BILL ANALYSIS Ó
AB 1748
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Date of Hearing: April 13, 2016
ASSEMBLY COMMITTEE ON EDUCATION
Patrick O'Donnell, Chair
AB 1748
(Mayes) - As Amended March 18, 2016
[Note: This bill is double-referred to the Judiciary Committee
and will be heard by that Committee as it relates to issues
under its jurisdiction.]
SUBJECT: Pupils: pupil health: opioid antagonist
SUMMARY: Authorizes school nurses and other trained personnel
to use naloxone hydrochloride (naloxone) or another opioid
antagonist to provide emergency medical aid to persons
suffering, or reasonably believed to be suffering, from an
opioid overdose. Specifically, this bill:
1)Authorizes, in the Business and Professions Code, a pharmacy
to furnish naloxone or another opioid antagonist to a school
district, county office of education (COE), or charter school
if all the naloxone or another opioid antagonist is furnished
exclusively for use at a school district schoolsite, COE
schoolsite, or charter school; and a physician and surgeon
provides a written order that specifies the quantity of
naloxone or another opioid antagonist to be furnished.
2)Requires records regarding the acquisition and disposition of
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naloxone or another opioid antagonist furnished to be
maintained by the school district, COE, or charter school for
a period of three years from the date the records were
created. Requires the school district, COE, or charter school
to be responsible for monitoring the supply of naloxone or
another opioid antagonist and ensuring the destruction of
expired naloxone or another opioid antagonist.
3)Authorizes school districts, COEs and charter schools to
provide emergency naloxone or another opioid antagonist to
school nurses or trained personnel for the purpose of
providing emergency medical aid to persons suffering, or
reasonably believed to be suffering, from an opioid overdose.
Prohibits school districts, COEs and charter schools from
receiving state funds for this purpose.
4)Establishes the following definitions:
a) "Authorizing physician and surgeon" may include, but is
not limited to, a physician and surgeon employed by, or
contracting with, a local educational agency, a medical
director of the local health department, or a local
emergency medical services director.
b) "Opioid antagonist" means naloxone or another drug
approved by the federal Food and Drug Administration (FDA)
that, when administered, negates or neutralizes in whole or
in part the pharmacological effects of an opioid in the
body, and has been approved for the treatment of an opioid
overdose.
c) "Qualified supervisor of health" may include, but is not
limited to, a school nurse.
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d) "Volunteer" or "trained personnel" means an employee who
has volunteered to administer naloxone or another opioid
antagonist to a person if the person is suffering, or
reasonably believed to be suffering, from an opioid
overdose, has been designated by a school, and has received
specified training.
5)Authorizes each private elementary and secondary school to
voluntarily determine whether or not to make emergency
naloxone or another opioid antagonist and trained personnel
available at its school. Requires a private school to evaluate
the emergency medical response time to the school and
determine whether initiating emergency medical services is an
acceptable alternative to naloxone or another opioid
antagonist and trained personnel. Prohibits a private
elementary or secondary school choosing to exercise the
authority provided by this bill from receiving state funds for
this purpose.
6)Authorizes each public and private elementary and secondary
school to designate one or more volunteers to receive initial
and annual refresher training regarding the storage and
emergency use of naloxone or another opioid antagonist from
the school nurse or other qualified person designated by an
authorizing physician and surgeon. Prohibits any school
choosing to exercise the authority provided by this bill from
receiving state funds for this purpose.
7)Requires the Superintendent of Public Instruction (SPI) to
establish minimum standards of training for the administration
of naloxone or another opioid antagonist and to review the
minimum standards of training every five years, or sooner as
deemed necessary by the SPI. Requires the SPI to consult with
organizations and providers with expertise in administering
naloxone or another opioid antagonist and administering
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medication in a school environment, including, but not limited
to, the State Department of Public Health, the Emergency
Medical Services Authority, the California School Nurses
Organization, the California Medical Association, the American
Academy of Pediatrics, and others.
8)Requires the training to include all of the following:
a) Techniques for recognizing symptoms of an opioid
overdose;
b) Standards and procedures for the storage, restocking,
and emergency use of naloxone or another opioid antagonist;
c) Emergency followup procedures, including calling the
emergency 911 telephone number and contacting, if possible,
the pupil's parent and physician;
d) Recommendations on the necessity of instruction and
certification in cardiopulmonary resuscitation (CPR); and,
e) Written materials covering the information required in
the training.
9)Requires training to be consistent with the most recent
guidelines for medication administration issued by the
California Department of Education (CDE).
10)Requires a school to retain for reference the written
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materials developed for the training.
11)Requires any school district, COE, or charter school electing
to utilize naloxone or another opioid antagonist for emergency
aid to distribute a notice at least once per school year to
all staff containing the following information:
a) A description of the volunteer request stating that the
request is for volunteers to be trained to administer
naloxone or another opioid antagonist to a person if the
person is suffering, or reasonably believed to be
suffering, from an opioid overdose; and,
b) A description of the training that the volunteer will
receive.
12)Requires a qualified supervisor of health at a school
district, COE, or charter school electing to utilize naloxone
or another opioid antagonist for emergency aid to do the
following:
a) Obtain from an authorizing physician and surgeon a
prescription for each school for naloxone or another opioid
antagonist.
b) Be responsible for stocking the naloxone or another
opioid antagonist and restocking it if it is used.
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13)Specifies that if a school district, COE, or charter school
does not have a qualified supervisor of health, an
administrator at the school district, COE, or charter school
shall carry out the duties.
14)Provides that a prescription may be filled by local or mail
order pharmacies or naloxone or another opioid antagonist
manufacturer.
15)Specifies that an authorizing physician and surgeon shall not
be subject to professional review, be liable in a civil
action, or be subject to criminal prosecution for the issuance
of a prescription or order pursuant to this bill, unless the
physician and surgeon's issuance of the prescription or order
constitutes gross negligence or willful or malicious conduct.
16)Specifies that a school nurse or, if the school does not have
a school nurse or the school nurse is not onsite or available,
a volunteer may administer naloxone or another opioid
antagonist to a person exhibiting potentially life-threatening
symptoms of an opioid overdose at school or a school activity
when a physician is not immediately available. Provides that
if the naloxone or another opioid antagonist is used it shall
be restocked as soon as reasonably possible, but no later than
two weeks after it is used. Naloxone or another opioid
antagonist shall be restocked before their expiration date.
17)Requires a volunteer to initiate emergency medical services
or other appropriate medical followup in accordance with the
training materials.
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18)Requires a school district, COE, or charter school electing
to utilize naloxone or another opioid antagonist for emergency
aid to ensure that each employee who volunteers under this
section will be provided defense and indemnification by the
school district, COE, or charter school for any and all civil
liability, in accordance with, but not limited to, that
provided in Division 3.6 (commencing with Section 810) of
Title 1 of the Government Code. Requires this information to
be reduced to writing, provided to the volunteer, and retained
in the volunteer's personnel file.
19)Specifies that a person trained to provide naloxone or
another opioid antagonist who acts with reasonable care in
administering naloxone or another opioid antagonist, in good
faith, to a person who is experiencing or is suspected of
experiencing an opioid overdose shall not be subject to
professional review, be liable in a civil action, or be
subject to criminal prosecution for this administration.
20)Authorizes a state agency, the CDE, or a public school to
accept gifts, grants, and donations from any source for the
support of the public school carrying out the provisions of
this bill, including, but not limited to, the acceptance of
naloxone or another opioid antagonist from a manufacturer or
wholesaler.
EXISTING LAW:
1)Requires school districts, COEs, and charter schools to
provide emergency epinephrine auto-injectors to school nurses
or trained personnel who have volunteered, and authorizes
school nurses or trained personnel to use epinephrine
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auto-injectors to provide emergency medical aid to persons
suffering, or reasonably believed to be suffering, from an
anaphylactic reaction. (Education Code (EC) Section 49414 et
seq.)
2)Authorizes, in the absence of a credentialed school nurse or
other licensed nurse onsite at the school, non-medical school
personnel to administer medication to a pupil in an emergency,
after receiving specified training:
a) Glucagon to be administered to students with diabetes
suffering from severe hypoglycemia. (EC Section 49414.5)
a) Emergency anti-seizure medication to be administered to
students with epilepsy suffering from seizures. (EC
Section 49414.7)
1)Authorizes peace officers to administer an opioid antagonist
to a person at risk of an opioid-related overdose. Requires
the Emergency Medical Services Authority to develop and adopt
training and standards for all prehospital emergency care
personnel regarding the use and administration of naloxone and
other opioid antagonists and to include the administration of
naloxone in the training and scope of practice, consistent
with current law, for emergency medical technician I
certification. (Health and Safety Code Section 1797.170)
2)Authorizes a licensed health care provider who is authorized
by law to prescribe an opioid antagonist to prescribe and
subsequently dispense or distribute 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
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person at risk of an opioid-related overdose. (Civil Code
Section 1714.22)
3)Permits a pharmacist to furnish naloxone pursuant to
standardized procedures or protocols developed and approved by
the California Board of Pharmacy and the Medical Board of
California. (Business and Professions Code Section 4052.01)
FISCAL EFFECT: Unknown
COMMENTS: This bill authorizes school districts, COEs and
charter schools to obtain naloxone or another opioid antagonist
and allow school nurses or other trained volunteer personnel to
provide naloxone or another opioid antagonist to persons
suffering, or reasonably believed to be suffering from an opioid
overdose, if a prescription is received from a physician and
surgeon. The bill requires the SPI to establish minimum
standards for training, in consultation with the State
Department of Public Health, the Emergency Medical Services
Authority, the California School Nurses Organization, the
California Medical Association, the American Academy of
Pediatrics, and others.
This bill is modeled after the provisions allowing school nurses
or trained personnel to use epinephrine auto-injectors to
provide emergency medical aid to persons suffering, or
reasonably believed to be suffering, from an anaphylactic
reaction. The major difference is that this bill simply
authorizes local educational agencies to obtain and administer
opioid antagonist while school districts, COEs and charter
schools are required to stock epinephrine auto-injectors.
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Opioid overdose. According to the author, "Drug overdoses are
now the leading cause of injury death in the United States,
surpassing motor vehicle crash deaths." According to the
Centers for Disease Control and Prevention (CDC), from 2000 to
2014, nearly half a million people died from drug overdoses; the
majority of drug overdose deaths involve an opioid, including
prescription pain relievers and heroin. The most common
prescription drugs involved in overdose deaths include
methadone, oxycodone (OxyContin ) and hydrocodone (Vicodin ).
More recently, fentanyl, a pain reliever that is 50 to 100 times
more potent than morphine, has been found in prescription
painkiller Norco or what individuals thought was Norco, killing
10 people in the Sacramento area within a two week period.
Problem among youth. The 2014 National Survey on Drug Use and
Health reported that 50.5% of people who misused prescription
painkillers got them from a friend or relative. The survey also
reported an estimated .7 percent of adolescents aged 12 to 17
(approximately 168,000) had a pain reliever use disorder in
2014, while 18,000, representing .1 percent of adolescents in
the same age group, had a heroin use disorder in 2014.
Symptoms of drug overdose. The Opioid Overdose Toolkit from the
Substance Abuse and Mental Health Services Administration
(SAMHSA), a division of the United States Department of Health
and Human Services, states that symptoms of drug overdose may
include extreme sleepiness, slow heartbeat and/or low blood
pressure, very small pupils in the eyes, fingernails or lips
turning blue/purple and breathing problems.
Naloxone hydrochloride. Naloxone is approved by the FDA as an
antidote to reverse opioid overdose. According to SAMHSA, "The
safety profile of naloxone is remarkably high, especially when
used in low doses and titrated to effect. When given to
individuals who are not opioid-intoxicated or opioid-dependent,
naloxone produces no clinical effects, even at high doses.
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Moreover, although rapid opioid withdrawal in tolerant patients
may be unpleasant, it is not life-threatening."
Naloxone is administered by a syringe or an auto-injector into a
large muscle or given under the skin. It was recently approved
by the FDA in a nasal spray form. Naloxone can reverse the
effects of an opioid overdose very quickly. In a 2014 National
Public Radio story, a deputy fire chief from Revere,
Massachusetts, said, "It's just incredible, it's like
magic?.There's somebody who's on the ground who's literally
dead. They have no pulse. Sometimes they're blue, sometimes
they're black. And you administer this stuff and sometimes, in
a minute or two or three, they're actually up and talking to
you." Naloxone is effective for 20 to 90 minutes, during which
time emergency services should be sought for the patient. When
injected into an overdose victim whose heart is still beating,
"it's virtually 100% effective," said Wilson Compton, deputy
director at the National Institute on Drug Abuse.
As communities and states throughout the country increased the
use of naloxone, prices have increased, particularly for the
nasal spray. According to the author, the Clinton Health
Matters Initiative has partnered with the manufacturer of the
nasal spray version to offer a discounted public interest price
and provide two free doses to every high school in the United
States. This bill allows a school to obtain naloxone from a
pharmacy or a manufacturer, including accepting donations from a
manufacturer.
Volunteers. According to the California School Nurses
Association, the ratio of school nurse to student in 2014-15 was
1:3,048, with just a total of 2,391 nurses for 6.2 million
students in the state. Without a nurse located at each
schoolsite, several recent new laws have tapped volunteers to
administer medical aid for varying conditions, including
epilepsy, diabetes, and anaphylactic reactions. Even with
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training, the Committee may wish to consider whether individuals
with no or little medical background should be given more and
more medical-type duties.
Training. This bill requires the SPI to develop minimum
standards for training volunteers, which is provided by a school
nurse or other qualified person designated by an authorizing
physician and surgeon. The training must cover techniques for
recognizing symptoms of an opioid overdose; standards and
procedures for storage, restocking, and emergency use of
naloxone; emergency followup procedures; and the importance of
instruction and certification in cardiopulmonary resuscitation.
The training shall also include written materials on the topics
covered by the training. According to the author's office, the
training is intended to include hands-on experience in
administering naloxone.
The California School Employees Association (CSEA) expresses
concerns about the over-reliance on the use of school personnel
(often classified employees) as volunteers. While "voluntary,"
CSEA is concerned that classified employees are often pressured
into stepping into volunteer roles. The bill contains language
requiring a school district, COE, or charter school to ensure
that volunteers will be provided defense and indemnification for
any and all civil liability in accordance with the Government
Code. The bill also specifies that a volunteer who acts with
reasonable care in administering naloxone or another opioid
antagonist in good faith shall not be subject to professional
review, be liable in a civil action or be subject to criminal
prosecution for this administration. To strengthen protections
for volunteers, staff recommends the following amendments:
1)Clarify that a volunteer may rescind his or her offer to act
as a volunteer at any time, including after receipt of
training.
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2)Require the notice to all staff to include information about a
volunteer's right to rescind his or her agreement to be a
volunteer.
3)Allow a volunteer to administer naloxone hydrochloride or
another opioid antagonist in the form the volunteer is most
comfortable with (syringe, auto-injector or nasal spray).
Immunity for school nurses. In addition to providing immunity
for volunteers, the bill also specifies that an authorizing
physician and surgeon shall not be subject to professional
review, be liable in a civil action, or be subject to criminal
prosecution for issuance of a prescription unless the action
constitutes gross negligence or willful or malicious conduct.
The California School Nurses Organization (CSNO) has a "Support
if Amended" position and seeks an amendment to provide
protection to school nurses similar to those provided to
physician and surgeons and volunteers. Since this bill is
double-referred to the Judiciary Committee, which will consider
these legal issues, the author may wish to consider the CSNO's
request in that Committee.
Writing in support of the bill, the Drug Policy Alliance states,
"Naloxone is non-narcotic, does not produce intoxication, and
has no potential for addiction or abuse?.Public health experts
agree that increasing access to naloxone is a key strategy in
preventing drug overdose deaths. The American Medical
Association, the White House office of National Drug Control
Policy, the US Department of Justice, and the Director of the
National Institutes of Drug Abuse, among others, have called for
expanded access to naloxone."
REGISTERED SUPPORT / OPPOSITION:
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Support
California School Nurses Organization (if amended)
Drug Policy Alliance
Opposition
None on file
Analysis Prepared by:Sophia Kwong Kim / ED. / (916) 319-2087