School-Based Health Centers Help Prevent & Treat Substance Use
School-based health centers (SBHCs) are ideal places to identify youth using substances and provide evidence-based services that inform them about the health risks associated with alcohol and drug use, motivate them to change their behaviors, and support them in addressing the concerns that may be underlying their substance use.
At the same time, SBHCs are ideally positioned to address the underlying risks that contribute to substance use and strengthen protective factors by improving school climate and implementing trauma-informed practices.
How Schools Can Respond to Overdoses
More students across California and the U.S. are overdosing from fentanyl that is increasingly being distributed as pills understood to be a different substance, and sometimes in colors and shapes that appeal to adolescents and young children.
Rainbow fentanyl can be found in many forms, including pills, powder, and blocks that can resemble sidewalk chalk or candy.
All schools should have naloxone available and staff should be trained to use it. Anyone can administer naloxone if they are given instructions.
See the links below for resources and more information.
Read the warning to school leaders from the California Department of Public Health about fentanyl dangers to children.
Schools can learn more about obtaining free naloxone from the following sources:
- Naloxone Distribution Project – California Department of Health Care Services (DHCS)
- Free Narcan (noloxone HCI) for Schools – Emergent Biosolutions
Schools can support students using substances by embracing a harm reduction framework:
- Harm Reduction Resources Near You – National Harm Reduction Coalition
Watch our recorded webinar on how one school-based health center is integrating naloxone for overdose treatment.
See our SBIRT Quick Guides for more information on how your school-based health center can address and treat substance use.
By Sai Tulugu
La Clínica is a federally qualified health center (FQHC) that operates several school-based health centers (SBHCs) in partnership with the Oakland Unified School District. The health center was founded in 1971 by a group of students at the University of California, Berkeley, as a community-based clinic to address the lack of high-quality and consistent healthcare for low-income residents in the East Bay.
La Clínica has been a pioneer in its approach to training providers to administer Naloxone – a medicine that rapidly reverses an opioid overdoses in as little as 2-3 minutes – in SBHCs. The Naloxone distribution programs started out of a concern from an employee who noticed the hyper-prevalent use of narcotics in the community, often being found in colorful, attractive forms to draw the attention of children.
Karen Gersten-Rothenberg, an associate medical director at La Clínica de la Raza, said SBHCs should focus on how opioids are distributed in the community when coming up with a strategy for addressing opioid use.
A common strategy is a drug exchange where the community can safely dispose of excess prescription or recreational substances in a safe, hygienic center. These centers could also be an opportune setting to distribute naloxone and answer questions about the use of naloxone.
Another strategy is an education program, where peer-health educators come to classrooms and explain to students what naloxone is and where they can access it.
Gersten-Rothenberg underscores the importance of using the harm-reduction model to give students the autonomy to make their own decisions about their health, while providing them the resources to be safe in the case of a medical emergency.
SBHCs may encounter concerns from the community, school board, or other entities. Focusing on community problems is an important strategy to explain to community members that the role of naloxone distribution is not to encourage opioid use, but rather to prevent emergencies from occurring due to misuse.
Another long-term goal of some public health entities is to educate pharmacists about naloxone and change the standard of care to require naloxone prescription with a standard opioid prescription.
Normalizing naloxone in the pharmaceutical setting, may influence opinions in the general public and lead to normalization in SBHC settings.
Support for Schools & SBHCs
The Naloxone Distribution Project (NDP) was created by the California Department of Health Care Services and provides free naloxone to registered entities including schools, universities, and community organizations.
Some steps to take include:
- Complete an application for the Naloxone Distribution Project (NDP)
- Ask for basic demographic information
- Obtain a Naloxone standing order or physician prescription
- Licensure Information (FEIN Number, Nonprofit status, etc)
- Develop a Distribution Plan
- Once naloxone is received, complete overdose reversal forms and submit to NDP
Telltale signs of an opioid overdose include
- an unresponsive person
- shallow and/or difficult breathing
- a person who is going in and out of consciousness
- a black circle in the pupils.
When in doubt, it is usually best to administer Naloxone as this medication has no effects on a person not in overdose.
In a person undergoing an opioid overdose, naloxone administration temporarily blocks opioid receptors and causes immediate relief.
Side effects such as body aches, increased blood pressure, fever, etc., and professional medical help should be sought.
Rescue breathing may be performed if possible. The person should also be watched until professional medical help is available.
Naloxone Distribution Resources
- Naloxone in Schools Toolkit – National Association of School Nurses
- Free Narcan for Eligible Schools – California MAT Expansion Project
- Naloxone Distribution Project – California Department of Health Care Services
Sai Tulugu is a member of the California School-Based Health Alliance Youth Board.
Youth Substance Use Impacts Long-Term Health Outcomes
School health providers are concerned about youth substance use because it impacts a student’s long-term health outcomes and their academic performance. Substance use is linked to lower grades, student absenteeism, and higher rates for high school dropout.1 Adolescent substance use is also highly predictive of adult substance abuse because the adolescent brain is still developing making it more susceptible to addiction. Nine out of ten people meeting the clinical criteria for a substance use disorder began using one or more addictive substances before the age of 18.2 Schools, school-based health programs, and school support services are ideally positioned to educate, prevent, and intervene early in youth substance use, preventing experimentation from escalating to misuse or addiction.
Nationwide, 14% of high school students have misused an opioid prescription.3 In California, 20% of 9th graders and 29% of 11th graders used alcohol or drugs at least once in the last month.4 Risk factors such as trauma, mental health conditions, and environmental factors can increase a young person’s likelihood of substance use.
Tobacco Use Is Still the Leading Cause of Preventable Death
Tobacco use continues to be the number one cause of preventable death in the United States and around the world. Tobacco killed one hundred million people worldwide in the 20th century and is on track to kill one billion people in the 21st century.5
The Role of SBHCs in Tobacco Use Prevention & Education
School-based health centers (SBHCs) can also help prevent tobacco use in students through health education and are well-positioned to provide tobacco cessation services.
- One of the unique advantages of a SBHC is its ability to go beyond the provision of clinical medical services and engage in public health activities at the schoolwide level.
- SBHC staff provide health education in classrooms, conduct schoolwide screenings, hold youth and parent education groups, and work with school staff to identify high-risk students.
- This ability of SBHCs to fuse clinical care and public health makes them well-suited for many prevention activities, such as tobacco prevention and cessation.
Peer education programs have demonstrated effectiveness in preventing youth tobacco use.7
- Young people are more receptive to tobacco prevention messages delivered by their peers than those delivered by their teachers.8,9
- For the peer educators, providing tobacco prevention education to their friends provides an opportunity for positive youth development.9
- SBHCs who are already providing group education should consider peer programs as a way to enhance the effectiveness of their prevention education.
Tobacco Use Is Typically Started & Established During Adolescence
- Approximately 90% of adult smokers tried their first cigarette before age 18 and nearly 700 children become regular smokers each day.10
- Each day in the United States, more than 3,800 youth aged 18 years or younger smoke their first cigarette, and an additional 2,100 youth and young adults become daily cigarette smokers.11
- E-cigarettes, including vapes, e-pens, e-pipes, and e-hookah, are known collectively as electronic nicotine delivery systems (ENDS). While cigarette use is on the decline, middle and high school students’ use of ENDS tripled from 2013 to 2014.12
Prevention Education Success Stories
The most effective way to reach young people with prevention education is through their peers.
School-based health centers excel at engaging youth in peer-to-peer education campaigns to improve population health.
The California School-Based Health Alliance and The Los Angeles Trust for Children’s Health – which serves as the Los Angeles Unified School District’s backbone health entity – partnered to educate high school students on tobacco and vaping prevention.
Youth learned about nicotine addiction, e-cigarette ingredients, and the harmful health effects of smoking and vaping from the Stanford University Tobacco Prevention Toolkit and then created projects to share their knowledge schoolwide.
Student Advisory Boards (SAB) at eight LAUSD high schools conducted a joint in-person and social media campaign to mark World No Tobacco Day to educate students on:
- E-cigarette ingredients and health dangers;
- Myths that perpetuate smoking and vaping;
- Misinformation and tactics the tobacco industry uses to attract underage consumers.
Youth leaders reached additional youth through interactive social media polls that educated them on the concept of addiction and the chemicals inside JUUL pods.
In-person events held at schools urged students to commit to stop smoking and vaping or to pledge to never start. One SAB participant participated in a press conference to spotlight how tobacco companies target young people and the African-American community specifically with menthol cigarettes.
Youth engagement teaches students valuable leadership skills while also empowering all students how to turn knowledge about a health challenge into advocacy and preventive action.
“I learned that [big tobacco] spends $1 million a minute on advertising.”
“What shocked me was … that cigarettes are responsible for the death of a lot of people but [tobacco companies] don’t get criminally charged”
“I was surprised how much I ended up learning from other students when I shared the information I got during trainings with them.”
These projects are supported with grants from the California Department of Education Tobacco-Use Prevention Education Program.
Resources for Practice
Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based approach to the screening and identification of individuals engaged in substance use, the delivery of early brief interventions in order to reduce use, and the referral to treatment for high-risk use. These quick guides give a brief overview of each “step” and implementation considerations for SBIRT within school-based health centers (SBHCs).
- Screening Quick Guide
- Brief Intervention Quick Guide
- Referral to Treatment Quick Guide
- Opioid Use Disorder Quick Guide
- Substance Use Identification & Treatment Guide for Native Youth
Frequently Asked Questions about Minor Consent for Substance Use Disorder Services in California has information on Family Code 6929.
CSHA’s School Discipline & Student Substance Use: A Guide for School-Based Health Providers
Many schools’ “zero tolerance” policies conflict with a public health approach to youth substance use that recognizes and addresses the underlying factors that contribute to substance use. This report highlights how – and why – schools should replace punitive discipline practices with recovery-focused approaches to student substance use. It also provides an overview of what is in California state law regarding discipline approaches to student substance use.
Alternatives to Suspension: Student Tobacco & Substance Use
This resource synthesizes some of the main points in the above report, with a specific lens to student tobacco use. It provides some helpful guidance, informed by best practices in the field, on how to create non-punitive discipline policies and important aspects to consider when implementing.
The Stanford Tobacco Prevention Toolkit offers theory-based and evidence-informed resources created by educators, parents, and researchers aimed at preventing middle and high school students’ use of tobacco and nicotine.
Stanford University has additional resources, including the Vaping Prevention Toolkit, the Cannabis Prevention Toolkit, the Vaping Information, Solutions, and Interventions Toolkit (VISIT), and the Healthy Futures Curriculum, which is an alternative to suspensions education program for students caught using tobacco substances on campus.
The Centers for Disease Control and Prevention (CDC) has useful information about the negative health effects associated with tobacco including reports, fact sheets, and videos created by youth explaining the harmful effects of tobacco with suggestions on how to prevent young people from using tobacco.
The truth campaign has a website and media campaign geared toward youth and young adults.
Resources for Parents
There are many resources out there for young people to learn more about the effects of tobacco and nicotine, but it can be overwhelming to read so much information. In hope of easing the burden and engaging more young people, CSHA put together some of the most youth-friendly tobacco education resources. These are select resources we believe youth would find the most relevant:
Websites Recommended by Our Youth Board & School-Based Health Providers
Our Youth Board and school-based health providers from across the state reviewed existing substance use prevention websites and found these websites to be the most youth-friendly and impactful:
Tobacco Cessation Resources
Interested in quitting tobacco, nicotine, or vaping? Our Youth Board researched the web for the most engaging and youth-friendly resources and selected these to share with young people:
- For ages 13-17
- 6-8 week program
- Daily text messages that help you quit smoking
- Helps you quit vaping, using inspiration from others who are just like you
- Available 24/7 to help with cravings, stresses, and slips
- Helps you quit cigarettes, vapes, and/or smokeless tobacco
- Work with a Quit Coach
- Youth resources as curated by one of CSHA’s Youth Board members
(1) D’Amico, E.J., et al. (2016). Alcohol and Marijuana Use Trajectories in a Diverse Longitudinal Sample of Adolescents: Examining Use Patterns from Age 11 to 17. Addiction, 111(10), 1825–1835; Engberg J., Morral A.R. (2006). Reducing substance use improves adolescents’ school attendance. Addiction, 101(12), 1741-1751.
(2) The National Center on Addiction and Substance Abuse (CASA) at Columbia University. (2011). Adolescent Substance Use: America’s #1 Public Health Problem. New York: CASA.
(3) Kann L., McManus T., Harris W. A., et al. (2018). Youth Risk Behavior Surveillance — United States, 2017. MMWR Surveill Summ 2018, 67(SS-8), 1–114. Retrieved from: http://dx.doi.org/10.15585/mmwr.ss6708a1.
(4) California Healthy Kids Survey. (2017). Alcohol/drug use in past month, by grade level [data file]. Retrieved from www.kidsdata.org.
(5) Campaign for Tobacco Free Kids. (2015).
(6) Ziedonis, Douglas M., et al. “Barriers and solutions to addressing tobacco dependence in addiction treatment programs.” (2007).
(7) Black, David R., Nancy S. Tobler, and John P. Sciacca. “Peer helping/involvement: an efficacious way to meet the challenge of reducing alcohol, tobacco, and other drug use among youth.” Journal of School Health 68.3 (1998): 87-93.
(8) Klepp, Knut‐Inge, Andrew Halper, and Cheryl L. Perry. “The efficacy of peer leaders in drug abuse prevention.” Journal of School Health 56.9 (1986): 407-411.
(9) Valente, Thomas W., et al. “Effects of a social-network method for group assignment strategies on peer-led tobacco prevention programs in schools.” American journal of public health 93.11 (2003): 1837-1843.
(10) US Department of Health and Human Services. “Preventing tobacco use among youth and young adults: a report of the Surgeon General.” Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health 3 (2012).
(11) US Department of Health and Human Services.
(12) Centers for Disease Control and Prevention. E-cigarette use triples among middle and high school students in just one year, MMWR. Morbidity and Mortality. (2015, April 16).