can accept gifts, grants, or donations to support public schools maintaining OAs, including, but not limited to, acceptance of OAs from manufacturer or wholesaler
		Florida—public schools may enter into arrangement with wholesale distributor/manufacturer for OAs at fair-market, free, or reduced prices
		Louisiana—governing authority of public or nonpublic schools may enter into arrangement with manufacturer or supplier to obtain OAs at fair market prices, reduced prices, or no cost
		Maine—school administrative unit or private school may enter into an arrangement with a manufacturer or third-party supplier to obtain OAs at fair market prices, reduced prices, or no cost
		Nevada—public school may accept gifts, grants, or donations from any source including, without limitation, the acceptance of OAs from manufacturer or wholesaler of OAs
		South Carolina—governing authority of school district or private school may enter into arrangements with manufacturers or third-party suppliers to obtain lifesaving medications at fair market prices, reduced prices, or no cost
Acquisition—funding	6
Local funding for schools to acquire OAs	5	California—each fiscal year, $3,500,000 is allocated to county offices of education to purchase and maintain stock OAs for school district or charter school
		Maryland—for fiscal year 2019, $3,000,000 appropriated to award grants to county boards to implement policy authorizing administration of OAs on school property
		Texas—school district, open-enrollment charter school, or private school may accept local funds to implement the maintenance and administration of OAs in schools
		Utah—no later than September 1, 2016 and with available funding, department of Health and Human Services must fund through Opiate Overdose Outreach Pilot program to persons in a position to assist an individual at risk of overdose (including schools)
		Washington—office of the superintendent of public instruction must develop and administer grant program providing funding to public schools to purchase OAs
Federal funding for schools to acquire OAs	1	Texas—school district or open-enrollment charter school or private school may accept federal funds to implement the maintenance and administration of OAs in schools
Acceptance of donations, gifts, or grants for schools to acquire OAs	4	California—state agency, department of education, or public school may accept gifts, grants, donations from any source for support of public school maintaining OAs
		Nevada—public school may accept gifts, grants, or donations from any source
		Texas—school district, open-enrollment charter school, or private school may accept gifts, grants, or donations to maintain and administer OAs in schools
		Washington—OAs in schools may be obtained from donation sources
Inventory logistics—storage	15
OAs in secure location	4	Florida—OA must be maintained in a secure location on the public school’s premises
		Georgia—local school systems or public schools, including charter schools, must acquire and maintain supply of OA in any secure location where individual may have overdose
		Iowa—school district may maintain supply of OAs in secure location at each location where student may be present
		Illinois—school district, public school, charter school, or nonpublic school must maintain supply of OA in any secure location where individual may have overdose
OAs in secure and accessible/unlocked location	4	Montana—OA must be kept in a secure and easily accessible location
		Nevada—OAs in public or private school must be stored in a designated, secure location that is unlocked and easily accessible
		Tennessee—public/nonpublic school authorized to maintain OAs in at least 2 unlocked, secure locations (e.g., school office, school cafeteria)
		Texas—supply of OAs must be stored in a secure location; easily accessible to school personnel, volunteers authorized and trained to administer
OAs in location accessible to school personnel	3	Indiana—school shall store OAs in a safe location; only school employees have access
		Texas—supply of OAs must be stored in a secure location; easily accessible to school personnel, volunteers authorized and trained to administer
		Washington—OAs in first aid kits and coach or sports first aid kits only accessible to school personnel designated to distribute or administer medication
OAs carried by school personnel	4	Arkansas—school nurse and resource officer must always carry OA
		Georgia—school personnel must be authorized to carry OA on person while in school, school-sponsored activity, or school-operated property
		Illinois—school nurse or trained personnel may carry OAs on person while in school or at a school-sponsored activity
		Washington—school nurse or designated trained school personnel may carry supply of school-owned OAs on field trips or sanctioned excursions
OA stored in building	2	Alaska—main school building of each school in the school district has at least 2 doses of OA on site
		Minnesota—each school building must have at least 2 doses of OA available on site
Other guidelines for storage of OAs	4	Arkansas—opioid overdose rescue kit to be located where readily available for public use; located within storage locations containing automated external defibrillator kit for public use
		Ohio—OAs must be stored following manufacturer or distributor instructions, including when distributed in automated mechanisms
		Rhode Island—OAs must be kept in visible, readily available location in schools (e.g. school office, cafeteria) along with measures to ensure the medication will not be compromised
		Washington—public schools encouraged place OAs in first aid kits on school property and in coach or sports first aid kits maintained by public school
Inventory logistics—formulation	6
Type of OA	2	Arkansas—public high school campus has opioid overdose rescue kit labeled “Overdose Rescue Kit—Naloxone Nasal Spray” or other language approved
		Minnesota—each school building must have at least two doses of nasal OA available on site
Quantity of OA	5	California—local education agencies provide 2 units of OA to their middle school, junior high school, and high school
		Minnesota—each school building must have at least 2 doses of nasal OA available on site
		Texas—school district must adopt policy with required number of OAs available at each campus
		Virginia—local school board must develop policy that includes maintenance of at least 2 unexpired doses of OA
		Washington—school district must obtain and maintain at least 1 set of OA doses in public school
Inventory logistics – inspection	4
Processes for monitoring OA supply	4	California—school district, county office of education, or charter school must maintain records of school-based OAs for three years as well as monitor the supply and ensure destruction of expired medication
		Ohio—government entity must establish processes for monitoring, replenishing for automated mechanisms distributing OA
		Texas—executive commissioner of Health and Human Services Commission must establish rules, including process of checking expiration at regular intervals
		Virginia—local school board must establish policy and procedure including schools inspecting OA supply at least annually, maintain records with relevant dates
Reporting—following OA administration	4
Report timing	4	Arkansas—school required to report following the use of an opioid overdose rescue kit
		Illinois—school district, public school, charter school, or nonpublic school must notify health care professional who provided prescription of OA within 24 h after OA administration; school must report to State Board of Education within 3 days after OA administration
		Indiana—school employee or nurse must make a report when stock OA medication administered and submit report to Department of Education no later than 10 days after medication administered
		Texas—school must report about incident no later than later than the 10th business day after the date a school personnel member or volunteer administers OA
Report recipient	4	Arkansas—school resource officer or nurse to report through the Criminal Justice Institute to the office of the Arkansas Drug Director within the Department of Human Services immediately following the use of an opioid overdose rescue kit
		Illinois—school must notify prescribing health care professional 24 h after OA administration; school must report to State Board of Education within 3 days after OA administration
		Indiana—school employee or nurse must make a report when stock OA medication administered and submit report to Department of Education no later than 10 days after medication administered
		Texas—school must report OA use to commissioner of state health services and physician or other person who prescribed OA
Report with specific information	2	Illinois—for the report to State Board of Education, school must provide information on (1) age and type of person who received OA (student, staff, or visitor); (2) location where suspected overdose occurred; (3) type of person who administered OA (school nurse, trained personnel); (4) other information required by State Board
		Texas—schools must report on the following information: (1) age of the person who received OA administration; (2) type of person who received OA administration (student, school personnel member or volunteer, visitor); (3) where medication was administered; (4) number of OA doses administered; (5) type of person who administered OA; and (6) other information required by commissioner of education
Reporting—annual report	4
Report recipient	4	Maryland—each year before or on October 1, public school must submit a report on each incident at the school that required OA use
		Nevada—by 30 days after last day of each school year, school district and charter school must submit report to the Division of Public and Behavioral Health of the Department of Health and Human Services
		Utah—grantees of the Opiate Overdose Outreach Pilot Program (e.g., schools) annually report overdose-related events to Department of Health and Human Services
		West Virginia—county boards of education are required to collect and compile aggregate data events requiring OA administration in county during school year and forward the data to State Superintendent of Schools that prepares annual report for Joint Committee on Government and Finance by December 31 of each year
Report with specific information	2	Nevada—school district and charter school must report number of OA doses administered at each school during school year
		Utah—grantees funded through Opiate Overdose Outreach Pilot Program (e.g., school) must report annually on: (1) amount of OA purchased and dispensed by the grantee during the reporting period; (2) number of individuals to whom the OA was dispensed by the grantee; (3) number of lives saved as a result of OA dispensed by the grantee
Parent/guardian involvement—school-parent engagement required	3
Liability waiver executed by parent/guardian	1	Illinois—parents or guardians of student must sign statement acknowledging that school district, public school, charter school, or nonpublic school and its employees and agents are not liable for injuries from OA administration to student and parents must protect school district, public school, charter school, or nonpublic school and its employees against any claims—both conditions with exception of willful and wanton misconduct
Share information on OA availability in schools	2	Montana—schools that stock OA must inform parents or guardians about potential use of OA for suspected overdose; school must make protocol available if requested
		Oregon—school district must provide to the parent or legal guardian of each minor student information regarding school-based OAs, including (1) description of OAs and their purpose; (2) risks administering to a person OA as well as risks of not administering OA; (3) statement with list of schools with OAs onsite; and (4) statement that school representative may administer OA to student in emergency if student is suspected to be experiencing overdose

Individuals who may administer

Most states (n = 34, 89%) describe in their law who may administer OAs in schools, with variation in the individuals allowed. Approximately half of states (n = 18, 47%) mention school nurses may administer the medication. Kansas and Rhode Island restrict OA administration to only school nurses. Sixteen states (42%) identify other authorized personnel who can administer OAs in schools, including employees designated by the school system (n = 5), school staff (n = 4), law (n = 3), and other entities (n = 3) (Table 3). Less than half of states (n = 15, 39%) allow any employee to administer OAs in schools. Finally, four states allow any person to administer the medication, including three states (Alaska, New Mexico, Virginia) for all cases and one state (Oklahoma) only if the person(s) designated to administer OAs are absent.

Training

In their laws, 25 states (66%) discuss training for schools that stock OAs and/or staff who administer it. Twenty-three states (61%) require school personnel to complete training to administer OAs. For the two states that do not require training, Oklahoma specifies schools can authorize training for school staff, and Utah mentions funds from the Opioid Overdose Outreach Pilot Program can be allocated toward training.

Of the 25 states that discuss training, 17 list specific topics with varied specificity. For example, Kansas requires school nurses to be trained on signs of overdose as well as procedures for OA maintenance, emergency follow-up, and healthcare provider reporting. In contrast, Kentucky provides fewer details, requiring education on the mechanism and reasons for administration.

In 11 states, laws indicate external agencies are responsible for establishing training requirements, programs, and materials for school systems. All 11 states identify health-related entities that are responsible for training (e.g., State Department of Health, Department of Mental Health and Substance Abuse Services, Board of Pharmacy). In three states (New Jersey, South Carolina, West Virginia), education-related entities (e.g., Board of Education, Department of Education) are responsible for training, with consultation from health-related agencies.

Acquisition

Twenty-two states (58%) legislate how schools can acquire OAs, including sources for prescribing, dispensing, funding, and/or distributing. For prescribing, 14 states (37%) mention prescriptions for school systems to acquire OAs; in 11 of them, legislation was enacted after March 29, 2023. Only Montana requires a prescription for the school’s medication. Eleven states mention standing orders—or pre-approved written instructions or protocols by a qualified healthcare provider that authorize particular actions—for schools to obtain OAs (Table 3). For dispensing, 17 states (45%) detail sources where schools can obtain OAs, such as healthcare professionals or entities and/or wholesale distributors or manufacturers (Table 3). Three states (Iowa, Maine, Tennessee) mention practice agreements for healthcare professionals to prescribe and dispense to school systems. Two states indicate the agreement allows pharmacists to dispense OAs to individuals in a position to assist a person at risk of overdose (Tennessee) or to a school district (Iowa). Maine’s law describes a collaborative practice agreement between licensed physician or school health advisor and school nurse for the administration of OAs in schools. With regard to funding, six states (21%) describe funding sources, such as local or federal funds and donations, gifts, or grants, for schools to obtain OAs (Table 3). For distribution, Alaska law requires the Department of Health to provide OAs to school districts, while Mississippi indicates any education employee can obtain medication from the Department of Health via written request.

Inventory logistics

In 21 states (55%), the laws describe inventory logistics for OAs in schools, including storage, formulation, and/or inspection. Eight states (21%) call on external agencies, including health-related (e.g., Department of Health, State Health Officer) and education-related (e.g., Board of Education, Department of Education, cooperative educational service agency) entities, to establish regulations for the inventory of OAs. Specific areas for regulation include maintenance (Texas, Virginia, West Virginia), storage (Connecticut, Virginia, Washington, Wisconsin), types and quantity (New Jersey, Rhode Island), and recordkeeping of administration (Wisconsin). Fifteen state laws (39%) describe storage requirements (e.g. location, carry), six (16%) mention formulation details (e.g., type, quantity), and four (11%) have language regarding inspection of OAs in schools (Table 3).

Incident response

Nine states (24%) describe procedures for schools to follow in response to a suspected overdose. Three states (California, Georgia, Illinois) mandate school systems or staff to activate emergency medical services or 9-1-1 and notify the student’s parent, guardian, or emergency contact. In Nevada, a school district or governing body must adopt policy that mandates seeking emergency assistance and notifying the affected student’s parent/guardian for a suspected drug overdose on school premises. The other five states specify only one of these emergency responses in their law. Three states (Louisiana, Montana, Wisconsin) require schools to contact 9-1-1 or emergency medical services in case of a suspected overdose. Two states (Oregon, West Virginia) require schools to notify parents/guardians of affected students.

Reporting

Eight states (21%) require schools to report OA use in schools. Four states (Arkansas, Illinois, Indiana, Texas) mention reporting following OA administration, with variation based on who, when, and what is reported (Table 3). Also, four states (Maryland, Nevada, Utah, West Virginia) require an annual report to the state on OA use in schools with differences in terms of specific agency and detail (Table 3).

Parent/guardian involvement

Five states (13%) mention parent or guardian involvement related to OA use in schools. Three states (Illinois, Montana, Oregon) mandate schools to engage with parents about school-based OA (Table 3). In contrast, West Virginia specifies schools are not required to give prior notice to parents/guardians about OA administration, and Connecticut allows parents/guardians to request OA not to be administered to their student.

Immunity

Most states (n = 32, 84%) include immunity in their laws, varying on entities protected from civil (n = 11), criminal (n = 1), or both civil and criminal (n = 11) liability for OA use in schools. Of them, 24 states mention school or school district employees are immune from liability. Further, 11 states specifically protect any individual who administers OAs. In addition, 10 states mention school systems (e.g., school, school districts, school boards) are not liable for injury or damage resulting from OA administration. Also, nine states mention other individuals or organizations who are immune, including prescribers (Illinois, Iowa, Louisiana, New Jersey, South Carolina, Tennessee, Washington, Wisconsin), dispensers (New Mexico, South Carolina, Tennessee, Washington), distributors (New Mexico), and training organizations (Louisiana). Finally, of the 32 states that include immunity in their laws, 18 specify exceptions, for example for willful misconduct, recklessness, and/or gross negligence.

Discussion

This study is the first known national review of state statutes on OAs in K-12 schools. Among the 38 states with laws related to OAs in schools, states differed in components mentioned and specificity for each component. Variability in state legislation results in varied implementation in schools, which may affect access to OAs in case of opioid overdose.

This review found nearly 75% of states have laws on OAs in K-12 schools, helping ensure access to potential life-saving medication for youth. Such school-specific laws can be part of broader legislative efforts to enhance OA access in communities, which can reach at-risk adolescents and reduce preventable deaths. It is important to acknowledge that, even without laws in place, schools may still have OAs; however, there may be fewer supports and protections for implementation. In fact, legislative efforts for OAs in schools can prioritize access in schools, provide guidance for successful implementation, and support safer school environments [43, 44], as seen with state laws for undesignated epinephrine and albuterol in schools [43, 45].

In terms of School types and levels, in our study, we found nearly all state laws related to OAs include public schools, however approximately half address non-public schools, which may reflect state-level differences in regulation of education systems. Additionally, less than 20% of states with statutes restrict OAs in schools based on school/grade level, often focusing on adolescents, who have higher rates of opioid-related fatalities than younger children [5, 46]. Notably, fatal opioid overdoses occur across all age groups [47]. Given students, staff, and visitors can be affected, equitable access to life-saving medication can be supported with legislation that ensures availability of OAs to all individuals in all schools across all states, thereby maximizing harm reduction for youth and others affected.

Beyond the presence of OAs in schools, key considerations in the legislation can affect implementation in the school. In terms of Inventory logistics, only six state laws specify the form and quantity of OAs to be supplied in schools. Lack of specificity can provide flexibility to school systems and state entities to decide the optimal form and quantity given local differences in epidemiology and regulations. While both the intranasal and intramuscular forms are equally effective and safe to use [48], the intranasal form is available over-the-counter, can be administered by bystanders, and may be preferred by individuals at-risk of overdose [49, 50]. As such, even though all forms of OAs can be available to schools, intranasal naloxone may be more readily implemented in schools with its ease of use by laypersons. In terms of quantity, data on pediatric accidental overdoses show just over half of affected children clinically improve with one dose of OA [51]. Given a sizeable proportion of overdoses require more than one dose of OA, states should mandate the sufficient supply of OAs in school to ensure at least two doses per affected individual, recognizing more than one person may experience an overdose at any given time.

Further, within Acquisition and Inventory logistics, about half of the states regulate the provision of OAs in schools while fewer regulate storage. For provision of the medication, nearly 40% of states with statutes require obtaining a prescription from healthcare professionals; however, such regulations may be cost-prohibitive for schools and pose administrative burdens, particularly in light of FDA’s approval of intranasal naloxone as over-the-counter. Efforts to stock OAs in schools can be supported by state agencies developing collaborations with dispensers and distributors, as seen in Alaska. Further, state-level funding for OAs may support improved student outcomes, as demonstrated by the success of the RESCUE Illinois Schools Program, a state-funded initiative that provides undesignated albuterol to Illinois schools [52, 53]. Along with provision, medication access can be further supported through storage of OAs in schools. Among the subset of states that regulate storage, most specify OAs are to be placed in locations that are secure or accessible to school personnel. Such regulations decrease medication access to bystanders. Importantly, research shows publicly available OAs empower the public to respond to opioid overdoses [54, 55]. One consideration is to integrate OAs in automatic external defibrillator (AED) kits [56], which mirrors community-based approaches shown to enhance OA access [57, 58]. Lastly, it is important to acknowledge some states may include such detailed information in implementation guidance that is developed post-legislation; however, setting minimum requirements can ensure legislation accomplishes its intended goals to enhance access to OAs. Similarly, when rules or implementation guidance are developed, it is important to have expertise from community-based naloxone distribution experts to share best practices and strategies to meet local needs for harm reduction.

Along with considerations for accessibility of OAs, state laws commonly discuss key components that influence response to overdose-related emergencies in schools, as described in Individuals who may administer and Training. Across states, school nurses and authorized personnel are most often designated to administer OAs. While school nurses are well-equipped to administer medication [59], one-third of K-12 schools do not have a full-time school nurse [60]. Sixteen states identify other authorized personnel to administer OAs, while fewer states allow any employee or person to administer. Such restrictions limit access to potentially life-saving medication. Given literature shows naloxone is bystander-friendly [61–63] and safe [18], state laws should allow anyone to administer OAs in schools. Further, two-thirds of states require training for individuals to administer with differences in topics and content delineated in laws; other states may include specifics on training in codes or implementation guidelines. Studies suggest training leads to increased knowledge and competency to properly respond to opioid overdoses [64]; however, one study demonstrated no differences in successful opioid overdose rescues between trained and untrained bystanders [65]. Additionally, informal trainings and peer education have proven effective to properly respond to overdoses [66, 67]. State laws should ensure information on proper response and OA use is readily available to all persons in schools who interact with students but should not enforce training requirements that may prevent responding to overdoses.

While states commonly address who can administer OAs, in terms of Incident response, Reporting, and Parent/guardian involvement, less than a quarter of states with these statutes describe emergency response and reporting of OA use. Inclusion of these topics in state statutes can help identify specific topics or create particular standards for implementation. Only six states require schools to contact emergency medical services, which is critical as OAs temporarily reverse an overdose [68] and medical observation is necessary [69]. In terms of parent engagement, five states mandate that schools report an overdose incident to a student’s parent/guardian and three states require engaging parents about school-based OAs. These findings may reflect the variation in state laws related to the age of consent for care or that contacting the parent may not always be safe for the student. However, it may be useful for families to be informed about opioid use and overdose among youth and availability of OAs to address incidents in school. Additionally, an informed parent may be in a unique position to ensure their affected child receives OUD treatment, if necessary [70]. In terms of reporting, approximately 20% of states with statutes require schools to report OA use to state education or health agencies. Annual reporting can inform state agencies and legislatures on the implementation of OAs in schools, which can support such harm reduction programs and policies so as to further enhance medication access and use. Additionally, reporting to local health agencies can inform public health responses about emerging trends in the opioid crisis [71]. However, involving any criminal justice agencies, like Arkansas requires reports through the Criminal Justice Institute, can reinforce stigma and criminalization on people with OUD, which may deter individuals from seeking help to avoid penalization [72–74]. Rather than such punitive efforts, state laws should include measures for reporting of OA use in schools to inform legislative and public health efforts focused on substance use and harm reduction.

While state laws have critical measures for schools to respond to the opioid crisis, no state laws include youth in preparation and response to opioid emergencies in schools. Youth are well-informed that the opioid crisis impacts them and their peers [75]. Thus, state laws should incorporate requirements for schools to educate youth on overdose response, as studies demonstrate the benefits of training youth in terms of enhancing knowledge and readiness to respond as well as empowering youth to share their knowledge with others, thereby diffusing awareness among their peers [31, 76]. Not only does such training support response efforts in schools, it can also translate to other settings, including homes where youth overdoses commonly occur [38]. Additionally, state laws should enable youth to carry OAs. Most state laws indicate school staff have access to OAs, while none indicate that students can. There have been national calls for youth to carry OAs [77, 78], including self-carry in schools [36], to help address overdoses. State laws can ensure students have the right to access OAs. Additionally, states can promote other preventative measures in schools that promote harm reduction, including distribution of naloxone and fentanyl strips to students [79, 80]. Such efforts can be critical for schools to prevent fatal overdoses and further promote harm reduction among youth. Finally, involving youth in the development and implementation of legislation for school-based OA access and administration can ensure they represent students’ needs.

For limitations, the study examined state statutes without analyzing administrative code (or regulations), implementation guidelines, case law, or local ordinances that also influence implementation of OAs in schools. Further, statutes may not be implemented as they are written, and potential gaps between legislation and implementation were not examined in this study. Additionally, statutes are subject to amendments, and as such the legislation captured in this study may not be sustained over time. Future research should examine changes in statutes and explore school implementation of OAs to further determine best practices.

Conclusion

This national review identified that most states have enacted legislation to ensure the presence of OAs in schools and detailed key components that influence access to OAs and response to opioid-related emergencies. Variations across these state laws impact their implementation. The adoption of language that consistently includes minimum standards based on best practices and outcomes can help promote equitable access to OAs in schools. The findings generate new insights about the potential of such policies and programs as a harm reduction strategy to enhance access to life-saving medication for youth and foster a prepared school environment in the face of the ongoing opioid crisis, ultimately saving lives.

Abbreviations

OA

Opioid antagonist

OUD

Opioid use disorder

US

United States

Author contributions

MK helped conceptualize and design the study, collected data, analyzed and interpreted data, and wrote first draft of manuscript. CC collected data, analyzed and interpreted data, and wrote first draft of manuscript. HH collected data and analyzed and interpreted data. SCR contributed to the design of the study and interpret data. CD contributed to the design of the study and interpret data. CF contributed to the design of the study and interpret data. NG contributed to the design of the study and interpret data. AL contributed to the design of the study and interpret data. AV conceptualized and designed the study, analyzed and interpreted data. All authors critically revised the manuscript and approved for publication.

Funding

Christina Freibott was supported by the National Institute on Drug Abuse (R36DA060997). Anna Volerman was supported by National Heart, Lung, and Blood Institute (K23HL143128).

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

No applicable.

Competing interests

The authors declare no competing interests.