LOS GATOS, Calif. - Los Gatos High School Principal Kevin Buchanan felt helpless on the third day of the 2021 school year.
It wasn't the typical first-week-back chaos. Instead, Buchanan was sitting on the ground, cradling the body of a student -- watching their face turn white, their body clammy, and their breaths become more and more shallow.
The student was experiencing an opioid-induced overdose.
"There was nothing I could do other than try to keep them awake until the paramedics arrived," said Buchanan.
Although this Los Gatos High School student survived the crisis, many students do not.
In 2021 alone, 36 teenagers died from opioid-related overdoses in the Bay Area, and according to the California Department of Public Health 224 teenagers statewide have overdosed fatally in the past two years.
Today, Los Gatos High School has naloxone hydrochloride in its health center.
Naloxone, also known as Narcan, is a nasal spray that can block opioid absorption and restore breathing in the case of an overdose.
"We had to do something," said Buchanan. "We had to prepare our staff for these situations."
While not the only harm reduction method, substance abuse experts say that naloxone is a useful tool since minimally trained bystanders can administer it.
According to the Centers for Disease Control, the number of naloxone prescriptions dispensed nationally doubled from 2017 to 2018. California has programs that provide free naloxone to schools.
However, schools decide to carry naloxone based on perceived drug usage at the school, and schools also need administrators to champion getting naloxone in their health centers.
There are no top-down state guidelines requiring schools to carry naloxone on campus; they have the option to do so voluntarily.
Some school districts in the Bay Area like Novato Unified started supplying naloxone to their health centers as early as 2017.
Palo Alto Unified and Campbell Union added it in 2018. In 2020, eleven school districts in the Bay Area had naloxone on campus.
This fall, the San Francisco Unified School District will explore creating a district protocol for opioid overdose.
Along with cities and towns, some counties are recommending schools provide naloxone -- though not requiring it. In September, the Santa Clara County Board of Supervisors earmarked $135,000 to provide naloxone kits to the county's 65 high schools.
Not more common, just more deadly
The teen overdose crisis is a recent phenomenon.
For decades, teens, as a demographic, were relatively insulated from increased opioid overdose deaths since teen drug use is often characterized by experimentation rather than addiction.
Although teen deaths due to overdoses have always existed, the spike in overdoses began just two years ago.
In 2020, the rate of overdose deaths doubled for teenagers in America. In 2021, the rate increased another 20 percent.
Yet during this time, illicit drug usage among teens has remained essentially the same.
"Drug use is not becoming more common," said Joseph Friedman, a Ph.D. researcher at the David Geffen School of Medicine at UCLA. "It's just becoming more dangerous."
As teens report experimenting with prescription drugs like benzodiazepines (Xanax) and stimulants (Adderall), there is a greater risk today of using counterfeit pills that look identical to prescription drugs.
There is also a great risk that the pill may contain fentanyl, a potent synthetic opioid.
According to the Centers for Disease Control, Fentanyl is about 50 to 100 times more potent than morphine and fuels overdoses.
In 2021, 77 percent of teenage overdoses in America came from fentanyl.
"We're seeing that a lot of the overdoses are kids who are just experimenting," said Friedman. "That changes the approach and urgency around harm reduction." Despite this crisis, the California Department of Education has been unwilling to do more than recommend schools stock naloxone on campus.
There aren't legal mandates requiring its presence at high schools.
The absence of naloxone reflects the autonomy given to school districts.
"Schools are perhaps the most local control part of our society," said Ori Tzvieli, the Contra Costa County Public Health Director.
Before schools can add naloxone to their health centers, the local school board must approve the new regulation, a process that can be time-intensive and cumbersome.
"By going school by school, we have to reach out and educate the school districts themselves. You have to find someone to champion this cause," said Gretchen Burns Bergman, executive director and co-founder of A New PATH, a harm reduction advocacy group in San Diego. "It's a tedious process."
Perceived risk may not reflect reality
In the Los Gatos-Saratoga Unified School District, for example, it took educators a year to move a naloxone protocol through the bureaucratic process and receive approval from the school board.
This school-by-school approach also allows schools to decide to carry naloxone based on their own perceived risk.
"We have two schools in our district," said Buchanan. "I don't think we experienced the same sense of urgency because the experience happened at our school."
This can be a problem when the greater school community lacks local statistics and data and underestimates community risk.
"People bury these stories," said Buchanan. "It's hard to get people to accept that this is a crisis."
The National Association of School Nurses President Linda Mendonca said that lack of awareness is the number one reason why schools do not keep naloxone on campus.
"People think this is not happening in [their] community, or they don't want to." The National Association of School Nurses publicly supports providing naloxone to high schools.
Proponents say more explicit policies including naloxone mandates from the state and local governing boards would help reduce the number of teenage overdoses.
Those mandates do exist in higher levels of education.
In August, Gov. Gavin Newsom signed legislation that requires California community colleges and state universities to make naloxone available on their campuses.
In 2019, Rhode Island Gov. Gina Raimondo signed a law mandating naloxone in public and private schools in the state.
The lack of naloxone in high schools isn't due to a lack of funding.
The California Department of Health Care Services runs the Naloxone Distribution Project that provides free naloxone to schools and organizations serving high-risk populations, teens being one.
In May, Gov. Newsom added $10 million in funds to the Naloxone Distribution Project as part of his budget revision.
The program now receives $15 million in state funds.
Schools in the Bay Area use this program to supply naloxone to their health centers.
For instance, Los Gatos High School received naloxone kits through this program, and schools in Contra Costa County are looking to do the same.
One additional concern surrounding naloxone is perceived liability.
Some schools worry families may hold them responsible if something goes wrong.
"There is a bureaucratic protection that I found in high schools," said Burns Bergman. "It is about not just stigma but about self-protection for liability."
UCLA's Friedman emphasizes that naloxone is safe, however.
More importantly, every state and the District of Columbia have laws that protect individuals from liability for administering naloxone since 2017.
"Accidentally using naloxone on someone who's not overdosing is not going to be dangerous to their health," said Friedman. "It should be considered a liability not to have naloxone around."