Opioid Crisis and Substance Misuse

Exam with school student having a educational test, thinking hard, writing answer in classroom
In October 2017, the U.S. Department of Health and Human Services declared a public health emergency to address rising overdose deaths related to the opioid crisis. This crisis, and substance misuse in general, impacts students and families of all backgrounds. Schools need adequate services to address student use, student trauma, and family adjustment. PBIS is well-positioned to address these needs through a structured, multi-tiered response with primary prevention, and targeted and intensive intervention supports.

What Is the Opioid Crisis and Substance Misuse?

In the late 1990s, pharmaceutical companies reassured the medical community that patients would not become addicted to prescription opioid pain relievers. Healthcare providers began to prescribe them at greater rates leading to widespread diversion and misuse of these medications. It became clear these medications could be highly addictive. Opioid overdose rates increased. In 2017, more than 47,000 Americans died as a result of an opioid overdose, including prescription opioids, heroin, and illicitly manufactured fentanyl. That same year, the National Institute of Drug Abuse estimated 1.7 million people in the United States suffered from substance use disorders related to prescription opioid pain relievers; 652,000 suffered from a heroin use disorder (not mutually exclusive).

A substance is defined as anything that can alter a person’s mood or cognition. Substances range from caffeine and alcohol to cocaine and opiates. Substance misuse refers to the use of a substance for a purpose not consistent with legal or medical guidelines. Substance misuse is not a diagnosed disease like substance abuse and dependence; it’s a problematic pattern of drug use. When talking about prescription opioids, drug misuse includes the use of controlled drugs, as classified by the federal government, either:

  • without a prescription,
  • for a reason other than the condition for which they were prescribed, or
  • in a manner other than what was prescribed (using higher quantity, more frequently, or for longer duration).

Why Address the Opioid Crisis and Substance Misuse in Schools?

It is important to identify clear targets for school-based interventions to support students affected by the opioid crisis. Schools are likely to see students affected by the crisis in the following three ways:

Students misuse and abuse substances

Adolescents die due to overdose at higher rates which makes direct prevention and intervention crucial. Of students who report high risk opioid use, many report their initial exposure to non-medical prescription opioid use early in their middle school years (ages 10-12) and demonstrate greatest risk for heroin use late in high school.[1]Research indicates peer use can influence individual risks and when a student overestimates how often their peers use, peer pressure becomes more potent (Sanders, Stogner, Seibert, & Miller, 2014).[2],[3]

Students experience trauma at home

Children of family members who use opioids and other substances are at even higher risk for a range of problematic outcomes, including a higher risk for developing opioid use disorder themselves, a higher likelihood of encountering traumatic experiences, and exposure to the child welfare system.[4]These traumas can hinder a child’s school success (Oral et al., 2016). Addressing this trauma within school settings is a natural fit as schools are great places to inspire change.

Families need help coping

Problems stemming from substance misuse are wide-ranging, and may include situations like sudden loss and unique family structures. For families with a sudden loss of a family member, shifting roles within the family can cause additional distress. New guardians may find themselves parenting children of a different generation than their own. Assisting families as they adjust to shifting roles might include school teams providing more explicit parenting supports or supports tailored to intergenerational parenting.

Substance Use Intervention within a Tiered Framework

PBIS implementation is associated with reduced rates of substance use in high schools compared to schools below implementation criteria. This suggests schools can leverage PBIS to make a difference for affected students. PBIS also improves school climate and a positive school climate promotes positive social-emotional health and reduced participation in behaviors like substance misuse and abuse.

School-based interventions targeting substance use can be systematically implemented within a tiered framework to achieve a coherent, preventive approach. The strategies listed here come from the resource Using the PBIS Framework to Address the Opioid Crisis in Schools.

Tier 1

Tier 1 interventions for substance misuse focus on both students and their families. Providing a safe, predictable, and positive environment for all students is vital for supporting their resiliency. Family engagement is especially important at Tier 1 as caregiver actions and supervision can significantly reduce student risk.

Tier 2

Tier 2 interventions support students and families impacted by or identified as at risk of engaging in substance use. At this level, supports could include small group instruction of targeted social-emotional skills like coping, problem solving, and situation-specific emotion regulation.

Tier 3

Tier 3 supports for student substance misuse include high-fidelity wraparound services, community resources, substance abuse recovery programs, and naloxone for opioid overdose. Incorporating the Interconnected Systems Framework (ISF) within an existing PBIS infrastructure provides behavioral health services for students with the highest needs and helps to ensure the school setting supports those with more intensive needs.

Get Started…

The availability of evidence-based programs and practices specifically designed to prevent and address opioid misuse is limited. Some guidance comes from expert recommendation, others from practical problem solving, and evidence-based approaches for broader substance use issues.

Schools are encouraged to start by ensuring they implement Tier 1 with fidelity. This implementation is associated with reduced rates of substance misuse. With the variety of student and family needs resulting from substance misuse, the PBIS framework organizes and leverages appropriate services in an efficient manner. Additional recommendations include:

  • Identify an existing team to review data and make decisions regarding this issue
  • Use existing data sources to screen for students needing additional support before more significant issues arise
  • Consider implementing social-emotional skills instruction across all tiers
  • Engage families and provide opportunities for caregivers to learn skills and strategies to prevent substance misuse
  • Consider adopting ISF to coordinate services with school-community providers
  • Partner with universities in using data for decision-making and implementation supports
  • Develop an emergency protocol for dealing with drug overdose on campus


US Department of Education Guidance Around the Opioid Crisis

This handout defines the opioid crisis at the federal level and offers guidance around the role schools play and what information students should know.

[1]Cerdá, M., Santaella, J., Marshall, B., Kim, J., & Martins, S. (2015). Nonmedical Prescription Opioid Use in Childhood and Early Adolescence Predicts Transitions to Heroin Use in Young Adulthood: A National Study. The Journal Of Pediatrics, 167(3), 605-612.e2. doi: 10.1016/j.jpeds.2015.04.071
[2]Nargiso, J., Ballard, E., & Skeer, M. (2015). A Systematic Review of Risk and Protective Factors Associated With Nonmedical Use of Prescription Drugs Among Youth in the United States: A Social Ecological Perspective. Journal Of Studies On Alcohol And Drugs, 76(1), 5-20. doi: 10.15288/jsad.2015.76.5
[3]Sanders, A., Stogner, J., Seibert, J., & Miller, B. (2014). Misperceptions of Peer Pill-Popping: The Prevalence, Correlates, and Effects of Inaccurate Assumptions About Peer Pharmaceutical Misuse. Substance Use & Misuse, 49(7), 813-823. doi: 10.3109/10826084.2014.880485
[4]Russell, B., Trudeau, J., & Leland, A. (2015). Social Influence on Adolescent Polysubstance Use: The Escalation to Opioid Use. Substance Use & Misuse, 50(10), 1325-1331. doi: 10.3109/10826084.2015.1013128

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