National Association of School Nurses Position Statement: Opioid Overdose Reversal Medication (Naloxone) and Care in the School Setting

It is the position of the National Association of School Nurses (NASN) that all students, as well as any person on school grounds, should have equitable access to safe and effective emergency overdose-reversal medication and care if an opioid overdose occurs in the school setting. As school health leaders and collaborators, the registered professional school nurse (hereinafter referred to as school nurse) contributes expertise that is necessary for the development and implementation of emergency preparedness and response procedures and evidence-based harm reduction training, protocols, policies, and interventions for opioid overdose care. These efforts include ensuring the availability of lifesaving naloxone in every school.

Naloxone, a medication that reverses the effects of an opioid overdose, saves lives by restoring breathing. In 2023, The U.S. Food and Drug Administration gave nationwide approval for nonprescription naloxone nasal spray, also known by brand names such as Narcan^® or RiVive^®. The nasal spray form of naloxone is available over-the-counter (OTC) for use in the emergency treatment of a known or suspected opioid overdose. Other forms of naloxone with higher doses or different delivery systems are available by prescription only (National Institute on Drug Abuse [NIDA], 2022).

In 2023, the White House Office of National Drug Control Policy Director and U.S. Secretary of Education jointly disseminated an official letter to educators stating that every school in the United States should maintain a supply of naloxone. In addition, this letter strongly advised that both school staff and students should be prepared to administer the lifesaving medication, in the event of a suspected overdose in school (Cardona & Gupta, 2023). The Federal Substance Abuse and Mental Health Services Administration (SAMHSA, 2023) has also recommended that every school, including elementary schools, should have naloxone readily available on-site to reduce overdose fatalities. Though schools may choose which form(s) of naloxone to use, school nursing knowledge is vital to guide medication administration decision-making.

While each state determines its own legislative and regulatory policies pertaining to medication administration and school nursing services in schools, all states have some form of law regarding access to naloxone (Legislative Analysis and Public Policy Association [LAPPA], 2022). It is critical that states respond to calls from federal agencies to provide naloxone in schools. School nurses have the skills to provide and oversee emergency medication and treatments using albuterol inhalers, epinephrine, glucagon, and automated external defibrillators. Adding access to naloxone in schools is one more way to protect students and members of the school community from a life-threatening condition (McDonald et al., 2020).

Any person, with or without training, may administer OTC naloxone nasal spray according to directions on the package labeling (FDA, 2023; SAMHSA, 2023). However, the presence of a school nurse in every school all day is the best practice for the safe management and oversight of medication administration in school, whether the medication is prescription or OTC (Butler et al., 2020; Lowe et al., 2022). Additionally, school nurses can offer valuable education that helps staff and students recognize the signs of a potential opioid overdose and familiarizes individuals with proper naloxone administration procedures. As a part of overdose response training, school nurses can emphasize the need for essential actions to call 911 for transport to an emergency department and to deliver rescue breaths for abnormal or absent respirations (LAPPA, 2021).

All local educational agencies should have written emergency operations plans to address suspected opioid overdose, as part of emergency preparedness and response protocols, procedures, and policies. School nurses are key contributors to the evidence-based development of this harm reduction planning (Readiness and Emergency Management for Schools [REMS] Technical Assistance [TA] Center, 2023). If within state parameters, policies may allow students to carry and administer overdose-reversal medications in school. School nurses can provide regular policy reviews and recommendations for revisions consistent with evolving scientific, medical, and public health developments. In collaboration with other professionals, school nurses can also advocate for preventive and restorative multi-tiered levels of student support and care coordination that protect the health, well-being, and best interests of students while reducing stigma surrounding substance use disorders (LAPPA, 2023). School nurses may contribute de-identified data to state and national reporting systems or a registry to collect, track, analyze, disseminate, and translate information about the incidences and outcomes of naloxone administration in schools. These statistics could inform research regarding the effectiveness of naloxone access as an intervention in school settings (King, 2024; McDonald et al., 2020).

School nursing expertise and collaboration are crucial for planning, coordinating, and implementing evidence-based emergency preparedness and response actions and essential healthcare for opioid overdose. These interventions include ensuring the availability and access to naloxone in every school to protect the lives of each student and member of the school community.