Preventing Opioid Overdoses on Campuses: The Naloxone Solution 

By Charlotte West    //    Volume 28,  Number 2   //    March/April 2020
Trusteeship Cover: March/April 2020

Colleges and universities are grappling with how to tackle the national opioid crisis as it spills onto campuses across the country. Several higher education institutions have initiated efforts to make the opioid antidote—naloxone—more widely available on their campuses and raise awareness of the epidemic so overdose deaths can be prevented.

In 2017, 19-year-old Jonathan Winnefeld died of an overdose of heroin laced with fentanyl just three days after his parents moved him into his dorm at the University of Denver. More recently, several student deaths at the University of Southern California suspected of being overdose-related prompted school officials to send a letter to students warning against the dangers of mixing opioids and alcohol.

In fact, drug overdoses are now the leading cause of injury-related deaths in the United States. According to the Center for Drug Control and Prevention, more than two-thirds of those deaths involved a prescription or illegal opioid. While the prevalence of opioid use on college campuses is not well-documented, young adults ages 18–25 are the biggest users of prescription drugs for nonmedical purposes.

These high-profile cases and alarming statistics have sparked debate among students, staff, and administrators at colleges and universities about their role in responding to the national opioid crisis. As states have changed laws to make naloxone—a drug that reverses the effects of an opioid overdose—more accessible without a prescription, campuses have started to consider how to make it available to their students. “The most common initial plan is to put a few doses of naloxone in the dorms, equip campus police [with it] or allow students to access naloxone in the campus pharmacy without a prescription,” said Lucas Hill, a clinical assistant professor at the University of Texas at Austin (UT Austin) College of Pharmacy.

A common question that Hill often encounters is what happens if naloxone is administered to someone who isn’t actually overdosing. For example, a student who has consumed a lot of alcohol might appear to be unresponsive. “Nothing is going to happen. Naloxone simply blocks the effect of opioids, like heroin or prescription painkillers,” he says. “So, if you don’t have any of those in your body, naloxone doesn’t do anything. It’s not helpful in a non-opioid overdose, but it’s also not harmful.”

Some colleges and universities have taken their over-dose-prevention efforts one step further to make naloxone, also known as narcan, available to anyone at key points on campus. Bridgewater State University in Massachusetts, for example, has stocked 60 naloxone kits in defibrillator boxes across campus, as well as several other kits in parking lots and on each floor of the campus garage. Anyone who needs it is allowed to take a dose. Other institutions have launched training programs for students, staff, and faculty in how to spot an overdose and administer naloxone, which is available in an injectable form and as a prepackaged nasal spray.

“There’s very little training involved in actually administering naloxone,” said Tanya Smith, director of Kennesaw State University’s (KSU) Office of Victim Services.

But people do need to know how to recognize an overdose, check vital signs, and what to do if someone’s heart has stopped, which would render naloxone ineffective. “If someone’s heart has stopped, you’ve got to do CPR first,“ Smith said.

After losing her 20-year-old daughter to a fatal overdose in 2013, Smith became an outspoken advocate for opioid education. Thanks to her efforts, KSU’s became the first university police department in Georgia and one of the first in the United States to train campus police to carry naloxone in 2014. She also successfully lobbied for a new medical amnesty law in Georgia that allowed people to call 911 without fear of arrest for possession or drug use. KSU also has a training program for students, staff, and faculty run through a campus recovery center.

“[Students] who are entering college are likely to experiment with drugs and alcohol. You may not be able to prevent use and abuse, but you can arm people at your university with something that they can use to restore breathing if someone is suffering from opioid overdose and buy them the time that they need to get to a hospital to get more advanced medical care,” Smith said.

State Efforts to Combat Opioid Overdoses on College Campuses

Some of the efforts at individual institutions have been spurred by state legislation to prevent opioid overdoses on college campuses. According to the California Department of Public Health, California has a statewide standing order that allows community organizations and other entities, including higher education institutions, to distribute naloxone. In 2017, Maryland lawmakers enacted legislation that requires all colleges and universities that accept state funding to provide preventative training to first-time students on the dangers of opioid use and have campus policy carry naloxone.

In 2019, as part of a larger opioid treatment bill, Washington state passed legislation that requires all public institutions that have residence halls with at least 100 students to develop a plan to maintain and administer naloxone “in and around” their dorms and to train staff to administer the drug in response to an opioid-related overdose.

Eleven of Washington’s 34 community colleges have at least one residence hall with 100 students or more. According to Joe Holliday, director of student services at the Washington State Board for Community and Technical Colleges, the 11 colleges collaborated to create a common template for the new plans, which are up to each campus to administer. The board convened a working group that included representatives of student services, campus leadership, campus safety, human resources, finance and administration, and campus housing.

Holliday said that the community colleges are generally supportive of the new requirement. “They see it as something that’s necessary and feel good about broadening their ability to support people,” he said.

He is not aware of any overdoses that have occurred on Washington state community college campuses. “We didn’t see it as a problem that we needed to proactively solve, but the legislature did,” Holliday added.

In January, Pennsylvania Governor Thomas Wolf announced that the state is awarding almost $1 million in federal grants to 13 higher education institutions to prevent and reduce the use of opioids by college students and to create naloxone training opportunities for postsecondary institutions.

“We consistently attack the state’s opioid crisis from all angles, and this grant will enable additional focus on an integral part of our work: prevention. . . . Educating college students on the risk of opioid use and training institutions of higher learning on how to administer naloxone are two ways we can save lives and lessen the impact of this crisis,” Wolf said in a statement.

In Pennsylvania, young adults ages 18–30 are among the groups most impacted by the opioid crisis, according to the Pennsylvania Department of Drug and Alcohol Programs.

Launching Operation Naloxone

In 2016, UT Austin received reports that a few students had died from overdoses during the winter break. The university convened the Committee on Substance Safety and Overdose Prevention and tasked student, faculty, and staff representatives from various units across campus to come up with a response. The result was an initiative known as Operation Naloxone.

The initial steps were to place naloxone in all of the UT Austin dorms, train resident assistants in how to administer the drug, and provide it to campus police. In fall 2016, the university launched a peer training program for student pharmacists to train other university students to respond effectively to opioid overdoses with naloxone. The pharmacy students did trainings with off-campus housing cooperatives or with other student organizations that might represent students who were at a higher risk for overdose off campus.

Hill said that one of the lessons they learned with Operation Naloxone is the importance of publicizing the availability of the opioid-reversal drug on campus. “It’s very likely there are students who are in our dorms who don’t know it’s available on the ground floor of the building,” he said. “Awareness campaigns are so important.”

Opioid Education as Part of a Larger Student Health Initiative

Columbia University launched its naloxone program in 2017 as part of a mental health and wellness initiative in partnership with the Jed Foundation, a nonprofit organization that aims to protect emotional health and prevent suicide for teenagers and young adults.

Previously, the only people on campus who had been trained to administer naloxone were campus police and first responders working with Columbia University Emergency Services (CUEMS), the university’s student volunteer ambulance service.

“It’s great the first responders are trained, but when you see what’s happening in communities outside of college campuses, it’s not the first responder who’s going to see someone who’s in need of naloxone. It’s often friends or family members or bystanders or community members,” said Melanie Bernitz, associate vice president and medical director of Columbia Health.

Bernitz and several colleagues have received a grant to pilot opioid education and naloxone training on the Columbia campus. They hope to use the results of their study to develop best practices for other colleges and universities.

The university had to register as an opioid prevention program with New York City, which provides the naloxone free of charge. They conducted several focus groups with students, medical staff, and key stakeholders around the university to develop and implement a training curriculum.

Bernitz said it was important to make the training relevant to the Columbia student population: “They wanted to understand what this looks like on our campus. What does this look like in terms of our responsibility as a student or a staff member? What does this look like more globally?”

The focus groups revealed that students were concerned about the potential ramifications of administering naloxone as well as reporting overdoses. “All students should know if your campus has a medical amnesty policy,” Bernitz said. “We address up front what it means if you do assist or report on campus, and then we’ll talk about legal ramifications and the Good Samaritan law within New York City.”

At Columbia, the Responsive Community Action Policy specifies that in the event of a medical emergency involving the use of alcohol or drugs, neither the student who receives medical assistance nor the student who reported the medical emergency will be subject to disciplinary action for use or possession of alcohol or use of drugs.

The interest from students has been overwhelming, Bernitz said. “We wanted to train 800 within the first year, and we hit 800 within the first three months,” she said.

Supriya Makam, a sophomore neuroscience major at Columbia College, led several of the student focus groups and helps conduct the naloxone trainings. She said that she’s been interested in addiction treatment since she was in high school. “Students really thought that there was a need for something like this and… they thought that it would be beneficial to further understand how much it’s affecting our community and what they can do to help,” she said.

Makam said that they were prepared for pushback from students. “We were preparing to address some concerns that students might have had because when you introduce a harm reduction method on a campus as big as Columbia, there’s obviously going to be backlash that this is supporting opioid addiction or promoting the use of it. But thankfully the majority of the students have taken this as an opportunity to empower themselves, which is a tool that I think is so necessary and so useful in an age when addiction is so rampant.”

Bernitz added that the program has also had buy-in from university leadership since its inception. They also consulted their general counsel to make sure that they were aware of the work that was happening. “We’ve been sharing these updates with the trustees as we move forward with the grant work. And they’ve been very, very supportive,” she said.

Broad Liability Protection and Good Samaritan Laws

One of the biggest concerns of leadership on campuses considering naloxone programs is the question of liability. According to Hill, all 50 states and the District of Columbia have enacted some kind of naloxone access laws. “The most common components of a naloxone access law is broad liability protection for anyone who prescribes, dispenses, or administers naloxone in good faith,” Hill said. “There really should be essentially no liability risk to the institution.”

He added that campuses should consider the fact that naloxone has a shelf life of two years and campuses need to be prepared to replace expired doses. They should also offer training to ensure that people are aware of how to use it effectively.

Hill said that health professions schools are a good place to start for any colleges and universities thinking about introducing naloxone programs. “Oftentimes faculty and students at those schools would be interested in collaborating to provide free trainings, or maybe help access grant dollars to cover the costs of medication,” he said.

He also suggested that campuses partner with local harm reduction groups or needle exchange programs that will often have access to naloxone and can provide expert training for staff, faculty, and students.

Hill and Bernitz both said that the most effective programs involve well-publicized, open trainings that provide free naloxone. If campuses require people to provide personal information to access naloxone kits, they may not reach those who need them most. “People who are personally at risk, or who know people who are at risk of overdose, will self-identify and they will come to those trainings and the naloxone you give them will be very likely to be used,” Hill said. But if you put in place barriers like requiring that people fill out a form, you create extra barriers that make the people who are at the highest level of risk, those who are actively using illegal drugs, unlikely to provide that information.”

At UT Austin, they have even started distributing naloxone at the beginning of public trainings in case people need to leave early.

Unfounded Fears

Hill has been contacted by dozens of other institutions that are interested in learning more about Operation Naloxone. He said that administrators often agree that it makes sense to have naloxone available on campus, but they are hesitant to publicize it.
“They are hesitant to engage in a big campaign to make students, faculty, and staff aware because that’s going to make parents think that there’s something wrong with their campus and they don’t want to send their students,” he said.

That fear is unfounded, according to Hill. “In real life we’ve never run into any issues with parents being wary because of this,” he said.

He added that even occasional use on non-opioid drugs could represent a risk for opioid overdose. “There is increasing concern that cocaine and other substances that college students might be more likely to use could be adulterated with an ultra potent opioid like fentanyl. We have certainly heard of incidents where students who don’t actually have an addiction, and who don’t even intend to use an opioid, have been exposed to a powerful opioid. And so there is a risk for overdose from occasional recreational use as well. That can be a compelling point to explain why we want to have naloxone around even though actual opioid addiction rates are pretty low among college students,” Hill explained.

Embracing a Broader Public Health Role

Program administrators have found that few if any of the naloxone kits placed around campus have been used. Hill said that research shows that naloxone distributed directly to harm reduction groups or to people who use drugs and their friends and family is much more likely to be used than naloxone given to a police department.

At UT Austin, “we have not ever had a dose in the dorms or had it used by campus police,” Hill said, but at least five doses of naloxone that were distributed at public trainings have been used. Hill adds that number may be higher, but it’s impossible to know for sure because there is no way to track it unless users choose to report it.

According to Smith, nine kits distributed by the recovery center or carried by campus police at KSU have been used, but only one was on campus and it was administered to someone who wasn’t affiliated with the university. One campus police officer used her naloxone dose on a family member.

Similarly, naloxone has never been used on campus at Columbia. Bernitz said that one student who completed the training administered a lifesaving dose off campus.

Bernitz said that they approached their pilot program with the goal of serving the larger community. “We’ve been very transparent about why we’re doing this work, using the data that we have to support it and not necessarily saying this is only to support students who may be using drugs on campus. It’s our participation in [fighting this national public health crisis], but not ignoring the fact that we may have students who need assistance on campus and it’s not something to shy away from,” Bernitz said.

The students also see it as a way to support their neighbors. “The bigger issue that we’re trying to address is the stigma surrounding addiction and treatment. And more than that, just because it’s not happening on Columbia’s campus itself doesn’t mean that it isn’t happening in Harlem, which is our community as well,” Makam said.

Hill described public distribution of naloxone as a public good. “You’re incurring costs that you’re hoping are going to help your specific population, but the fact is that campus probably isn’t where most overdoses among students are going to occur,” Hill said. “But the most important outcome is deaths prevented.”

CHARLOTTE WEST is a freelance education reporter. Her work has appeared in the Hechinger Report, USA Today, the Washington Post, and International Educator, among others.

TAKEAWAYS

■  Drug overdoses are the leading cause of injury-related deaths in the United States, and as the opioid crisis has worsened, colleges can become a major player in helping to prevent overdose deaths. Opioid use on college campuses is not well documented, but young adults ages 18–25 are the biggest users of prescription drugs for nonmedical purposes. Some institutions have made the opioid antidote—naloxone—more accessible on campuses.
■  Some institutions have naloxone kits stocked around campus so that they are available to anyone who needs them. Some institutions have created training programs so that students, staff, and faculty can spot overdoses and know how to administer naloxone.
■  Some states have created legislation to require higher education institutions to start combatting overdoses on campuses. For example, Maryland requires that colleges and universities accepting state funding provide training to first-time students on opioid use dangers. Washington state enacted a law requiring that all resident halls with more than 100 students at public institutions develop a plan to maintain and administer naloxone “in and around” dorms.
■  One of the greatest concerns about naloxone programs on college campuses comes around liability. All 50 states and the District of Columbia have enacted access laws that give broad liability protection for naloxone, which should limit or eliminate liability risks for institutions.