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. Existing law prohibits a person who has completed that training and who administers, in good faith and not for compensation, naloxone hydrochloride or another opioid antagonist to a person who appears to be experiencing an opioid overdose from being subject to professional review, liable in a civil action, or subject to criminal prosecution for the persons acts or omissions in administering the naloxone hydrochloride or another opioid antagonist, unless the persons acts or omissions constituted gross negligence or willful and wanton misconduct, as provided.

This bill would prohibit a school district, county office of education, or charter school from prohibiting a pupil 12 years of age or older, while on a schoolsite or participating in school activities, from carrying or administering, for the purposes of providing emergency treatment to persons who are suffering, or reasonably believed to be suffering, from an opioid overdose, a naloxone hydrochloride nasal spray or any other opioid overdose reversal medication that is federally approved for over-the-counter, nonprescription use, as provided. The bill would prohibit a pupil 12 years of age or older of those local educational agencies who administers those opioid antagonists on a schoolsite or while participating in school activities to a person who appears to be experiencing an opioid overdose, from being held liable in a civil action or being subject to criminal prosecution for their acts or omissions, unless the pupils acts or omissions constitute gross negligence or willful and wanton misconduct, as provided. The bill would also prohibit those local educational agencies, or an employee of those local educational agencies, from being subject to professional review, liable in a civil action, or subject to criminal prosecution for a pupils acts or omissions in administering those opioid antagonists, unless an act or omission of the local educational agency, or the employee of the local educational agency, constitutes gross negligence or willful and wanton misconduct connected to the administration of those opioid antagonists.

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. Existing law prohibits a person who has completed that training and who administers, in good faith and not for compensation, naloxone hydrochloride or another opioid antagonist to a person who appears to be experiencing an opioid overdose from being subject to professional review, liable in a civil action, or subject to criminal prosecution for the persons acts or omissions in administering the naloxone hydrochloride or another opioid antagonist, unless the persons acts or omissions constituted gross negligence or willful and wanton misconduct, as provided.

This bill would prohibit a school district, county office of education, or charter school from prohibiting a pupil 12 years of age or older, while on a schoolsite or participating in school activities, from carrying or administering, for the purposes of providing emergency treatment to persons who are suffering, or reasonably believed to be suffering, from an opioid overdose, a naloxone hydrochloride nasal spray or any other opioid overdose reversal medication that is federally approved for over-the-counter, nonprescription use, as provided. The bill would prohibit a pupil 12 years of age or older of those local educational agencies who administers those opioid antagonists on a schoolsite or while participating in school activities to a person who appears to be experiencing an opioid overdose, from being held liable in a civil action or being subject to criminal prosecution for their acts or omissions, unless the pupils acts or omissions constitute gross negligence or willful and wanton misconduct, as provided. The bill would also prohibit those local educational agencies, or an employee of those local educational agencies, from being subject to professional review, liable in a civil action, or subject to criminal prosecution for a pupils acts or omissions in administering those opioid antagonists, unless an act or omission of the local educational agency, or the employee of the local educational agency, constitutes gross negligence or willful and wanton misconduct connected to the administration of those opioid antagonists.

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. Existing law prohibits a person who has completed that training and who administers naloxone hydrochloride or another opioid antagonist, in good faith and not for compensation, to a person who appears to be experiencing an opioid overdose from being subject to professional review, liable in a civil action, or subject to criminal prosecution for the persons acts or omissions in administering the naloxone hydrochloride or another opioid antagonist, unless the persons acts or omissions constituted gross negligence or willful and wanton misconduct, as provided.

This bill would prohibit a school district, county office of education, or charter school from prohibiting a pupil 12 years of age or older, while on a schoolsite or participating in school activities, from carrying or administering, for the purposes of providing emergency treatment to persons who are suffering, or reasonably believed to be suffering, from an opioid overdose, specified opioid overdose reversal medications that are a naloxone hydrochloride nasal spray or any other opioid overdose reversal medication that is federally approved for over-the-counter, nonprescription use, as provided. The bill would prohibit a pupil 12 years of age or older of those local educational agencies who administers naloxone hydrochloride or another opioid antagonist those opioid antagonists on a schoolsite or while participating in school activities, in good faith and not for compensation, to a person who appears to be experiencing an opioid overdose, from being held liable in a civil action or being subject to criminal prosecution for their acts or omissions, unless the pupils acts or omissions constitute gross negligence or willful and wanton misconduct, as provided. The bill would also prohibit those local educational agencies, or an employee of those local educational agencies, from being subject to professional review, liable in a civil action, or subject to criminal prosecution for a pupils acts or omissions in administering naloxone hydrochloride or another opioid antagonist, those opioid antagonists, unless an act or omission of the local educational agency, or the employee of the local educational agency, constitutes gross negligence or willful and wanton misconduct connected to the administration of the naloxone hydrochloride or another opioid antagonist. those opioid antagonists.

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. Existing law prohibits a person who has completed that training and who administers naloxone hydrochloride or another opioid antagonist, in good faith and not for compensation, to a person who appears to be experiencing an opioid overdose from being subject to professional review, liable in a civil action, or subject to criminal prosecution for the persons acts or omissions in administering the naloxone hydrochloride or another opioid antagonist, unless the persons acts or omissions constituted gross negligence or willful and wanton misconduct, as provided.

This bill would prohibit a school district, county office of education, or charter school from prohibiting a pupil, pupil 12 years of age or older, while on a schoolsite or participating in school activities, from carrying or administering, for the purposes of providing emergency treatment to persons who are suffering, or reasonably believed to be suffering, from an opioid overdose, specified opioid overdose reversal medications that are federally approved for over-the-counter, nonprescription use, as provided. The bill would prohibit a pupil 12 years of age or older of those local educational agencies who administers naloxone hydrochloride or another opioid antagonist on a schoolsite or while participating in school activities, in good faith and not for compensation, to a person who appears to be experiencing an opioid overdose, from being held liable in a civil action or being subject to criminal prosecution for their acts or omissions, unless the pupils acts or omissions constitute gross negligence or willful and wanton misconduct, as provided. The bill would also prohibit those local educational agencies, or an employee of those local educational agencies, from being subject to professional review, liable in a civil action, or subject to criminal prosecution for a pupils acts or omissions in administering naloxone hydrochloride or another opioid antagonist, unless an act or omission of the local educational agency, or the employee of the local educational agency, constitutes gross negligence or willful and wanton misconduct connected to the administration of the naloxone hydrochloride or another opioid antagonist.

Existing law authorizes a minor who is 12 years of age or older to consent to medical care and counseling relating to the diagnosis and treatment of a drug- or alcohol-related problem. Existing law exempts replacement narcotic abuse treatment, except as specified, from these provisions.

This bill would authorize a minor to consent to receiving, and to carry and administer, naloxone hydrochloride or other opioid antagonist approved by the United States Food and Drug Administration for overdose reversal if approved by a physician and surgeon or physician assistant, as specified. The bill would prohibit a minor permitted to carry and administer naloxone hydrochloride pursuant to these provisions from being held liable in a civil action or from being subject to a criminal prosecution if they administer naloxone hydrochloride or other opioid antagonist in good faith and not for compensation to a person who appears to be experiencing an opioid overdose.

Existing law authorizes a minor who is 12 years of age or older to consent to medical care and counseling relating to the diagnosis and treatment of a drug- or alcohol-related problem. Existing law exempts replacement narcotic abuse treatment, except as specified, from these provisions.

This bill would authorize a minor to consent to receiving, and to carry and administer, naloxone hydrochloride or other opioid antagonist if approved by a physician and surgeon or physician assistant, as specified. The bill would prohibit a minor permitted to carry and administer naloxone hydrochloride pursuant to these provisions from being held liable in a civil action or from being subject to a criminal prosecution if they administer naloxone hydrochloride or other opioid antagonist in good faith and not for compensation to a person who appears to be experiencing an opioid overdose.

CONCURRENCE IN SENATE AMENDMENTS

CSA1 Bill Id:AB 2998

Author:(McKinnor)

As Amended Ver:June 20, 2024

Majority vote

SUMMARY

Prohibits school districts, county offices of education (COE), and charter schools from preventing a student 12 years of age or older from carrying or administering federally approved over-the-counter opioid reversal medication.

Senate Amendments

Clarify the definition of federally approved over-the-counter opioid reversal medications.

COMMENTS

1. Fentanyl. Fentanyl is a potent synthetic opioid drug approved by the United States 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 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 the Department of Public Health (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.

1. Reversing opioid overdoses. Naloxone hydrochloride (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.

As of July 2023 the FDA approved Narcan and RiVive, for over-the-counter (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."

According to the Substance Abuse and Mental Health Services Administration, there are no federal age restrictions on who may purchase nonprescription Narcan.

1. NH Availability in California school districts. The 2023-24 state budget appropriated $3,500,000 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. 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.

In their NDP frequently asked questions, DHCS states "California has no statute requiring minors to obtain parental or guardian consent prior to receiving NH. Additionally, Civil Code Section 1714.22 indicates that NH may be distributed to a family member, friend, or other person in a position to assist a person at risk of a suspected opioid-related overdose."

According to the Author

This bill addresses the urgent need to expand access to naloxone by allowing minors aged 12 and above to administer the medication during opioid overdoses. The author argues that this bill empowers individuals to intervene effectively and potentially save lives in emergency situations, contributing to our efforts to combat the opioid epidemic in California.

Arguments in Support

The Los Angeles Unified School District (LAUSD) is the sponsor of this bill, stating "in October of 2022, LAUSD began receiving over the counter Narcan through California's NDP to be provided to school nurses or other trained personnel; however, in the moment of crisis these nurses or trained persons may not be available to attend to student's needs. In February of 2023, as an extra layer of defense against the fentanyl epidemic, LAUSD created a policy that clarifies students will not face disciplinary actions if they carry the medication on campus. In addition, this bill protects youth from liability and criminal prosecution for administering the naloxone in good faith to combat an opioid overdose."

Arguments in Opposition

None on file.

FISCAL COMMENTS

According to the Senate Appropriations Committee, pursuant to Senate Rule 28.8, negligible state costs.

VOTES:

ASM HEALTH: 16-0-0

YES: Bonta, Waldron, Aguiar-Curry, Arambula, Wendy Carrillo, Flora, Haney, Jones-Sawyer, Maienschein, McCarty, Joe Patterson, Rodriguez, Sanchez, Santiago, Schiavo, Weber

ASM EDUCATION: 7-0-0

YES: Muratsuchi, Addis, Alvarez, Bonta, Flora, Hoover, McCarty

ASM APPROPRIATIONS: 15-0-0

YES: Wicks, Sanchez, Arambula, Bryan, Calderon, Wendy Carrillo, Dixon, Mike Fong, Grayson, Haney, Hart, Jim Patterson, Pellerin, Ta, Villapudua

ASSEMBLY FLOOR: 71-0-9

YES: Addis, Aguiar-Curry, Alanis, Alvarez, Arambula, Bains, Bauer-Kahan, Bennett, Berman, Boerner, Bonta, Bryan, Juan Carrillo, Wendy Carrillo, Chen, Connolly, Davies, Dixon, Essayli, Flora, Mike Fong, Vince Fong, Gallagher, Garcia, Gipson, Grayson, Haney, Hart, Hoover, Irwin, Jackson, Jones-Sawyer, Kalra, Lackey, Lee, Low, Lowenthal, Maienschein, McCarty, McKinnor, Muratsuchi, Stephanie Nguyen, Ortega, Pacheco, Jim Patterson, Joe Patterson, Pellerin, Petrie-Norris, Quirk-Silva, Ramos, Rendon, Reyes, Rodriguez, Blanca Rubio, Sanchez, Santiago, Schiavo, Soria, Ta, Ting, Valencia, Villapudua, Waldron, Wallis, Ward, Weber, Wicks, Wilson, Wood, Zbur, Robert Rivas

ABS, ABST OR NV: Calderon, Cervantes, Megan Dahle, Friedman, Gabriel, Holden, Mathis, Papan, Luz Rivas

SENATE FLOOR: 38-0-2

YES: Alvarado-Gil, Archuleta, Ashby, Atkins, Becker, Blakespear, Bradford, Caballero, Cortese, Dahle, Dodd, Durazo, Eggman, Glazer, Gonzalez, Grove, Hurtado, Jones, Laird, Limón, McGuire, Menjivar, Min, Newman, Nguyen, Niello, Ochoa Bogh, Padilla, Portantino, Roth, Rubio, Seyarto, Skinner, Smallwood-Cuevas, Stern, Wahab, Wiener, Wilk

ABS, ABST OR NV: Allen, Umberg

UPDATED

VERSION: June 20, 2024

CONSULTANT: Riana King / Kristene Mapile / HEALTH / (916) 319-2097 FN: 0003778

 CONSENT  

Bill No: AB 2998

Author: McKinnor (D), et al.

Amended: 6/20/24 in Senate

Vote: 21

SENATE EDUCATION COMMITTEE: 7-0, 6/12/24

AYES: Newman, Ochoa Bogh, Cortese, Glazer, Gonzalez, Limón, Wilk

SENATE JUDICIARY COMMITTEE: 10-0, 6/18/24

AYES: Umberg, Wilk, Allen, Ashby, Caballero, Durazo, Niello, Roth, Stern, Wahab

NO VOTE RECORDED: Laird

SENATE APPROPRIATIONS COMMITTEE: Senate Rule 28.8

ASSEMBLY FLOOR: 71-0, 5/21/24 (Consent) - See last page for vote

SUBJECT: Opioid overdose reversal medications: pupil administration

SOURCE: Los Angeles Unified School District

DIGEST:

This bill prohibits a local educational agency (LEA), county office of education (COE), or charter school from prohibiting a pupil 12 years or older from carrying or administering an opioid overdose reversal medication.

ANALYSIS:

Existing law:

1. Requires the governing board of each community college district (CCD) and the Trustees of the California State University (CSU), and requests the Regents of the University of California (UC), to stock fentanyl test strips in the campus health center and distribute the test strips through the campus health center. (EC § 67384)
2. Requires COEs, among other requirements, to be eligible for funds to purchase at least two units for each middle school, junior high school, high school, and adult school schoolsite within their jurisdiction, but are not required to participate. (EC § 49414.8)
3. Requires an LEA that serve pupils in any of grades 7 to 12, to include in their school safety plan, a protocol in the event a pupil is suffering or is reasonably believed to be suffering from an opioid overdose. (EC § 32282(K))
4. Permits a school nurse or trained personnel who has 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))
5. 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 are provided defense and indemnification by the LEA, COE, or charter school 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. (EC § 49414.3(i))
6. Provides a school no more than two weeks to restock their supply of naloxone or another opioid antagonist after use. (EC § 49414.3(h)
7. Permits a licensed health care provider who is authorized by law to prescribe an opioid antagonist to 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 other person in a position to assist a person at risk of an opioid-related overdose. (CIV § 1714.22 et. sq.)

This bill prohibits a LEA, COE, or charter school from prohibiting a pupil 12 years or older from carrying or administering, for the purposes of providing emergency treatment to persons who are suffering, or reasonably believed to be suffering, from an opioid overdose, either (a) a naloxone hydrochloride (narcan) nasal spray that is federally approved for over-the-counter (OTC), nonprescription use or (b) any other opioid overdose reversal medication that is federally approved for OTC, nonprescription use.

Comments

1. Need for the bill. According to the author, “AB 2998 addresses the urgent need to expand access to naloxone by allowing minors aged 12 and above to administer the medication during opioid overdoses. This bill empowers individuals to intervene effectively and potentially save lives in emergency situations, contributing to our efforts to combat the opioid epidemic in California.”
2. Addressing Fentanyl Among California Youth. Pursuant to AB 1748 (Mayes, Chapter 557, Statutes of 2016), among other things, requires the Superintendent of Public Instruction 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 California Department of Education (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 California Department of Public Health (CDPH), 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 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.

While schools are authorized but not required to stock naloxone, some 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 (which requires school employees who elect to administer naloxone, to be trained in the administration, and to keep the naloxone stocked and stored appropriately). San Diego Unified School District created its naloxone toolkit to aid other LEAs and inform parents and guardians.

Further, the Legislature has adopted a series of legislation such as SB 10 (Cortese, Chapter 856, Statutes of 2023), which requires school safety plans of schools, including charter schools, serving students in grades 7 to 12 to include a protocol for responding to a student's opioid overdose; SB 114 (Committee on Budget and Fiscal Review, Chapter 48, Statutes of 2023) that, among other items, provides $3.5 million ongoing Proposition 98 General Fund to COE to distribute opioid antagonists, with the intent that it complement efforts of the Naloxone Distribution Project; and AB 889 (Joe Patterson, Chapter 123, Statutes of 2023) which required LEAs, COE, and charter schools to annually inform parents or guardians of the dangers associated with using synthetic drugs and post this information on their respective internet websites.

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. CDPH issued the standing order in 2017 to address this need and support equitable naloxone access. The standing order:
2. Allows community organizations and other non-prescribing entities (organizations that do not employ or contract with a medical provider that has a license to prescribe and can issue a standing order and provide oversight for the distribution and administration of naloxone) 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
3. 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, schools, and other organizations may apply to use the statewide standing order if they meet certain conditions.

1. Naloxone: Training Requirements Under The Standing Order. Civil Code 1714.22 requires a person who is prescribed or possesses an opioid antagonist, pursuant to the standing order, to receive training provided by an opioid overdose prevention and treatment training program. This includes learning the causes of an opiate overdose, mouth-to-mouth resuscitation, how to contact appropriate emergency medical services, and how to administer an opioid antagonist (CIV 1714.22 (a)(2)). While CDPH makes opioid reversal medication training available online through its website, current statute does not require an individual who purchases OTC opioid reversal medication to receive training.
2. The U.S. Food and Drug Administration: Approval of OTC Naloxone. On March 29, 2023, the U.S. Food and Drug Administration (FDA) approved narcan, 4-milligram (mg) naloxone hydrochloride nasal spray for OTC, nonprescription, use – the first naloxone product approved for use without a prescription.

The FDA first approved naloxone nasal spray in 2015 as a prescription drug. 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 naloxone 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.

On July 28, 2023, the FDA approved RiVive, a (3mg) naloxone nasal spray for OTC, nonprescription use for the emergency treatment of known or suspected opioid overdose. This is the second nonprescription naloxone product the agency has approved, helping increase consumer access to naloxone without a prescription. 

Related/Prior Legislation

SB 997 (Portantino, 2024) would require middle and high schools operated by a LEA to stock and distribute fentanyl test strips, in addition to authorizing LEAs, COEs, and charter schools to develop and adopt a policy that allows pupils in middle schools and high schools to carry federally approved naloxone.

AB 461 (Ramos, Chapter 525, Statutes of 2023) required the governing board of each CCD and the Trustees of the CSU to provide information about the use and location of fentanyl test strips as part of established campus orientations, to notify students of the presence and location of fentanyl test strips, and requires that each campus health center stock and distribute fentanyl test strips, as specified.

SB 114 (Committee on Budget and Fiscal Review, Chapter 48, Statutes of 2023), among other items, provided $3.5 million ongoing Proposition 98 General Fund to COE to distribute opioid antagonists, with the intent that it complement efforts of the Naloxone Distribution Project.

FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: No

SUPPORT: (Verified 8/5/24)

Los Angeles Unified School District (source)
American Academy of Pediatrics, California
Association of California School Administrators
California Academy of Family Physicians
California Association of Alcohol and Drug Program Executives
California Coalition for Youth
California Medical Association
Office of the Riverside County Superintendent of Schools
Santa Clara County Office of Education

OPPOSITION: (Verified 8/5/24)

None received

ARGUMENTS IN SUPPORT: According to the Los Angeles Unified School District, “The Los Angeles Unified School District (Los Angeles Unified) is pleased to sponsor Assembly Bill 2998 by Assemblymember McKinnor, legislation to allow minors ages 12 and over to carry and administer over-the-counter or nonprescription naloxone hydrochloride as an emergency measure on school grounds. Naloxone is a crucial emergency response for individuals experiencing overdose from substances like fentanyl, and temporarily reverses the effects of an overdose in emergency scenarios. Naloxone is a safe, highly effective medicine used to reverse overdoses and save lives. Research shows that the availability of naloxone along with overdose education is effective at decreasing overdoses. In October of 2022, Los Angeles Unified began receiving over the counter Narcan through California’s Naloxone Distribution Project to be provided to school nurses or other trained personnel; however, in the moment of crisis these nurses or trained persons may not be available to attend to student’s needs. In February of 2023, as an extra layer of defense against the fentanyl epidemic, Los Angeles Unified created a policy that clarifies students will not face disciplinary actions if they carry the medication on campus. In addition, this bill protects youth from liability and criminal prosecution for administering the naloxone in good faith to combat an opioid overdose. The exponential rise in fentanyl deaths highlights the urgent need for action. This bill will increase the potential for people to receive immediate, lifesaving countermeasures in case of an overdose that would otherwise be impossible. For these reasons, Los Angeles Unified is pleased to sponsor AB 2998 by Assemblymember McKinnor, and is grateful for your commitment to student health.”

ASSEMBLY FLOOR: 71-0, 5/21/24

AYES: Addis, Aguiar-Curry, Alanis, Alvarez, Arambula, Bains, Bauer-Kahan, Bennett, Berman, Boerner, Bonta, Bryan, Juan Carrillo, Wendy Carrillo, Chen, Connolly, Davies, Dixon, Essayli, Flora, Mike Fong, Vince Fong, Gallagher, Garcia, Gipson, Grayson, Haney, Hart, Hoover, Irwin, Jackson, Jones-Sawyer, Kalra, Lackey, Lee, Low, Lowenthal, Maienschein, McCarty, McKinnor, Muratsuchi, Stephanie Nguyen, Ortega, Pacheco, Jim Patterson, Joe Patterson, Pellerin, Petrie-Norris, Quirk-Silva, Ramos, Rendon, Reyes, Rodriguez, Blanca Rubio, Sanchez, Santiago, Schiavo, Soria, Ta, Ting, Valencia, Villapudua, Waldron, Wallis, Ward, Weber, Wicks, Wilson, Wood, Zbur, Robert Rivas

NO VOTE RECORDED: Calderon, Cervantes, Megan Dahle, Friedman, Gabriel, Holden, Mathis, Papan, Luz Rivas

Prepared by: Kordell Hampton / ED. / (916) 651-4105

8/7/24 13:38:47

**** END ****

SENATE JUDICIARY COMMITTEE

Senator Thomas Umberg, Chair

2023-2024 Regular Session

Bill No: AB 2998 (Author:McKinnor)

Version: April 29, 2024

Hearing Date: June 18, 2024

Fiscal: Yes

Urgency: No

Consultant: CK

SUBJECT

Opioid overdose reversal medications: pupil administration

DIGEST

This bill prevents local educational agencies (LEAs) from prohibiting pupils aged 12 and older from carrying or administering opioid overdose reversal medications. The bill provides qualified immunity to such pupils for the good faith use of such medications at school when it appears someone is suffering an overdose and no liability is to attach to the LEAs or their employees for the pupil’s actions. This immunity does not cover action or inaction that constitutes gross negligence or willful and wanton misconduct.

EXECUTIVE SUMMARY

According to the Johns Hopkins Bloomberg School of Public Health, “[o]ver 500,000 people have died from opioid overdoses since 1999 [and] an estimated 93,000 people died from opioid overdoses in 2020, more than in any other year.” Opioid overdoses are characterized by central nervous system and respiratory depression, leading to coma and death. While there are various opioid antagonists, the most popular appears to be naloxone, which has the ability to counteract depression of the central nervous and respiratory system caused by an opioid overdose. Naloxone is administered by either injection into vein or muscle or via a nasal atomizer. Once administered, naloxone takes effect after around a minute, potentially saving the person’s life.

There are a host of bills that have and are currently making their way through the Legislature that attempt to address the troubling spike in opioid use and overdose. This bill paves the way for pupils, ages 12 and older, to be enlisted in the response to the crisis. LEAs are prevented from prohibiting these pupils to carry opioid antagonists. Pupils administering such medication in the face of a perceived overdose are shielded from liability, as provided, with similar immunity for the LEAs in connection with pupil administration.

The bill is sponsored by the Los Angeles Unified School District. It is supported by the American Academy of Pediatrics and the Riverside County Superintendent of Schools. No timely opposition was received by this Committee. The bill passed out of the Education Committee on a vote of 7 to 0.

PROPOSED CHANGES TO THE LAW

Existing law:

1. Provides that every person is responsible, not only for the result of their willful acts, but also for an injury occasioned to another by the person’s want of ordinary care or skill in the management of their property or person, except so far as the latter has, willfully or by want of ordinary care, brought the injury upon themselves. (Civ. Code § 1714(a).)
2. Provides that no person who, in good faith, and not for compensation, renders emergency medical or nonmedical care at the scene of an emergency shall be liable for any civil damages resulting from any act or omission. The scene of an emergency shall not include emergency departments and other places where medical care is usually offered. This applies only to medical, law enforcement, and emergency personnel, as specified. (Health & Saf. Code § 1799.102(a).)
3. Extends to all other persons not covered by the above who are rendering medical or nonmedical care or other assistance in such situations immunity from civil damages resulting from any act or omission other than acts or omissions constituting gross negligence or willful or wanton misconduct. (Health & Saf. Code § 1799.102(b).)
4. Provides that notwithstanding any other law, a person who possesses or distributes an opioid antagonist pursuant to a prescription or standing order shall not be subject to professional review, be liable in a civil action, or be subject to criminal prosecution for this possession or distribution. Further provides that a person not otherwise licensed to administer an opioid antagonist, but trained as required and who acts with reasonable care in administering an opioid antagonist, in good faith and not for compensation, to a person who is experiencing or is suspected of experiencing an overdose shall not be subject to professional review, be liable in a civil action, or be subject to criminal prosecution for this administration. (Civ. Code § 1714.22(f).)
5. Requires the State Department of Public Health, upon appropriation, 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 FDA-approved opioid antagonists 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 treatment providers. (Health & Saf. Code § 1179.80(a).)
6. Provides that notwithstanding any other law, school personnel who volunteer to be trained to administer naloxone hydrochloride (naloxone) or another opioid antagonist, in good faith and not for compensation, to a person who appears to be experiencing an opioid overdose shall 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 opioid antagonist. (Educ. Code § 49414.3(j)(1).)
7. Provides that a person who, in good faith and not for compensation, renders emergency treatment at the scene of an opioid overdose or suspected opioid overdose by administering an opioid antagonist is not be liable for civil damages resulting from an act or omission related to the rendering of the emergency treatment unless such act or omission constitutes gross negligence or willful or wanton misconduct. Similar immunity applies to a person who, in good faith and not for compensation, furnishes an opioid antagonist to a person for use at the scene of an opioid overdose or suspected opioid overdose. (Health & Saf. Code § 1799.113.)

This bill:

1. Prohibits an LEA from prohibiting a pupil 12 years of age or older, while on a schoolsite or participating in school activities, from carrying or administering, for the purposes of providing emergency treatment to persons who are suffering, or reasonably believed to be suffering, from an opioid overdose, either (1) a naloxone hydrochloride nasal spray that is federally approved for over-the-counter, nonprescription use or (2) any other opioid overdose reversal medication that is federally approved for over-the-counter, nonprescription use.
2. Provides that a pupil 12 years of age or older of an LEA who administers naloxone hydrochloride or another opioid antagonist on a schoolsite or while participating in school activities, in good faith and not for compensation, to a person who appears to be experiencing an opioid overdose is not liable in a civil action or subject to criminal prosecution for their acts or omissions in administering it, unless the pupil’s acts or omissions constitute gross negligence or willful and wanton misconduct.
3. Provides that an LEA, or an employee of an LEA, shall not be subject to professional review, liable in a civil action, or subject to criminal prosecution for a pupil’s acts or omissions in administering naloxone hydrochloride or another opioid antagonist, unless an act or omission of the LEA or the employee constitutes gross negligence or willful and wanton misconduct.
4. Defines LEA to mean a school district, county office of education, or charter school.

COMMENTS

• • • 1. The opioid epidemic

As stated, it is not only this state, but the entire country, that is being ravaged by opioid overdose deaths. Examples of opioids include heroin, oxycodone (OxyContin®), hydrocodone (Vicodin®), codeine, and morphine. One major cause of the dramatic rise in overdose numbers is the increasing use of one particularly dangerous iteration, fentanyl:

The death toll has spiked in recent years, largely as a result of the growing ubiquity of the powerful opioid fentanyl.

The legally prescribed painkiller has become a popular illicit street drug over the last decade. It has also killed thousands of people who unknowingly consumed other drugs such as cocaine or heroin that were surreptitiously laced with fentanyl.

The U.S. Centers for Disease Control and Prevention has described fentanyl as up to 50 times as potent as heroin and 100 times as potent as morphine.

More than 71,000 people died in the U.S. of overdoses caused by synthetic opioids — primarily fentanyl — in 2021, an increase of more than 23% from the previous year. In 2012, the CDC recorded just 1,615 overdose deaths involving fentanyl in the U.S.

In the face of such distressing failure to reduce deaths from opioids, methods for addressing the crisis that many once considered too risky or even unthinkable are now being debated by state and local officials and rolled out in communities devastated by overdoses.^[1]

One critical tool in the fight against opioid overdoses is an opioid antagonist, which is a drug that attaches to opioid receptors and reverses and blocks the effects of other opioids.^[2] Naloxone is a popular form of this medicine that can rapidly reverse an opioid overdose. Naloxone can quickly restore normal breathing to a person if their breathing has slowed or stopped because of an overdose. Crucially, naloxone has little to no effect on someone who does not have opioids in their system.

Opioid antagonists should be given to any person who shows signs of an opioid overdose or when an overdose is suspected. Naloxone can be given as a nasal spray or it can be injected into the muscle, under the skin, or into the veins.

• • • 1. Civil liability and immunity

As a general rule, California law provides that persons are responsible, not only for the result of their willful acts, but also for an injury occasioned to another by their want of ordinary care or skill in the management of their property or person, except so far as the latter has, willfully or by want of ordinary care, brought the injury upon themselves. (Civ. Code § 1714(a).) Liability has the primary effect of ensuring that some measure of recourse exists for those persons injured by the negligent or willful acts of others; the risk of that liability has the primary effect of ensuring parties act reasonably to avoid harm to those to whom they owe a duty.

Conversely, immunity from liability disincentivizes careful planning and acting on the part of individuals and entities. When one enjoys immunity from civil liability, they are relieved of the responsibility to act with due regard and an appropriate level of care in the conduct of their activities. Immunity provisions are also disfavored because they, by their nature, preclude parties from recovering when they are injured, and force injured parties to absorb losses for which they are not responsible. Liability acts not only to allow a victim to be made whole, but to encourage appropriate compliance with legal requirements.

Although immunity provisions are rarely preferable, the Legislature has, in limited scenarios, approved measured immunity from liability (as opposed to blanket immunities) to promote other policy goals that could benefit the public. Immunities are generally afforded when needed to ensure the willingness of individuals to continue taking on certain roles that may involve some risk and to incentivize certain conduct, such as the provision of life-saving or other critical services. Examples include protections for use of CPR (Civ. Code § 1714.2); use of an automated external defibrillator (Civ. Code § 1714.21); providing emergency care at the scene of an emergency (Health & Saf. Code §§ 1799.102, 1799.106); and performing emergency rescue services (Health & Saf. Code § 1799.107). However, as indicated above, rarely is immunity absolute, and these immunities generally do not cover grossly negligent conduct or intentional misconduct.

• • • 1. Incentivizing the administration of opioid antagonists

In order to maximize the life-saving capabilities of opioid antagonists, this bill provides qualified immunity to students as young as 12 who, in good faith, and not for compensation, administer naloxone hydrochloride or another opioid antagonist to a person who appears to be experiencing an opioid overdose while at school or an associated activity.^[3] The person is immune from civil and criminal liability for acts or omissions related to such administration. The immunity also covers the LEA and its employees with regard to the pupils actions or omissions. The above immunities do not apply to acts or omissions constituting gross negligence or willful or wanton misconduct.

These provisions mimic, and supplement, similar existing laws. For instance, Education Code section 49414.3 authorizes LEAs to designate volunteers to train on emergency use of naloxone hydrochloride or another opioid antagonist. A school nurse or trained volunteer is authorized to administer naloxone hydrochloride or another opioid antagonist to a person exhibiting potentially life-threatening symptoms of an opioid overdose at school or a school activity. The LEA is required to ensure that each employee who volunteers will be provided defense and indemnification for any and all civil liability. A person trained to administer an opioid antagonist that, in good faith and not for compensation, provides it to a person who appears to be experiencing an opioid overdose is shielded from professional review, liability in a civil action, and criminal prosecution for their acts or omissions in administering the opioid antagonist. As here, the immunity does not apply in a case of gross negligence or willful and wanton misconduct of the person.

Just last year AB 1166 (Bains, Ch. 97, Stats. 2023) extended qualified immunity to a person who, in good faith, and not for compensation, renders emergency treatment at the scene of an opioid overdose or suspected opioid overdose by administering an opioid antagonist. The immunity also covers a person who, in good faith, and not for compensation, furnishes the opioid antagonist for use in such situations. Again, these immunities do not apply to acts or omissions constituting gross negligence or willful or wanton misconduct.

The bill also tracks with the immunity provisions of Section 1799.102 of the Health and Safety Code, often referred to as the “Good Samaritan Law.” That statute provides immunity for those rendering emergency medical or nonmedical care at the scene of an emergency, as specified.

The bill additionally restricts an LEA from prohibiting pupils who are 12 years of age or older from carrying or administering these opioid antagonists for the purposes of administering them in an emergency.

According to the author:

AB 2998 addresses the urgent need to expand access to naloxone by allowing minors aged 12 and above to administer the medication during opioid overdoses. This bill empowers individuals to intervene effectively and potentially save lives in emergency situations, contributing to our efforts to combat the opioid epidemic in California.

The Los Angeles Unified School District, the sponsor of this bill, writes in support:

Naloxone is a crucial emergency response for individuals experiencing overdose from substances like fentanyl, and temporarily reverses the effects of an overdose in emergency scenarios. Naloxone is a safe, highly effective medicine used to reverse overdoses and save lives. Research shows that the availability of naloxone along with overdose education is effective at decreasing overdoses.

In October of 2022, Los Angeles Unified began receiving over the counter Narcan through California’s Naloxone Distribution Project to be provided to school nurses or other trained personnel; however, in the moment of crisis these nurses or trained persons may not be available to attend to student’s needs. In February of 2023, as an extra layer of defense against the fentanyl epidemic, Los Angeles Unified created a policy that clarifies students will not face disciplinary actions if they carry the medication on campus. In addition, this bill protects youth from liability and criminal prosecution for administering the naloxone in good faith to combat an opioid overdose.

The exponential rise in fentanyl deaths highlights the urgent need for action. This bill will increase the potential for people to receive immediate, lifesaving countermeasures in case of an overdose that would otherwise be impossible.

SUPPORT

Los Angeles Unified School District (sponsor)

American Academy of Pediatrics, California

Association of California School Administrators

California Academy of Family Physicians

California Coalition for Youth

California Medical Association

Los Angeles Unified School District

Office of the Riverside County Superintendent of Schools

Santa Clara County Office of Education

OPPOSITION

None received

RELATED LEGISLATION

Pending Legislation:

SB 472 (Hurtado, 2023) requires each public school to maintain at least two doses of naloxone on its campus, and to report to the California Department of Health Care Services on why they are not exercising their authority, if applicable, to distribute naloxone and how they came to that determination. SB 472 was held in the Senate Appropriations Committee.

SB 868 (Wilk, 2023) requires local educational agencies to equip each classroom with a trauma kit and to offer training to employees on the use of such kits. Employees who render emergency care with such kits are granted qualified immunity from civil damages, as provided. AB 868 is currently in the Assembly Appropriations Committee.

AB 1841 (Weber, 2024) requires the governing board of each community college district and the Trustees of the California State University to notify, by sending an email at the beginning of each academic semester or term, students of the presence and location of fentanyl test strips and opioid overdose reversal medication, and to distribute, at the beginning of each academic semester or term, two doses of a federally approved opioid overdose reversal medication obtained through the Naloxone Distribution Project to residential advisors. AB 1841 is currently in the Senate Health Committee.

Prior Legislation:

SB 234 (Portantino, Ch. 596, Stats. 2023) requires public schools, institutions of higher education, stadiums, concert venues, and amusement parks to maintain unexpired doses of naloxone hydrochloride or another opioid antagonist on its premises and provides qualified immunity to those administering such opioid antagonists and to medical professionals for prescribing it.

AB 1166 (Bains, Ch. 97, Stats. 2023) See Comment 3.

AB 1810 (Levine, Ch. 906, Stats. 2022) authorized schools to designate and train persons to provide anti-seizure medication in an emergency involving a pupil diagnosed with a seizure disorder. The persons must be provided defense and indemnification and are granted qualified immunity, as specified.

AB 635 (Ammiano, Ch. 707, Stats. 2013) afforded qualified immunity from civil liability, criminal prosecution, or professional review to licensed health care providers who issue prescriptions or standing orders, as specified; and immunity from civil action or criminal prosecution, or professional review, to any persons who possess or distribute naloxone pursuant to a prescription or standing order, or acting with reasonable care in administering naloxone, as specified.

PRIOR VOTES:

Senate Education Committee (Ayes 7, Noes 0)

Assembly Floor (Ayes 71, Noes 0)

Assembly Appropriations Committee (Ayes 15, Noes 0)

Assembly Education Committee (Ayes 7, Noes 0)

Assembly Health Committee (Ayes 16, Noes 0)

**************

1. Connor Sheets, As fentanyl overdose deaths keep rising, efforts to reverse trend meet liability fears (December 27, 2022) Los Angeles Times, https://www.latimes.com/california/story/2022-12-27/as-overdose-deaths-keep-rising-bold-efforts-to-reverse-the-trend-emerge. All internet citations are current as of June 3, 2024. ↑

2. Naloxone DrugFacts (January 2022) National Institute on Drug Abuse, https://nida.nih.gov/publications/drugfacts/naloxone. ↑

3. Other laws in this space generally define “opioid antagonist” to include naloxone hydrochloride or any other opioid antagonist that is federally approved for the treatment of an opioid overdose. The author has agreed to an amendment providing a definition for the medication covered. ↑

SENATE COMMITTEE ON EDUCATION

Senator Josh Newman, Chair

2023 - 2024 Regular

Bill No: AB 2998 Hearing Date: June 12, 2024

Subject: Opioid overdose reversal medications: pupil administration.

NOTE: This bill has been referred to the Committees on Education and Judiciary. A "do pass" motion should include referral to the Committee on Judiciary.

SUMMARY

This bill prohibits a local educational agency (LEA), county office of education (COE), or charter school from prohibiting a pupil 12 years or older from carrying or administering an opioid overdose reversal medication.

BACKGROUND

Existing Law:

Education Code (EC)

1. Requires the governing board of each community college district (CCD) and the Trustees of the California State University (CSU), and requests the Regents of the University of California (UC), to stock fentanyl test strips in the campus health center and distribute the test strips through the campus health center. (EC § 67384)
2. Requires COEs, among other requirements, to be eligible for funds to purchase at least two units for each middle school, junior high school, high school, and adult school schoolsite within their jurisdiction, but are not required to participate. (EC § 49414.8)
3. Requires an LEA that serve pupils in any of grades 7 to 12, to include in their school safety plan, a protocol in the event a pupil is suffering or is reasonably believed to be suffering from an opioid overdose. (EC § 32282(K))
4. Permits a school nurse or trained personnel who has 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))
5. 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 are provided defense and indemnification by the LEA, COE, or charter school 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. (EC § 49414.3(i))
6. Provides a school no more than two weeks to restock their supply of naloxone or another opioid antagonist after use. (EC § 49414.3(h)

Civil Code (CIV)

1. Permits a licensed health care provider who is authorized by law to prescribe an opioid antagonist to 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 other person in a position to assist a person at risk of an opioid-related overdose. (CIV § 1714.22 et. sq.)

ANALYSIS

1. This bill prohibits a LEA, COE, or charter school from prohibiting a pupil 12 years or older from carrying or administering, for the purposes of providing emergency treatment to persons who are suffering, or reasonably believed to be suffering, from an opioid overdose, either (1) a naloxone hydrochloride (narcan) nasal spray that is federally approved for over-the-counter (OTC), nonprescription use or (2) any other opioid overdose reversal medication that is federally approved for OTC, nonprescription use.

STAFF COMMENTS

1. Need for the bill. According to the author, “AB 2998 addresses the urgent need to expand access to naloxone by allowing minors aged 12 and above to administer the medication during opioid overdoses. This bill empowers individuals to intervene effectively and potentially save lives in emergency situations, contributing to our efforts to combat the opioid epidemic in California.”
2. Addressing Fentanyl Among California Youth. Pursuant to AB 1748 (Mayes, Chapter 557, Statutes of 2016), among other things, requires the Superintendent of Public Instruction 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 California Department of Education (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 California Department of Public Health (CDPH), 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 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.

While schools are authorized but not required to stock naloxone, some 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 (which requires school employees who elect to administer naloxone, to be trained in the administration, and to keep the naloxone stocked and stored appropriately). San Diego Unified School District created its naloxone toolkit to aid other LEAs and inform parents and guardians.

Further, the Legislature has adopted a series of legislation such as SB 10 (Cortese, Chapter 856, Statutes of 2023), which requires school safety plans of schools, including charter schools, serving students in grades 7 to 12 to include a protocol for responding to a student's opioid overdose; SB 114 (Committee on Budget and Fiscal Review, Chapter 48, Statutes of 2023) that, among other items, provides $3.5 million ongoing Proposition 98 General Fund to COE to distribute opioid antagonists, with the intent that it complement efforts of the Naloxone Distribution Project; and AB 889 (Joe Patterson, Chapter 123, Statutes of 2023) which required LEAs, COE, and charter schools to annually inform parents or guardians of the dangers associated with using synthetic drugs and post this information on their respective internet websites.

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. CDPH issued the standing order in 2017 to address this need and support equitable naloxone access. The standing order:
2. Allows community organizations and other non-prescribing entities (organizations that do not employ or contract with a medical provider that has a license to prescribe and can issue a standing order and provide oversight for the distribution and administration of naloxone) 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
3. 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, schools, and other organizations may apply to use the statewide standing order if they meet certain conditions.

Naloxone: Training Requirements Under The Standing Order.

Civil Code 1714.22 requires a person who is prescribed or possesses an opioid antagonist, pursuant to the standing order, to receive training provided by an opioid overdose prevention and treatment training program. This includes learning the causes of an opiate overdose, mouth-to-mouth resuscitation, how to contact appropriate emergency medical services, and how to administer an opioid antagonist (CIV 1714.22 (a)(2)). While CDPH makes opioid reversal medication training available online through its website, current statute does not require an individual who purchases OTC opioid reversal medication to receive training.

1. The U.S. Food and Drug Administration: Approval of OTC Naloxone. On March 29, 2023, the U.S. Food and Drug Administration (FDA) approved narcan, 4-milligram (mg) naloxone hydrochloride nasal spray for OTC, nonprescription, use – the first naloxone product approved for use without a prescription.

The FDA first approved naloxone nasal spray in 2015 as a prescription drug. 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 naloxone 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.

On July 28, 2023, the FDA approved RiVive, a (3mg) naloxone nasal spray for OTC, nonprescription use for the emergency treatment of known or suspected opioid overdose. This is the second nonprescription naloxone product the agency has approved, helping increase consumer access to naloxone without a prescription. 

1. Related Legislation.

SB 997 (Portantino, 2024) would require middle and high schools operated by a LEA to stock and distribute fentanyl test strips, in addition to authorizing LEAs, COEs, and charter schools to develop and adopt a policy that allows pupils in middle schools and high schools to carry federally approved naloxone.

AB 461 (Ramos, Chapter 525, Statutes of 2023) requires the governing board of each CCD and the Trustees of the CSU to provide information about the use and location of fentanyl test strips as part of established campus orientations, to notify students of the presence and location of fentanyl test strips, and requires that each campus health center stock and distribute fentanyl test strips, as specified.

SB 114 (Committee on Budget and Fiscal Review, Chapter 48, Statutes of 2023), among other items, provides $3.5 million ongoing Proposition 98 General Fund to COE to distribute opioid antagonists, with the intent that it complement efforts of the Naloxone Distribution Project.

SB 10 (Cortese, Chapter 856, Statutes of 2023) requires school safety plans of schools, including charter schools, serving students in grades 7 to 12 to include a protocol for responding to a student's opioid overdose; requires the CDE to post informational materials on its website on opioid overdose prevention; and encourages COEs to establish working groups on fentanyl education in schools.

SUPPORT

Los Angeles Unified School District (Sponsor)

American Academy of Pediatrics, California

Association of California School Administrators

California Academy of Family Physicians

California Association of Alcohol and Drug Program Executives

California Medical Association

Office of The Riverside County Superintendent of Schools

Santa Clara County Office of Education

OPPOSITION

None received

-- END --

Date of Hearing: May 15, 2024

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Buffy Wicks, Chair

ABPCA Bill Id:AB 2998

Author:(McKinnor) – As Amended Ver:April 29, 2024

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

SUMMARY:

This bill prohibits a school district, county office of education, or charter school from prohibiting a pupil 12 years or older from carrying or administering an opioid overdose reversal medication.

Specifically, this bill:

1. Prohibits a local educational agency (LEA) from preventing a pupil 12 years of age or older from carrying or administering a federally-approved naloxone hydrochloride (NH) nasal spray or any other opioid reversal medication that is federally-approved for over-the-counter, non-prescription use for the emergency treatment of persons who are suffering, or reasonably believed to be suffering, from an opioid overdose at a schoolsite or when participating in school activities.
2. Requires that a pupil 12 years of age or older be exempt from civil liability for administering an opioid antagonist on a schoolsite to a person suffering from an opioid overdose, unless the pupil’s acts or omissions constitute gross negligence or willful and wanton misconduct.
3. Provides that an employee of an LEA is not to be subject to professional review, liable in a civil action, or subject to criminal prosecution for a pupil’s acts or omissions in administering an opioid antagonist, unless an act or omission of the employee constitutes gross negligence or willful or wanton misconduct.

FISCAL EFFECT:

No state costs.

COMMENTS:

1. Purpose. According to the author:

AB 2998 addresses the urgent need to expand access to naloxone by allowing minors to administer the medication during opioid overdoses. This bill empowers individuals to intervene effectively and potentially save lives in emergency situations, contributing to our efforts to combat the opioid epidemic in California.

1. Background. Existing law authorizes LEAs 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. LEAs and charter schools enrolling students in grades seven to 12 must also include in their comprehensive school safety plan a protocol for NH use in the event a student is suffering, or reasonably believed to be suffering, from an opioid overdose.
   
   The Los Angeles Unified School District, the state’s largest school district, announced plans to stock NH 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 NH at schools with students in sixth grade or higher. Since 2020, Elk Grove Unified School District has provided NH 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 NH and made NH available to registered nurses at the district’s high schools.
   
   The Department of Health Care Services, which runs the state’s Naloxone Distribution Project, states, “California has no statute requiring minors to obtain parental or guardian consent prior to receiving NH.” According to the federal Substance Abuse and Mental Health Services Administration, there are no federal age restrictions on who may purchase non-prescription NH.
2. Related Legislation. Numerous bills in recent years have addressed the opioid crisis, including:
   1. 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.
   2. AB 19 (Joe Patterson), of the current legislative session, requires public schools to maintain at least two doses of NH or another opioid antagonist. AB 19 was held in Senate Appropriations Committee.
   3. AB 1915 (Arambula) requires the California Department of Public Health to develop a training program and toolkit for public school students in grades nine to 12 to gain skills in how to identify and respond to an opioid overdose, including the administration of a federally-approved opioid overdose reversal medication. AB 1915 is pending in this committee.
   4. AB 3271 (Joe Patterson) requires each public school that has chosen to permit school nurses or voluntarily trained personnel to use NH or another opioid antagonist to maintain at least two units of NH or another opioid antagonist on its site. AB 3271 is pending in this committee.
   5. SB 472 (Hurtado), of the current legislative session, would have required each campus of a public school to maintain and distribute pursuant to the standing order for NH at least two doses of NH or another opioid antagonist, among other provisions. SB 472 was held in Senate Appropriations Committee.

Analysis Prepared by: Allegra Kim / APPR. / (916) 319-2081

Date of Hearing: April 24, 2024

ASSEMBLY COMMITTEE ON EDUCATION

Al Muratsuchi, Chair

ABPCA Bill Id:AB 2998 (

Author:McKinnor) – As Amended Ver:April 11, 2024

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

SUBJECT: Opioid overdose reversal medications: pupil administration

SUMMARY: Prohibits school districts, county offices of education (COE), and charter schools from preventing a student from carrying or administering an opioid reversal medication. Specifically, this bill:

1. Prohibits school districts, COEs, and charter schools from preventing a student from carrying or administering a federally-approved naloxone hydrochloride (NH) nasal spray or any other opioid reversal medication that is federally-approved for over-the-counter (OTC), non-prescription use for the emergency treatment of persons who are suffering, or reasonably believed to be suffering from an opioid overdose at a schoolsite or when participating in school activities.
2. Requires that a student be exempt from civil liability for administering an opioid antagonist on a schoolsite to a person suffering from an opioid overdose, unless the student’s acts or omissions constitute gross negligence or willful and wanton misconduct.
3. Requires that an employee of a school district, COE, or charter school not be subject to professional review, liable in a civil action, or subject to criminal prosecution for a student’s acts or omissions in administering an opioid antagonist, unless an act or omission of an employee constitutes gross negligence or willful or wanton misconduct.

EXISTING LAW:

1. 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. (Education Code (EC) 49414.3)
2. Requires that the comprehensive school safety plan developed by school districts and COEs enrolling students in grades 7 to 12 include a protocol in the event a student is suffering or reasonably believed to be suffering from an opioid overdose. (EC 32282)
3. Requires the school safety plan developed by charter schools enrolling students in grades 7 to 12 include a protocol in the event a student is suffering or reasonably believed to be suffering from an opioid overdose. (EC 47605 and 47605.6)
4. Encourages COEs to establish a County Working Group on Fentanyl Education in Schools for outreach, building awareness, and collaborating with local health agencies regarding fentanyl overdoses and encourages the working group to include representatives of local educational agencies (LEAs) within the county as well as the county public health department. Also requires the California Department of Education (CDE) to curate and maintain on its website, informational materials containing awareness and safety advice on how to prevent an opioid overdose. (EC 49428.16)
5. Authorizes a pharmacy to furnish NH or another opioid antagonist to a school district, COE, or charter school provided that the NH or another opioid antagonist is for use exclusively at the school site and if a physician provides a written order that specifies the quantity of NH or another opioid antagonist is to be furnished. (Business and Professions Code (BPC) 4119.8)
6. Authorizes a minor who is 12 years of age or older to consent to medical care and counseling related to the diagnosis and treatment of a drug or alcohol-related problem. (Family (FAM) 6929)

FISCAL EFFECT: Unknown

COMMENTS:

Need for the bill. According to the author, “AB 2998 addresses the urgent need to expand access to naloxone by allowing minors to administer the medication during opioid overdoses. This bill empowers individuals to intervene effectively and potentially save lives in emergency situations, contributing to our efforts to combat the opioid epidemic in California.”

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 1960s 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 have been 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 by 625% among ages 10-19 from 2018 to 2020, and there were 177 fentanyl-related overdose deaths and 1,165 opioid-related overdose emergency departments visits among youth ages 10 to 19 years old in 2022.

Current law requires the Superintendent of Public Instruction (SPI) to establish minimum training standards for school employees who volunteer to administer NH 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 NH or another opioid antagonist to pupils. 

The CDE, in conjunction with the CDPH, has developed resources and information that LEAs can readily share with parents and students to help keep them safe. The Fentanyl Awareness and Prevention webpage 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. 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.

In July 2023, the Food and Drug Administration (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 is 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.”

Naloxone Distribution Project. A 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 1% of the overdose reversals reported in the NDP occurred in schools and universities.

Should there be age restrictions on accessing NH? In their NDP frequently asked questions, DHCS states, “California has no statute requiring minors to obtain parental or guardian consent prior to receiving NH.” According to the Substance Abuse and Mental Health Services Administration, there are no federal age restrictions on who may purchase nonprescription NH. The Committee may wish to consider whether there should be a minimum age requirement for a student to be permitted to carry and administer an opioid antagonist on school grounds.

Some California school districts have opted to make NH available. The Los Angeles Unified School District (LAUSD), the state’s largest school district, announced plans to stock NH 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 NH at schools with students in sixth grade or higher. Since 2020, Elk Grove Unified School District has provided NH 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 NH and made it available to them at that district’s high schools.

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

1. Limit the authorization for a student to carry and administer NH or another approved opioid antagonist to those 12 years of age or older.

Arguments in support. The Los Angeles Unified School District (LAUSD), the sponsor of the measure, writes “Naloxone is a crucial emergency response for individuals experiencing overdose from substances like fentanyl, and temporarily reverses the effects of an overdose in emergency scenarios. Naloxone is a safe, highly effective medicine used to reverse overdoses and save lives. Research shows that the availability of naloxone along with overdose education is effective at decreasing overdoses.

In October of 2022, LAUSD began receiving OTC Narcan through California’s Naloxone Distribution Project to be provided to school nurses or other trained personnel; however, in the moment of crisis these nurses or trained persons may not be available to attend to student’s needs. In February of 2023, as an extra layer of defense against the fentanyl epidemic, Los Angeles Unified created a policy that clarifies students will not face disciplinary actions if they carry the medication on campus. In addition, this bill protects youth from liability and criminal prosecution for administering the naloxone in good faith to combat an opioid overdose.

The exponential rise in fentanyl deaths highlights the urgent need for action. This bill will increase the potential for people to receive immediate, lifesaving countermeasures in case of an overdose that would otherwise be impossible.”

Related legislation. AB 3271 (Joe Patterson) of the 2023-24 Session would require each public school that has chosen to permit school nurses or voluntarily trained personnel to use NH or another opioid antagonist to provide emergency medical aid to persons suffering from an opioid overdose, to maintain at least two units of NH or another opioid antagonist on its site.

AB 1915 (Arambula) of the 2023-24 Session would require the CDPH to develop, by July 1, 2026, a training program and toolkit for public school students 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.

SB 997 (Portantino) of the 2023-24 Session would require middle and high schools operated by a LEA to stock and distribute fentanyl test strips, in addition to authorizing LEAs, COEs, and charter schools to develop and adopt a policy that allows pupils in middle and high schools to carry federally approved NH.

AB 2429 (Alvarez) of the 2023-24 Session would require that if the governing board of a school district or the governing body of a charter school requires a course in health education for graduation from high school, it include, commencing with the 2026–27 school year, instruction on the dangers associated with fentanyl use, as specified.

AB 1915 (Arambula) of the 2023-24 Session would have established a voluntary training program for high school students on how to administer NH during an opioid overdose; required the CDPH to develop the training and resource materials in collaboration with specified entities; and required schools that elect to stock NH to place it in specified locations. This bill was held in the Assembly Appropriations Committee.

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.

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.

AB 19 (Joe Patterson) of the 2023-24 Session would have required public schools to maintain at least two doses of NH or another opioid antagonist to provide emergency medical aid to a person suffering from an opioid overdose. This bill was held in the Senate Appropriations Committee.

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 NH or another opioid antagonist pursuant to the standing order for NH and requires LEAs, COEs, and charter schools to report to the DHCS for failure to distribute NH. This bill was held in the Senate Appropriations Committee.

AB 915 (Arambula) of the 2023-24 Session would have required 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 have authorized public middle and high schools serving pupils in grades 5 to 12 to voluntarily determine whether or not to host the program on their campuses. The bill would require have required 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. 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 NH or another opioid antagonist to provide emergency medical aid to persons suffering, or reasonably believed to be suffering, from an opioid overdose.

REGISTERED SUPPORT / OPPOSITION:

Support

American Academy of Pediatrics, California

Association of California School Administrators

California Association of Alcohol and Drug Program Executives

Los Angeles Unified School District

The Los Angeles Trust for Children's Health

Opposition

None on file

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

Date of Hearing: April 9, 2024

ASSEMBLY COMMITTEE ON HEALTH

Mia Bonta, Chair

ABPCA Bill Id:AB 2998 (

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

SUBJECT: Minors: consent to medical care.

SUMMARY: Permits minors 12 years of age and above to consent to receiving, carrying, and administering naloxone hydrochloride (NH) or another opioid antagonist approved by the United States Food and Drug Administration (FDA) for overdose reversal if approved by a physician or physician assistant. Specifically, this bill:

1. Permits minors 12 years of age and above to consent to receiving, carrying, and administering NH or another opioid antagonist approved by the FDA for overdose reversal on a school campus, park or recreational center, or other places of public accommodations, if approved by a physician or physician assistant.
2. Provides protection from civil liability or criminal prosecution for minors who are permitted to administer an opioid antagonist, in good faith, to a person who appears to be experiencing an opioid overdose.

EXISTING LAW:

1. Authorizes a minor who is 12 years of age or older to consent to medical care and counseling relating to the diagnosis and treatment of a drug- or alcohol-related problem, excluding replacement narcotic abuse treatment. [Family Code (FAM) § 6929]
2. Authorizes a minor 16 years of age or older to consent to replacement narcotic abuse treatment that uses buprenorphine, without the consent of the minor’s parent or guardian only if, and to the extent, expressly permitted by federal law. [FAM § 6929 - 6929.1]
3. Establishes ongoing funding for county offices of education (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]
4. 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.]
5. 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)]
6. 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)]
7. 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 §4119.8]
8. Authorizes the State Department of Public Health (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 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 treatment providers. [Health and Safety Code §1179.80]
9. Prohibits a person who possesses or distributes an opioid antagonist pursuant to a prescription or standing order from being subject to professional review, being liable in a civil action, or being subject to criminal prosecution for this possession or distribution. Prohibits a person who is not otherwise licensed to administer an opioid antagonist, but trained as required, who acts with reasonable care in administering an opioid antagonist, in good faith and not for compensation, to a person who is experiencing or is suspected of experiencing an overdose, from being subject to professional review, being liable in a civil action, or being subject to criminal prosecution for this administration. [Civil Code §1714.22]

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

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, this bill addresses the urgent need to expand access to naloxone by allowing minors aged 12 and above to administer the medication during opioid overdoses. The author argues that this bill empowers individuals to intervene effectively and potentially save lives in emergency situations, contributing to our efforts to combat the opioid epidemic in California.
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 Substance Use Disorder (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 departments 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 (CDE), in conjunction with DPH, provides local educational agencies (LEAs) 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.”

According to the Substance Abuse and Mental Health Services Administration, there are no federal age restrictions on who may purchase nonprescription Narcan.

• 1. NH Availability in California school districts. The 2023-24 state budget appropriated $3,500,000 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.

In their NDP frequently asked questions, DHCS states “California has no statute requiring minors to obtain parental or guardian consent prior to receiving NH. Additionally, Civil Code §1714.22 indicates that NH may be distributed to a family member, friend, or other person in a position to assist a person at risk of a suspected opioid-related overdose.”

1. SUPPORT. The Los Angeles Unified School District (LAUSD) is the sponsor of this bill, stating “in October of 2022, LAUSD began receiving over the counter Narcan through California’s NDP to be provided to school nurses or other trained personnel; however, in the moment of crisis these nurses or trained persons may not be available to attend to student’s needs. In February of 2023, as an extra layer of defense against the fentanyl epidemic, LAUSD created a policy that clarifies students will not face disciplinary actions if they carry the medication on campus. In addition, this bill protects youth from liability and criminal prosecution for administering the naloxone in good faith to combat an opioid overdose.”
2. RELATED LEGISLATION.
   1. AB 1915 (Arambula) requires 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. AB 1915 is currently 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. PREVIOUS LEGISLATION.
   1. AB 816 (Haney), Chapter 456, Statutes of 2023, creates an exception that allows a minor who is at least 16 years of age or older to consent to narcotic replacement therapy as part of their substance abuse treatment plan.
   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, upon passage of this Committee, it will be referred to the Assembly Judiciary Committee.
5. SUGGESTED AMENDMENT. There is no state or federal law that prohibits minors from accessing, carrying, receiving, or administering NH. Additionally, minors are allowed to purchase OTC NH without a physician’s approval. This bill as drafted could unintentionally require physician approval for NH access and create barriers to access that don’t currently exist. Additionally, a physician traditionally prescribes a medication that a patient takes themselves. But NH is not self-administered, it is administered to a third party in event of an overdose. It is unclear how a physician would provide approval for a minor to administer NH to another person. Instead of altering minor consent laws, the committee may wish to consider amending this bill to instead make it clear that students are allowed to carry and administer NH on campus, which is the intended goal of the author and sponsors.

REGISTERED SUPPORT / OPPOSITION:

Support

Los Angeles Unified School District (sponsor)

American Academy of Pediatrics, California

Association of California School Administrators

California Association of Alcohol and Drug Program Executives, Inc.

The Los Angeles Trust for Children’s Health

Opposition

None on file.

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