Existing law authorizes school districts, county offices of education, and charter schools to provide emergency naloxone hydrochloride or another opioid antagonist to school nurses or voluntary trained personnel, and authorizes those nurses and voluntary trained personnel to use naloxone hydrochloride or another opioid antagonist to provide emergency medical aid to persons suffering, or reasonably believed to be suffering, from an opioid overdose, as provided.

This bill would require each individual public school operated by a school district, county office of education, or charter school that has elected to make a school nurse or trained personnel available at the school pursuant to those provisions to maintain at least two doses units of naloxone hydrochloride or another opioid antagonist for purposes of those authorizations. By imposing additional duties on public schools, the bill would impose a state-mandated local program.

Existing law authorizes school districts, county offices of education, and charter schools to provide emergency naloxone hydrochloride or another opioid antagonist to school nurses or voluntary trained personnel, and authorizes those nurses and voluntary trained personnel to use naloxone hydrochloride or another opioid antagonist to provide emergency medical aid to persons suffering, or reasonably believed to be suffering, from an opioid overdose, as provided.

This bill would require each individual public school operated by a school district, county office of education, or charter school to maintain at least two doses of naloxone hydrochloride or another opioid antagonist for purposes of those authorizations. By imposing additional duties on public schools, the bill would impose a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that, if the Commission on State Mandates determines that the bill contains costs mandated by the state, reimbursement for those costs shall be made pursuant to the statutory provisions noted above.

Existing law authorizes school districts, county offices of education, and charter schools to provide emergency naloxone hydrochloride or another opioid antagonist to school nurses or voluntary trained personnel, and authorizes those nurses and voluntary trained personnel to use naloxone hydrochloride or another opioid antagonist to provide emergency medical aid to persons suffering, or reasonably believed to be suffering, from an opioid overdose, as provided.

This bill would require each individual public school operated by a school district, county office of education, or charter school to maintain at least two doses of naloxone hydrochloride or another opioid antagonist for purposes of those authorizations. By imposing additional duties on public schools, the bill would impose a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that, if the Commission on State Mandates determines that the bill contains costs mandated by the state, reimbursement for those costs shall be made pursuant to the statutory provisions noted above.

SENATE COMMITTEE ON

Senator Anthony Portantino, Chair

2023 - 2024 Regular Session

AB 19 (Joe Patterson) - Pupil health: opioid antagonists

Bill Summary:

This bill requires each school that has elected to make a school nurse or trained personnel available to maintain at least two doses units of naloxone hydrochloride or another opioid antagonist on its campus.

Fiscal Impact:

By requiring schools to maintain at least two doses of naloxone hydrochloride or another opioid antagonist on their campuses, this bill could result in ongoing Proposition 98 General Fund costs in the hundreds of thousands to low millions of dollars each year. This estimate assumes a cost of $47.50 per dose but could be less to the extent that doses are not used. Opioid reversal medication typically has a shelf life of two to three years. To the extent that the Commission on State Mandates determines the bill’s requirements to be a higher level of service, there could be cost pressure on the K-12 Mandate Block Grant.

Background:

Existing law permits a school nurse or trained personnel who have volunteered to provide emergency naloxone hydrochloride or another opioid antagonist, by nasal spray or by auto-injector, to persons suffering, or reasonably believed to be suffering, from an opioid overdose.

Existing law provides a school no more than two weeks to restock their supply of naloxone hydrochloride or another opioid antagonist after use. It also requires an LEA electing to utilize naloxone hydrochloride or another opioid antagonist for emergency aid to ensure that each employee who volunteers are provided defense and indemnification for any and all civil liability. This information shall be reduced to writing, provided to the volunteer, and retained in the volunteer’s personnel file.

Proposed Law:

This bill requires each school that has elected to make a school nurse or trained personnel available to maintain at least two doses units of naloxone hydrochloride or another opioid antagonist on its campus.

Related Legislation:

SB 234 (Portantino, 2023) would require public school, institutions of higher education, stadiums, concert venues, and amusement parks to maintain unexpired doses of naloxone hydrochloride or any other opioid antagonist on its premises. This bill is pending in the Assembly Health Committee.

SB 472 (Hurtado, 2023) would require each public school to maintain at least two doses of naloxone hydrochloride on its campus. This bill was held on the Suspense File in this Committee.

Staff Comments:

SB 114 (Committee on Budget and Fiscal Review, 2023), the education trailer bill, proposes $3.5 million in ongoing Proposition 98 General Fund to county offices of education to distribute opioid antagonists, with the intent that it complement efforts of the Naloxone Distribution Project.

-- END --

SENATE COMMITTEE ON EDUCATION

Senator Josh Newman, Chair

2023 - 2024 Regular

Bill No: Hearing Date: June 21, 2023

Subject: .

SUMMARY

This bill requires each public school operated by a local educational agency (LEA), county office of education (COE), or charter school to maintain at least two doses of naloxone hydrochloride (naloxone) or another opioid antagonist on its campus.

BACKGROUND

Existing Law:

Education Code (EC)

1. Permits school nurses or trained personnel who have volunteered to provide emergency naloxone or another opioid antagonist, by nasal spray or by auto-injector, to persons suffering, or reasonably believed to be suffering, from an opioid overdose. (EC § 49414.3(a))
2. Requires the Superintendent of Public Instruction (SPI) to establish and revise, every five years or sooner, minimum training standards for administering naloxone or another opioid antagonist as specified. The California Department of Education (CDE) shall maintain a clearinghouse for best practices in training nonmedical personnel to administer naloxone or another opioid antagonist to pupils. (EC § 49414.3(e))
3. Requires an LEA, COE, or charter school electing to utilize naloxone or another opioid antagonist for emergency aid to ensure that each employee who volunteers is provided defense and indemnification by the LEA, COE, or charter school for any civil liability. This information shall be reduced to writing, provided to the volunteer, and retained in the volunteer’s personnel file. (EC 49414.3(i))
4. Provides a school with no more than two weeks to restock their supply of naloxone hydrochloride or another opioid antagonist after use. (EC § 49414.3(h))
5. If a school district, charter school, or private school elects to offer an athletic program, the school district, charter school, or private school shall annually give the Opioid Factsheet for Patients published by the Centers for Disease Control and Prevention to each athlete. The athlete and, if the athlete is 17 years of age or younger, the athlete’s parent or guardian shall sign a document acknowledging receipt of the Opioid Factsheet for Patients and return that document to the school district, charter school, or private school before the athlete initiates practice or competition. The Opioid Factsheet for Patients may be sent and returned through an electronic medium, including, but not limited to, fax or email. (EC § 49476)
6. Requires each LEA and COE to be responsible for the overall development of all comprehensive school safety plans for its schools operating in kindergarten or any grades 1 through 12. (EC § 32281(a))
7. Specifies that the school site council or safety planning committee is responsible for developing the comprehensive school safety plan. (EC § 32281(b))
8. Specifies that the comprehensive school safety plan must include an assessment of the current status of school crime committed on school campuses and at school-related functions and identification of appropriate strategies and programs to provide or maintain a high level of school safety and address the school’s procedures for complying with existing laws related to school safety, including child abuse reporting procedures; disaster procedures; an earthquake emergency procedure system; policies regarding pupils who commit specified acts that would lead to suspension or expulsion; procedures to notify teachers of dangerous pupils; a discrimination and harassment policy; the provisions of any schoolwide dress code; procedures for safe ingress and egress of pupils, parents, and school employees to and from school; a safe and orderly environment conducive to learning; and rules and procedures on school discipline. (EC § 32282(a))
9. Requires the comprehensive school safety plan to be evaluated at least once a year. (EC § 32282(d))

Civil Code (CIV)

1. Permits a licensed health care provider who is authorized by law to prescribe an opioid antagonist may issue standing orders for the distribution of an opioid antagonist to a person at risk of an opioid-related overdose or to a family member, friend, or another person in a position to assist a person at risk of an opioid-related overdose. (CIV § 1747.22(c))

ANALYSIS

This bill requires each public school operated by an LEA, COE, or charter school to maintain at least two doses of naloxone or another opioid antagonist on its campus.

STAFF COMMENTS

1. Need for the bill. According to the author,” Until my neighbor, high school teen Zach Didier, lost his life to Fentanyl, I had no idea how kids were getting their hands on this poison. Zach ingested a pill of what he believed to be Percocet. As a father of four children, I can't imagine having to experience what my neighbor went through which is why I am authoring Assembly Bill 19. According to the California Department of Education in 2012, California suffered 82 tragic deaths attributed to fentanyl overdoses, and last year that number jumped to more than 6,000. Fentanyl deaths accounted for more than 80 percent of all drug-related deaths among California’s young people in 202. AB 19 is part of my three-pronged approach to helping solve the Fentanyl crisis - accountability, education, and safety. This measure is about safety. It is time we take the initiative to have simple and proven preventative care available to schools where our kids spend a majority of their time. Fentanyl is being disguised as candy and is readily available in every community - why aren't we putting this on every campus? I was pleased to hear that the Governor has set aside $3.5 million in Prop 98 to fund this program for all middle and high school sites to maintain naloxone on campus, which answers any questions about funding for Assembly Bill 19. I am proud that this is a bipartisanship issue having the governor, Democrats, and Republicans recognize this policy will save children's lives.”
2. Governor’s Proposed Budget. The Governor’s budget proposes $3.5 million ongoing for all middle and high school sites to maintain at least two doses of naloxone or another medication to reverse an opioid overdose on campus for emergency aid and an additional $79 million to the Naloxone Distribution Project (NDP).
3. Addressing Fentanyl Among California Youth. According to the California Department of Public Health (CDPH), fentanyl-related overdose deaths increased 625 percent among ages 10-19 from 2018 to 2020. In 2021, there were 224 fentanyl-related overdose deaths among teens ages 15–19 in California. Pursuant to AB 1748 (Mayes) Chapter 55, Statutes of 2016, among other things, the SPI must establish minimum training standards for school employees who volunteer to administer naloxone or another opioid antagonist. In addition to setting minimum training standards, the CDE must maintain on its website a clearinghouse for best practices in training nonmedical personnel to administer naloxone or another opioid antagonist to pupils. 

In conjunction with the CDPH, the CDE provides LEAs with resources and information that they can readily share with parents and students to help keep them safe. The shareable Fentanyl Awareness and Prevention toolkit page offer information about the risks of fentanyl and how to prevent teen use and overdoses. In addition to the toolkit, the CDPH’s Substance and Addiction Prevention branch provides resources for parents, guardians, caretakers, educators, schools, and youth-serving providers.

LEAs and COEs have also adjusted to address this growing crisis. For example, the Lake County Office of Education and Washington Unified School District in West Sacramento recently implemented a local school naloxone policy consistent with state statutes. San Diego Unified School District created its naloxone toolkit to aid other LEAs and inform parents and guardians.

This bill would require each public school operated by an LEA, COE, or charter school to maintain at least two doses of naloxone or another opioid antagonist on its campus.

1. Statewide Standing Order for Naloxone. Naloxone can help reduce opioid overdose deaths in California, but many organizations find it challenging to obtain the required standing order to get naloxone from healthcare providers. According to CDPH, of the 6,843 opioid-related overdose deaths in 2021, 5,722 were related to fentanyl. CDPH issued the standing order in 2017 to address this need and support equitable naloxone access. The standing order:
   
   1. Allow community organizations and other entities in California that are not currently working with a physician to distribute naloxone to a person at risk of an opioid-related overdose or to a family member, friend, or another person in a position to assist; and
   2. Allow for the administration of naloxone by a family member, friend, or other person to a person experiencing or reasonably suspected of experiencing an opioid overdose.

Among the organizations and entities that can distribute naloxone under the order are colleges and universities. An individual at risk of experiencing an overdose or someone who can assist an individual at risk is allowed to do so. Under the statewide standing order, staff of community organizations and other entities distributing naloxone must be trained. They are also required to provide training to individuals who receive naloxone from them. Colleges and other organizations may apply to use the statewide standing order if they meet certain conditions.

A separate distribution program administered through The Department of Health Care Services (DHCS) allows universities and colleges to apply for and obtain naloxone at no cost to the institution. According to the CDPH website, since October 2018, their NDP has distributed over 1 million units of naloxone and recorded over 57,000 overdose reversals.

According to the DHCS website, schools are eligible entities that may receive naloxone through the NDP.

1. Health Education Framework. The health education standards shape the direction of health education instruction for children and youths in California’s public schools: they provide LEAs with fundamental tools for developing health education curricula and improving student attainment in this area, and they help ensure that all students in kindergarten through high school receive high-quality health education instruction, providing students with the knowledge, skills, and confidence to lead healthy lives. Health education has undergone a paradigm shift over the last 15 years. Data from national and state surveys, including the California Healthy Kids Survey, indicated that although youths knew what was harmful to their health, they did not have the skills to avoid risky behaviors. To ensure students not only knew about the harms of drugs, alcohol, and tobacco but also learned how to prevent and recognize these behaviors, the State Board of Education adopted a revised health education curriculum in 2019. The framework aims to achieve the following goals through different grades.
2. Kindergarten
   1. Ability to explain why medicines are used and why they can be helpful or harmful.
   2. Recognize that medicines should be taken only under the supervision of a trusted adult, that some household products are harmful if ingested or inhaled, and that tobacco smoke is detrimental to health and should be avoided.
3. Grade 2
   1. Distinguish between helpful and harmful substances (including alcohol, tobacco, and other drugs).
   2. Explain why household products are harmful if ingested or inhaled; that a drug is a chemical that changes how the body and brain work; why it is dangerous to taste, swallow, sniff, or play with unknown substances; why it is essential to follow the medical recommendations for prescription and nonprescription medicines.
   3. Identify rules for taking medicine at school and home and refusal skills when confronted or pressured to use alcohol, tobacco, or other drugs.
4. Grade 4
   1. Describe the harmful short- and long-term effects of alcohol, tobacco, and other drugs, including inhalants.
   2. Explain the differences between medicines and illicit drugs and why individual reactions to alcohol and drug use may vary.
   3. Identify family and school rules about alcohol, tobacco, and drug use; ways to cope with situations involving alcohol, tobacco, and other drugs.
5. Grade 6
   1. Explain short- and long-term effects of alcohol, tobacco, inhalant, and other drug use, including social, legal, and economic implications; the dangers of secondhand smoke; the stages of drug dependence and addiction and the effects of drugs on the adolescent brain.
   2. Identify positive alternatives to alcohol, tobacco, and other drug use; the benefits of a tobacco-free environment; and the effects of alcohol, tobacco, and other drug use on physical activity, including athletic performance.
   3. Differentiate between the use and misuse of prescription and nonprescription medicines.
6. Grades 7-8
   1. Describe the harmful short- and long-term effects of alcohol, tobacco, and other drugs, including steroids, performance-enhancing drugs, and inhalants; the relationship between using alcohol, tobacco, and other drugs and engaging in other risky behaviors; the consequences of using alcohol, tobacco, and other drugs during pregnancy, including fetal alcohol spectrum disorders.
   2. Explain the dangers of drug dependence and addiction; the short- and long-term consequences of using alcohol and other drugs to cope with problems; why most youths do not use alcohol, tobacco, or other drugs; school policies and community laws related to the use, possession, and sale of alcohol, tobacco, and illegal drugs.
   3. Analyze the harmful effects of using diet pills without physician supervision.
7. Grades 9-12
   1. Describe the health benefits of abstaining from or discontinuing alcohol, tobacco, and other drugs; the use and abuse of prescription and nonprescription medicines and illegal substances.
   2. Explain the impact of alcohol, tobacco, and other drug use on brain chemistry, brain function, and behavior; the connection between alcohol and tobacco use and the risk of oral cancer; the impact of alcohol and other drug use on vehicle crashes, injuries, violence, and risky sexual behavior.
   3. Identify the social and legal implications of using and abusing alcohol, tobacco, and other drugs.
   4. Analyze the consequences for the mother and child of using alcohol, tobacco, and other drugs during pregnancy—including fetal alcohol spectrum disorders and other birth defects; the effects of binge drinking and its relationship to cancer; to liver, pancreatic, and cardiovascular diseases; and a variety of gastrointestinal problems, neurological disorders, and reproductive system disorders.
   5. Clarify myths regarding the scope of alcohol, tobacco, and other drug use among adolescents.
8. Committee Amendment. The committee recommends, and the author has agreed to the following amendment:
9. Requires each school that has elected to make a school nurse or trained personnel available at the school pursuant to this section shall maintain at least two doses units of naloxone hydrochloride or another opioid antagonist on its campus, rather than all schools.
10. Related Legislation

SB 234 (Portantino, 2023) would require schools kindergarten to 12 grade, institutions of higher education, stadiums, concert venues, and amusement parks, at all times, to maintain unexpired doses of naloxone hydrochloride or any other opioid antagonist on its premise, ensure that at least two employees are aware of the location of the naloxone or other opioid antagonist, and expand community colleges ability to administer naloxone. SB 234 also provides civil protections to a person who administers naloxone or another opioid antagonist on a college campus stadium, concert venue, or amusement park to a person who appears to be experiencing an opioid overdose. This bill is currently in Assembly Education Committee.

AB 1748 (Mayes) Chapter 557, Statutes of 2016, authorizes LEAs to provide an emergency opioid antagonist to school nurses or trained personnel and authorizes a school nurse or trained personnel to administer an opioid antagonist to a person suffering from an opioid overdose.

AB 899 (Joe Patterson, 2023) requires LEAs to annually inform the parents or guardians of each enrolled pupil of the dangers associated with synthetic drugs that are not prescribed by a physician, such as fentanyl. This bill is currently in Senate Education Committee.

SB 472 (Hurtado, 2023) would require each campus of a public school operated by an LEA, COE, or charter school to maintain at least two doses on its campus, and distribute, naloxone or another opioid antagonist pursuant to the standing order for naloxone and requires LEAs, COEs, and charter school to report to the DHCS for failure to distribute naloxone. This bill was held in Senate Appropriations.

SUPPORT

California Academy of Family Physicians

California Association of School Business Officials

California District Attorneys Association

California Teachers Association

Emergency Nurses Association, California State Council

Health Officers Association of California

Los Angeles County Office of Education

San Diego County District Attorney's Office

Steinberg Institute

OPPOSITION

None received

-- END --

ASSEMBLY THIRD READING

ATR Bill Id:AB 19

Author:(Joe Patterson, et al.)

As Amended Ver:February 27, 2023

Majority vote

SUMMARY

Requires public schools to maintain at least two doses of naloxone hydrochloride or another opioid antagonist to provide emergency medical aid to a person suffering from an opioid overdose.

Major Provisions

1. Requires each individual public school operated by a school district, county office of education (COE), or charter school, to maintain at least two doses of naloxone hydrochloride or another opioid antagonist to provide emergency medical aid to a person suffering from an opioid overdose.

COMMENTS

Current law authorizes, but does not require, schools to stock and administer opioid antagonists. This bill would require each school in a school district, COE, or charter school to maintain at least two doses of naloxone hydrochloride or equivalent on its campus for use, as prescribed by current law.

Addressing Fentanyl Among California Youth. According to the California Department of Public Health (CDPH), fentanyl-related overdose deaths increased 625% among ages 10-19 from 2018 to 2020. In 2021, there were 224 fentanyl-related overdose deaths among teens ages 15–19 years old in California. Current law requires the SPI to establish minimum training standards for school employees who volunteer to administer naloxone or another opioid antagonist. In addition to setting minimum training standards, the CDE must maintain on its website a clearinghouse for best practices in training nonmedical personnel to administer naloxone or another opioid antagonist to pupils.

The CDE, in conjunction with the CDPH, provide LEAs with resources and information that they can readily share with parents and students to help keep them safe. The Fentanyl Awareness and Prevention toolkit page offers information about the risks of fentanyl and how to prevent teen use and overdoses. In addition to the toolkit, the CDPH's Substance and Addiction Prevention branch also provides resources for parents, guardians, caretakers, educators, schools, and youth-serving providers.

Governor's Proposed Budget. Currently, the Governor's budget proposes $97 million in new investments to tackle the fentanyl and opioid crisis, including $3.5 million for all middle and high school sites to maintain at least two doses of naloxone hydrochloride or another medication to reverse an opioid overdose on campus for emergency aid. The proposal also includes $79 million to the Naloxone Distribution Project, $10 million in grants for education, testing, recovery, and support services, as well as $4 million to make test strips more widely available.

According to the Author

"Until my neighbor, high school teen Zach Didier, lost his life to Fentanyl, I had no idea how kids were getting their hands on this poison. Zach ingested a pill of what he believed to be Percocet. As a father of four children, I can't imagine having to experience what my neighbor went through which is why I am authoring Assembly Bill 19. According to the CDE in 2012, California suffered 82 tragic deaths attributed to fentanyl overdoses, and last year that number jumped to more than 6,000. Fentanyl deaths accounted for more than 80% of all drug-related deaths among California's young people in 2021. AB 19 is part of my three-pronged approach to helping solve the Fentanyl crisis - accountability, education, and safety. This measure is about safety.

It is time we take the initiative to have simple and proven preventative care available to schools where our kids spend a majority of their time. Fentanyl is being disguised as candy and is readily available in every community - why aren't we putting this on every campus? I was pleased to hear that the Governor has set aside $3.5 million in Prop 98 to fund this program for all middle and high school sites to maintain naloxone on campus, which answers any questions about funding for Assembly Bill 19. I am proud that this is a bipartisanship issue having the governor, Democrats, and Republicans recognize this policy will save children's lives."

Arguments in Support

According to the Los Angeles COE, "With the rapid increase in the prevalence of fentanyl abuse and poisonings amongst teenagers, schools are not properly equipped to save the life of a child suffering from the effects of fentanyl. The Los Angeles Times reported in September 2022 that seven teenagers, including a fifteen-year-old, died from overdosing on pills possibly containing fentanyl. That same month, a school administrator in Bakersfield was sent to the hospital due to exposure of counterfeit prescription pills containing fentanyl.

Fentanyl overdoses accounted for more than 80% of all drug-related deaths among California's young people in 2021. More than 770 Californians under the age of 24 died of fentanyl overdoses last year, a 21-fold increase since 2016. The access to opioids and drugs such as fentanyl is too easily available and to not have a standing state law that requires K-12 schools to have the preventives easily available is a concern.

While some K-12 schools have opted to offer this inexpensive life-saving medication, most still do not provide Naloxone on campus. AB 19 would require K-12 schools to have naloxone as a lifesaving measure on campus for students experiencing an opioid overdose. This bill ensures that our schools are prepared for the potential of an opioid overdose, which is becoming more common as fentanyl is flooding into California and doses have been made to look like prescription drugs and even candy."

Arguments in Opposition

None on file

FISCAL COMMENTS

According to the Assembly Appropriations Committee:

1. Ongoing Proposition 98 General Fund costs of about $1.1 million annually for each public school to maintain at least two doses of naloxone hydrochloride or another opioid antagonist on its campus.
2. This estimate assumes a cost of $47.50 per dose and 11,000 public schools. It also assumes all doses are used annually. Costs could be less to the extent doses are not used, as opioid reversal medication typically has a shelf life of around two to three years. In addition, costs could be higher or lower, because Narcan, the most widely used opioid antagonist, was very recently approved for over-the-counter use and sale, which could affect its price.
3. If the Commission on State Mandates determines the bill's requirements to be a reimbursable state mandate, the state would need to reimburse these costs to LEAs or provide funding through the K-12 Mandate Block Grant.

VOTES

ASM EDUCATION: 7-0-0

YES: Muratsuchi, Megan Dahle, Juan Carrillo, Hoover, Lee, McCarty, Quirk-Silva

ASM APPROPRIATIONS: 15-0-1

YES: Holden, Megan Dahle, Bryan, Calderon, Wendy Carrillo, Dixon, Mike Fong, Hart, Lowenthal, Mathis, Papan, Pellerin, Sanchez, Weber, Ortega

ABS, ABST OR NV: Robert Rivas

UPDATED

VERSION: February 27, 2023

CONSULTANT: Debbie Look / ED. / (916) 319-2087 FN: 0000834

Date of Hearing: April 26, 2023

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Chris Holden, Chair

ABPCA Bill Id:AB 19

Author:(Joe Patterson) – As Amended Ver:February 27, 2023

Urgency: No State Mandated Local Program: Yes Reimbursable: Yes

SUMMARY:

This bill requires each public school to maintain at least two doses of naloxone hydrochloride or another opioid antagonist on its campus.

FISCAL EFFECT:

Ongoing Proposition 98 General Fund costs of about $1.1 million annually for each public school to maintain at least two doses of naloxone hydrochloride or another opioid antagonist on its campus.

This estimate assumes a cost of $47.50 per dose and 11,000 public schools. It also assumes all doses are used annually. Costs could be less to the extent doses are not used, as opioid reversal medication typically has a shelf life of around two to three years. In addition, costs could be higher or lower, because Narcan, the most widely used opioid antagonist, was very recently approved for over-the-counter use and sale, which could affect its price.

If the Commission on State Mandates determines the bill’s requirements to be a reimbursable state mandate, the state would need to reimburse these costs to LEAs or provide funding through the K-12 Mandate Block Grant.

COMMENTS:

1. Purpose. According to the author:

It is time we take the initiative to have simple and proven preventative care available to schools where our kids spend a majority of their time. Fentanyl is being disguised as candy and is readily available in every community - why aren't we putting this on every campus? I was pleased to hear that the Governor has set aside $3.5 million in Prop 98 to fund this program for all middle and high school sites to maintain naloxone on campus, which answers any questions about funding for Assembly Bill 19. I am proud that this is a bipartisanship issue having the governor, Democrats, and Republicans recognize this policy will save children's lives.

1. Background. Naloxone hydrochloride is the generic name for an opioid antagonist that rapidly reverses an opioid overdose. On March 29, 2023, the Food and Drug Administration approved “Narcan,” a brand of naloxone hydrochloride nasal spray, for over-the-counter use and sale. This is the first naloxone hydrochloride product approved for use without a prescription. This will allow this medication to be sold directly to consumers in drug stores, grocery stores, and online.

The California Department of Public Health (CDPH) administers the Naloxone Distribution Project (NDP). NDP provides free naloxone hydrochloride to various eligible entities, including schools, colleges and universities, community organizations, and first responders. According to CDPH, since October 2018, NDP has distributed over one million units of naloxone hydrochloride.

Current law authorizes schools to provide emergency naloxone hydrochloride or another opioid antagonist to school nurses or trained volunteer personnel to provide emergency medical aid to a person suffering, or reasonably believed to be suffering, from an opioid overdose.

1. Governor’s Budget Proposal. The Governor’s budget for the 2023-24 fiscal year proposes $97 million to address the opioid crisis, including $3.5 million in ongoing Proposition 98 General Fund for all middle schools and high schools to maintain at least two doses of naloxone hydrochloride or another medication to reverse an opioid overdose on campus for emergency aid. The Governor’s proposal assumes each of the state’s approximately 5,400 middle and high school students are to maintain a 12-dose kit at a cost of $570 per kit. The Legislative Analyst’s Office estimates it would cost about $550,000 in ongoing Proposition 98 General Fund to provide two doses to each of the state’s middle and high schools.

This bill requires all public schools, including elementary schools, to maintain at least two doses of naloxone hydrochloride or another medication to reverse an opioid overdose on campus for emergency aid.

1. Prior Legislation. SB 367 (Hurtado), Chapter 218, Statutes of 2022, requires each community college district and the Trustees of the California State University, and requests the Regents of the University of California, to apply to participate in NDP and distribute opioid overdose reversal medication once approved.
2. Related Legislation. AB 915 (Arambula) of this legislative session would require the CDPH to establish, by March 1, 2025, a certification training program for public high school students in grades nine to 12 to gain skills in how to administer naloxone hydrochloride nasal spray during an opioid overdose, and how to store and dispose of the nasal spray, among other provisions. The bill is in the Assembly Health Committee.

SB 472 (Hurtado) of this legislative session requires each public school to maintain at least two doses of naloxone hydrochloride or another opioid antagonist on its campus, among other provisions. The bill is in the Senate Appropriations Committee.

Analysis Prepared by: Natasha Collins / APPR. / (916) 319-2081

Date of Hearing: April 12, 2023

ASSEMBLY COMMITTEE ON EDUCATION

Al Muratsuchi, Chair

ABPCA Bill Id:AB 19 (

Author:Joe Patterson) – As Amended Ver:February 27, 2023

SUBJECT: Pupil health: opioid antagonists

SUMMARY: Requires public schools to maintain at least two doses of naloxone hydrochloride or another opioid antagonist to provide emergency medical aid to a person suffering from an opioid overdose. Specifically, this bill:

1. Requires each individual public school operated by a school district, county office of education (COE), or charter school, to maintain at least two doses of naloxone hydrochloride or another opioid antagonist to provide emergency medical aid to a person suffering from an opioid overdose.
2. Makes other technical changes.

EXISTING LAW:

1. Authorizes school districts, COEs and charter schools to provide emergency naloxone or another opioid antagonist to school nurses or trained volunteer personnel for the purpose of providing emergency medical aid to persons suffering, or reasonably believed to be suffering, from an opioid overdose. (Education Code (EC) 49414.3)
2. Authorizes public and private elementary and secondary schools to voluntarily determine whether or not to make emergency naloxone or another opioid antagonist and trained personnel available at its school. Requires a school to evaluate the emergency medical response time to the school and determine whether initiating emergency medical services is an acceptable alternative to naloxone or another opioid antagonist and trained personnel. Prohibits a private elementary or secondary school choosing to exercise the authority provided by this bill from receiving state funds for this purpose.
3. Authorizes public and private elementary and secondary schools to designate one or more volunteers to receive initial and annual refresher training regarding the storage and emergency use of naloxone or another opioid antagonist from the school nurse or other qualified person designated by an authorizing physician and surgeon. Specifies that a benefit must not be granted to or withheld from any individual based on his or her offer to volunteer and prohibits retaliation against any individual for rescinding his or her offer to volunteer, including after receiving training. Specifies that a school district, COE, or charter school choosing to exercise the authority provided by this bill must provide the training for the volunteers at no cost to the volunteer and during the volunteer's regular working hours.
4. Requires the Superintendent of Public Instruction (SPI) to establish minimum standards of training for the administration of naloxone or another opioid antagonist and to review the minimum standards of training every five years, or sooner as deemed necessary. Requires the SPI to consult with organizations and providers with expertise in administering naloxone or another opioid antagonist and administering medication in a school environment, including the California Society of Addiction Medicine, the Emergency Medical Services Authority, the California School Nurses Organization, the California Medical Association, and the American Academy of Pediatrics.
5. Requires the training to include all of the following:
6. Techniques for recognizing symptoms of an opioid overdose;
7. Standards and procedures for the storage, restocking, and emergency use of naloxone or another opioid antagonist;
8. Basic emergency follow-up procedures, including, but not limited to, a requirement for the school or charter school administrator, or if the administrator is not available, another school staff member to call the emergency 911 telephone number and to contact the student’s parent or guardian;
9. Recommendations on the necessity of instruction and certification in cardiopulmonary resuscitation (CPR); and,
10. Written materials covering the information required in the training.
11. Requires training to be consistent with the most recent guidelines for medication administration issued by the California Department of Education (CDE).
12. Requires the CDE to include on its website a clearinghouse for best practices in training nonmedical personnel to administer naloxone or another opioid antagonist to pupils.
13. Requires any school district, COE, or charter school electing to utilize naloxone or another opioid antagonist for emergency aid to distribute a notice at least once per school year to all staff containing the following information:
14. A description of the volunteer request stating that the request is for volunteers to be trained to administer naloxone or another opioid antagonist to a person if the person is suffering, or reasonably believed to be suffering, from an opioid overdose;
15. A description of the training that the volunteer will receive;
16. The right of an employee to rescind his or her offer to volunteer; and
17. A statement that no benefit will be granted to or withheld from any individual based on his or her offer to volunteer and that there will be no retaliation against any individual for rescinding his or her offer to volunteer, including after receiving training.
18. Requires a qualified supervisor of health, or administrator, at a school district, COE, or charter school electing to utilize naloxone or another opioid antagonist for emergency aid to do the following:
19. Obtain from an authorizing physician and surgeon a prescription for each school for naloxone or another opioid antagonist; and
20. Stock the naloxone or another opioid antagonist and restocking it if it is used.
21. Provides that a prescription may be filled by local or mail order pharmacies or naloxone or another opioid antagonist manufacturer.
22. Specifies that an authorizing physician and surgeon shall not be subject to professional review, be liable in a civil action, or be subject to criminal prosecution for the issuance of a prescription or order pursuant to this bill, unless the physician and surgeon's issuance of the prescription or order constitutes gross negligence or willful or malicious conduct.
23. Specifies that a school nurse or, if the school does not have a school nurse or the school nurse is not onsite or available, a volunteer may administer naloxone or another opioid antagonist to a person exhibiting potentially life-threatening symptoms of an opioid overdose at school or a school activity when a physician is not immediately available. Provides that if the naloxone or another opioid antagonist is used it must be restocked as soon as reasonably possible, but no later than two weeks after it is used. Naloxone or another opioid antagonist must be restocked before their expiration date.
24. Specifies that volunteers may administer naloxone or another opioid antagonist only by nasal spray or by auto-injector, in the authorized form the volunteer is most comfortable with.
25. Requires that a school district, COE, or charter school electing to utilize naloxone or another opioid antagonist for emergency aid ensure that each employee who volunteers under this section be provided defense and indemnification by the school district, COE, or charter school for any and all civil liability. Requires this information to be reduced to writing, provided to the volunteer, and retained in the volunteer's personnel file.
26. Specifies that a person trained to provide naloxone or another opioid antagonist who administers naloxone or another opioid antagonist, in good faith and not for compensation, to a person who appears to be experiencing an opioid overdose not be subject to professional review, be liable in a civil action, or be subject to criminal prosecution for their acts or omissions in administering the naloxone or another opioid antagonist. Specifies that the protection does not apply in a case of gross negligence or willful and wanton misconduct of the person who renders emergency care treatment by the use of naloxone or another opioid antagonist. Specifies that any public employee who volunteers to administer naloxone or another opioid antagonist is not providing emergency medical care "for compensation" notwithstanding the fact that they are a paid public employee.
27. Authorizes a state agency, the CDE, or a public school, to accept gifts, grants, and donations from any source for the support of the public school carrying out the provisions of this section, including, but not limited to, the acceptance of naloxone or another opioid antagonist from a manufacturer or wholesaler. (EC 49414.3)

FISCAL EFFECT: The Office of Legislative Counsel have keyed this as a possible state-mandated local program.

COMMENTS:

Need for the bill. According to the author, “Until my neighbor, high school teen Zach Didier, lost his life to Fentanyl, I had no idea how kids were getting their hands on this poison. Zach ingested a pill of what he believed to be Percocet. As a father of four children, I can't imagine having to experience what my neighbor went through which is why I am authoring Assembly Bill 19. According to the CDE in 2012, California suffered 82 tragic deaths attributed to fentanyl overdoses, and last year that number jumped to more than 6,000. Fentanyl deaths accounted for more than 80% of all drug-related deaths among California’s young people in 2021. AB 19 is part of my three-pronged approach to helping solve the Fentanyl crisis - accountability, education, and safety. This measure is about safety.

It is time we take the initiative to have simple and proven preventative care available to schools where our kids spend a majority of their time. Fentanyl is being disguised as candy and is readily available in every community - why aren't we putting this on every campus? I was pleased to hear that the Governor has set aside $3.5 million in Prop 98 to fund this program for all middle and high school sites to maintain naloxone on campus, which answers any questions about funding for Assembly Bill 19. I am proud that this is a bipartisanship issue having the governor, Democrats, and Republicans recognize this policy will save children's lives."

Current law authorizes, but does not require, schools to stock and administer opioid antagonists. This bill would require each school in a school district, COE, or charter school to maintain at least two doses of naloxone hydrochloride or equivalent on its campus for use, as prescribed by current law.

Dangers associated with Fentanyl. Fentanyl is a potent synthetic opioid drug approved by the Food and Drug Administration (FDA) for use as an analgesic and anesthetic. It is approximately 50 times stronger than heroin and 100 times stronger than morphine. First developed in 1959, it was introduced in the 1960’s as an intravenous anesthetic. Fentanyl is legally manufactured and distributed in the United States; however, there are two types of fentanyl: pharmaceutical fentanyl and illicitly manufactured fentanyl. Both are considered synthetic opioids. Pharmaceutical fentanyl is prescribed by doctors to treat severe pain, especially after surgery and for advanced-stage cancer. Most recently, cases of fentanyl-related overdoses are linked to illicitly manufactured fentanyl that is distributed through illegal drug markets for its heroin-like effect. It is often added to other drugs because of its extreme potency, which makes drugs cheaper, more powerful, more addictive, and more dangerous.

Addressing Fentanyl Among California Youth. According to the California Department of Public Health (CDPH), fentanyl-related overdose deaths increased 625% among ages 10-19 from 2018 to 2020. In 2021, there were 224 fentanyl-related overdose deaths among teens ages 15–19 years old in California. Current law requires the SPI to establish minimum training standards for school employees who volunteer to administer naloxone or another opioid antagonist. In addition to setting minimum training standards, the CDE must maintain on its website a clearinghouse for best practices in training nonmedical personnel to administer naloxone or another opioid antagonist to pupils. 

The CDE, in conjunction with the CDPH, provide LEAs with resources and information that they can readily share with parents and students to help keep them safe. The Fentanyl Awareness and Prevention toolkit page offers information about the risks of fentanyl and how to prevent teen use and overdoses. In addition to the toolkit, the CDPH’s Substance and Addiction Prevention branch also provides resources for parents, guardians, caretakers, educators, schools, and youth-serving providers.

Reversing opioid overdoses. Naloxone is the generic name for an opioid antagonist that rapidly reverses an opioid overdose. It attaches to opioid receptors and reverses and blocks the effects of other opioids. Naloxone can quickly restore normal breathing to a person if their breathing has slowed or stopped because of an opioid overdose. Naloxone comes in two FDA-approved forms: injectable and prepackaged nasal spray.

On March 29, 2023 the FDA approved Narcan, naloxone hydrochloride nasal spray for over-the-counter (OTC), nonprescription use. This is the first naloxone product approved for use without a prescription. This will allow this medication to be sold directly to consumers in drug stores, grocery stores, as well as online. According to an FDA Commissioner, “Today’s approval of OTC naloxone nasal spray will help improve access to naloxone, increase the number of locations where it’s available and help reduce opioid overdose deaths throughout the country. We encourage the manufacturer to make accessibility to the product a priority by making it available as soon as possible and at an affordable price.”

Narcan nasal spray was first approved by the FDA in 2015 as a prescription drug. According to the FDA, in accordance with a process to change the status of a drug from prescription to nonprescription, the manufacturer provided data demonstrating that the drug is safe and effective for use as directed in its proposed labeling. The manufacturer also showed that consumers can understand how to use the drug safely and effectively without the supervision of a healthcare professional. The application to approve Narcan nasal spray for OTC use was granted priority review status and was the subject of an advisory committee meeting in February 2023, where committee members voted unanimously to recommend it be approved for marketing without a prescription.

CDPH Statewide Standing Order for Naloxone. Naloxone can help reduce opioid overdose deaths in California, but many organizations find it difficult to obtain the required standing order to obtain naloxone from health care providers. According to CDPH, of the 6,843 opioid-related overdose deaths in 2021, 5,722 were related to fentanyl. CDPH issued the standing order, in 2017, to address this need and support equitable naloxone access. The standing order:

1. Allows community organizations and other entities in California that are not currently working with a physician, to distribute naloxone to a person at risk of an opioid-related overdose or to a family member, friend, or other person in a position to assist.
2. Allows for the administration of naloxone by a family member, friend, or other person to a person experiencing or reasonably suspected of experiencing an opioid overdose.

Among the organizations and entities that can distribute naloxone under the order are colleges and universities. An individual at risk of experiencing an overdose or someone who can assist an individual at risk is allowed to do so. Under the statewide standing order, staff of community organizations and other entities distributing naloxone must be trained. They are also required to provide training to individuals who receive naloxone from them. Colleges and other organizations may apply to use the statewide standing order if they meet certain conditions.

A separate distribution program administered through the Department of Health Care Services (DHCS) allows schools, universities and colleges to apply for and obtain naloxone at no cost to the institution. According to the CDPH website, since October 2018, their Naloxone Distribution Project (NDP) has distributed over 1 million units of naloxone, and recorded over 57,000 overdose reversals.

Governor’s Proposed Budget. Currently, the Governor’s budget proposes $97 million in new investments to tackle the fentanyl and opioid crisis, including $3.5 million for all middle and high school sites to maintain at least two doses of naloxone hydrochloride or another medication to reverse an opioid overdose on campus for emergency aid. The proposal also includes $79 million to the Naloxone Distribution Project, $10 million in grants for education, testing, recovery, and support services, as well as $4 million to make test strips more widely available.

California’s Opioid Settlements. According to the DHCS, on July 21, 2021, a $26 billion offer to settle was made by opioid manufacturer Janssen Pharmaceuticals (parent company of Johnson & Johnson) and the “big three” distributors, McKesson, AmerisourceBergen, and Cardinal Health (“the Distributors”) to resolve their liabilities in over 3,000 opioid crisis-related lawsuits nationwide. It's estimated that California will receive approximately $2.05 billion from the Janssen and Distributors (J&D) Settlement Agreements over the next 18 years. The majority of this money will be provided to local agencies to be used for opioid abatement activities. California has joined additional lawsuits against manufacturers, distributors, and other entities responsible for aiding the opioid epidemic and anticipates receiving funds from future opioid judgment and settlement agreements.

Some California school districts have opted to make Naloxone available. The Los Angeles Unified School District (LAUSD), the state’s largest school district, announced plans to stock naloxone at over 1,400 elementary, middle, and high schools in response to numerous incidents of students experiencing overdoses, including at least one death in 2022. San Diego Unified School District, the state’s second-largest school system stocks naloxone at schools with students in sixth grade or higher. Since 2020, Elk Grove Unified School District, a large district in Northern California, has provided naloxone to school security officers and their supervisors. In Los Angeles County, the Palos Verdes Peninsula Unified School District trained all the district’s registered nurses on how to administer naloxone and made it available to them at that district’s high schools.

Arguments in support. According to the Los Angeles COE, “With the rapid increase in the prevalence of fentanyl abuse and poisonings amongst teenagers, schools are not properly equipped to save the life of a child suffering from the effects of fentanyl. The Los Angeles Times reported in September 2022 that seven teenagers, including a fifteen-year-old, died from overdosing on pills possibly containing fentanyl. That same month, a school administrator in Bakersfield was sent to the hospital due to exposure of counterfeit prescription pills containing fentanyl.

Fentanyl overdoses accounted for more than 80% of all drug-related deaths among California’s young people in 2021. More than 770 Californians under the age of 24 died of fentanyl overdoses last year, a 21-fold increase since 2016. The access to opioids and drugs such as fentanyl is too easily available and to not have a standing state law that requires K-12 schools to have the preventives easily available is a concern.

While some K-12 schools have opted to offer this inexpensive life-saving medication, most still do not provide Naloxone on campus. AB 19 would require K-12 schools to have naloxone as a lifesaving measure on campus for students experiencing an opioid overdose. This bill ensures that our schools are prepared for the potential of an opioid overdose, which is becoming more common as fentanyl is flooding into California and doses have been made to look like prescription drugs and even candy.”

Related legislation. AB 889 (Joe Patterson) of the 2023-24 Session would require a school district, COE, and charter school to annually inform parents or guardians of the dangers associated with using synthetic drugs at the beginning of the first semester or quarter of the regular school term, and to post this information on their websites.

SB 10 (Cortese) of the 2023-24 Session would require LEAs and COEs to include strategies for the prevention and treatment of an opioid overdose in their school safety plans, and require the CDE to develop training materials on the use of emergency opioid antagonists for school personnel, and safety materials for parents, guardians, and pupils in conjunction with the California Health and Human Services Agency (CalHHS).

SB 234 (Portantino) of the 2023-24 Session would require schools kindergarten to 12th grade, institutions of higher education, stadiums, concert venues, and amusement parks, at all times, to maintain unexpired doses of naloxone hydrochloride or any other opioid antagonist on its premise, ensure that at least two employees are aware of the location of the naloxone hydrochloride or other opioid antagonist, and expand community colleges ability to administer naloxone.

SB 472 (Hurtado) of the 2023-24 Session would require each campus of a public school operated by an LEA, COE, or charter school to maintain at least two doses on its campus, and distribute, naloxone hydrochloride or another opioid antagonist pursuant to the standing order for naloxone and requires LEAs, COEs, and charter school to report to the DHCS for failure to distribute naloxone.

AB 915 (Arambula) of the 2023-24 Session would require the CDPH to establish, by March 1, 2025, a certification training program for public middle school and public high school students in grades 5 to 12 to gain skills in how to administer Narcan nasal spray, during an opioid overdose, and how to store and dispose of Narcan nasal spray. The bill would also authorize public middle and high schools serving pupils in any of grades 5 to 12 to voluntarily determine whether or not to host the program on their campuses. The bill would require the CDE to collaborate with drug prevention organizations, community health centers and experts, and nonprofits with related expertise to provide pupils with integrated, comprehensive, accurate, and unbiased educational materials on opioid and drug overdose prevention, opioid and drug safety, and stigma reduction.

AB 33 (Bains) of the 2023-24 Session would establish the Fentanyl Addiction and Overdose Prevention Task Force to undertake specified duties relating to fentanyl abuse.

AB 1058 (Jim Patterson) of the 2023-24 Session would increase penalties for possession for the purposes of sale and for transportation and sale of a controlled substance if the controlled substance involved was more than 28.35 grams of fentanyl, more than 28.35 grams of an analog of fentanyl, a substance containing more than 28.35 grams of fentanyl, or a substance containing more than 28.35 grams of an analog of fentanyl.

AB 1748 (Mayes) Chapter 557, Statutes of 2016, authorizes school nurses and other trained personnel to use naloxone hydrochloride (naloxone) or another opioid antagonist to provide emergency medical aid to persons suffering, or reasonably believed to be suffering, from an opioid overdose.

AB 635 (Ammiano), Chapter 707, Statutes of 2013, revised certain provisions from a pilot program authorizing prescription of opioid antagonists for treatment of drug overdose and limiting civil and criminal liability, expanded these provisions statewide, and removed the 2016 sunset date for the pilot program. This bill permitted a licensed health care provider who is authorized by law to prescribe an opioid antagonist, if acting with reasonable care, to prescribe and subsequently dispense or distribute an opioid antagonist to a person at risk of an opioid-related overdose or a family member, friend, or other person in a position to assist the person at risk, and limited the professional and civil liability of licensed health care providers and persons who possess or distribute opioid antagonists.

SB 1438 (Pavley), Chapter 491, Statutes of 2014, required the development of training and other standards for the administration of naloxone by emergency medical technicians and other pre-hospital emergency care personnel.

REGISTERED SUPPORT / OPPOSITION:

Support

Opposition

None on file

Analysis Prepared by: Debbie Look / ED. / (916) 319-2087