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Introduction

Illicit drug use and opioid overdose deaths are a public health crisis that is beginning to bleed into the school systems. In 2022, 1 out of 10 eighth graders reported using an illegal substance in the past year, with 1 out of 5 tenth graders and 1 out of 3 seniors (1). Due to these increasing numbers, every school nurse needs to recognize the signs of illicit drug use, understand what steps should be taken in the event of an opioid overdose, determine how to promote prevention programs for students, and understand how vital feeling connected to staff and peers is to an adolescent.  

Defining the Issue

While most youth in the U.S. are in good health, their behaviors at and around school can lead to poor outcomes in their present and future. The CDC defines high-risk substance abuse as any use by an adolescent of substances with a high risk of adverse outcomes such as loss of life, injury, school dropout, or criminal justice involvement (5). These can include but are not limited to the use of illicit drugs (i.e., heroin, cocaine, methamphetamine, hallucinogens, ecstasy, or inhalants), the use of injection drugs, and the misuse of prescription drugs (5). While adolescents are known to partake in different types of illicit substances, this article will focus more on the use of illegal drugs such as opioids, the vital role the school nurse plays in the prevention of the use of these drugs, and the recognition and treatment of an opioid overdose as this could be most fatal in the school system.  

Epidemiology

Illicit drug use in adolescents is hazardous and concerning. Illegal drug use among adolescents decreased between 2020-2021, and in 2022 most of the reported substance use among adolescents had held steady at these lowered levels (20). The lower levels of illicit drug use could be from school closures and the effects of social distancing from the COVID-19 pandemic. Unfortunately, while on the lower end, illegal drug use is still occurring at unsafe levels amongst our youth here in the U.S., and as nurses, we need to be constantly concerned and on alert.

Around 14% of adolescent students reported the misuse of prescription opioids (5), and these habits can be linked to promiscuous sexual behaviors, the experience of violence, as well as suicide and mental health risks (5). In addition, the use of illicit drugs, particularly opioids, has the potential to lead to overdose and possible death. From 2019 to 2021, overdose deaths among individuals from the ages of 14-18 increased (6). The deaths involving illicitly manufactured fentanyls (IMFs) increased by 182%. 90% of these deaths included opioids, 25% included counterfeit pills, and 84% involved IMFs (6). The increase in overdose deaths in adolescents comes from increases in dangerous drug use and not from most students using illicit drugs (13). A majority of pre-teen and adolescent drug overdoses are preventable and should not end in the loss of life.  

Etiology

Brain growth and development, particularly during adolescence, have been studied and reviewed. One area of the brain that is still developing during adolescence is the prefrontal cortex. This area allows one to assess situations, make decisions, and keep emotions and desires under control (8). Because this area of the brain is still developing, it places adolescents at an increased risk of trying drugs and continuing them (8).   

Substance use during one’s adolescent years has the potential to create several long-term adverse effects. It has been discovered through the CDC’s research that the majority of adults who met the criteria for having a substance abuse disorder (SUD) started misusing substances and illicit drugs during their teen and young adult years (5). The risk factors for illegal drug use in adolescents are multifactorial, and the risk factors can be split into the following four categories;  

Family risk factors 

• Parental drug/alcohol abuse 
• Intrauterine exposure to drugs/alcohol  
• Conflict in the parental marriage 
• Disturbed family environment/family dysfunction 
• Favorable parental attitudes toward high-risk behavior 
• Substance use among siblings 
• Negative life events  
• Poor parenting, including but not limited to rejection, lack of warmth, lack of consistent discipline, and child abuse/maltreatment.  

Individual risk factors 

• Difficult temperament/inflexibility, depression, and withdrawal 
• Early aggressive behavior 
• Motor, language, and cognitive impairments  
• Poor social and problem-solving skills 
• Sensation seeking behaviors 
• Lack of self-control 
• Attention deficit hyperactivity disorder (ADHD) 
• Poor impulse control, impulsivity, poor concentration 
• Tobacco use, cannabis use 
• Poor grades/achievements/school failure/low commitment to school  
• Low self-esteem, perceived incompetence 

Peer risk factors 

• Deviant peer group 
• Peer attitudes towards drugs 
• Attending college 
• Social adversity 
• Substance-using peers 
• Decrease in social support accompanying entity into a new social setting  

Community risk factors  

• Laws and norms favorable toward alcohol and drug abuse  
• Poverty 
• Urban settings 
• Availability and access to alcohol  
• Community/school violence (3)(5).  

Additionally, mental health concerns can exacerbate one’s risk factor for using illicit drugs. It has been theorized that individuals with certain mental health illnesses use illegal drugs to treat their mental health illnesses (12). Those who have had experience with trauma may resort to using illicit substances to block out the trauma. Recognizing risk factors in adolescent students is very important to determine which students may be at risk for engaging in illegal drug use behavior. ​

Pathophysiology

It is well known that drugs have adverse effects on the brain and the body. However, these effects can be exaggerated and even more dangerous for adolescents. Drugs can interfere with how neurons in the brain process, send, and receive signals via chemical messengers called neurotransmitters. Some drugs, such as marijuana or heroin, can stimulate neurons because their chemical structure is models that of a natural neurotransmitter within the body. The drugs can then connect to and initiate the neurons, sending unusual messages through the brain’s pathways (21). Additionally, other drugs, such as cocaine and amphetamines, can amplify the regular communication between neurons by releasing abnormally large amounts of natural transmitters. (21).  

The areas of the brain affected by drugs include but are not limited to;  

• The Basal ganglia 
• The extended amygdala 
• The prefrontal cortex 

As mentioned before, one of the areas of the brain affected by drugs is the prefrontal cortex. This area commands the ability to think, solve problems, plan, make decisions, and exert self-control over impulses. This area of the brain is also the last one to mature, thereby making teenagers the most vulnerable to developing an addiction to illicit substances (20). It is important as nurses to remember just how important it is to educate our students and their families on the dangers of illegal drug use, especially in these formative years.  

Signs and Symptoms  

Different signs and symptoms can occur when an adolescent partakes in the use of illicit drugs. The earliest signs can be a change in mannerisms and behavior. Additional signs include frequent change of friends, withdrawal from family bonding, violent or unusually impaired sense of judgment, slurring of speech, and limited and unusually talkative (2).  

An opioid overdose occurs once someone has taken too much of an opioid. If an individual has taken an opioid such as fentanyl, they are at a higher risk for a life-threatening overdose due to the potency of the drug (9). There are several risks for an opioid overdose, which include: 

• Mixing opioids with other substances like benzodiazepines or alcohol 
• Using opioids after a break in use due to a decreased tolerance 
• Taking too many opioids  
• Additional health conditions 
• A previous overdose 
• Using opioids that a pharmacy did not prescribe 
• Using opioids alone (9)
  

An individual who uses opioids or illicit drugs may experience non-life-threatening effects or life-threatening effects. Non-life-threatening effects include nausea, vomiting, and sleepiness (9). Life-threatening impacts that could lead to death include infrequent or absent breathing, slowed or irregular heartbeat, no response to stimuli, and severe allergic reactions (9).  

Several body systems require rapid assessment in the event of a suspected opioid overdose. The most important include breathing and responsiveness (9).  

In the event of an opioid high, it is still critical to assess the student’s respiratory and neurologic status first (9). 

Role of school nurses and staff in early identification 

As mentioned previously, all staff need to be educated on how to handle a potential opioid use or overdose event. School nurses need to receive continuous training on how to recognize and treat an opioid overdose. Depending on available resources, this can be accomplished locally within school districts or even at the state level.  

Actions to take for a student overdose

An essential aspect of treating an opioid overdose is educating the nursing staff in the case of a potential opioid overdose within the school setting. Multiple school districts across the United States have developed guidelines for what to do in a suspected opioid overdose situation. One such resource is available to all districts in New York, and the New York State Center for School Health provides the following guidelines (16). Every school district should have policies similar to these to ensure all staff know how to handle a potential overdose situation.  

Recognize the signs of Opioid Overdose:

• Unresponsive/minimally responsive 
• Slow breathing (<10/minute) or not breathing, snoring with gurgling 
• Limp body 
• Pale skin 
• Lips and fingertips are cyanotic 

What to do for a suspected overdose:

• Assess the person for signs of overdose (see above) 
• Stimulate the victim by shaking, shouting, performing sternal rub
  
• Call 911 (EMS) 
• Activate the School Emergency response (including AED).  
• Notify the 911 operator that the “student is not breathing.” 
• Provide CPR/rescue breaths if needed 
• For an unresponsive victim, GIVE NALOXONE (explained in the next section) 
• Turn the person on their side (recovery position) 
• Monitor and support the individual until EMS arrives 
• Naloxone can be given again in 2-3 minutes if needed. (Be sure to communicate and report the times and frequency of Naloxone to EMS staff) 

If a student is suspected of being under any influence of opioids, EMS should still be contacted. While the student may not be displaying signs of an overdose, they need to be taken to the hospital to be monitored. The nurse should remain with the student and continuously assess their breathing and responsiveness. The nurse should attempt to keep the student awake until EMS arrives (9).  

Intervention Strategies

Naloxone Use 

One of the most essential things that can be done during an opioid overdose is to focus on the patient’s breathing and airway. Naloxone (Narcan) is an opioid antagonist that works by temporarily reversing the respiratory effects of opioids (11). If this medication is administered quickly, it can restore breathing to an individual who is currently experiencing an opioid overdose (11).  

If a state and school allow Naloxone, the typical medication administration form will be intranasal. According to the makers of intranasal Naloxone, the following graphic shows the steps to follow for administration (17).  

Figure 1.

If Naloxone is administered, ensure that EMS has also been contacted and is en route. Continuously monitor the student for improved signs of breathing. If the student does not demonstrate improved signs of breathing after 2-3 minutes, another dose should be administered. If the student stops breathing, CPR should be immediately started and maintained until EMS arrives and takes over (17).  

Figure 1.  

Note: A graphic from the naloxone website detailing the administration instructions. Obtained from Resources for using Narcan® (naloxone hcl) nasal spray. For Using NARCAN® (naloxone HCl) Nasal Spray. (n.d.). https://narcan.com/resources  

If Naloxone is administered, ensure that EMS has also been contacted and is en route. Continuously monitor the student for improved signs of breathing. If the student does not demonstrate improved signs of breathing after 2-3 minutes, another dose should be administered. If the student stops breathing, CPR should be immediately started and maintained until EMS arrives and takes over (17).  

Future of Naloxone in Schools

The National Association of School Nurses (NASN) adopted a position on naloxone use in schools. They believe that when emergencies occur in a school, proper management, preparedness, and response plans must be in place to achieve positive outcomes. 

The NASN echoes the science of why Naloxone is essential and how it contributes to reversing respiratory distress caused by opioids. The organization further states that every school nurse should know the legal implications of using Naloxone. “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” (11).  

Across the country, numerous school districts enact policies and guidelines for using Naloxone in schools. One such state is Washington. SB 5380 was passed in 2019, requiring school districts with 2,000 or more students to have Naloxone at each high school (19). Additionally, WA state mandated for the 2020-21 school year that their school districts adopt an opioid-related overdose policy (14). The guidelines for these districts require that policies and training requirements include information on the identification of overdose symptoms, how to obtain opioid reversal medication on school property, how to attain these medications through donations, the administration and distribution of opioid reversal medication by specifically trained school personnel, free training resources that meet training requirements and sample standing orders for the reversal medication (14).  

Furthermore, other states across the country are beginning to join in the fight against opioid overdose deaths in adolescents. The following graphic exemplifies which states require some or all of their schools to have Naloxone, while the other part shows which states have laws that explicitly allow for Naloxone use in schools (18).  

Figure 2.

Prevention Programs

School nurses need to be aware of prevention strategies to assist in directing adolescents away from illicit substance abuse. The school environment has distinctive advantages for implementing intervention plans. In addition, equipment and human resources can be utilized to provide adolescents with different intervention measures. However, An important aspect to remember is that adolescents are in different educational and developmental stages, so measures should be tailored and focused (10). A scoping review published in 2023 recommends five categories of interventions that may be helpful to implement in school systems to prevent illicit substance abuse. All of these studies showed a decrease in alcohol use, tobacco use, illegal drug use, or all 3 (10). They are as follows;  

Cognitive-behavioral skill enhancement 

Examples include weekly lessons on social and emotional training, interventions based on culture conducted through 10 detailed lessons entailing cultural resilience, and a standard care and classroom education program. 

Exercise interventions 

Examples included yoga to decrease smoking habits, education programs centered on team collaboration by gender, including interactive classroom sessions, exercise training, and combining exercise with an interactive CD-ROM to adapt exercise plans for students to implement independently.  

Peer interventions and Family school cooperation 

Examples include 20 sessions of life skills training led by experienced students and teachers, motivational interviewing performed by therapists to parents and students, and the “Amplifying Our Futures” program, which identifies adolescents at risk for substance abuse and pairs them with a young adult mentor in recovery.  

Electronic interventions  

Examples include watching videos and public service announcements (PSAs) about alcohol, cannabis, and tobacco, internet-based intervention plans, and adopting alcohol media literacy programs to reduce the chance of substance-use-related advertisements having effects on this population.  

The U.S. Department of Education has taken a stance on how schools can help prevent adolescent substance misuse while creating supportive learning environments (15). These include but are not limited to;  

• School leaders, staff, and teachers can generate safe environments and positive student cultures.  
• Evidence-based prevention programs can be provided in school settings.  
• Schools can be prepared if a drug poisoning or overdose occurs on campus. 
• Districts and schools can collaborate with students in recovery and students whose family members are experiencing addiction  

Educational Resources

Every school nurse should have resources available in the local community, statewide, and nationwide to offer to other school nurses, staff, parents, and students to decrease illicit drug use. The following educational resources are available for all school nurses (13);  

Table 1.

Fostering Connectedness in School

The Centers for Disease Control and Prevention (CDC) encourages fostering connectedness in schools to improve students’ health and learning. The CDC defines school connectedness as when students feel that peers and adults in their school care about their education and them as individuals (7). Suppose students believe that the adults and peers in their school care about them and their learning; they are more likely to have positive health and academic outlooks. This can lead to a decrease in violence, sexual health risk, poor mental health, and substance use (7). The school systems can increase school connectedness through classroom management, LGBTQ+ inclusive practices, and positive youth development practices (4). Allowing students to feel heard and cared for can make all the difference in their decisions to partake in dangerous and fatal behaviors.   

Conclusion  

Illicit drug use is on the rise in adolescents, and school nurses can make a positive difference in the prevention of drug use, detection of high-risk students, and treatment in the event of an opioid overdose. The school nurse needs to understand that illicit drug use stems from multiple risk factors present in the life of an adolescent student. Whether it is a student’s home life, mental health, or brain development, these factors all play an essential role in how a student copes. Ensuring students feel connected with staff and peers is a great way to motivate and foster positive health and academic outlooks.   

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