Almost 22 percent of U.S. high school students have been offered, sold, or given an illegal drug on school premises, according to a 2016 study (Kann, McManus, Harris, & Shanklin). Opioid misuse is an epidemic in America, and it is often initiated during the high school years. In fact, a startling 90 percent of adults struggling with addiction began using alcohol, tobacco, and other drugs before the age of 18 (CASA, 2011).
Opioids—a drug class that includes morphine, heroin, methadone, and oxycodone, among others—largely work to relieve the sensation of pain. Users report not only experiencing relief from physical pain, but also feeling more relaxed and less stressed, making these drugs appealing to high school students facing the pressures of athletic and academic success. In low doses and short-term use, opioids are not dangerous, but long-term use can lead to addiction and dependency.
It is vital for educators and school personnel to be able to identify students who are misusing opioids so that they can be assessed and receive necessary treatments. Early assessments and brief interventions are highly effective in changing the course of opioid misuse for teens. Here are seven things all educators should know about opioid use.
1. Students are often introduced to opioids legitimately.
Students commonly first encounter opioids through an official medical prescription after dental work or minor surgery. Teenagers may not recognize that opioids are dangerous because they are prescribed by doctors. They may continue using them because they believe the drugs help them relax or deal with pain or stress.
For example, an athlete who is prescribed opioids post-surgery for an injury might continue to misuse the drug to increase pain tolerance during games so as to "not let his teammates down." High-achieving, perfectionist, and extremely motivated students may be tempted to use opioids to experience euphoria, temporarily reduce their stress, and sustain longer periods of uninterrupted study time.
A common misconception is that teenagers use drugs to experiment. In fact, relatively few teenagers (15 percent) report that they last misused a prescription drug to experiment with its effects (Partnership for a Drug-Free America, 2013).
2. It is very easy to overdose on opioids.
Teenagers may not realize how dangerous it is to combine opioids with other drugs such as alcohol. With an increase in how many homes have these drugs, as well as increased instances of illegal distribution, teens may think it is "no big deal" to use the drugs, or combine them, when they are so readily available. In fact, most adolescents who abuse prescription drugs are given the pills for free by a friend (Johnston et al., 2017).
It is also easy for teens to take these drugs in excessive quantities, resulting in an overdose (a decreased ability to breathe) and possibly death. Any route of ingestion, from taking a pill to injecting, can result in an overdose. Contrary to popular beliefs, many teenagers insufflate (snort) heroin instead of injecting it. Higher potency opioids, like fentanyl—which is up to 50 times more powerful than heroin—are often mixed with other opioids, increasing the chance of an overdose. Many people who overdose are not aware that the opioid they ingested was mixed with other types of opioids. For instance, drug dealers are making counterfeit pills that have the markings of oxycodone, but actually contain higher amounts of cheaper opioids like fentanyl.
Through school assemblies, handouts, videos, and other resources, schools can educate students and their families about the high risk of overdose. The National Institute on Drug Abuse provides free educational materials tailored specifically for students and schools.
3. Knowing which signs to look for can help you identify students who may need intervention.
Changes in social and academic functioning, as well as evidence of opioid withdrawal, are often seen in students with longer term opioid use. Signs and symptoms of opioid use can include a high, which is characterized by an altered mental state of euphoria or confusion; sleepiness; glazed eyes; nausea or vomiting; small pupils; and difficulty breathing. Track marks—the visible scarring or darkening along the veins at the site of injection—and signs of infection may be seen on injection users, and are typically located on a person's forearms. Withdrawal is extremely unpleasant and involves nausea, vomiting, sweating, intense abdominal cramping, and restlessness.
The connection students have with their school community can increase the likelihood of early intervention when opioid use is suspected. Schools should provide after-school activities when possible, which can help decrease unsupervised free time. Students need to know that counselors, coaches, and teachers are available for emotional support. Let students know that they aren't in trouble. Schools with less punitive drug policies allow concerned teachers and staff to talk openly with students about drug use without fear of immediate disciplinary action.
4. Drug testing is not always the answer.
Widespread drug testing in schools is not recommended by multiple institutions, including the American Academy of Pediatrics, because it may alienate students from seeking help due to fear of negative consequences, such as suspension or exclusion from extracurricular activities, that may have been established for anyone with a positive drug screen (Levy, Schizer, & Committee on Substance Abuse, American Academy of Pediatrics, 2015). Proper interpretation of these screens may also require an understanding of what medications a student is prescribed, which can be in direct conflict with medical confidentiality. Opioids are also only detectable in standard urine drug screens for a short period of time (a few days), which can create a sense of false confidence if the test is negative.
However, there is a screening tool schools can use to detect risky substance use. The CRAFFT Screening Interview is a six-question tool that can be applied to opioid use and is available online for free. Historically, schools have anonymously administered the CRAFFT as a way of understanding the amount of substance misuse among the school population. Counselors and staff can also use individual CRAFFT questions when talking with students, or give them the full screen if there are concerns about substance use. While the CRAFFT is intended for counselors, classroom teachers and coaches can educate their students about the potential impact of the high-risk behaviors from the CRAFFT and refer anyone who is suspected of substance use for additional screening.
Any student suspected of using opioids who appears to be high, confused, or having trouble waking up may be at risk of an overdose. In this case, a medical assessment should be completed immediately by emergency responders. If a student is suspected of using opioids on school grounds, staff should also investigate if other students were involved.
5. Talking about the issue—to parents, students, and the community—can reduce the stigma and let teens get help.
The beginning of the school year is an excellent opportunity to provide educational materials on opioids to students, parents, and teachers. You can discuss how to reduce access to opioids; the safety and health risks of opioids; and how to respond when you suspect someone close to you is using them. Schools can share helpful prevention information throughout the year as well, such as how to properly dispose of unused prescriptions, monitor any required opioid pain medication in the household, and access overdose treatments such as naloxone.
Schools can also form an opioid prevention committee, composed of interested staff or student members, as well as designated administrative staff who can approve and support the committee's activities. Staff in the health or physical education office can take a lead role in health content. Athletic directors and coaches can emphasize prevention and treatment through the committee, as well as monitor for signs of students misusing drugs on sports teams. Similar to efforts against drunk driving, student members of the committee can encourage the use of pledges to not use opioids, while staff can come together to develop schoolwide protocols on how to respond to potential opioid use.
6. A point person can look out for students at high risk or in recovery.
Assigning a point person for teens who are at high risk of opioid use or in recovery can help identify any stressors or changes in behavior that indicate opioid use or a relapse. For example, a football coach might work closely to aid the transition of an athlete returning to school after treatment for an addiction. The school counselor may also work in this capacity with scheduled check-ins throughout the week. The point person would be responsible for communicating any concerns (such as missing class, appearing intoxicated or high, or demonstrating unusual behaviors). The school counselor may want to be the designated point person to represent the school by communicating these concerns to parents or guardians and outside treatment providers. Minimizing major stressors, while providing a student with adequate support at school and at home, can reduce the risk of relapse.
7. There are boundaries to how schools can intervene.
Although schools can and should be concerned about opioid misuse, they cannot mandate treatment for a student. Fortunately, there are steps schools can take to encourage treatment. The Family Educational Rights and Privacy Act allows schools to contact the parents of any student under 21 who has violated school policy or the law regarding substance use. Schools can offer the incentive of fewer suspension days, reduced consequences, or no disciplinary action if the student receives a mental health evaluation and ongoing treatment. Schools can also create a list of providers and centers that offer expert mental health and substance abuse assessments.
Ensuring the safety of students and staff should be top priority. The National Association of School Nurses (NASN) advocates for the possession of naloxone, the overdose rescue medication, on school grounds. Public school systems are also beginning to endorse the access and use of this medication. Access to naloxone is dependent on state laws; it is available over the counter in certain states, while other states still require a prescription.
Stopping the Epidemic
The school is often the primary community for students at risk for opioid misuse. Some schools are just beginning to plan and execute protocols for opioid use; others are already responding to a crisis, but all secondary schools will eventually in some way face this public health crisis. The use of internal health care personnel, careful observation, assessments, and brief interventions can empower schools to positively impact the opioid crisis.
