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