Digital Repository Masters Projects Spring 2023 A Need for Naloxone in Every School Ann Schultz Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Schultz, A. 2023. A need for naloxone in every school. Weber State University Masters Projects. https://dc.weber.edu/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact scua@weber.edu. WSU REPOSITORY MSN/DNP A Need for Naloxone in Every School Project Title by Ann Schultz Student’s Name A project submitted in partial fulfillment of the requirements for the degree of MASTERS OF NURSING Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, UT 4/02/23 Date Ann Schultz, BSN, RN, MSN student 4/02/23 Student Name, Credentials Date (electronic signature) 4/2/2023 MSN Project Faculty (electronic signature) Date Melissa NeVille Norton (electronic signature) Date DNP, APRN, CPNP-PC, CNE Graduate Programs Director Note: The program director must submit this form and paper. 1 A Need for Naloxone in Every School Ann Schultz, BSN, RN, MSN Student Weber State University Annie Taylor Dee School of Nursing 2 Abstract The United States is experiencing a drug overdose epidemic, evidenced by drug overdose being the leading cause of injury-related death. Furthermore, opioids are a factor in 70% of drug overdoses. Although teen drug use is declining, opioid overdose deaths in teens are drastically increasing due to more dangerous and potent drugs. Naloxone is an opioid antagonist used to reverse the life-threatening effects of an opioid overdose. Because many children and teens spend half of their day at school, there is a risk of drug use while on campus. In addition, schools are responsible for anticipating and managing various emergencies while students and staff are at school. This project aims to increase the availability and training of naloxone in the school setting. Evidence-based information about the benefits of increased access to naloxone help to validate this project's importance and forward the movement of naloxone in schools. Expanding naloxone availability to include elementary, middle, and high schools is a core harm reduction strategy that addresses the opioid epidemic, increases student and staff safety at school, and can prevent tragic outcomes. Keywords: opioid, drug overdose, opioid overdose, naloxone, naloxone in schools 3 A Need for Naloxone in Every School In 2022, The Centers for Disease Control and Prevention identified that drug overdoses are the leading cause of injury-related death in the United States. Opioids are a factor in seven out of every ten overdose deaths. Although federal data from 2021 show a decrease in teen drug use, down 11% in 10th graders, overdose deaths have increased due to more potent and dangerous drugs (National Institute on Drug Abuse, 2022a). Moreover, fatal opioid overdoses among teenagers ages 14 to 18 are rising at an alarming pace, with 1,150 teens who died of a drug overdose in 2021 compared to 490 teens in 2019 (Friedman et al., 2022). Therefore, these startling statistics show a critical need for opioid overdose prevention strategies, education, and training on naloxone administration throughout the community. Opioids are pain management drugs made from opium in a poppy plant or synthesized in a laboratory (World Health Organization, 2021). This substance interacts with opioid receptors in the brain to produce analgesic, sedative, and sometimes euphoric effects. The National Institute of Drug Abuse (2022b) states that opioids are a class of drugs that include pain relievers available by prescription, such as morphine, oxycodone (OxyContin), codeine, hydrocodone (Vicodin), and many others. Other opioids include heroin, an illegal drug, and fentanyl, a synthetic opioid prescribed to treat severe pain and up to one hundred times more potent than morphine (National Institute on Drug Abuse, 2022b). According to the United States Drug Enforcement Administration (n.d), illicitly used fentanyl is often mixed with other illicit drugs or pressed into counterfeit tablets made to look like prescription opioid medications. The potency and method of administration, either by inhalation, ingestion, or injection, can lead to potentially lethal outcomes. Overdose deaths often result from a user knowingly using fentanyl but not 4 knowing it contains a lethal dose or unknowingly using fentanyl when they thought it was heroin or prescription pills. When abused, opioids are highly addictive and can lead to a fatal overdose when too much of the drug is taken, the potency is too strong, or it is combined with other drugs or alcohol. According to the World Health Organization (2021), opioid use can lead to overdose and death because of its effect on the central nervous system, resulting in depression in the respiratory system. An opioid overdose can be identified by pinpoint pupils, unconsciousness/non-responsiveness, and difficulty breathing, such as slowed or stopped breathing. In addition, the Centers for Disease Control and Prevention (2021) report that in 2021, over 70% of overdose deaths involved a prescription opioid, heroin, or synthetic opioids, such as fentanyl. Naloxone is an opioid antagonist designed to reverse opioid overdose rapidly and is a temporary treatment to reverse the deadly respiratory depressive effects of the drug (Centers for Disease Control and Prevention, 2021). In conjunction with a timely emergency response system, naloxone administration has proven to be an effective strategy in preventing overdose in opioid deaths. Therefore, the World Health Organization (2021) recommends that people likely to witness an opioid overdose should have access to naloxone and training in managing an opioid overdose. Drug overdose emergencies can happen anywhere in the community, and it is crucial to have the appropriate supplies and training for immediate response. School nurses are often the first responders to a health emergency in the school setting but are not always in each building. Therefore, school nurses are in the perfect position to provide opioid overdose education and naloxone administration training to school personnel to prepare staff to respond in an emergency. 5 In addition, by incorporating naloxone as part of the emergency plan, school staff will have the tools to provide lifesaving measures to prevent overdose deaths. Statement of Problem The North Thurston Public Schools (NTPS) have received naloxone kits for every school in the district. However, a recently approved policy only provides coverage for storing and administering naloxone in high schools but not elementary and middle schools. Therefore, naloxone cannot be kept at these schools without a policy. NTPS needs a policy that includes naloxone storage and administration in each school building. Furthermore, NTPS would benefit from a training program to educate staff members regarding where naloxone is stored in each school, how to use it, and opioid overdose response management. This MSN project analyzes how implementing naloxone into the emergency response protocol in the K-12 school setting affects the ability of the school personnel to respond to opioid-related drug overdose situations in one school year. Furthermore, this project aims to increase the availability and training of naloxone in the school setting. The goal will be accomplished by creating and incorporating a policy for naloxone in the school emergency plan for each school building in North Thurston Public Schools. In addition, a naloxone training program will be created and distributed to school personnel. These objectives ensure that staff members have the tools and education to provide lifesaving measures to prevent overdose deaths in the school setting. Ways Project Contributes to Intended Recipients Schools are responsible for keeping students and staff safe by anticipating and preparing to respond to various emergencies (National Association of School Nurses, 2020). Implementing naloxone into the emergency preparedness plan will improve the safety of students, staff, and 6 visitors. In addition, this training will benefit the community by increasing the number of lay persons trained to respond to an opioid overdose situation. Overall, this project contributes to preventing overdose deaths and saving lives in schools and the community. Rationale for Importance of Project Over the past decade, drug prevention organizations, such as the Office of National Drug Control Policy (The White House, 2021), have encouraged schools to stock naloxone because they are centralized community points. Schools equipped with naloxone better prepare staff to intervene in an overdose among students, staff, parents, spectators at sporting events, or even pedestrians near campus (Blad, 2022). School districts that allow for k-12 naloxone storage and staff training are examples of a proactive approach to a community problem. In addition, the National Association of School Nurses (2020) states that safe and effective management of opioid-related overdoses must be incorporated into school emergency preparedness and response plans. As a result, school nurses have a crucial role in advocating for naloxone in every school and providing school personnel with training programs on how to respond quickly in drug overdose situations to save lives. Literature Review and Framework Schools are responsible for anticipating and preparing to respond to various emergencies (National Association of School Nurses, 2020). Access to naloxone as part of a school's emergency preparedness will improve opioid overdose response, emergency preparation, and harm reduction (National Association of School Nurses, 2020). This section will review the framework for implementing a naloxone training program in North Thurston Public Schools (NTPS). In addition, a literature review will be performed to gather evidence-based research to analyze the efficacy of this practice change. 7 Framework The Iowa Model is a framework with a problem-solving approach that provides clear and concise steps to guide nurses in designing an evidence-based change, from problem identification to sustaining the change in practice (Chiwaula et al., 2021). This model encourages nurses to challenge current practice because clinically relevant questions can improve healthcare outcomes through the evidence-based practice (EBP) process (Melnyk & Fineout-Overholt, 2019). The first six steps of this model include the following: 1. defining a purpose or problem 2. aligning priorities with stakeholders 3. forming a team 4. gathering and synthesizing evidence 5. implementing EBP 6. evaluating the practice change Next, a pilot study is performed to trial the EBP, and if successful, the EBP is implemented and results disseminated. Furthermore, there are several feedback loops to reassess, redesign, and modify the project based on evaluative data (Melnyk & Fineout-Overholt, 2019). This process ensures the adaption of evidence specific to the practice setting, the patient's needs/preferences, and the promotion of adoption within the healthcare system. This framework creates a pathway for introducing a district-wide naloxone policy and training program in North Thurston Public Schools. The PICOT question has been decided, NTPS stakeholders consisting of the district administration have approved the project, and a team has been formed. After conducting research, a pilot study will be designed and implemented to assess a group of school personnel for naloxone awareness before and after 8 implementing an opioid education and naloxone training program. Following the pilot study, stakeholders will decide on adopting the district-wide naloxone policy/training program, and if approved, the change will be integrated into practice. Finally, an ongoing evaluation will be conducted to assess for modifications and sustainability. Strengths/Limitations The Iowa model has its strengths and limitations. This framework focuses not only on the problem at hand but also on the priority of the problem. Therefore, stakeholders' buy-in is essential at the beginning of this process. If the topic is not a priority to the organization, clinicians must consider another issue or opportunity (Melnyk & Fineout-Overholt, 2019). This step can limit clinicians who see a problem or want to improve workplace practice, but it does not fit the organizational priorities. A strength of this framework is the collaboration of staff members in examining, supporting, and implementing clinically relevant findings. Gathering and synthesizing high-quality research helps to provide sufficient evidence to justify the continuation of the change process. Several feedback loops throughout this process aid the team in making necessary changes and moving forward. However, these feedback loops can also be seen as a limitation because this model is not linear but requires frequent evaluation and the time and willingness to readjust the plan. Clinicians may have to reassemble, redesign, or consider alternatives if there is insufficient evidence to support the practice change or if the pilot study does not produce positive and appropriate results for adopting the change (Melnyk & Fineout-Overholt, 2019). The critical components to successfully implementing an EBP practice change using the Iowa Model are having a clear purpose, sufficient time, quality research, and appropriateness of the practice (Business Bliss Consultants FZE, 2020). 9 Analysis of Literature A review of research was conducted to search for information on the best evidence-based practices for using naloxone in the community. Moreover, the Office of the Surgeon General (2022) states that research indicates that when naloxone and overdose education are available to community members, overdose deaths decrease in those communities. Therefore, increasing naloxone availability in schools is a critical step toward reducing overdose deaths and improving the safety of students and school personnel. Search Strategies A literature search was conducted to identify current evidence. Initial exploration included databases such as Google Scholar, Weber State University's Stewart Library's OneSearch and Advanced Search (which span multiple databases), CINAHL, PubMed, Wiley Online Library, Cochrane Library, and Ovid. Furthermore, only articles from 2017 through 2022 were included in this literature review to keep the information current. Keywords to guide the literature search included naloxone, Narcan, overdose education, naloxone administration, naloxone training, and school nurse. Various Boolean combinations were created with the abovementioned keywords to create a broad search. Several themes were identified throughout the literature search. The first theme is nonmedical bystander administration. This section emphasizes how the layperson can administer naloxone. The second theme discusses how training increases overdose recognition and management. Lastly, the third theme analyzes how school nurses can implement a naloxone training program and the effect that naloxone training can have in the school setting. Non-Medical Bystander Administration 10 Lay administration of naloxone is a safe and effective community-based approach and harm reduction tactic to decrease the opioid overdose epidemic. According to the Legislative Analysis and Public Policy Association (2022), non-medical bystander naloxone administration is increasing due to expanding implementation of Good Samaritan and naloxone access laws throughout the United States. These laws provide legal immunity to laypeople who administer naloxone in good faith. In an umbrella review of systematic reviews, Razaghizad et al. (2021) found consistent and favorable results regarding the effectiveness of naloxone administration by a non-medical bystander (n=2,336 naloxone administrations). Findings concluded that bystander naloxone administration was highly effective, yielding a conservative overdose survival rate of 96.3 percent (95% CI: 95.5, 97.1) with naloxone administration. Additionally, a quasi-experimental study revealed that counties with broad community access to naloxone (greater than 100 naloxone kits per 100,000 population) have an opioid overdose death rate that is 0.88 times lower (95% CI: 0.76, 1.02) than that of counties with less naloxone access (Naumann et al., 2019). Furthermore, a critically appraised qualitative review of eleven studies used thematic analysis to highlight the challenges and advantages of naloxone administration from the perspective of the person using it (Brooker et al., 2019). First, participants detail naloxone administration as an emotional experience, with initial feelings of nervousness and fear before administration. They then describe pride in their capability to save a life after naloxone administration. According to the National Institute on Drug Abuse (2021), statistical modeling suggests that increasing naloxone distribution among laypersons and emergency personnel could prevent 21% of opioid overdose deaths. Moreover, most overdose death reduction would result from increased distribution to laypersons. Training Increases Overdose Recognition and Management 11 Several studies have shown that naloxone training programs effectively improve knowledge around overdose recognition and using naloxone. For example, in a peer-reviewed convenience sample study by Beauchamp (2021) of 196 participants, pre and post-test scores were evaluated with opioid overdose education and naloxone training. Results indicated significantly improved post-test scores after the training program. Furthermore, two studies assessed the effect of overdose education and naloxone distribution programs (OEND) in the community (Razaghizad et al., 2021; Brandt et al., 2021). Findings concluded that OEND programs produce long-term knowledge improvement regarding opioid overdose, improve participants' attitudes toward naloxone, provide sufficient training to manage overdoses safely and effectively, and reduce opioid-related mortality. Two research studies (Kano et al., 2020; Dahlem et al., 2022) used purposive samples of qualitative interviews to assess attitudes and beliefs toward naloxone after participants received training and responded to an opioid overdose. Kano et al. (2020) studied a group of drug users (n=14), and Dahlem et al. (2022) surveyed Law Enforcement Officers (n=14). Both studies found that participants who received overdose education and naloxone training reported improved attitudes and beliefs toward naloxone and experienced feelings of fulfillment after delivering naloxone. The evidence reviewed indicates that naloxone training increases knowledge of overdose recognition and management, bystander confidence in responding to an opioid overdose, and the chances of recovery for the victim. School Nurses Can Implement a Naloxone Training Program School nurses are in an ideal position to incorporate naloxone training into the school emergency response plan and provide opioid education and naloxone training to school personnel. Two peer-reviewed cross-sectional studies were performed on school nurses to assess 12 the availability and administration of naloxone in schools. The first study consisted of a nonrandom sample of 633 school nurses throughout North and South Carolina (Pattison-Sharp et al., 2017), and the second was a convenience study with an online survey sent to school nurses (n=362) throughout Pennsylvania (McDonald et al., 2020). Both studies revealed that school nurses commonly encounter opioids, need increased access to naloxone, and want additional training on opioids for themselves and students. The most common reasons for not having naloxone available included lacking support and the belief that naloxone was unnecessary in their school (Pattison-Sharp et al., 2017). In a peer-reviewed study by Cipriano and Zaric (2018), researchers aimed to assess the cost-effectiveness of equipping high schools with naloxone kits throughout the Toronto School District. Results indicated that, though the naloxone program was relatively inexpensive, it may not be a cost-effective use of resources because of the low risk of opioid overdose in schools. In contrast, McDonald et al. (2020) found that 5.2% of school nurses (n=362) who had a naloxone supply reported that it had been administered in their school or at a school-sponsored activity. NTPS has received two free naloxone kits for each school building, and school nurses will perform mandatory emergency response training at the beginning of the school year. Therefore, there will be no additional costs to NTPS for implementing a naloxone training program. Summary of Literature Review Findings and Application to the Project The literature reviewed the benefits and challenges of increasing access to naloxone, including implementing naloxone into a school emergency protocol. These studies identify a need for increased overdose education and community access to naloxone. The research also suggests that overdose education and naloxone distribution programs increase participant knowledge and willingness to use naloxone in an opioid overdose emergency, increasing victims' 13 survival rates. The expansion of naloxone administration training and use among all groups of community members, including schools, helps to decrease the mortality rate in people using opioids and serves as a safety net to provide access to lifesaving treatment (Pourtaher et al., 2022). By implementing a naloxone training program for staff members, schools can be better prepared for opioid emergencies and serve as an added source for naloxone access in the community. Project Methodology The following section will cover the plan for implementing an opioid education and naloxone training program within NTPS. Several deliverables have been created to aid in the instruction and evaluation of training effectiveness. Moreover, an interdisciplinary team has been created to provide knowledge, review training materials, and continue the project after completion. Finally, feedback from evaluative data will aid in reassessing the project plan for modifications and improvement. Description and Development of Project Deliverables Project deliverables are the resources needed to implement the change process and make a program successful. Audiovisual and printed materials will educate school personnel about the training program. These materials are also meant to aid school nurses in completing yearly emergency preparedness training for staff members. In addition, pre-and post-surveys will be used to assess if school staff has gained value from the education. Together, these resources will ensure that safe and effective management of opioid-related overdoses in schools is incorporated into the school emergency response plans. PowerPoint Presentation 14 To implement an opioid education and naloxone training program at NTPS, a PowerPoint presentation (see Appendix A) has been created to provide training to school staff members. This presentation has been prerecorded and narrated so school personnel can view it conveniently. In addition, each school's nurse will disseminate the presentation via email. The presentation will take approximately ten to fifteen minutes to complete and includes information on the reason for naloxone use, administration instructions, and emergency management of an opioid overdose. The school nurses can also use the slides from the PowerPoint to incorporate naloxone education into the emergency training presentation taught to school faculty at the beginning of each school year. Pre- and Post-Survey A pre-and post-survey (see Appendix B) has been created as an evaluation method to assess the effectiveness of opioid education and naloxone PowerPoint training. The pre-survey assesses the learner's current knowledge and comfort level using naloxone. The post-survey evaluates for increased knowledge about naloxone use and improved confidence with naloxone administration. These surveys will be linked with the PowerPoint presentation in an email with clear instructions to take the pre-survey, watch the presentation, and finish by completing the post-survey. Naloxone Administration Handout NTPS has been gifted naloxone nasal spray kits by the Wellness Division of the Thurston County Public Health and Social Services Department (TCPHSS). These kits have been approved by the NTPS Board of Directors to be placed in each high school building. In addition, an infographic (see Appendix C) has been created to be attached to each naloxone kit. The infographic will include information on recognizing an opioid overdose, three simple steps on 15 naloxone administration, and six steps to managing an opioid overdose. Moreover, this infographic can serve as a checklist for school nurses to use as documentation for completing training for school staff. Plan and Implementation Process Following the Iowa model, the project plan is to use evidence-based research to support the development of a beneficial naloxone training program for school nurses to incorporate into yearly emergency preparedness education for school staff. Additionally, an addendum to the current naloxone policy will be proposed to include elementary and middle schools to store naloxone. Throughout this process, feedback loops will guide modifications based on evaluative data. Additionally, an interdisciplinary team will be created to support developing and expanding the opioid education and naloxone training program. Finally, the program will be presented for review by the NTPS Board of Directors as stakeholder buy-in is the crucial component for the success of the change process. Interdisciplinary Teamwork To begin the overdose education and naloxone training project, a partnership was created with a content expert, a school nurse at NTPS, who will oversee and disseminate training materials. Additionally, there will be support from the Health Educator and Outreach Specialist at TCPHSS, who first introduced the naloxone training program to the school nurses in 2022. This team member will continue to give updated guidance on naloxone training and aid in supplying naloxone for each school building as needed. Furthermore, the NTPS group of school nurses will implement the training for staff members within each school. At the administration level, the NTPS Director of Student Support is the point of contact for the NTPS Board of Directors and legal team. The Director of Student Support will evaluate 16 and submit all training materials and the proposal for an addendum to the current naloxone policy to include an overdose education and naloxone training program in elementary, middle, and high schools. This proposal will need to be reviewed by the NTPS legal team and Board of Directors for consideration of acceptance into school policy. Timeline After reviewing the naloxone training program with the NTPS Director of Student Support, a realistic timeline has been set (see Appendix D). First, the deliverables and an addendum to the naloxone policy will be created and reviewed by the content expert and MSN course advisor for accuracy. Next, the deliverables and policy addendum will be sent to the Director of Student Support for evaluation. Next, she will submit the proposed policy change and deliverables to the NTPS internal legal team and Board of Directors for approval or denial. Finally, with approval, the opioid education and naloxone training program can be implemented into action. Plan for Evaluation of Project Evaluating the opioid education and naloxone training project is essential in the Iowa model to provide feedback for revision and improvement. The pre and post-surveys are a formative method of evaluating the effectiveness of the PowerPoint presentation training. Additionally, the infographic used as documentation for training pass-off will aid school nurses in tracking the amount of staff that have completed the training. Finally, formative feedback will come from a survey sent to the school nurses to evaluate in this training was valuable and beneficial to them (see Appendix E). Ethical Considerations 17 Implementing a district-wide naloxone policy for the safe and effective management of opioid-related overdoses ensures that all students, staff, and visitors have equal access to lifesaving measures. Additionally, this initiative reflects social responsibility by increasing access points to naloxone within the community. The opioid overdose and naloxone training will be offered to all school personnel through email, including a pre-survey, PowerPoint presentation, and post-survey. Staff members can participate in the training; if they choose to take the surveys, they will be taken anonymously. Discussion The following sections will include information on plans for project presentation and dissemination. Next, this section will review how advocacy for naloxone in schools is a strategic solution for a significant community problem that can facilitate school nurses to become active leaders in their communities. Furthermore, the strengths and limitations of the project will be discussed, and recommendations for project continuation and improvement will be made. Evidence-based Solutions for Dissemination Project presentation and dissemination are essential in sharing significant findings and furthering plans for practice change. For this project, a poster format will be used to present findings to peers and faculty at Weber State University in the final semester of the Master of Science in Nursing (MSN) program. Additionally, findings will be disseminated to NTPS school nurses during a professional development meeting. Finally, this opportunity will be used to partner with the healthcare team to review the project plan, policy addendum, and ideas for improvement. Significance to Advance Nursing Practice 18 According to Gallup, Inc. (2023), nurses are the most honest and ethical profession. As school nurses become involved in opioid education and naloxone advocacy, they can have a powerful influence on schools and the community. Offering opioid education and naloxone training in schools helps to bring awareness about the possible addictive and dangerous properties of opioid drugs and ensures that proper emergency planning is performed in case of an opioid overdose at school. In addition, school nurses can become leaders in the community by educating students and families on healthy behaviors, advocating for naloxone use, and effectively planning for and managing emergencies in the school setting (Partnership to End Addiction, 2016). Implications The essential strength of the opioid education and naloxone training program is that it is a strategy led by school nurses to increase awareness about the risks of drug use and gain access to the necessary medication for opioid emergencies. Research by Townsend et al. (2019) indicates that increasing access to naloxone throughout the community can avert 21% of opioid overdose deaths. Furthermore, this project aims to bring the severity of opioid addiction to the forefront of school conversation, improve stigmas related to opioid use, and provide clarity on the Good Samaritan law to decrease hesitancy about naloxone use in an emergency. Lastly, this program is simple and easy to incorporate into emergency preparedness training at each school. The most significant limitation of the project is the approval of naloxone in elementary and middle schools by the NTPS Board of Directors and legal team. This step must happen before deliverables can be disseminated to school personnel. The naloxone policy was first implemented in January of 2022, and reviews occur every other year. The following policy review may not happen until January 2024. Even if the future policy does not allow for naloxone 19 acceptance into elementary and middle schools, this program can be implemented in high schools to assist school nurses with mandatory yearly emergency preparedness training for school staff. Recommendations The next step is to collaborate with NTPS school nurses to discuss the importance of naloxone in every school and push for a policy change that includes approval for elementary and middle schools to carry naloxone. This policy change would ensure equal access to naloxone throughout the school district and fulfill the responsibility of every school to anticipate and prepare to respond to various emergencies. One gap in knowledge to be aware of is the limited data about the incidence of opioid overdoses in schools and the number of schools that carry naloxone. The lack of evidence-based research regarding naloxone in schools is because community naloxone distribution is a new strategy in drug overdose prevention. For further continuation and success of the project, two recommendations are made to improve the opioid education and naloxone training program. First, it is necessary to obtain naloxone trainer devices for each school to allow hands-on training for staff and increase comfort levels with this medication. Second, the project could include a 'Be Drug-Free' program for students appropriate for each grade level. The program would consist of presentations to educate students about the dangers of drug use and how to say no when offered drugs. This early intervention strategy would help to prevent students from starting drug use at a young age. Conclusions Opioid-related overdose deaths among teens are rising alarmingly due to more dangerous and potent drugs. In addition, most children spend nearly half of each day at school, and the school is responsible for keeping them safe while on campus. Therefore, properly managing 20 incidents at school, including drug-related emergencies, leads to positive outcomes and increased student safety. Early access to naloxone is an effective strategy for preventing opioid overdose deaths. By ensuring access to naloxone in each school building and implementing opioid education and naloxone training for staff members, school districts can improve opioid overdose response, reduce the risk of harm to students, and avoid tragic outcomes such as death. 21 References Beauchamp, G. A. (2021, November 23). A study on the efficacy of a naloxone training program. https://www.cureus.com/articles/72343-a-study-on-the-efficacy-of-a-naloxonetraining-program Blad, E. (2022, October 10). Why districts are stocking naloxone in response to the opioid crisis. Education Week. https://www.edweek.org/leadership/why-districts-are-stockingnaloxone-in-response-to-the-opioid-crisis/2022/10 Brandt, L., Yanagida, T., Campbell, A. N. C., Jones, J. D., Schultes, M. T., Martinez, S., & Comer, S. D. (2021, September). Multi-informant implementation and intervention outcomes of opioid overdose education and naloxone distribution in New York City. Global Implementation Research and Applications, 1(3), 209–222. https://doi.org/10.1007/s43477-021-00021-4 Brooker, A. S., & Farrah, K. (2019, December 11). Administration of naloxone in a home or community setting: A rapid qualitative review. Canadian Agency for Drugs and Technologies in Health. https://www.ncbi.nlm.nih.gov/books/NBK554745/ Business Bliss Consultants FZE. (2020, June 9). Applications of the Iowa Model of evidencebased practice. NursingAnswers.net. https://nursinganswers.net/essays/applications-ofthe-iowa-model-of-evidence-based-practice.php Centers for Disease Control and Prevention. (2021, March 8). America's drug overdose epidemic: Putting data to action. U.S. Department of Health and Human Services. https://www.cdc.gov/injury/features/prescription-drug-overdose/index.html Centers for Disease Control and Prevention. (2022, June 2). Opioids. U.S. Department of Health and Human Services. https://www.cdc.gov/opioids/index.html 22 Chiwaula, C. H., Kanjakaya, P., Chipeta, D., Chikatipwa, A., Kalimbuka, T., Zyambo, L., Nkata, S., & Jere, D. L. (2021). Introducing evidence based practice in nursing care delivery, utilizing the Iowa model in intensive care unit at Kamuzu Central Hospital, Malawi. International Journal of Africa Nursing Sciences, 14, 100272. https://doi.org/10.1016/j.ijans.2020.100272 Cipriano, L. E., & Zaric, G. S. (2018). Cost-effectiveness of naloxone kits in secondary schools. Drug and Alcohol Dependence, 192, 352–361. https://doi.org/10.1016/j.drugalcdep.2018.08.003 Dahlem, C. H. G., Granner, J., & Boyd, C. J. (2022, April). Law enforcement perceptions about naloxone training and its effects Post-Overdose reversal. Journal of Addictions Nursing, 33(2), 80–85. https://doi.org/10.1097/jan.0000000000000456 Gallup, Inc. (2023, February 16). Honesty/ethics in professions. Gallup.com. https://news.gallup.com/poll/1654/honesty-ethics-professions.aspx Friedman, J. M. (2022, April 12). Trends in Drug Overdose Deaths Among U.S. Adolescents, January 2010 to June 2021. Adolescent Medicine | JAMA | JAMA Network. https://jamanetwork.com/journals/jama/articleabstract/2790949?guestAccessKey=0ad128b6-7d7c-4319-bbeb51e13d9c4f12&utm_source=For_The_Media&utm_medium=referral&utm_campaign=ft m_links&utm_content=tfl&utm_term=041222 Kano, M., Salvador, J. G., Katzman, W., Sussman, A. L., & Takeda, M. Y. (2020). "You've got to care to carry this stuff" Community implications from take-home naloxone use: A qualitative study. Journal of Substance Abuse Treatment, 115, Article 108030. https://doi.org/10.1016/j.jsat.2020.108030 23 Legislative Analysis and Public Policy Association. (2022, September 22). Naloxone: Summary of state laws. https://legislativeanalysis.org/naloxone-summary-of-state-laws/ Melnyk, B. M., & Fineout-Overholt, E. (2019). Evidence-Based Practice in Nursing & Healthcare: A Guide to Best Practice (Fourth). Wolters Kluwer. McDonald, C. C., Pinto‐Martin, J., Compton, P., Parikh, M., & Meisel, Z. F. (2020). School nurse reported supply and administration of naloxone in schools. Public Health Nursing, 37(3), 347–352. https://doi.org/10.1111/phn.12715 National Association of School Nurses. (2020, June). Naloxone in the school setting. NASN. https://www.nasn.org/nasn-resources/professional-practice-documents/positionstatements/psnaloxone#:%7E:text=NASN%20POSITION%20It%20is%20the%20position%20of%20t he,into%20the%20school%20emergency%20preparedness%20and%20response%20plan s. National Institute on Drug Abuse. (2021, June). Naloxone for opioid overdose: Lifesaving science. https://nida.nih.gov/publications/naloxone-opioid-overdose-life-saving-science National Institute on Drug Abuse. (2022a, June 3). Monitoring the future 2021 survey results. https://nida.nih.gov/research-topics/trends-statistics/infographics/monitoring-future-2021survey-results National Institute on Drug Abuse. (2022b, July 18). Opioids. https://nida.nih.gov/researchtopics/opioids Naumann, R. B., Durrance, C. P., Ranapurwala, S. I., Austin, A. E., Proescholdbell, S., Childs, R., Marshall, S. W., Kansagra, S., & Shanahan, M. E. (2019). Impact of a community- 24 based naloxone distribution program on opioid overdose death rates. Drug and Alcohol Dependence, 204, Article 107536. https://doi.org/10.1016/j.drugalcdep.2019.06.038 NicePNG. (n.d.). Nasal spray. https://www.nicepng.com/ourpic/u2q8t4u2t4a9u2y3_nasal-spraynarcan-nasal-spray-png/ Office of the Surgeon General. (2022, April 8). U.S. Surgeon General's advisory on naloxone and opioid overdose. HHS.gov. https://www.hhs.gov/surgeongeneral/reports-andpublications/addiction-and-substance-misuse/advisory-on-naloxone/index.html Partnership to End Addiction. (2016, January 13). Commentary: Naloxone use in schools: School nurses on the front lines. drugfree.org. https://drugfree.org/drug-and-alcoholnews/commentary-naloxone-use-schools-school-nurses-front-lines/ Pattison-Sharp, E., Estrada, R. D., Elio, A., Prendergast, M., & Carpenter, D. M. (2017). School nurse experiences with prescription opioids in urban and rural schools: A cross-sectional survey. Journal of Addictive Diseases, 36(4), 236–242. https://doi.org/10.1080/10550887.2017.1361725 Pourtaher, E., Payne, E. R., Fera, N., Rowe, K., Leung, S. J., Stancliff, S., Hammer, M., Vinehout, J., & Dailey, M. W. (2022, September 19). Naloxone administration by law enforcement officers in New York State (2015–2020). Harm Reduction Journal, 19(1). https://doi.org/10.1186/s12954-022-00682-w Razaghizad, A., Windle, S. B., Filion, K. B., Gore, G., Kudrina, I., Paraskevopoulos, E., Kimmelman, J., Martel, M. O., & Eisenberg, M. J. (2021). The effect of overdose education and naloxone distribution: An umbrella review of systematic reviews. American Journal of Public Health, 111(8), 1516–1517. https://doi.org/10.2105/ajph.2021.306306a 25 Townsend, T., Blostein, F., Doan, T. T., Madson-Olson, S., Galecki, P., & Hutton, D. W. (2019). Cost-effectiveness analysis of alternative naloxone distribution strategies: First responder and lay distribution in the United States. International Journal of Drug Policy, 75, 102536. https://doi.org/10.1016/j.drugpo.2019.07.031 The White House. (2021, November 17). White House releases state model law to help make access to naloxone consistent across the country. https://www.whitehouse.gov/ondcp/briefing-room/2021/11/17/white-house-releasesstate-model-law-to-help-make-access-to-naloxone-consistent-across-the-country/ United States Drug Enforcement Administration. (n.d.). Facts about fentanyl. DEA. Retrieved September 25, 2022, from https://www.dea.gov/resources/facts-about-fentanyl World Health Organization (WHO). (2021, August 4). Opioid overdose. https://www.who.int/news-room/fact-sheets/detail/opioidoverdose#:%7E:text=WHO%20recommends%20that%20naloxone%20be%20made%20a vailable%20to,on%20airway%20management%2C%20assisting%20ventilation%20and %20administering%20naloxone 26 Appendix A PowerPoint Presentation https://youtu.be/c5zr1GdXV3k 27 28 29 30 31 32 33 34 35 36 Appendix B Surveys Naloxone (Narcan) Pre-test https://www.surveymonkey.com/r/Z2ZLQ2R 1. Do you know what Narcan is used for? o Yes o No 2. List three symptoms of an opioid overdose. 1. _________________ 2. _________________ 3. _____________________ 3. Do you know how to use Narcan? o Yes o No 4. How comfortable and confident do you feel using Narcan in an emergency? o Not confident o Somewhat confident o Very confident 5. Do you know where Narcan is located in your building? o Yes o No 6. What do you want to learn about Narcan during this presentation? 37 Naloxone (Narcan) Post-Test https://www.surveymonkey.com/r/Q38G9ZG 1. Do you know what Narcan is used for? o Yes o No 2. List three symptoms of an opioid overdose. 1. _________________ 2. _________________ 3. _____________________ 3. Do you know how to use Narcan? o Yes o No 4. How comfortable and confident do you feel using Narcan in an emergency? o Not confident o Somewhat confident o Very confident 5. Do you know where Narcan is located in your building? o Yes o No 6. What did you learn about Narcan during this presentation? 38 Appendix C Naloxone (Narcan) Administration Handout 39 Appendix D Timeline 40 Appendix E School Nurse Evaluation https://www.surveymonkey.com/r/Q3RFSWM 1. Was the PowerPoint presentation helpful in teaching your school personnel about Narcan? o Yes o No 2. Were you able to use any of the PowerPoint slides in your annual emergency preparedness training? o Yes o No 3. Was the Narcan PowerPoint presentation helpful to you? o Yes o No 4. Did you include Narcan training in your emergency training for school personnel? o Yes o No 5. Were you able to include the Narcan administration handout with each Narcan kit? o Yes o No