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The National Prescription Drug Take Back Day aims to provide a safe, convenient, and anonymous means of disposing of prescription drugs, while also educating the general public about the potential for abuse and medications.

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The 6 question screen is quick, relatively easy to administer and can be applied to opioid use (Welsh, 2018).

https://www.integration.samhsa.gov/clinical-practice/sbirt/CRAFFT_Screening_interview.pdf

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SBIRT: Screening

The first component of the SBIRT process is screening, which provides a quick and simple method of identifying patients who use substances at at-risk levels, as well as those who are already experiencing substance use-related issues. The typical screening process involves the use of a brief one-three question prescreen, such as the National Institute on Alcohol Abuse and Alcoholism's (NIAAA) 3 Question Screen or the National Institute on Drug Abuse's (NIDA) quick screen. If a person screens positive on one of these screening instruments, they would then be given a longer alcohol or drug use screening such as the AUDIT or the ASSIST. The screens usually assess patient self-reported information about substance use, and any health care professional can easily score the results.

CIHS compiled the below resources, include screening examples, that could be used to implement SBIRT, as well as manuals and guidelines on how to utilize some of the screenings.

Screening Manuals

The World Health Organization's Alcohol Use Disorders Identification Test (AUDIT) Manual guides AUDIT use in primary care.

The World Health Organization's Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) guides ASSIST use in primary care.

Adolescent Screening, Brief Intervention, and Referral to Treatment for Alcohol and Other Drug Use: Using the CRAFFT Screening Tool provides adolescent primary care providers the resources needed to efficiently incorporate CRAFFT, brief advice, and referrals for further evaluation and treatment for alcohol and other drug use into routine adolescent visits.

NIDA's Screening for Drug Use in General Medical Settings Resource Guide provides clinicians serving adult populations in general medical settings with the screening tools and procedures necessary to conduct screening, brief intervention, and/or treatment referral for patients who may have or may be at risk of developing a substance use disorder.

Brief Initial Screens

NIAAA 3 Question Screen is a three-question screen developed by NIAAA to assess problem alcohol use.

Longer Screens

ASSIST obtains information from patients about lifetime use of substances, as well as current substances use associated problems over the last 3 months. It can identify a range of problems associated with substance use, including acute intoxication, regular use, dependent or 'high risk' use, and injecting behavior.

AUDIT is a simple method of screening for excessive drinking and brief assessment. It can help identify excessive drinking as the cause of a presenting illness. It also provides a framework for intervention to help drinkers reduce or cease alcohol consumption and thereby avoid the harmful consequences of their drinking.

Michigan Alcoholism Screening Test (MAST) is a quick and accurate screen designed to assess problems with alcohol use.

Behavioral Health Screens

The Wisconsin Initiative to Promote Healthy Lifestyles' (WIPHL) Sample Behavioral Health Screen assesses a patients' drug and alcohol use, as well as screens for depression and exposure to domestic violence.

Global Assessment of Individual Needs Short Screen (GAIN-SS) was created by Chestnut Behavioral Health to screening a general population and quickly and accurately identifies clients who may have one or more behavioral health disorders.

The Patient Health Questionnaire (PQ-9) is the nine-item depression scale of the Patient Health Questionnaire. The PHQ-9 is a powerful tool for assisting primary care clinicians in diagnosing depression as well as selecting and monitoring treatment.

SBIRT: Screening

The first component of the SBIRT process is screening, which provides a quick and simple method of identifying patients who use substances at at-risk levels, as well as those who are already experiencing substance use-related issues. The typical screening process involves the use of a brief one-three question prescreen, such as the National Institute on Alcohol Abuse and Alcoholism's (NIAAA) 3 Question Screen or the National Institute on Drug Abuse's (NIDA) quick screen. If a person screens positive on one of these screening instruments, they would then be given a longer alcohol or drug use screening such as the AUDIT or the ASSIST. The screens usually assess patient self-reported information about substance use, and any health care professional can easily score the results.

CIHS compiled the below resources, include screening examples, that could be used to implement SBIRT, as well as manuals and guidelines on how to utilize some of the screenings.

Screening Manuals

The World Health Organization's Alcohol Use Disorders Identification Test (AUDIT) Manual guides AUDIT use in primary care.

The World Health Organization's Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) guides ASSIST use in primary care.

Adolescent Screening, Brief Intervention, and Referral to Treatment for Alcohol and Other Drug Use: Using the CRAFFT Screening Tool provides adolescent primary care providers the resources needed to efficiently incorporate CRAFFT, brief advice, and referrals for further evaluation and treatment for alcohol and other drug use into routine adolescent visits.

NIDA's Screening for Drug Use in General Medical Settings Resource Guide provides clinicians serving adult populations in general medical settings with the screening tools and procedures necessary to conduct screening, brief intervention, and/or treatment referral for patients who may have or may be at risk of developing a substance use disorder.

Brief Initial Screens

NIAAA 3 Question Screen is a three-question screen developed by NIAAA to assess problem alcohol use.

Longer Screens

ASSIST obtains information from patients about lifetime use of substances, as well as current substances use associated problems over the last 3 months. It can identify a range of problems associated with substance use, including acute intoxication, regular use, dependent or 'high risk' use, and injecting behavior.

AUDIT is a simple method of screening for excessive drinking and brief assessment. It can help identify excessive drinking as the cause of a presenting illness. It also provides a framework for intervention to help drinkers reduce or cease alcohol consumption and thereby avoid the harmful consequences of their drinking.

Michigan Alcoholism Screening Test (MAST) is a quick and accurate screen designed to assess problems with alcohol use.

Behavioral Health Screens

The Wisconsin Initiative to Promote Healthy Lifestyles' (WIPHL) Sample Behavioral Health Screen assesses a patients' drug and alcohol use, as well as screens for depression and exposure to domestic violence.

Global Assessment of Individual Needs Short Screen (GAIN-SS) was created by Chestnut Behavioral Health to screening a general population and quickly and accurately identifies clients who may have one or more behavioral health disorders.

The Patient Health Questionnaire (PQ-9) is the nine-item depression scale of the Patient Health Questionnaire. The PHQ-9 is a powerful tool for assisting primary care clinicians in diagnosing depression as well as selecting and monitoring treatment.

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Screening is the first component of the SBIRT, which provides a quick and simple method of identifying patients who use substances at at-risk levels, as well as those who are already experiencing substance use-related issues. The typical screening process involves the use of a brief one-three question pre-screen.

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Post a question or knowledge you may have or wonder about the Opioid Epidemic in America.

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As more families struggle with opioid addiction, educators face the terrible trickle-down effects on students.

Read more

By Amanda Litvinov

Here's what we know about the opioid crisis: It is the most widespread and deadly drug epidemic this country has ever known. Since 2000, it has claimed more than 300,000 Americans, and deaths continue to rise among men and women of all races, according to the U.S. Centers for Disease Control.

Last year, nearly 200 American lives were lost every day to drug overdose, and at least two-thirds of those were linked to opioids. Most who die are between the ages of 25 and 44, and many of them have children.

The crisis has pushed the number of incarcerated moms to an all-time high.

We have far less concrete information about the epidemic's effects on kids-those who were born addicted to opioids, those who have lost parents to overdose or incarceration, or those who are growing up with family members in the grips of addiction.

This fall, NEA Today spoke with 10 educators from two of the hardest hit and longest-suffering states on the opiate map-West Virginia and Ohio-where teachers, counselors, nurses, and administrators face physical, cognitive, and emotional needs they don't always know how to meet.

There is the kindergartner who becomes so violent, he can hurt adults. There is the second-grade boy being raised by his great-grandmother, who announced excitedly during class that his baby sister-"you know, the one that's hooked on drugs from my mommy's belly"-was to be released from the hospital. There are the hungry and the unwashed and the silent children. There's the third grader who sometimes shows up at school still in her pajamas. She is a foster child, who puts herself on the bus. Another in her grade found both of her parents overdosed in their car (they survived). There are elementary students and middle schoolers who feed and bathe and diaper younger siblings when there isn't an adult around who is capable of doing it. Tweens are cutting themselves, and teens are caught dipping into the drugs that have surrounded them for so long.

"Some days learning the ABCs and 123s is not what is most important for that student," says Julie Sturgill, a third-grade teacher in the Dawson-Bryant School District in the Appalachian foothills of southeastern Ohio. Some days, she says, are more about survival. She has washed stinky coats, texted with colleagues at all hours about a student in crisis, and recently allowed an exhausted child to sleep during class. "I never imagined helping to meet such basic needs would be such a big part of my job."

How Did We Get Here? A Brief Timeline of America's Opioid Crisis

1990s

2010

2012

2014

2015

Use of synthetic opioids - such as fentanyl, which is 50 times more potent than heroin - skyrockets.

October 2017

AP Photo/Evan Vucci, File

October 2018

AP Photo/J. Scott Applewhite, File

'We Take Them As They Are'

Educators here, as in all public schools, must attend to state standards and the next big test. But they must also keep track of which parents have restraining orders against them and when students need to be released to make their counseling appointments. They keep an eye out for hungry kids so they can slip extra snacks into their backpacks.

Both Jackson County, W.Va., and Lawrence County, Ohio, have faltered and rallied as industries have come and gone. Their once-proud downtowns and neighborhoods are riddled with structures half-fallen, boarded up, or piled with debris.

But their schools are inviting and colorful, filled with student photos and projects, marking their school as a place where each and every one of them belongs.

"Our kids don't come with a label that says, 'My mom is an addict,' or 'My dad just got out of prison,' or 'My family is going through the recovery process,'" Sturgill says calmly. "We just take them as they are and try to figure out what's best for them."

There is no part of Julie Sturgill's life that is untouched by addiction. She has lived the nightmare of seeing her own daughter become addicted to drugs. Now, she is raising her granddaughter.

Madison, who has white blond hair and a whisper of a voice, was exposed to drugs before she was born. Sturgill says her daughter worked hard to get clean, but has since relapsed, so for the past two years, Madison has lived with Julie and her husband, Rick. They are now Madison's legal guardians.

After a day in the classroom facing more challenging behaviors among 8- and 9-year-olds than she's ever known in her 20 years of teaching, Sturgill runs a book club as part of a new grant-funded aftercare program for at-risk kids. Not all of those children have families struggling with addiction, but many of them do.

Some evenings and every weekend, Sturgill can be found at church where she and her husband are growing a ministry designed to help people in treatment or long-term recovery and their supporters build a community. Pastor Rick, as his congregants call him, lost his own son to heroin addiction years ago.

As much as her own family has suffered, Julie Sturgill says she is lucky.

"I can do this homework with my granddaughter, I have the ideal schedule, I have the financial means, whereas many grandparents don't have good health and might be living on very limited means in retirement," she says.

Every educator we spoke with said that the growing number of children being raised by someone other than their parents is one of the most obvious shifts among their students.

Across the country, 2.6 million children are being raised by family members who are not their birth parents. These "grandfamilies" are most often formed outside of the foster care system, which leaves grandparents or other adult kin to figure out how to nurture children who may be shouldering multiple adverse childhood experiences. Decades of research shows that chronic stress can disrupt neurodevelopment in children and lead to negative coping mechanisms-substance abuse, risky behaviors, and self-harm-in adolescence.

Given the shortage of mental health supports in the community and the difficulty many families have accessing those services, schools are the best place to provide all the supports these children need. But years of insufficient funding have undercut schools' ability to respond when crisis hits.

So educators do the best they can every day, with every student, even when it comes at a personal cost.

'I Just Want to Fix Them'

Traci Musick, an English teacher at Dawson-Bryant High School in Lawrence County, Ohio, has a recurring dream in which she is trying to tape her broken students back together. It began after she invited her students to journal about their own lives.

One wrote that he was adopted because his parents, both of whom were addicted to drugs, just couldn't take care of him and his brother. Another student chronicled how she and her mother, who also had substance abuse problems, stayed in different places all over the county, and sometimes her mother's boyfriends made unwanted advances.

"I quit the journals for a while because it got to be too much," says Musick. "I get too emotionally invested-I just want to fix them." As a mandatory reporter, she also found herself talking to the principal several times a week.

But they realized how much students needed to tell their stories, and her principal encouraged her to bring the journal writing back. She did, and added reading assignments by authors who have achieved in spite of the physical and emotional damage caused by their parents' alcohol and drug abuse.

"Our staff is just phenomenal when it comes to building those caring relationships when something is going on with one of our kids," says Audra Deere, who taught business and accounting for over 20 years before becoming Dawson-Bryant's director of student services a few years ago.

She recently attended a training on trauma-informed care that she wishes every educator in their region could attend.

"It spelled out in plain English the reasons for some of the behaviors we're seeing," said Deere. That youngster who keeps breaking the rules by putting up the hood of his hoodie might seem defiant, but maybe it's a small comfort that makes him feel safer, she explained.

'This Has to be Their Happy Place'

Educators here are acutely aware that any child in their classroom, whether they are from a poor or well-off family, might be processing a hidden trauma, and they strive to make them feel safe at school. But few of these educators had the benefit of any formal training in trauma-informed care.

Nearby Rock Hill School District, which is more rural and has more families in poverty, has received an NEA grant to start a trauma-sensitive school. Several educators will attend the National Conference for Creating Trauma Sensitive Schools in February to kick off the process.

Guidance counselor Bridgette Malone says some of the ways Rock Hill High School has changed since she graduated here just over a decade ago are chilling.

"By the time they're in high school, the kids think it's normal-drug use and overdoses and people in your family getting arrested. Like that's just something that happens," she says. Malone works with many teens who are at greater risk of depression, anxiety, and substance abuse having grown up with adults using drugs. Starting this year, Rock Hill students with substance abuse problems will have access to a drug counselor if they request help.

That's a good thing, of course, but educators know the best way to break the cycle of drug abuse is to address students' physical and mental health needs far earlier.

And that is going to take a renewed investment in our public schools.

In a rare bipartisan moment, Congress passed a major package of opioid legislation in October that, with input from NEA, establishes grants to implement evidence-based, trauma-informed care in areas hit hard by the opioid crisis.

But it could take years for those supports to materialize. In the meantime, educators will stock clothing closets, stuff backpacks with food for the weekend, and, if necessary, set aside instruction to respond to student needs in the moment. Whatever it takes to make students feel safe and loved.

"I don't let my kids come into the classroom without a smile, and I hug them as they leave," says Julie Sturgill. "This has to be their happy place, because for some of them it's the happiest place they have in their lives right now."

Jackson County,
West Virginia

Losing Sleep

On a recent fall afternoon, after more than 600 students had cleared out for the day, Ripley Elementary School in Ripley, West Virginia, was a tranquil place. Aerators bubbled softly in a row of fish tanks. In one of several charming murals lining a main hallway, turtles and schools of fish swam across a gentle underwater scene.

Days are rarely so peaceful for the educators who work in Ripley, a town of 3,000 whose families are breaking down in large part due to drug addiction. Like many communities hit by the opioid crisis, Ripley relies on its public schools to serve as a safety net for its kids.

Signs of the town's downward spiral are everywhere: Flyers posted along Main Street ask for volunteers to serve as court advocates for local children. An electric sign along the main road asks citizens to become foster parents, while the rate of child removals in the county explodes.

The signs of wear and tear on the educators who help these children every day don't show on the surface. But when they talk about "their kids," they choke up a little. They have to pause and take a breath.

"Sometimes you wake up at 3 a.m. and you can't sleep because a student's situation is on your mind," says fourth-grade teacher Mike Knopp, who has been in the classroom for 15 years. "It scares me to think how they could end up. I've seen my former students in the obituaries, or found out on Facebook that we lost one to drugs or suicide...it hurts."

Educators here say more children each year are racking up adverse childhood experiences, stressful and traumatic events that include abuse, neglect, and witnessing the worst-like mommy and daddy being taken away late at night in a police car or an ambulance.

The three teachers we spoke with in Ripley-Knopp, second-grade teacher Lori Mahan, and Title I Reading Interventionist Dr. Leslie Haynes-who have more than 75 years of classroom experience between them, shared with us the questions that they lose sleep over: Why aren't their teaching strategies working with a growing number of students? Does prenatal exposure to opioids cause the severe problems they're seeing with students retaining information or is toxic stress more to blame? Where will funding come from for evidence-based prevention efforts and supports for kids in trauma? Nearly two decades into the opioid crisis, why can't we answer those questions?

Turning Point

Both the state of West Virginia and Jackson County have taken steps to slow the spread of the opioid crisis. It started with a wakeup call of the worst kind.

Between 2006 and 2008, 16 teens and young adults in Jackson County died after overdosing on the powerful opioid fentanyl. They were found dead in cars, in bathrooms, and on front yards. The last death was the kindergarten teacher's son.

With a federal Drug Free Communities grant, the Jackson County Health Department brought together schools, hospitals, law enforcement, mental health care providers, and the faith community to find better ways to educate the public about the signs of drug use and prevention strategies that included identifying classroom supplies that a child could use to get high. It has resulted in teen drug use rates lower than the national average.

West Virginia also pioneered the Handle With Care program that allows law enforcement to inform school administrators immediately after a child has had a traumatic event in the home. Flagging a student means, at the very least, the student won't be punished for not having his homework or being unable to participate during class.

If Jackson County is ahead of the game in some ways, there is still a tremendous weight on its educators, made heavier by the chronic underfunding of public education. West Virginia spent 11 percent less per pupil in 2018 than it did in 2008, even as the opioid crisis grew exponentially worse.

"We're trying to teach them to read and do math, but also provide all the love and support and encouragement-that's a lot in a day," says Knopp.

"What could we do if we actually had smaller classes [and mental health supports] for any kid who needs it?"

When the school district had better funding, class sizes topped out at 17. These days, class sizes are as high as 26 students to a single teacher, which drastically decreases the amount of one-on-one time the teacher can spend with any one student.

Ripley Elementary has 11 special needs classrooms and an alternative education room that serves children from across the county with more profound behavioral issues. The district just hired a social worker for the first time, but there is still a shortage of counselors and essential services such as play therapy.

"A lot of these stories of drug addiction are coming out of good, middle-class, even well-off families," says Lori Mahan. "If we had more mental health services and less stigma around using them, these families would stand a chance and we might be able to beat this opioid crisis."
All photos by Luis Gomez

For More

NEA Resources
Teaching Children from Poverty and Trauma Handbook Partnership for Resilience The Six Pillars of Community Schools Toolkit
NEA edCommunities Group: Trauma Informed Classrooms/Strategies (You must be a member of EdCommunities to access this content. Registration is free and open to all)

NEA Foundation Grant Opportunity
The NEA Foundation wants to help NEA members everywhere access top-notch professional development-including educators working in communities hit hard by the opioid crisis. If your district cannot cover the cost of training educators in trauma-informed care, consider applying for an NEA Foundation Learning and Leadership Grant as an individual or as a group.

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Teaching the Children of the Opioid Crisis

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As more families struggle with opioid addiction, educators face the terrible trickle-down effects on students. Read more By Amanda Litvinov Here's what we know about the opioid crisis: It is the most widespread and deadly drug epidemic this country has ever known.

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Preventing and Reducing Youth and Young Adult Substance Misuse: Schools, Students, Families

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ED hosted a three-part miniseries on the opioid crisis. The first webinar looked at how the opioid crisis affected students and families, and the policies and practices that could help address the crisis in schools. The second webinar provided examples of how the opioid crisis was impacting schools and students and highlighted strategies to support students impacted by the crisis.

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1. How can schools prevent and respond to the opioid epidemic with adolescents in schools?

2. How can school leaders respond to the opioid epidemic to better help students, families and the community?

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When President Donald Trump dramatically declared the opioid crisis a "national health emergency" a month ago, he was announcing the grim reality that those of us working for and in low-income communities of color have faced on the ground for a generation-that opioids and other drugs kill and destroy hope.

In mainstream American society, climbing the rungs of the socioeconomic ladder is a laborious undertaking, particularly in communities where poverty is nearly impossible to escape. Racial and ethnic minorities in urban areas have historically struggled with economic hardships. Where our state and federal laws have criminalized drug addictions, opioids just add to the other challenges in our communities-and especially in our schools.

While opioid addictions are exposed as being more prevalent in white, rural America, there are endless accounts of how these addictions have penetrated the walls of, and terrorized, poor inner-city neighborhoods. This scourge of drug abuse in urban communities extends back as early as the 1960s and continues to devastate urban communities in 2017.

In a study published in the International Journal of Drug Policy, researchers concluded through data from the National Survey on Drug Use and Health (2011 and 2012) that "... adults living in America's cities abuse prescription opioid medications significantly more often than adults living in the nation's rural areas."

They partially attribute the higher rate of opioid medication abuse in urban areas to city-dwelling adults' higher intake of substances in general and attribute the higher urban rate of opioid medication abuse to the greater level of inappropriate consumption of drugs, medications, and alcohol during childhood, as well as the relatively early age at which urban-dwelling children typically first get involved in substance use.

As a result, overdose rates in our urban communities have more than doubled among Black Americans, Latinos, and Native Americans.

Now we have learned that both pharmaceutical manufacturers and doctors are complicit through overprescribing opioids, and that neither federal nor local authorities have developed penalties for this practice, revealing an unconscionable lack of concern for victims.

Nevertheless, urban schools and school districts are developing multifaceted approaches to effectively teach and work with students and families.

Some of these efforts include: well-developed education and prevention efforts beginning in early elementary school; professional development for teachers and staff on opioids and their effects; increased school-based counseling services, school-based mental health services, and school-based medical and health access; partnerships with outside agencies that provide services and access for students and families in need; and having school-stocked Naloxone, an opioid overdose reversal drug, on hand.

Our school districts, cities, counties, regions, states, and educators must come together and develop our own approaches to confronting this scourge in our schools if the next generation is to continue our forward momentum as the future leaders and foundations of tomorrow.

I am calling on my colleagues to create a national summit on the opioid problem in our schools and to begin crafting solutions that can dovetail with those developed by the federal government.
Micah Ali (mali@compton.k12.ca.us) is a member of California's Compton Unified School District and the 2017-18 chair of the CUBE steering committee.

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Opioid Crisis Another Dilemma for Urban Education

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Story by Micah Ali When President Donald Trump dramatically declared the opioid crisis a "national health emergency" a month ago, he was announcing the grim reality that those of us working for and in low-income communities of color have faced on the ground for a generation-that opioids and other drugs kill and destroy hope.

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Amid Opioid Crisis, Schools Help Students Heal

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Teaches Educators How to Recognize, Respond to Addiction

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AUGUSTA - All public high schools and middle schools in Maine would stock the overdose antidote naloxone under a plan being developed by the Mills administration that echoes national efforts to combat the threat of opioids.

Gordon Smith, the state's director of opioid response, said having the antidote on hand in a school building could save the life of a student, staff member or visitor. The administration is also working on improving prevention education and may expand it to grades as young as pre-kindergarten, Smith said.

Although a growing number of states are embracing access to naloxone in school buildings, the idea of doing so in Maine is raising concerns among some educators and lawmakers about normalizing drug use and imposing more responsibilities on school staff.

Still, Smith said being able to reverse an overdose in school with an easily dispensed nasal spray version of Narcan, the brand name for naloxone, should be widely embraced by the education community.

"I don't think anyone wants to see a kid die because we don't have it available," Smith said. He said Gov. Janet Mills would prefer to see local school districts voluntarily embrace a staff training program, but if need be the administration would back legislation to make it mandatory.

"It would be really silly to have an adult have to stand around while friends (students) help each other because the laws don't support the teacher saving a kid's life, I think that's silly," Smith said. "We are not going to put ourselves in a situation where kids can save kids but responsible adults can't touch them. If we have to change the law, we'll do it."

Maine is grappling with an opioid crisis that has been claiming lives at the rate of one a day for several years. There were 418 drug overdose deaths in 2017, including 354 caused by opioids such as fentanyl, heroin and prescription painkillers, according to the Maine Attorney General's Office. Totals for 2018 aren't available yet, but the office is projecting a decrease to 307 opioid-related deaths.

It's unclear how many overdoses have occurred on school properties in Maine. State records on fatal overdoses show that most involve people beyond their high school years. Among the 960 deaths from opioid overdoses in Maine from 2014 to 2017, 76 people, or 8 percent, were younger than age 25, according to the Kaiser Family Foundation.

Pender Makin, the state education commissioner, said in a written statement that she has seen how the opioid epidemic affects students and their families.

"I believe that we need to take all measures that have the potential to save lives and guide people, and our community, to recovery," she said.

The city of Portland has had naloxone at its three public high schools since the 2017-18 school year, said Tina Veilleux, the school nurse coordinator for Portland Public Schools and the nurse at the Reiche Community School.

"School nurses have to deal with any emergency that comes up on the grounds, on the campus, and sadly that could certainly be one of them and nurses want to be prepared," she said.

Veilleux said the overdose antidote has not been used in the Portland high schools. She supports the idea of broader distribution to other high schools and middle schools in Maine.

The National Association of School Nurses, which includes 16,000 members nationwide, issued a statement in 2016 endorsing the distribution of naloxone in schools as a preparedness response to the nation's opioid crisis.

Mills, Maine's former attorney general, has taken an aggressive approach to increasing the distribution of the antidote and clashed notably with former Republican Gov. Paul LePage, who rejected calls for easier access to naloxone while he blocked for months a law that allows the antidote to be issued by pharmacists without a prescription.

In 2016, Mills went around LePage using funds from her office to provide naloxone to 26 different police departments in Maine, which subsequently reported repeatedly using it to save lives. Mills and Smith most recently announced a pilot project to put the antidote in public buildings in the same way that automatic external defibrillators, used to treat sudden cardiac arrest, are made available.

Naloxone is an opioid antagonist that works by binding opioid receptors in the brain, reversing and blocking the effects of other opioids, according to the National Institute on Drug Abuse, an agency of the federal government. While it can stop or slow down the effects and quickly restore normal breathing in a person who has overdosed with heroin or prescription painkillers, the medication does not help with the underlying substance use disorders.

Most recently it has become available in a nasal spray that can be easily administered by police or other emergency responders and requires little or no medical training to administer.

About a dozen states, including New Jersey, Virginia, Maryland and Rhode Island, have passed laws that provide naloxone in public schools, coupled with training for school employees. Some of the state funding has been supplemented with grants from Adapt Pharma, the company that markets Narcan. The company cooperates with the Clinton Foundation on a program to provide two free doses of naloxone to any high school in the nation that requests it.

Since 2016, the foundation has distributed more than 6,000 doses of the antidote to more than 1,000 high schools, colleges and universities.

Other states, including Alabama, have also recently passed legislation allowing school districts to voluntarily enroll in state-funded naloxone programs that provide training and supplies to the schools that want it.

In March, Virginia's Democratic Gov. Ralph Northam signed into law a bill that allows school nurses to administer the antidote.

That's the route state Sen. Scott Cyrway, R-Benton, a retired deputy sheriff and state coordinator for the Drug Abuse Resistance Education program, said he could support. Cyrway said he would likely oppose putting naloxone into the hands of all teachers or requiring that it be universally available in public schools by state mandate.

"It's enabling," Cyrway said. "You might as well put up a sign that says, 'Go ahead, we're ready for you.'"

Cyrway also said that if naloxone is used in a school, a school resource officer should be involved in that process.

He said he supports the goal of expanding prevention education to lower grades but would like to see the state adopt the D.A.R.E. curriculum, driven by law enforcement, which covers grades K-12 with age-specific lesson plans.

Smith said D.A.R.E.'s curriculum is something that he and Mills are considering, but both are skeptical of the effectiveness of D.A.R.E. programming overall.

School officials and teacher union representatives offered qualified support for the idea of having naloxone available in all middle and high schools in Maine.

Grace Leavitt, executive director of the Maine Education Association, the union that represents most public school teachers, said teachers want to do their part to help combat the state's overdose crisis, which still claims on average one Maine life each day. But the union would be opposed to a mandate requiring teachers to be trained to dispense naloxone, especially if it came without funds to support it.

Leavitt said a program that allows teachers to volunteer to be trained to dispense naloxone would be more readily embraced.

"Schools are used for a lot of community events by the public," Leavitt said. "This is a significant public health issue, so having Narcan available for use by the public at events is certainly important and needed.

"As far as schools for the students, I just wouldn't want to see it mandated that that is now part of a teacher's job," she said. "We are there to educate, we are there to teach."

Equally important for the MEA, Leavitt said, would be an effort to ensure that each Maine high school have a full-time nurse on duty. Currently, many districts have a single nurse who serves multiple schools. Likewise, some Maine high schools don't have a school resource officer available every day.

Veilleux, the Portland school nurse coordinator, agrees that any program for teachers and naloxone should be voluntary. She said not all school staff members are going to be willing or able to administer naloxone.

"We always have some other staff people trained for that and other emergencies if the nurse isn't available," Veilleux said. "But not all staff will want to be trained. I wouldn't want it mandated for all staff."

She said expanding prevention education is also important and that simply making naloxone more available and talking about the issue openly helps remove the stigma from substance use disorders and build awareness of the disease.

"There really are not too many people who have not been affected by this," she said.

Steve Bailey, executive director of the Maine School Management Association, which represents the state's school superintendents and school boards, said administrators are going to want specifics on how naloxone in schools would be rolled out in Maine.

Bailey said he didn't believe there would be widespread opposition to making the antidote more readily available by having it in public schools, but the details of how that happens will be important to work out.

"Knowing the benefit that's there with it, it would seem to be a very positive opportunity for that to be available within school districts," Bailey said.

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Maine pursues plan to stock schools with anti-overdose medication

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AUGUSTA - All public high schools and middle schools in Maine would stock the overdose antidote naloxone under a plan being developed by the Mills administration that echoes national efforts to combat the threat of opioids.