Existing law requires instruction to be given in the elementary and secondary schools by appropriately trained instructors on drug education and the effects of the use of tobacco, alcohol, narcotics, dangerous drugs, as defined, and other dangerous substances. Existing law authorizes a public or private elementary or secondary school to determine whether or not to make emergency naloxone hydrochloride or another opioid antagonist and trained personnel available at its school, and to designate one or more volunteers to receive related training to address an opioid overdose, as specified.

Commencing with the 202324 fiscal year, and for each fiscal year thereafter, existing law appropriates $3,500,000 from the General Fund to the State Department of Education for allocation to county offices of education for the purpose of purchasing and maintaining a sufficient stock of emergency opioid antagonists for school districts and charter schools within their jurisdiction to maintain a minimum of two units at each middle school, junior high school, high school, and adult school schoolsite, as provided.

This bill would require school districts, county offices of education, and charter schools that voluntarily determine to make naloxone hydrochloride or another opioid antagonist available on campus to ensure that the naloxone hydrochloride or another opioid antagonist is placed in an appropriate location that is widely known and easily accessible, during school hours and after school hours. The bill would require the naloxone hydrochloride or another opioid antagonist to be located on campus in at least one of several specified locations.

This bill would require the State Department of Public Health to develop an opioid overdose training program and program toolkit, as defined, to be made available to public high schools for public high school pupils to be trained on how to identify and respond to an opioid overdose, including by administering a federally approved opioid overdose reversal medication, as provided. The bill would require the department, by July 1, 2026, to notify public high schools of the availability of the program toolkit. The bill would require the department to provide the program toolkit upon request to those public high schools that opt to host the program on their campuses and to consider making its representatives available to provide the training onsite at public schools upon request. The bill would require the department to campuses, and to collaborate with local, state, and national organizations, as provided, to provide pupils with integrated, comprehensive, accurate, and unbiased educational materials on opioid and drug overdose prevention, opioid and drug safety, and stigma reduction. The bill would require the department to collect, on an annual basis, data on the number of pupils participating in the program and to share this information with the Legislature and the Senate and Assembly Budget Subcommittees on Education, Health, and Human Services, as provided.

Existing law requires instruction to be given in the elementary and secondary schools by appropriately trained instructors on drug education and the effects of the use of tobacco, alcohol, narcotics, dangerous drugs, as defined, and other dangerous substances. Existing law authorizes a public or private elementary or secondary school to determine whether or not to make emergency naloxone hydrochloride or another opioid antagonist and trained personnel available at its school, and to designate one or more volunteers to receive related training to address an opioid overdose, as specified.

Commencing with the 202324 fiscal year, and for each fiscal year thereafter, existing law appropriates $3,500,000 from the General Fund to the State Department of Education for allocation to county offices of education for the purpose of purchasing and maintaining a sufficient stock of emergency opioid antagonists for school districts and charter schools within their jurisdiction to maintain a minimum of two units at each middle school, junior high school, high school, and adult school schoolsite, as provided.

This bill would require school districts, county offices of education, and charter schools that voluntarily determine to make naloxone hydrochloride or another opioid antagonist available on campus to ensure that the naloxone hydrochloride or another opioid antagonist is placed in an appropriate location that is widely known and easily accessible, during school hours and after school hours. The bill would require the naloxone hydrochloride or another opioid antagonist to be located on campus in at least one of several specified locations.

This bill would require the State Department of Public Health to develop an opioid overdose training program and program toolkit, as defined, to be made available to public high schools for public high school pupils to be trained on how to identify and respond to an opioid overdose, including by administering a federally approved opioid overdose reversal medication, as provided. The bill would require the department, by July 1, 2026, to notify public high schools of the availability of the program toolkit. The bill would require the department to provide the program toolkit upon request to those public high schools that opt to host the program on their campuses and to consider making its representatives available to provide the training onsite at public schools upon request. The bill would require the department to collaborate with local, state, and national organizations, as provided, to provide pupils with integrated, comprehensive, accurate, and unbiased educational materials on opioid and drug overdose prevention, opioid and drug safety, and stigma reduction. The bill would require the department to collect, on an annual basis, data on the number of pupils participating in the program and to share this information with the Legislature and the Senate and Assembly Budget Subcommittees on Education, Health, and Human Services, as provided.

Date of Hearing: April 24, 2024

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Buffy Wicks, Chair

ABPCA Bill Id:AB 1915

Author:(Arambula) – As Amended Ver:April 1, 2024

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

SUMMARY:

This bill requires the California Department of Public Health (CDPH), by July 1, 2026, to establish a certification training program for high school students in grades nine through 12 to gain skills to identify and respond to an opioid overdose. The training is to include information about how to administer opioid overdose reversal medication. A local educational agency (LEA) serving students in grades nine through 12 may voluntarily determine whether or not to offer the training program.

The bill also requires an LEA serving students in any grade of nine through 12 that voluntarily makes naloxone hydrochloride or another opioid antagonist available on campus to ensure the opioid antagonist is placed in an appropriate location widely known and easily accessible, during school hours and after school hours.

FISCAL EFFECT:

1. One-time and ongoing General Fund costs of about $480,000 for in the 2025-26 fiscal year and $700,000 for the 2026-27 fiscal year and thereafter to CDPH for two positions to carry out the requirements of this bill. CDPH notes General Fund costs could be less to the extent Opioid Settlements Funds are available for these purposes.
2. Ongoing Proposition 98 General Fund costs to an LEA to provide the training, should an LEA opt to provide the training. Costs to conduct the training will depend on how LEAs deliver the training and how CDPH designs the training.

According to the Legislative Analyst’s Office, the General Fund faces a structural deficit in the tens of billions of dollars over the next several fiscal years.

COMMENTS:

1. Background. Naloxone hydrochloride is the generic name for an opioid antagonist that rapidly reverses an opioid overdose. 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
2. Related Legislation. AB 915 (Arambula) is very similar to this bill. AB 915 was held in the Senate Appropriations Committee.

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

Date of Hearing: April 9, 2024

ASSEMBLY COMMITTEE ON HEALTH

Mia Bonta, Chair

ABPCA Bill Id:AB 1915

Author:((Arambula) – As Amended Ver:April 1, 2024

SUBJECT: Pupil health: drug education: opioid overdose training program.

SUMMARY: Requires the State Department of Public Health (DPH) to develop by July 1, 2026, a training program and toolkit for public school pupils in grades nine to 12, to gain skills in how to identify and respond to an opioid overdose, including the administering of a federally approved opioid overdose reversal medication. Specifically, this bill:

1. Requires the DPH to develop by July 1, 2026, a training program and program toolkit for public school pupils in grades nine to 12, inclusive, to gain skills in how to identify and respond to an opioid overdose, including the administering of a federally approved opioid overdose reversal medication.
2. Requires DPH, by July 1, 2026, to notify public high schools of the availability of the program toolkit.
3. Requires DPH to provide the program toolkit upon request to public high schools that opt to host the program on their campuses.
4. Requires DPH, in establishing the program, to collaborate with local, state, and national organizations, which may include community health centers, community health 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.
5. Authorizes the program to include, but not be limited to, the following:
   1. Informational videos, graphics, or in-person training on what to do and how to respond during a drug or opioid overdose. Authorizes DPH to use any existing content or other relevant materials already developed, or develop new materials;
   2. Information on how to recognize signs of a drug or opioid overdose; and,
   3. Information on how to respond in an emergency involving a drug or opioid overdose.
6. Requires the program toolkit to encourage and support opioid overdose training instruction in person at public high schools from appropriately trained instructors from local, state, and national organizations, which may include community health centers, community health experts, nonprofit organizations with related expertise, and school staff. Requires instructors who are not employed by the school to undergo state-approved background checks.
7. Requires the program to provide resource materials related to drug and opioid use and or prevention, appropriate for use with students of all races, genders, sexual orientations, and ethnic and cultural backgrounds, students with disabilities, and English learners.
8. Requires any school district, county office of education (COE), or charter school, serving students in grades nine to 12, that chooses to make naloxone hydrochloride (NH) or another opioid antagonist available on campus to ensure that it is placed in an appropriate location, as determined by the governing board or body, that is widely known and easily accessible, both during school hours and after school hours. Requires that the NH or another opioid antagonist is located in at least one of the following locations on campus:
   1. School nurse’s office;
   2. Athletic trainer’s office;
   3. Front office;
   4. Performing arts auditorium;
   5. Library;
   6. Cafeteria; or,
   7. Athletic gym.
      

EXISTING LAW:

1. Establishes DPH, directed by a state Public Health Officer (PHO), to be vested with all the duties, powers, purposes, functions, responsibilities, and jurisdiction as they relate to public health disease prevention, as specified. Gives the PHO, broad authority to detect, monitor, and prevent the spread of communicable disease in the state. [Health & Safety Code (HSC) §131050 and §120130, et seq.]
   
2. Authorizes the DPH, in order to reduce the rate of fatal overdose from opioid drugs including heroin and prescription opioids, to award funding to local health departments, local government agencies, or on a competitive basis to community-based organizations, regional opioid prevention coalitions, or both, to support or establish programs that provide naloxone, or any other opioid antagonist that is approved by the United States Food and Drug Administration (FDA) for the treatment of an opioid overdose, to first responders and to at-risk opioid users through programs that serve at-risk drug users, including, but not limited to, syringe exchange and disposal programs, homeless programs, and substance use disorder (SUD) treatment providers. [HSC §1179.80]
3. Establishes within the California Health and Human Services Agency a grant program to reduce fentanyl overdoses and use throughout the state by providing six one-time grants: two in northern California, two in the central valley, and two in southern California. [Welfare and Institutions Code §3200]
4. Permits a pharmacy to furnish NH or another opioid antagonist to a school district, COE, or charter school pursuant to existing law if certain requirements are met. [Business and Professions Code (BPC) §4119.8]
5. Authorizes a pharmacy, wholesaler, or manufacturer to furnish NH or other opioid antagonists to a law enforcement agency if specified conditions are met. [BPC §4119.9]
6. Classifies controlled substances under the California Uniform Controlled Substances Act, into five schedules and places the greatest restrictions and penalties on the use of those substances placed in Schedule I. Classifies the drug fentanyl in Schedule II. [HSC §11054-11058]
   
7. Establishes ongoing funding for COEs to purchase and maintain sufficient stock of emergency NH or another opioid antagonist for local educational agencies within its jurisdiction. [Education Code (EDC) §49414.8]
8. Authorizes school districts, COEs, and charter schools to provide emergency NH 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. [EDC §49414.3 et seq.]
9. Authorizes public and private elementary and secondary schools to voluntarily determine whether or not to make emergency NH 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 NH or another opioid antagonist and trained personnel. [EDC §49414.3 (c)]
10. Requires the Superintendent of Public Instruction (SPI) to establish minimum standards of training for the administration of NH 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 NH 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. [EDC §49414.3(e)]

FISCAL EFFECT: Unknown. This bill has not yet been analyzed by a fiscal committee.

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, the fentanyl and opioid crisis is a state and nationwide public health emergency that has taken the lives of so many young people. Fentanyl prevention, education, and training on how to assist someone who is experiencing an opioid overdose is lifesaving. According to DPH, in 2021 there were 7,175 deaths because of an opioid overdose. The state can take a leadership role to inform people of how to treat those who undergo a potentially fatal overdose. This bill will establish a training program and toolkit for high school pupils. It will outline key methods on how to support a peer experiencing an opioid overdose, with the use of NH nasal sprays. The author concludes that through comprehensive and evidence-based training, students can prepare and learn ways to support their peers experiencing a drug-related overdose.
2. BACKGROUND. California is facing an overdose epidemic. According to a California Health Care Foundation report, 9% of Californians have met the criteria for a SUD within the last year. While the health care system is moving toward acknowledging SUDs as a chronic illness, only about 10% of people with an SUD within the last year received treatment. Overdose deaths from both opioids and psychostimulants (such as amphetamines), are soaring. This issue, compounded by the increased availability of fentanyl, has resulted in a 10-fold increase in fentanyl related deaths between 2015 and 2019. According to DPH, fentanyl-related overdose deaths increased 625% among youth ages 10 to 19 from 2018 to 2020. DPH’s Opioid Overdose Dashboard reported there were 177 fentanyl-related overdose deaths and 1,165 opioid-related overdose emergency department visits among youth ages 10 to 19 years old in 2022. 
   1. Fentanyl. Fentanyl is a potent synthetic opioid drug approved by the 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 US; 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.
      
      The California Department of Education, in conjunction with DPH, provides local educational agencies with resources and information that they can provide to parents and students. The 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, DPH’s Substance and Addiction Prevention branch also provides resources for parents, guardians, caretakers, educators, schools, and youth-serving providers.
   2. Reversing opioid overdoses. NH 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. NH can quickly restore normal breathing to a person if their breathing has slowed or stopped because of an opioid overdose. NH comes in two FDA-approved forms: injectable and prepackaged nasal spray. 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 of Narcan 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 over-the-counter (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.

As of July 2023 the FDA approved Narcan and RiVive, for OTC, nonprescription use. These are the first NH products approved for use without a prescription. This approval will allow the medications to be sold directly to consumers in drug stores, grocery stores, as well as online. According to an FDA Commissioner, “The approval of OTC NH nasal spray will help improve access to NH, 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.”

• 1. NH Availability in California school districts. The 2023-24 state Budget appropriated $3.5 million annually for COEs to purchase and maintain a sufficient stock of emergency opioid antagonists for school districts and charter schools within their jurisdiction, and to maintain a minimum of two units at each middle school, junior high school, high school, and adult school site. As a condition of receiving the funding, each school or charter school must ensure two staff members meet minimum training standards.
  2. DPH statewide standing order for NH. NH can help reduce opioid overdose deaths in California, but many organizations find it difficult to obtain the required standing order to obtain NH from health care providers. According to DPH, of the 7,175 opioid-related overdose deaths in 2021, 83% or 5,961 were related to fentanyl. The number of deaths each year involving fentanyl increased dramatically between 2012 and 2021. During this time period fentanyl related overdose deaths increased by more than 7,250% from 82 to 5,961 in 2021. DPH issued a standing order, in 2017, to address this need and support equitable NH access. The standing order:
     1. Allows community organizations and other entities in California that are not currently working with a physician, to distribute NH to a person at risk of an opioid-related overdose or to a family member, friend, or other person in a position to assist; and,
     2. Allows for the administration of NH 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 NH 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 NH must be trained. They are also required to provide training to individuals who receive NH from them. Colleges and other organizations may apply to use the statewide standing order if they meet certain conditions. As of November 2023, DPH stated that a standing order is no longer needed for Narcan due to its OTC status, all other formulations remain available by prescription only and require a standing order to distribute and administer.

• 1. Naloxone Distribution Project. A separate distribution program administered through the Department of Health Care Services (DHCS), the Naloxone Distribution Project (NDP) allows various entities, including schools, universities and colleges, to apply for and obtain NH at no cost to the institution. As of February 20, 2024 the NDP has approved more than 10,800 applications for NH (17% of which are from schools and universities), distributed more than 3.8 million kits of NH and reversed more than 245,000 opioid overdoses. DHCS reports that less than one percent of the overdose reversals reported in the NDP occurred in schools and universities.

1. SUPPORT. Generation Up (GENup) is a sponsor of this bill, stating they are committed to student safety, and the explosion in youth opioid overdoses is a serious threat to student well-being. GENup continues that students aren't taught how to deal with stigma and safety around opioid use, and this bill counters that shortfall by prioritizing youth accessibility to medication and knowledge that can save the lives of their peers, families, and communities. GENup argues that equipping and empowering students to deliver care in emergency situations may mean the difference between life and death.
2. RELATED LEGISLATION.
   1. AB 1996 (Alanis) requires DPH to develop an opioid overdose training program for stadium, concert venue, and amusement park staff. AB 1996 is pending in Assembly Health Committee.
   2. AB 3271 (Joe Patterson) requires 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 to maintain at least two units of naloxone hydrochloride or another opioid antagonist on campus. AB 3271 is pending in Assembly Health Committee.
   3. AB 2998 (McKinnor) permits minors 12 years of age and above to consent to receiving, carrying, and administering NH or another opioid antagonist if approved by a physician. AB 2998 is pending in Assembly Health Committee.
3. PREVIOUS LEGISLATION.
   1. AB 915 (Arambula) of 2023 was substantially similar to AB 1915. AB 915 was held in the Senate Appropriations Committee suspense file.
   2. AB 1748 (Mayes), Chapter 557, Statutes of 2016, authorizes school nurses and other trained personnel to use NH or another opioid antagonist to provide emergency medical aid to persons suffering, or reasonably believed to be suffering, from an opioid overdose.
   3. SB 1438 (Pavley), Chapter 491, Statutes of 2014, required the development of training and other standards for the administration of NH by emergency medical technicians and other pre-hospital emergency care personnel.
   4. 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. Permits 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.
4. DOUBLE REFERRAL. This bill is double referred, it passed the Assembly Committee on Education with a 7-0 vote on March 20, 2024.

REGISTERED SUPPORT / OPPOSITION:

Support

Generation Up (sponsor)

Alameda County Office of Education

American Academy of Pediatrics, California

California Academy of Child and Adolescent Psychiatry

California Federation of Teachers AFL-CIO

County Health Executives Association of California

Los Angeles County Office of Education

Opposition

None on file.

Analysis Prepared by: Riana King / HEALTH / (916) 319-2097

Date of Hearing: March 20, 2024

ASSEMBLY COMMITTEE ON EDUCATION

Al Muratsuchi, Chair

ABPCA Bill Id:AB 1915 (

Author:Arambula) – As Introduced Ver:January 24, 2024

[This bill is double referred to the Assembly Health Committee and will be heard by that Committee as it relates to issues under its jurisdiction.]

SUBJECT: Pupil health: drug education: opioid overdose training program

SUMMARY: Establishes a voluntary training program for high school students in how to administer naloxone hydrochloride during an opioid overdose; requires the California Department of Public Health (CDPH) to develop the training and resource materials in collaboration with specified entities; and requires schools that elect to stock naloxone hydrochloride to place it in specified locations. Specifically, this bill:

1. Establishes the Opioid Overdose Prevention Training Program (Program) and requires the CDPH to develop an opioid overdose prevention training program and program toolkit to be made available to public high schools opting to train high school students in grades 9 to 12 in how to identify and respond to an opioid overdose, including by administering a federally approved opioid overdose reversal medication.
2. Requires the CDPH to collaborate with local, state, and national organizations, including community health centers, community health experts, and nonprofits with related expertise, to provide integrated, comprehensive, accurate, and unbiased educational materials on opioid and drug overdose prevention, opioid and drug safety, and stigma reduction.
3. Authorizes the CDPH to use any existing content or other relevant materials already developed, or to develop new materials.
4. Specifies that the program may include, but is not limited to, all of the following:
5. Informational videos, graphics, or in-person training on what to do and how to respond during a drug or opioid overdose;
6. Information on how to recognize signs of a drug or opioid overdose; and
7. Information on how to respond in an emergency involving a drug or opioid overdose.
8. Requires the Program toolkit to include resource materials related to drug and opioid use and prevention, appropriate for use with students of all races, genders, sexual orientations, and ethnic and cultural backgrounds, students with disabilities, and English learners.
9. Requires the program toolkit to encourage and support opioid overdose training instruction in person at public high schools from appropriately trained instructors from local, state, and national organizations, which may include community health centers, community health experts, nonprofit organizations with related expertise, and school staff. Requires that instructors who are not employed by the school undergo state-approved background checks.
10. Requires the CDPH to notify public high schools of the availability of the program toolkit by July 1, 2026, and to provide the toolkit upon request to public high schools opting to host the program on their campuses.
11. Requires the CDPH to consider making its representatives available to provide the training onsite at public high schools upon request.
12. Requires the CDPH to collect data annually on the number of students participating in the Program to determine the efficacy of the program training resources and informational efforts, and to share this information with the relevant fiscal sub-committees of the Legislature, as specified.
13. Requires any school district, county office of education (COE), or charter school that chooses to make naloxone hydrochloride or another opioid antagonist available on campus to ensure that it is placed in an appropriate location, as determined by the governing board or body. The location should be widely known and easily accessible, both during school hours and after school hours. Requires that the naloxone hydrochloride or another opioid antagonist is located in at least one of the following locations on campus:
14. School nurse’s office;
15. Athletic trainer’s office;
16. Front office;
17. Performing arts auditorium;
18. Library;
19. Cafeteria; or
20. Athletic gym.
21. Defines “Program” as the opioid overdose prevention training program established by this measure.
22. Defines “Program toolkit” as the opioid overdose prevention training program materials necessary for a public high school to self-administer the program.
23. Defines “public high school” as a public school, including a charter school, serving students in grades 9-12 inclusive.

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. (EC 49414.3)
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 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. (EC 49414.3)
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, the American Academy of Pediatrics. (EC 49414.3)
5. Requires the training standards 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. (EC 49414.3)
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. (EC 49414.3)
13. 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:
14. Obtain from an authorizing physician and surgeon a prescription for each school for naloxone or another opioid antagonist; and
15. Stock the naloxone or another opioid antagonist and restock it if it is used. (EC 49414.3)
16. 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 its expiration date. (EC 49414.3)
17. Specifies that volunteers may administer naloxone or another opioid antagonist only by nasal spray or by auto-injector, and in the authorized form the volunteer is most comfortable with. (EC 49414.3)
18. Requires that a school district, COE, or charter school electing to utilize naloxone or another opioid antagonist for emergency aid to ensure that each employee who volunteers 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.
19. 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. (EC 49414.3)
20. 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 these provisions, including, the acceptance of naloxone or another opioid antagonist from a manufacturer or wholesaler. (EC 49414.3)

FISCAL EFFECT: Unknown

COMMENTS:

Need for the bill. According to the author, “The fentanyl and opioid crisis is a state and nationwide public health emergency that has taken the lives of so many young people. Fentanyl prevention, education, and training on how to assist someone who is experiencing an opioid overdose is lifesaving. According to CDPH, in 2021 there were 7,175 deaths because of an opioid overdose. The state can take a leadership role to inform people of how to treat those who undergo a potentially fatal overdose. This bill will establish a training program and toolkit for high school pupils. It will outline key methods on how to support a peer experiencing an opioid overdose, with the use of naloxone hydrochloride nasal sprays. Through comprehensive and evidence-based training, students can prepare and learn ways to support their peers experiencing a drug-related overdose.”

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.

Rising rates of opioid overdoses. According to the data from the CDPH, although drug use among young people has decreased in recent years, it has become deadlier as more substances are laced with fentanyl. Fentanyl overdose deaths among 10-24 year-olds in California rose from 59 in 2017 to 794 in 2021.

National data illustrate the disparate impact of opioid overdoses. The Center for Disease Control (CDC) data notes that in 2020, opioid overdoses rose 30% compared to 2019, leading to 91,799 deaths. However, the increase was not uniform. The death rate among Black Americans increased by 44%, the greatest increase among all racial and ethnic groups, and double that for white Americans. Young Black people between the ages of 15 and 24 experienced an 86% increase in opioid death rate.

Addressing fentanyl use among California youth. 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, currently provides LEAs with resources and information that they can provide to parents and students. 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. Opioid antagonists are medications that block the activation of opioid receptors in the central or peripheral nervous systems, thereby blocking the effects of opioids. They are used to treat opioid overdose and other conditions. One of these is Naloxone. According to the CDPH “Naloxone is a life-saving medication used to reverse an opioid overdose, including heroin, fentanyl, and prescription opioid medications. Naloxone can be quickly given through nasal spray in the nose or an injectable or auto-injector into the outer thigh or another major muscle. Naloxone is safe and easy to use, works almost immediately, and is not addictive. Naloxone has very few negative effects, and has no effect if opioids are not in a person’s system.”

On March 29, 2023, the FDA approved Narcan, a naloxone hydrochloride nasal spray for over-the-counter (OTC), nonprescription use. This is the first opioid antagonist 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.”

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 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. Allows community organizations and other entities, including colleges and universities, 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.

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.

Some California school districts have opted to make Naloxone available. The Los Angeles Unified School District, 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. The 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, the 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.

Is it appropriate to have young people trained to administer naloxone? There is no precedent in state law to allow students to administer medication. This proposal to allow students to administer naloxone hydrochloride would represent a significant departure from current practice.

The CDPH website includes an 11-minute training video to equip public health agencies, community organizations, friends, family members, and others with the knowledge and skills needed to prevent opioid-related deaths by using naloxone, a drug that can reverse an overdose. It includes a six-point checklist on how to recognize when a person is overdosing and demonstrates how to dispense naloxone and provide post-overdose care.

According to the National Association of School Nurses, the use of naloxone as an opioid overdose reversal agent by laypeople and first responders has doubled from 2017-2018 and has proven to be an effective strategy in preventing overdose opioid deaths. Since 2017, every state and the District of Columbia have laws that provide protection from criminal liability for naloxone administration by laypersons or first responders.

In considering a similar bill proposing a naloxone student training program in New Jersey, supporters argued that the education would be no different than training in CPR or other first aid measures. Proponents claim it will equip students with the tools and skills they need to help save lives. They further point out that a school nurse cannot be everywhere at once. Since overdose response must be quick to save the life in danger, it is important for others to be able to administer the naloxone.

Recommended Committee Amendments. Staff recommend that the bill be amended as follows:

1. Remove the requirement for CDPH to consider making representatives available to provide the training onsite at public high schools upon request.
2. Remove the requirement that CDPH collect data annually on the number of students participating in the Program and report to the Legislature.

Arguments in support. The American Academy of Pediatrics, California writes “The fentanyl crisis among California youth is an urgent public health emergency. Fentanyl, a synthetic opioid more potent than morphine, is FDA-approved to treat severe pain related to surgery or complex pain conditions. However, illicitly manufactured fentanyl and other illegally produced opioids are increasingly found in the drug supply and contribute to a dramatic rise in drug overdose deaths in the United States. There is an imminent need to train young people in how to reverse an overdose. In California, fentanyl alone has contributed to more than 80% of all drug-related deaths in 2021 due to overdose among young people. Across the state, 7,000 people died from a fentanyl overdose in 2021. Naloxone hydrochloride can reverse an opioid overdose instantly. It is administered either by injection or as a nasal spray, which helps block the harmful effects of opioids and restores breathing.

Data from the 2020 National Survey of Children’s Health (NSCH) indicates that 282 deaths occurred among adolescents in 2019 and 546 deaths occurred in 2020 from a drug overdose. AB 1915 will support the training and development of young people to learn how to respond safely to an opioid overdose emergency and take action to prevent a fatal death from happening.”

Related legislation. AB 915 (Arambula) was substantially similar to this bill. It was held in the Senate Appropriations Committee.

AB 19 (Joe Patterson) of the 2023-24 Session would have required 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. This bill was held in the Senate Appropriations Committee.

AB 889 (Joe Patterson) Chapter 123, Statutes of 2023, requires 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) Chapter 856, Statutes of 2023, adds to the list of requirements for a comprehensive school safety plan, a protocol in the event a pupil is suffering or is reasonably believed to be suffering from an opioid overdose. Requires the CDE, in collaboration with the California Health and Human Services Agency, to establish the State Working Group on Fentanyl Education in Schools to promote public education, awareness, and prevention of fentanyl overdoses, with the outreach aimed at staff and pupils in schools.

SB 472 (Hurtado) of the 2023-24 Session would have required 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 required LEAs, COEs, and charter schools to report to the DHCS for failure to distribute naloxone. This bill was held in the Senate Appropriations Committee.

AB 1748 (Mayes) Chapter 557, Statutes of 2016, authorizes school nurses and other 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.

AB 635 (Ammiano), Chapter 707, Statutes of 2013, revised certain provisions from a pilot program authorizing the prescription of opioid antagonists for the 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.

REGISTERED SUPPORT / OPPOSITION:

Support

Alameda County Office of Education

American Academy of Pediatrics, California

California Academy of Child and Adolescent Psychiatry

County Health Executives Association of California

Generation Up

Opposition

None on file

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