Should NC schools carry overdose reversal drug?
Posted June 2, 2016
Carrboro, N.C. — The call came over the radio. A student in the lunchroom at Carrboro High School. On the floor. Not breathing. The school nurse ran to the cafeteria. So did the school resource officer, Sgt. Grant Mayfield.
"The student’s laying face up and starting to turn blue at that point," Mayfield recalled. "It’s the scariest thing I’ve ever seen."
Emergency responders were on their way, but Mayfield and the nurse needed to do something. They prepared to give the student rescue breaths.
"You’re just sinking, looking at this student, trying to figure out, ‘OK, what to do next?’" Mayfield said.
The student had overdosed on opioids, a drug that comes in the form of heroin or prescription pain relievers, such as OxyContin, Percocet and Vicodin.
One of the fastest ways to help someone who is having an overdose is to give a medicine called naloxone, also known as Narcan. It comes in a nasal spray or injection and can help the person start breathing again.
Mayfield didn't have the medication. Neither did the school nurse.
School nurse: This topic 'is hot right now'
As opioid overdoses continue to spike across the country, education leaders and health experts in North Carolina and beyond are beginning to consider some important questions: Should schools carry naloxone? How can they get access to the drug? Who would be trained to administer it? How much does it cost?
At Carrboro High School, Sgt. Mayfield said he has seen two students overdose on opioids in the four years he has worked as the school's resource officer. Both students survived, including the student who stopped breathing and turned blue on the lunchroom floor three years ago.
If the same situation happened today, Mayfield would react differently. He now carries an emergency kit with naloxone nasal spray, which he keeps in his office at Carrboro High. He has had it since October 2014, when the Carrboro Police Department began carrying it.
Mayfield is one of the few school resource officers in the state who carry the drug.
Carrboro High and nearby McDougle Middle in Chapel Hill are the only two schools WRAL News could find in the state that have the drug on hand. At both schools, the resource officers are the only ones who have access to the nasal spray and are trained to use it.
Mayfield estimates he could assemble the nasal spray kit in 10 to 15 seconds and get the drug inside a student's nostrils long before emergency crews arrive.
"Knowing that I'm the only one in this school that has it, to save those extra few minutes if needed, I like that," Mayfield said. "My school principal is all for it. She's very happy that we have it. The school nurse ... she was ecstatic about it because they don't even have access to this, which is kind of surprising to me."
School nurses in North Carolina have been discussing whether they should have access to the drug and be trained to use it. The topic came up at the School Nurse Association of North Carolina's executive board meeting in Raleigh two weeks ago.
"This was one of the topics that is hot right now," said SNANC President Laura Marino.
Marino predicts that the drug could be available in all North Carolina public schools by the end of 2016. But how that could happen is unclear. Marino says she would rely on guidance from the state's school nurse consultant, Ann Nichols.
The North Carolina Department of Public Instruction has not taken a stance on the topic of naloxone in schools. Agency leaders say they also rely on Nichols, the state school nurse consultant, for guidance. But what kind of guidance she might give is unknown.
WRAL News was unable to speak with Nichols. Her employer, the North Carolina Department of Health and Human Services, declined multiple requests to interview her and said all questions must be sent to the agency's communications office.
"If the Department of Public Instruction pursues providing or maintaining Narcan in schools, the Division of Public Health is happy to serve in an advisory role," DHHS spokeswoman Alex Lefebvre wrote in an emailed response to WRAL. "However, DPI is the most appropriate agency for you to speak with about providing or maintaining Narcan in schools."
DPI referred questions back to the Department of Health.
CDC: 'Opioid overdose epidemic is worsening'
It's unclear how many students overdose on opioids in North Carolina public schools each year. The state Department of Health and Human Services collects data on student injuries and other medical emergencies and reports the findings in its Annual School Health Services Report.
However, the latest report available on DHHS' website is from the 2012-13 school year. It shows public schools reported 130 drug overdoses that year requiring some kind of emergency or other medical care. The report does not detail what kinds of drugs the students took or what schools or districts the students attended.
A spokeswoman for DHHS said it is not uncommon for the agency to be several years behind on reports due to the magnitude of data the agency handles. She said the latest Annual School Health Services reports from 2013-14 and 2014-15 are being worked on and will be released sometime this summer.
Since 2000, the U.S. has seen a 200 percent increase in the rate of overdose deaths involving opioid pain relievers and heroin, according to the Centers for Disease Control and Prevention. A January report from the agency found that the "opioid overdose epidemic is worsening" and that "there is a need for continued action to prevent opioid abuse, dependence and death."
In North Carolina, nearly 10,000 people died from opiate poisoning deaths from 1999 to 2014, according to DHHS.
The number one sign of an overdose is unresponsiveness, according to the North Carolina Harm Reduction Coalition, a nonprofit that has been working to increase awareness about opioid overdoses. Other signs include not breathing, turning blue, deep snoring, vomiting, gasping and gurgling.
The coalition has given away more than 27,000 emergency kits of naloxone to homeless shelters, law enforcement officers, drug users, parents of drug users and others since 2013, according to Tessie Castillo, NC Harm's advocacy and communications coordinator. The kits have helped reverse more than 3,000 overdoses in the state.
NC Harm began offering the drug after the state passed a Good Samaritan law in 2013, which encourages people to seek medical help for an overdose, grants civil and criminal immunity to anyone who administers naloxone in good faith and allows community-based organizations to distribute the drug through a special prescription, or standing order, from a doctor.
Demand for the drug has been so high that NC Harm has had trouble keeping it on the shelves. The group has not worked with any public schools, but Castillo said they "absolutely" support having the drug in schools.
"I'm not sure giving it to nurses at the schools is the best way. Data says the people most likely to use (naloxone) are users themselves and their peers," she said. "You'd be better off giving it to kids and peers, but the more the merrier. We'd never be against giving it to anyone."
One of the reasons NC Harm and others are open to more people having access to naloxone is that it only works if a person has opioids in their system. If the drug is mistakenly given to someone experiencing a different kind of medical emergency, it will have no effect, according to the group.
NC Harm purchases naloxone from Adapt Pharma, an Ireland-based drug company that has offices in Pennsylvania. The company made news earlier this year after it offered to give two free doses of its Narcan Nasal Spray to every high school in the U.S.
So far, North Carolina has not taken the company up on its offer. However, an Adapt Pharma spokesman said seven to 10 school districts in the state have contacted the company to ask about the drug. He declined to identify the school districts, saying releasing that information would be a violation of HIPAA, the federal law that protects the privacy and security of health information.
"Some schools have asked, 'How do I do this? How do I get it operationalized?'" said Thom Duddy, Adapt Pharma's executive director of communications.
The company has delivered about 1,800 doses of Narcan Nasal Spray to schools around the country since the drug became commercially available in February. Duddy says the company is currently working with schools in five states – Kentucky, New Hampshire, Ohio, Pennsylvania and West Virginia.
School nurse: I'd rather have a violent student than a dead one
One of the questions school nurses and others have asked is how schools can get access to naloxone. Among the health experts, nurses, school officials and others WRAL News spoke with, opinions differ about how to do that.
Some say the State Board of Education or local school boards would need to write a policy allowing schools to carry the drug. Others say new legislation would need to be passed, similar to the state's EpiPen law in 2014, which requires public schools to have emergency epinephrine auto-injectors in each school.
Adapt Pharma, the drug company offering two free doses of naloxone to all U.S. high schools, says schools simply need to get a doctor to write a prescription for the drug for all students in the district. Once the company receives the prescription, it will ship the drug to the schools.
Jay Campbell, executive director of the North Carolina Board of Pharmacy, said he does not know of any state pharmacy laws that would prevent schools from getting the drug.
"I'm not aware of any impediment of having a school nurse getting a prescription," he said. "I’m not aware of any legal barrier to that."
The North Carolina General Assembly has been talking about the legality of naloxone recently but not specifically in regards to schools.
Lawmakers are considering a proposal that would make North Carolina the third state in the nation with a standing order for naloxone. That means it would be available to anyone who asks for it at a pharmacy, using a standing statewide prescription by the state health director.
The bill passed in the Senate with a 49-0 vote and will go to the House for debate. Only Maryland and Pennsylvania have similar statewide orders.
While lawmakers and others debate how easy it should be to get the drug, Linda Joseph, nurse coordinator for Chapel Hill-Carrboro City Schools, says she and other school nurses are waiting to see if they will be allowed to carry the drug.
"I had a discussion with our liaison (at DHHS), and she said that's an option coming down the road for us. (But) we haven't gone down the road any further," Joseph said. "We're sitting on the fence at the moment."
Joseph worries that the drug will be given to school nurses without the proper training and support.
One concern is that people who receive naloxone are sometimes known to "wake up in 'fight or flight' mode where they may become combative," according to NC Harm. However, that only happens in about 8 percent of patients and is especially rare if the drug is administered by someone they know and trust, according to the group.
"You would have to have something in place, a protocol, so the nurse is safe to give it," Joseph said.
But not all schools have a full-time nurse. That means principals, teachers or others may need to be trained to give the drug to students.
"I totally agree with having any kind of emergency medication, especially Narcan," said Laura Marino, president of the School Nurse Association of North Carolina. "(But) the biggest concern is adding something else to our schools for nonmedical people to perform. Is it needed? Yes. But that is definitely a big concern."
One thing Marino isn't as worried about is how students may react to the drug.
"I'd rather have an angry, violent student than a dead one," she said.