GLEN BURNIE, Md. – It was nearly two weeks before school opened, and Anne Arundel County's school nurses were already getting quizzed.
The scenario: An 8-year-old boy is acting strange and sleepy. His pupils are tiny, and his breathing is labored.
How would they treat him?
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The newly hired nurses and nurse assistants voiced mixed opinions. Then the supervisor overseeing the training session in a Maryland county walloped by the opioid epidemic made a suggestion: The overdose reversal drug Narcan.
"What do we have to lose?" Maureen Neall asked.
Nearly 50,000 Americans died from opioid overdoses last year – more than from car accidents. Now schools across the nation are preparing for what some believe is inevitable: Overdoses at schools.
High schools, middle schools and even some elementary schools are stocking nurse's offices with naloxone or Narcan, the brand name for the nasal spray version of the injectable drug. Some have been required by new state laws to keep the drug on hand. Others are taking advantage of a private drug company's offer of two free kits to any high school that asks.
Advocates liken the effort to having the lifesaving allergy drug EpiPen or portable defibrillators used for cardiac arrest.
But critics question the need. Some say the effort would be better directed toward communities and institutions that see more overdoses.
"I have not seen a single data point that an overdose happened at a school," said Eliza Wheeler, an overdose response strategist with the Harm Reduction Coalition in Oakland, California. "The problem here is how they came up with that – investing millions of dollars into a problem with no data to know whether it is even happening?"
No federal agency tracks overdoses at schools, but it's clear that teens and young adults in big cities and small towns alike are using and dying from heroin and, increasingly, the more powerful synthetic opioid fentanyl.
Overdose deaths among people aged 15 to 24 jumped nearly 33 percent from 2015 to 2016, according to the Centers for Disease Control and Prevention. Preliminary numbers from 2017 show that total overdose deaths surged still higher, but do not include deaths by age groups.
Nurses who work with students daily say it's only a matter of time before a community's ills spill over to its schools.
"I knew what was going on in the nation and our state," she said. "I figured whatever is going on in our county will be in our schools."
In 2015, Siska-Creel created the county's overdose prevention training initiative, the first school program certified by the State of Maryland. She secured $12,500 in public funds to buy two doses of Narcan for each of the county's 125 schools, and she trained school nurses and support staff on how to administer the drug.
Ten days after the program launched in early 2016, Siska-Creel said, a teenage student appeared in a high school health center "acting funny." The unidentified girl began to fade; within minutes she was not responding to questions.
The school nurse administered two doses of naloxone. The student recovered, Siska-Creel said, and was transported to a hospital for followup care.
Anne Arundel schools have used naloxone three more times on students, one a high-school student who was nodding off in class last year.
What started with one determined nurse in one county has become a statewide requirement. The Start Talking Maryland Act, passed by the Maryland General Assembly last year, requires all public schools to carry naloxone and to teach students about the dangers of heroin and other opioids.
The state appropriated $3 million to pay for naloxone, opioid education and other requirements. Now counties must report the number of times that naloxone has been administered at schools. Anne Arundel is the only school district that has used the antidote since 2017, a state education official said.
New Jersey passed legislation this year that requires all high schools – public, private and charter – to stock naloxone. It authorizes school nurses to administer up to three doses of naloxone to a student, staff member or visitor without fear of prosecution.
"Our first goal was to stop these deaths," said Assemblyman Vincent Mazzeo, who sponsored the legislation. "This epidemic is hitting all forms of life here. We already have defibrillators. We think this is a proactive approach."
But across the Hudson River, schools in New York City are taking a different approach.
With no known overdoses at school during regular school hours since 2005, city education officials say they do not see the need to stock the antidote at every school. City schools offer substance abuse education and intervention services as well as mental health for students and their families.
A special education teacher was found dead in a Bronx school bathroom last November with a syringe and a small baggie containing drug residue.
Medical examiners concluded that Matthew Azimi overdosed on fentanyl. One man was accused of selling the lethal drug to Azimi and another was charged with selling heroin and fentanyl near the school. But Azimi is believed to have died after school hours.
Elsewhere in New York State, suburban and rural districts are keeping the drug on hand.
The state has committed more than $300 million to programs to fight the opioid epidemic. More than 100 school districts have enrolled in overdose prevention programs and trained more than 11,000 non-medical school personnel on how to recognize an overdose and administer naloxone.
Student overdoses have been rare in New York, but there are at least two known cases.
Students received naloxone at high schools in Suffolk County and Ulster County in 2017, according to state health officials. They did not have information about how those two students fared after getting the antidote.
Rhode Island, viewed as one of the most aggressive states in confronting the opioid epidemic, requires all public middle, junior and high schools to carry naloxone. No Rhode Island school has used the antidote on a student overdose, a health department spokesman said.
At least 10 states have passed legislation about naloxone in schools. Some states such as Maryland, New Jersey and Rhode Island require schools to stock the antidote. More often, states allow a local school board or superintendent to decide.
"It's a community decision," said Donna Mazyck, executive director of the National Association of School Nurses.
The association adopted the position three years ago that schools and school nurses should make naloxone available to respond to overdoses.
Adapt Pharma, the company that markets Narcan, gave the association a $25,000 grant in 2016. The nurses spent the money to create a "brand agnostic" training kit for opioid emergencies that schools can download from its website.
The association has also offered training or supplies for CPR, epinephrine injectors and albuterol inhalers.
"Health departments have grappled with this across the nation," Mazyck said. "Schools just happen to be one more place in the community."
While many states are ponying up taxpayer funds to buy naloxone, Adapt Pharma has offered high schools two starter kits of Narcan free of charge.
The Irish company with U.S. headquarters outside Philadelphia launched the program through the Clinton Foundation in April 2016, spokesman Thom Duddy said. It has since donated or sold 3,436 kits to 1,167 schools nationwide.
The states that have received the most free kits are Massachusetts, New Hampshire, New Jersey, Pennsylvania and Georgia.
A Narcan kit that contains two doses. The drug expires after two years. Most states have passed standing orders that allow pharmacies to sell Narcan and other naloxone products without a prescription. Narcan retails for $130 to $150, according to the prescription drug website GoodRx.
Adapt Pharma charges a discounted group purchase price of $75 per kit to entities such as emergency medical crews, government agencies, community organizations and schools not covered by the program's giveaway program.
The company does not track whether its donated kits are used, Duddy said, in part to avoid the possibility of violating federal patient-confidentiality laws. So it does not know whether a donated kit has ever saved a student.
Company officials see the kits as part of a larger educational offering, a talking point that can help reduce the stigma of addiction and instruct students about the slippery slope from common pain medication such as Vicodin and Percocet to opioid addiction and overdose.
Adapt also sees the free kits as another potential safeguard for the larger community. The kits can be available should an adult overdose at a high school football game, a school play or a school-based polling place.
"We firmly believe schools are the cornerstone of every community in the United States," said Mike Kelly, president of Adapt Pharma's U.S. operations.
Critics say scarce resources should be steered toward groups that faceater risk of overdose.
Corey Davis, senior attorney at the National Health Law Program,cited examples such as paroled inmates with histories of drug abuse or opioid-dependent people in abstinence-based treatment programs.
"I can't imagine Adapt is claiming this is the best use of resources," Davis said.
Wheeler, of the Harm Reduction Coalition, said the key to reversing overdoses is giving naloxone directly to drug users.
"People use drugs with other people who use drugs – or alone," Wheeler said. "They are the ones witnessing overdoses."
Other higher-priority groups might include parents of people who are addicted, or public places such as restaurants, libraries or public restrooms.
Wheeler said it's difficult for an organization like hers to pay for enough naloxone to cover drug users on the street or in at-risk communities. Some harm-reduction organizations have resorted to bake sales to raise money.
"We often joke: 'At least we know where all the naloxone is being kept,'" Wheeler said. "It's in the schools."
Others defend the idea of naloxone in schools, even if the drug is not frequently used.
Toni Torsch, of Baltimore County, Maryland, has advocated for wider distribution of naloxone, compassionate laws and public investment in fighting the opioid crisis since her 24-year-oldson died from an overdose in 2010.
Daniel Carl Torsch started using OxyContin at 17. He eventually turned to cheaper heroin in what became a seven-year battle that included four stays at inpatient treatment centers.
On Dec. 3, 2010, Torsch thought her son was in a good place. He had recently completed a long-term rehab stint in Florida, and seemed healthy and happy.
"He had life in his eyes," Torsch said. "I had my boy back."
But as she prepared to leave their home that day, she knocked on his bedroom door. There was no answer.
She nudged the door open. He lay on a bed. No signs of life.
She did not know about naloxone when her son died. After she learned about the drug from a documentary, she advocated for its wider use. Now she says that many others can be spared if they get the antidote in time, or learn about the dangers of abuse before taking their first pill or injection.
"I found out later who he was getting his pills from – normal families. Right there in school," Torsch said.
In Anne Arundel County, Siska-Creel said she has heard many similar stories of mothers and fathers who have lost children.
She also hears from skeptics about stocking naloxone in schools.
"People came to me who said, 'You will never use it. It's a waste of money. It's going to affect our property values.'" she said.
"You know what? I am not going to wait for a child to die. I am not willing to wait for that to happen."
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