Identifying & Managing Illicit Drug Use in Adolescents

Course Highlights

  • In this course we will learn about illicit drug use in adolescents, and why it is important for school nurses to recognize the signs, symptoms, and potential interventions.
  • You’ll also learn the risks of an opioid overdose.
  • You’ll leave this course with a broader understanding of how to care for students who are suffering from an overdose.


Contact Hours Awarded: 1.5

Course By:
Mallory Lawler

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The following course content

Introduction to Illicit Drug Use in Adolescents

Illicit drug use and opioid overdose deaths are a public health crisis that is beginning to bleed into the school systems. In 2017, 2.2 million adolescents between the ages of 12-17 stated they were currently using illicit substances (5). Due to this increasing number, it is important for every school nurse to recognize the signs of illicit drug use, understand what steps should be taken in the event of an overdose, how to promote prevention programs for students, and understanding how important feeling connected to staff and peers is to an adolescent. 

Quiz Questions

Self Quiz

Ask yourself...

  1. What do you think are some factors that can lead to substance abuse in adolescence? 
  2. How many students in your building have one or more of those factors?

Factors Leading to Illicit Drug Use 

Brain growth and development, particularly during one’s adolescent years, has been highly studied and reviewed. One area of the brain that is still developing during adolescents is the prefrontal cortex. This area of the brain is responsible for allowing one to assess situations, make decisions, and keep emotions and desires under control (5). Because this area of the brain is still developing, it places adolescents at an increased risk of trying drugs and continuing them (5).   

Substance use during one’s adolescent years has the potential to create several long-term negative effects. It is estimated that 90% of individuals with addictions began using substances during their adolescent years (2). There are several factors that can lead to illicit drug use. These risk factors include family history of addiction, mental health concerns, behavioral or impulse control problems, exposure to trauma, and environmental factors (2).  

A family history of addiction does not mean an adolescent will become addicted to illicit substances because it is in their genes. These individuals have a higher chance of using illicit substances due to the environment they find themselves in. If they witness their parents or family members using drugs, they may believe that activity is okay. If their caregiver is addicted to drugs, they may not fully care for the adolescent, leading to feelings of neglect, which can be a precursor for illicit drug use.  

Mental health concerns can exacerbate one’s risk factor for using illicit drugs. It has been hypothesized that individuals with certain mental health illnesses use illicit drugs to treat their mental health illnesses (8). Behavioral or impulse control problems are a risk factor for using illicit drugs since individuals with these problems cannot understand the danger of using illicit substances. These individuals have also been described as someone with an “addictive personality” (2).  

Those who have had experience with trauma may resort to using illicit substances to block out the trauma. Individuals who have had illicit drugs in their environment may not understand the danger of the drug or what addiction is.  

Signs and Symptoms of Opioid Overdose 

An opioid overdose occurs once someone has taken too much of an opioid. If an individual has taken an opioid such as fentanyl, they are at a higher risk for a life-threatening overdose due to the potency of the drug (6). There are several risks for an opioid overdose, these include: 

  • Mixing opioids with other substances like benzodiazepines or alcohol 
  • Using opioids after a break in use due to a decreased tolerance 
  • Taking too many opioids  
  • Other health conditions 
  • A previous overdose 
  • Using opioids that a pharmacy did not prescribe 
  • Using opioids alone (6) 

An individual may experience non-lifethreatening effects or lifethreatening effects. Non-lifethreatening effects include nausea, vomiting, and/or sleepiness (6). Lifethreatening effects that could lead to death include infrequent or absent breathing, slowed or irregular heartbeat, no response to stimuli, and severe allergic reaction (6).  

There are several body systems that require rapid assessment in the event of a suspected opioid overdose. The most important include breathing and responsiveness (6).  

System Behavior
  • Infrequent or absent breathing 
  • Respiratory rate is shallow with < 8 breaths/minute
  • Not responsive to stimuli
  • Unconscious or unable to wake
  • Deep snoring, gurgling or choking sounds (death rattle)
  • Pinpoint pupils
  • Pale, clammy skin
  • Blue or ashy lips or fingernails
  • Slow or irregular heartbeat

In the event of an opioid high, it is still critical to assess the students respiratory and neurologic status first (6). 

System Behavior
  • Breathing 
appears normal
  • Responsive to stimuli
  • Looks sleepy
  • Speech slurred or slow
  • Pinpoint pupils
  • Normal skin tone
  • Normal heart rate


Actions to Take for a Student Overdose 

If a student is suspected of being under the influence of opioids, EMS should be contacted. While the student may not be displaying signs of an overdose, they need to be taken to the hospital to be monitored. The nurse should remain with the student and continuously assess their breathing and responsiveness. The nurse should attempt to keep the student awake until EMS arrives (6).  

If the student is experiencing an opioid overdose, immediate medical attention is required. EMS should be contacted, and Naloxone should be administered, if available. If Naloxone is not available and the student begins to experience respiratory or cardiac arrest, CPR should be started immediately and be continued until EMS takes over.  

Future of Naloxone in Schools  

Naloxone is an opioid antagonist that works by temporarily reversing the respiratory effects of opioids (4). If this medication is administered quickly, it can restore breathing to an individual that is currently experiencing an opioid overdose (4). The National Association of School Nurses (NASN) adopted a position on naloxone use in schools. They believe that when emergencies occur in a school, proper management is needed to achieve positive outcomes. 

The NASN echoes the science of why naloxone is important, and how it contributes to reversing respiratory distress caused by opioids. The organization further states that every school nurse should be cognizant of the legal implications surrounding the use of naloxone. “School nurse access to naloxone as part of their school’s emergency preparedness will improve opioid overdose response, response preparation, and harm reduction and avoid horrific outcomes such as death” (4).  

If a state and school allow for naloxone use, the typical form of medication administration will be intranasal. Per the makers of intranasal Narcan, there are three steps to follow for administration (9). 

  1. Peel off the back of the package to remove the device; hold the device with your thumb on the plunger and two fingers on the nozzle. 
  2. Insert the tip of the nozzle into either nostril; ensure the entire nozzle is inserted into the student’s nostril.
  3. Press down on the plunger to release the medication. 

If Narcan is administered, ensure that EMS has also been contacted and is in route. Continuously monitor the student for improved signs of breathing. If the student does not demonstrate improved signs of breathing after 2-3 minutes, another dose should be administered (9). If the student stops breathing, CPR should be immediately started and maintained until EMS arrives and takes over. 

Quiz Questions

Self Quiz

Ask yourself...

  1. Do you believe Naloxone use in your building would be helpful? Why or why not?
  2. Is there a time a student has come to your office with signs/symptoms of substance abuse and you did not realize it? 

Illicit Drug Use Prevention Programs 

Multiple studies have shown that the science of prevention may affect the probability of later problems (7). The main goal in adolescent substance abuse prevention is to reduce risk factors and overall enhance/reinforce protective factors (7). Depending on the addiction, medication may be used in combination with a form of behavioral therapy or counseling. Individuals with an opioid addiction can take methadone, buprenorphine, extended-release naltrexone, or lofexidine (5). For individuals that are addicted to stimulants or cannabis, behavioral therapies are the best course of treatment because no medications are currently available for this type of addiction.  

There are several types of behavioral therapies for individuals struggling with illicit drug use and addictions.  

Cognitive-Behavioral Therapy

Helps individuals recognize, avoid and cope with situations in which they may use drugs. 

Contingency Management

Uses positive reinforcement for attending counseling sessions, remaining drug-free, or taking prescribed medications.  

Motivational Enhancement Therapy

Focuses on strategies that make the most of an individual’s readiness to change their current behavior and enter into treatment 

Family Therapy

Focuses on utilizing the family to address influences on drug patterns and improve overall family function

Twelve-Step Facilitation

• Delivered in 12-week sessions

• No medical treatments, but allow the individual to social and complementary support

Follows 12 steps of acceptance, surrender, and active involvement in recovery

Fostering Connectedness in School 

The Centers for Disease Control and Prevention (CDC) encourages fostering connectedness in schools as a way to improve both the health and learning of students. If students believe that the adults and peers in their school care about them and their learning, they are more likely to have positive health and academic outlooks (3). The CDC has determined four factors that can strengthen school connectedness for students. These include adult support, belonging to a positive peer group, commitment to education, and a positive school environment (3).   

Quiz Questions

Self Quiz

Ask yourself...

  1. Does your school foster connectedness with its students? 
  2. How could you incorporate connectedness in your school? 
  3. Do you believe this connectedness could positively impact the lives of your students? 


Illicit drug use is on the rise in adolescents and can be seen while the adolescent is at school. It is important that the school nurse understands what an overdose looks like and how to effectively treat a student who is suffering from one. It is also important for the school nurse to understand that illicit drug use stems from multiple facets of life. Whether it is a student’s home life, mental health, or brain development, these factors all play an important role in how a student copes. Ensuring that a student feels connected with staff and peers is a great way to motivate and foster positive health and academic outlooks.   

References + Disclaimer

  1. High risk substance use in youth. (2020, October 22). Retrieved April 10, 2021, from 
  2. Risk factors for addiction. (2017, February 14). Retrieved April 10, 2021, from
  3. Fostering school connectedness: Information for school districts and school administrators. (2019, November 21). Retrieved April 10, 2021, from,positive%20health%20and%20academic%20outcomes.
  4. Naloxone in the school setting. (2020, June). Retrieved April 10, 2021, from,emergency%20preparedness%20and%20response%20plans.
  5. Drugs, brains, and behavior: The science of addiction. (2020, June). Retrieved April 10, 2021, from
  6. Klein, N. (2020, January). Opioid-related overdose policy guidelines & training in the school setting. Retrieved April 10, 2021, from
  7. Gray, K. M., & Squeglia, L. M. (2018). Research Review: What have we learned about adolescent substance use?. Journal of child psychology and psychiatry, and allied disciplines, 59(6), 618–627. 
  8. National Institute on Drug Abuse. (2021, April 13). Why is there comorbidity between substance use disorders and mental illnesses? Retrieved April 18, 2021, from
  9. How to USE NARCAN® (Naloxone) nasal spray. (2020, August). Retrieved April 18, 2021, from


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