The opioid epidemic has risen to be one of the United States’ leading public health crises. Since the 1980s, the liberal use of narcotics to treat acute pain quickly became an industry among pharmaceutical companies as intent for these drugs shifted to an economical motive. Today, even with the use of prescription drug monitoring programs (PDMP), opioid-related drug deaths are still a prominent problem in America. According to the Centers for Disease Control and Prevention (CDC), opioid-related deaths in 2018 averaged 128 deaths per day^[1]. Monitoring prescriptions and providing information on the risks and benefits of long-term narcotic pain management has helped to slow the prescription rate among providers. However, much of the problem remains in the users. Philadelphia is one of the cities most greatly affected by the opioid epidemic. As of May 2014, it was estimated that 50,000 people overused prescription painkillers and opioids in one year, and there were about 70,000 heroin users in the Philadelphia area^[2]. Furthermore, nearly one in every four U.S. high school seniors has had some form of lifetime exposure to prescription opioids, whether it was medically or non-medically related^[3]. We propose that education, presented in an age-appropriate way, is the best method to reduce opioid misuse and related deaths among the population. Implementing a curriculum in Pennsylvania for grades K-12 would help narrow the margin between the problem and the solution for the current opioid epidemic.

There are two different philosophies to approaching the opioid epidemic. The first is through the lens of abstinence. Abstinence can be very difficult to achieve, and it involves complete avoidance of using a drug to overcome an addiction. This may involve disposing of or removing the medication from one’s household after detoxification to avoid relapse. Opioids lead to a rapid onset of addiction because the portion of the limbic system that deals with reward seeking is constantly activated. For this reason, it is important to continuously educate adolescents about the risks associated with any illicit drug use. One example of this is the D.A.R.E (Drug Abuse Resistance Education) program, instituted in 1983 in Los Angeles. This was an educational curriculum designed to educate students about prescription and non-prescription drugs and to prevent use of controlled substances, participation in gangs, and violent behavior. The D.A.R.E. program is continuously evolving and growing, and has been adding new curriculums focused on the opioid epidemic. The main goal of this program is to caution students about the dangers of drug use and to coach students on how to “say no” to drugs. The program also sheds light on the advantages of living a drug-free life^[4]. However, the strategy of pure abstinence can be a challenge without instilling interpersonal skills in students. In addition, teaching students about the severe effects of drug addiction may actually backfire and instead intentionally convey that other substances, such as alcohol, vaping or tobacco, are better alternatives.

The second model through which the opioid epidemic can be confronted is through the harm reduction theory. This theory claims that drug use and abuse will happen regardless; therefore instead of condemning those actions, one can work to minimize the harmful effects and educate individuals on the most appropriate ways to seek help. Drug use has a complex mixture of psychological, social, and biological influences; therefore, it is not very feasible to call for total abstinence. Instead, there must be a nonjudgmental coalition of resources available for these individuals to quit. This allows patients to take over as the primary agents of their health^[5,6]. We believe that this model is the best approach to education. It is through the harm reduction theory that we intend to create an opioid education and prevention curriculum to educate young people on the opioid epidemic.

Due to the gravity of the current opioid epidemic and the widespread exposure to prescription opioids by young individuals, there is an increasing need to supply all levels of education with knowledge about the dangers of drug misuse. In this article, we propose an opioid education and prevention curriculum in the state of Pennsylvania, in accordance with harm reduction theory, which will serve as a paradigm to help tackle the progression of the opioid crisis in the United States.

The Ohio HOPE Curriculum

In 2014, the Ohio House Bill 367 was passed, which required each Ohio school districts’ board of education to incorporate instruction on opioid abuse and prevention within its health curriculum. The goal of this program was to educate students on the dangers and detrimental effects of prescription opioid abuse and methods for prevention. A professor at Wright State University, Dr. Kevin Lorson, worked in conjunction with the Ohio Department of Higher Education to develop the HOPE (Health and Opioid Abuse Prevention Education) curriculum for grades K-12 in 2016. This curriculum meets the Ohio HB 367 requirements for schools to provide instruction on the risks of prescription opioid abuse. The HOPE high school curriculum has seven core standards: functional knowledge, analyzing the influence of others, accessing valid and reliable information, interpersonal communication, decision-making, goal setting, and advocating for drug abuse prevention. The curriculum was designed to be taught by a licensed health education instructor during a designated drug abuse prevention unit in their health class. The curriculum spans ten lessons and combines PowerPoint presentations, interactive lesson plans and assessments^[7].

Lesson 1’s main topic is the proportion of teens in Ohio that are currently using or have used marijuana, heroin, alcohol or tobacco/vape products. Data is readily available from 2013 and 2019 via the Ohio Department of Health’s Youth Risk Behavior Survey^[8]. Students are also tasked with discussing how drug use may impact a wide range of people in their lives. Students are afforded the opportunity to learn about the long and short term effects of various drugs.

In Lesson 2, students are taught about the various stages and effects of addiction. They learn about effective techniques to help loved ones that may possibly be suffering from addiction and substance use disorder. The activity within this lesson demonstrates the wide range of effects that addiction can potentially have on the students’ own lives and families.

Lesson 3 educates students about the proper use of prescription and over the counter (OTC) medicines. This is a comprehensive lesson regarding healthy medication use behaviors. Students are taught the differences between OTC and prescriptions drugs, as well as how to properly follow prescription directions. They are also provided with multiple resources to use to determine proper use of medications.

Lesson 4 explains decision-making by utilizing a process called, “Stop, Think, Choose”. Students are tasked with identifying barriers to living without drugs as well as the benefits of thorough decision making. One of the hallmarks of this lesson is for students to identify a trusted adult in their lives which the student would feel comfortable asking for help.

In Lesson 5, students learn about preventing opioid abuse. Drugs such as heroin, fentanyl and cocaine, as well as treatment options such as naloxone are discussed. Students also have the chance to study the long term effects of opioid abuse, and are tasked with analyzing the impact of opioid abuse on their families, relationships and future aspirations. Teachers discuss how culture and society may inadvertently promote drug use or abuse.

Lesson 6 discusses influences on healthy choices. Factors such as peer pressure, genetics, geography, home environment, and stressors are discussed with students. Students may be asked to discuss both the positive and negative influences in their lives that may or may not foster unhealthy habits.

In Lesson 7, refusal and communication skills are taught for students to resist peer pressure. Students are taught multiple ways to say “no” to drugs, demonstrating the abstinence theory as discussed above^[7]. A lesson 8 teaches students about the hazards of driving under the influence and also offers them a chance to thoughtfully contemplate what to do if they were offered a ride by someone under the influence. Students have the opportunity to read multiple stories of intoxicated drivers and the victims of those actions^[3]. Lesson 9 discusses the importance of asking for help and methods of receiving help. Students are provided with resources if themselves or loved ones are ever in need. In Lesson 10, students are taught about advocacy, and use everything they have learned over the course to formulate a “staying drug-free” message. Students are encouraged to direct the lesson themselves and take ownership of their decisions and choices to stay drug free^[7].

An important aspect of Ohio’s HOPE curriculum is that it applies both the harm reduction theory as well as abstinence. The program focuses mostly on a “stay drug free” message, teaching abstinence, but it also empowers students to make healthy decisions. We have used the HOPE curriculum as a template for our curriculum, however applying more of a harm reduction theory message and including a stronger focus on opioid education and prevention for grades K-12. With the knowledge that this type of curri culum has been successful in Ohio, our hope is to implement this improved and more sustainable curriculum in Pennsylvania which will eventually serve as a paradigm for other states ravished by the opioid epidemic.

Medical Aspects of Opioid Education and Addiction

Opioids can be very dangerous if misused and can lead to overdose and death, as they have the potential to depress the central nervous system (CNS). As a result, there are several other topics that need to be taken seriously and discussed in schools along with opioid education. In order for students to fully understand their curriculum on opioids, it is important to first equip them with a background on the physiology of drug addiction and opioids, various alternatives, and pain management. In this section, we provide a basic understanding of these topics, including non-opioid drugs used for pain control, athletes and the use of anabolic steroids, and the pathway in which drugs affect the brain.

Opioids and the Physiology of Drug Addiction

Opioids, such as heroin, fentanyl, morphine, hydrocodone, and oxycodone, are a class of analgesic drugs with a high potential for addiction^[9]. They work by activating mu, kappa, or delta receptors in the central and/or peripheral nervous systems. Activation of the receptors in the CNS stimulates the release of dopamine, leading to its analgesic and euphoric effects^[10].

Misuse of prescription opioids for pain control is a risk factor for future opioid abuse; once tolerance develops, individuals tend to require higher doses of opioids to attain adequate pain control^[11,12]. Research studies have shown that prolonged opioid abuse leads to significant irreversible brain damage and subsequent impairment of one’s decision making capacity^[13]. Two of the most commonly abused opioids with high mortality rates are heroin and fentanyl. Heroin is a derivative of morphine, a natural product obtained from opium poppy plants. Fentanyl is a synthetic opioid, 80-100 times more potent than morphine, and approximately 25-50 times more potent than heroin^[14]. Both heroin and fentanyl are often mixed with cocaine, MDMA, and/or methamphetamine for enhanced euphoric effect. In addition, fentanyl is often added to heroin to increase its potency; this is often sold as “pure/raw” or “high-grade” heroin. Many users are not aware of fentanyl content in heroin, and become more prone to overdosing behavior^[10].

It is valuable to be able to recognize both the short term, long term, and withdrawal effects of opioid use. Short term effects include extreme euphoria, dry mouth, constipation, nausea, and vomiting. In severe cases, seizures, depressed mentation and respiratory drive leading to hypoxia may occur. Long term effects include psychological disorders, and increased risk of both viral and bacterial infections such as hepatitis, HIV, and bacteremia related complications. Withdrawal symptoms can often start as early a few hours after last use of the drug. However, they usually peak between 24 to 48 hours after the last dose of heroin. They may include restlessness, severe myalgias, diarrhea, vomiting, sleep disturbances, and severe cravings^[10].

There are several drugs that are used to treat acute opioid intoxication as well as withdrawal. In the management of opiate addiction, naloxone is a drug that is used to treat acute heroin overdose. It is an opioid receptor antagonist, used to reverse CNS symptoms, especially respiratory depression. Narcan nasal spray and Evzio (hand held auto-injection) have been FDA approved for use by family members or caregivers to use in situations warranting reversal of opioid overdose^[14]. Buprenorphine/naloxone combination (Suboxone), naltrexone, and methadone are replacement therapies which are used to decrease the symptoms of withdrawal and lower the risk of overdose. In addition to pharmacological therapy, cognitive behavioral therapy is also often used to help treat patients’ addictions.

Alternatives to Opioids

Chronic pain is a very common and costly medical condition that often requires a comprehensive and multidisciplinary approach. This may include physical therapy, psychological care, and pharmacologic management. Given the high addiction potential of opioids, non-opioid therapy should be attempted first. There are several alternatives to opioids that can also be used in the treatment of acute and chronic pain. Two main classes of non-opioid medications include acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs).

Acetaminophen, the active component in Tylenol, is one of the most widely used synthetic non-opioid pain relievers & fever reducers. It acts at the cellular level by inhibiting cyclo-oxygense (COX)-2 to reduce both inflammation and body temperature. Acetaminophen is generally best used for mild to moderate pain, migraines, tension headaches, and fever. Though widely used, it may be associated with certain undesirable side effects. Its use has been linked to liver failure and sometimes has led to liver transplant or death. However, the hepatotoxicity typically correlates with higher doses of acetaminophen that exceed the recommended maximum dose^[15,16]. Other adverse effects include cholestatic jaundice, pancreatitis, thrombocytopenia, agranulocytosis and anaphylaxis^[17]. Despite these adverse effects, acetaminophen is still recommended for mild to moderate pain and as a fever reducer over opioids.

NSAIDs are also used for acute pain control in order to spare the use of opioids. Common NSAIDs include aspirin, naproxen, ibuprofen, indomethacin, and celecoxib. The primary mechanism of action of these drugs is the inhibition of the cyclooxygenase (COX) enzyme. NSAIDs are used for their analgesic, antipyretic and antiinflammatory effects, and therefore are indicated for use in mild to moderate pain, arthritic conditions, fever, migraines, gout, and dysmenorrhea. Depending on the specific drug, various NSAIDs have been known to cause gastrointestinal and renal side effects, such as dyspepsia, peptic ulcer disease, acute renal failure, and worsening hypertension^[18]. In patients chronically treated with NSAIDs, yearly monitoring of blood work is recommended^[19].

Although there are a variety of adverse effects from acetaminophen and NSAIDs, one must weigh the pros and cons compared to the use of opioids. Opioids have a high potential for addiction, and a risk of overdose and death. It is crucial to educate children on the differences between these pills and the OTC pills in their medicine cabinets, as well as methods on taking them properly and in the correct dosages to avoid the adverse effects.

Anabolic Steroid Use in Athletes and Marijuana

After the discovery of testosterone in 1935, many other derivatives known as anabolic-androgenic steroids have been synthesized to produce the effects of the original molecule. Anabolic steroids are used to enhance athletic performance along with physical appearance. Despite their association with short term behavior and long term healthcare problems, their use is still widely prevalent in the American population with a noted rise in use by teenagers. Androgens are responsible for the development of male reproductive system and secondary sexual characteristics whereas their anabolic effects lead to an increase in protein synthesis. Overall this results in greater muscle mass, strength, along with resultant euphoria, and a feeling of increased aggressiveness. The ease of achieving these without a rigorous training schedule and strict diet has led to recreational and widespread use. However, the potential adverse effects include reproductive harm, prostate cancer, testicular atrophy, liver damage, blood clots, mood swings, aggression and depression^[20].

The prevalence of self-reported use of anabolic steroids in adolescents has ranged from 5 to 11% of males and up to 2.5% of females^[20,21]. Athletes have been shown to represent a significant portion of the user population. Anabolic steroid use in adolescents is also associated with prior history of cocaine, injectable drugs, alcohol, marijuana, and smokeless tobacco use^[22]. Educational programs directed toward potential users of anabolic steroids have aimed to discourage use by advocating for greater awareness of medical risks such as increased aggressiveness, emotional lability, advanced acne, gynecomastia, male pattern baldness and testicular atrophy. Even if the potential benefits of anabolic steroids are acknowledged, many health professionals are concerned that admitting to such benefits may inadvertently condone their use.

Discussing the clinical repercussions of anabolic steroids is only part of the decision-making process, as some anabolic steroid users believe that, regardless of medical and psychosocial consequences, steroids are necessary to be competitive in their field. 40% of teens report that their decision to take steroids was inspired by professional athletes that took them^[23]. Teen athletes may be motivated to use steroids to obtain prestigious college sports scholarships, high school popularity, and improvement with body image issues. If teens and athletes were more educated about the harmful use of steroids in addition to opioids as discussed above, perhaps there would be a notable reduction in prevalence.

It has been found that approximately 85% of teen athletes do not have any information about the adverse effects of steroids, despite the fact that fewer than 25% of the nation’s schools provide education on anabolic steroids, the pressures to use them, and healthy alternatives that individuals can take. Although statements were issued by American Academy of Pediatrics and American College of Sports Medicine that condemn use of anabolic steroids, it has become increasingly evident that prohibitions against anabolic steroid use have been insufficient to curtail use^[21,22]. Especially since anabolic steroid use has been associated with prior history of other types of drug use, it is imperative to educate students on all types of substances which can be abused and cause harm. Education programs can play a key role in preventing anabolic steroid use and potentially other drugs as well. They are also important for providing accurate information to adolescents so they can make informed decisions about drug use.

Another particular substance that has made a unique evolution in its perception by both the general public and government is marijuana. Marijuana still remains illegal under federal law in the United States, classified as a Schedule 1 Drug. This classification puts cannabis in the same category as heroin, LSD, and ecstasy. However, many would argue against this harsh classification, as it has been seen by independent state legalization of medical and recreational marijuana use starting with California in 1996. Despite the observed benefits of the “normalization” of marijuana use for treatment of chronic pain, the abuse of the substance has grown more and more in recent years, particularly in the adolescent cohort. According to the CDC, 1 in 10 users of cannabis will become addicted and for those who begin using before the age of 18 that number rises to 1 in 6^[25,26]. For this reason, marijuana education is of utmost importance in the prevention of substance addiction and potential abuse by adolescents. It is important to include information regarding marijuana in health education curriculums to teach students about its proper use as well as indications for medical marijuana.

The Ethics of Harm Reduction Theory and Opioids

The driving force behind creating a curriculum on opioid education and prevention is the notion that drug addiction is a tangible reality that will not simply disappear, however its severity may be reduced. The philosophy of harm reduction reconciles this actuality by focusing on minimizing the negative results that go hand-in-hand with drug abuse^[27]. Harm reduction techniques have both a medical and ethical impact on the individual and society as a whole. Harm reduction techniques accept the individuals as they are, while also tailoring a person’s education and prevention to fit his or her needs^[26]. Furthermore, there are certain principles that are quintessential to an understanding of harm reduction, as listed by the Harm Reduction Coalition:

● Harm reduction accepts, for better and or worse, that licit and illicit drug use is part of our world and chooses to work to minimize its harmful effects rather than simply ignore or condemn them.

● Understands drug use as a complex, multi-faceted phenomenon that encompasses a continuum of behaviors from severe abuse to total abstinence, and acknowledges that some ways of using drugs are clearly safer than others.

● Establishes quality of individual and community life and well-being–not necessarily cessation of all drug use–as the criteria for successful interventions and policies.

● Calls for the non-judgmental, non-coercive provision of services and resources to people who use drugs and the communities in which they live to assist them in reducing attendant harm.

● Ensures that drug users and those with a history of drug use routinely have a real voice in the creation of programs and policies designed to serve them.

● Affirms a drug user themselves as the primary agents of reducing the harms of their drug use, and seeks to empower users to share information and support each other in strategies which meet their actual conditions of use.

● Recognizes that the realities of poverty, class, racism, social isolation, past trauma, sex-based discrimination and other social inequalities affect both people’s vulnerability to and capacity for effectively dealing with drug-related harm.

● Does not attempt to minimize or ignore the real and tragic harm and danger associated with licit and illicit drug use^[25].

The opioid epidemic is growing, fatal overdoses are increasing, and people are becoming more and more frustrated by legal and political barriers to new forms of treatment being put in place to stop this problem. Education and prevention programs have been shown to decrease heroin abuse, decrease crime and decrease disease worldwide. Half of all new drug users in the United States are under the age of 18. Experimentation is a way of life in middle schoolers and high schoolers and plays a major role in drug addiction. However, just because a school child experiments with drugs does not mean he/she will become addicted. Creating a curriculum that is realistic, educates students on the signs and realities of addiction, and explores the common reasons why students abuse drugs will go a long way to decreasing the drug addiction problem in the United States. Curiosity, peer pressure, stress, emotional struggles, and a desire to escape are common reasons why young students experiment with drugs. We know the majority of adults who are addicted first experimented with drugs before they turned 21. If we explore these issues realistically and address the common reasons honestly, it will promote more good than harm, not only for opioid users but also for their associates and communities at large. If we as a society, value human life as sacred, we must find a way to prevent opioid overdose deaths. An opioid education and prevention curriculum is one way to reduce the harm of this epidemic in a realistic way.

Overview of Our K-12 Lesson Plans

Each unit in the K-12 curriculum will be separated into five lessons. Each lesson will be covered over a single 60 or 90 minute class period during five separate months of the school year. Ideally, these lessons will take place during a health class or another set aside time period. It is vital to begin this curriculum early on in a child’s development to build a strong foundation upon which a healthy and informed life can be built. This curriculum spans across the many different stages of an individual’s development, and this fact is key to its efficacy. Individuals go through a myriad of changes as they advance from kindergarten to high school, so it is imperative to have a curriculum that reflects and embraces these different developmental stages.

K-2 Rationale: Before tackling the nuance and complexity of the opioid epidemic at large, a sturdy foundation of social skills must be thoughtfully constructed. When students are equipped with the requisite skills to decisively navigate their environment, they can more effectively avoid engaging in risky behaviors, especially as they pertain to drug use. The mission of the K-2 curriculum is to foster such skills as self-management, social aptitude, and communication. Through deliberate exploration and refinement of these skills, students will be empowered to achieve superior life outcomes.

3-5 Rationale: Having laid the foundation of social skills in the K-2 unit, students may now learn to apply those skills to more specific topics regarding drug use and addiction. Specifically, students will be trained to employ empathy and uncover the reality behind the persistent stereotypes and generalizations regarding drug use and addiction. By deconstructing the stigma associated with these subjects, students can begin engaging in more productive discussions aimed at harm reduction. Upon completion of this unit, students will be able to comfortably discuss drugs, addiction, and asking for help. Becoming familiarized with these subjects will go on to serve students further as they advance toward the grades 6-8 curriculum, where they will further explore this material in the context of their own lives.

6-8 Rationale: At this point, students have developed functional social skills to assist them in effectively navigating the complex implications of drug abuse and addiction. As these students advance to middle school, they will encounter new challenges that will require new tactics. For this reason, it is critical that students be equipped with age appropriate skills to combat the pervasive influence of peer pressure. By dissecting the fundamentals of peer pressure and analyzing the effects of one’s peers on their individual behavior, students will come to recognize how to make healthy decisions amid the flood of social temptations they are sure to experience in middle school. This focus will also serve to bolster students’ comprehension of societal implications of drug abuse, which will be explored in greater depth when they reach high school.

High School Rationale: In the culminating unit of this curriculum, students will continue refining their social skills and begin to analyze the implications of drug abuse and addiction from a macro level. Students will come to understand the scope of the opioid epidemic at large and the ways in which it has acutely impacted the city of Philadelphia. Each lesson will last a total of 90 minutes with a final 30 minute final exam. Upon completion of this unit, students will have earned the tools they will need to make informed, healthy decisions regarding drugs amidst the opioid crisis.

Recommendations

In this section, we propose a series of recommendations regarding methods to apply the curriculums for grades K-12. This includes various forms of implementing or integrating the lessons, ideal type of schools at which to pioneer the curriculums, and methods of assessing its success.

● Ohio’s HOPE curriculum has served as a template for our lesson plans, which will be used as a paradigm for schools in Pennsylvania and eventually other schools across the United States, while applying the harm reduction theory. The curriculums are intended to be integrated into students’ current health education classes. For example, a health class in ninth grade that lasts the entire year will have five classes dedicated solely to opioid education.

● The lesson plans for K-12 will follow and apply the National Health Education Standards (NHES), which are written expectations and goals for students throughout grades pre-K to grade 12^[28].

● Philadelphia has been shown to be one of the major cities most impacted by the opioid crisis in Pennsylvania. As a result, we recommend piloting this program at a private, religious-based high school in the suburbs of Philadelphia. We believe that these types of schools might have more autonomy and flexibility in beginning such a program and rearranging the curriculum, as there might be less administrative barriers and more private funds and donations. If this is successful, the curriculum will serve as a paradigm for other school districts across Pennsylvania and potentially even throughout the United States^[29-31].

● Examples of places where students may complete community service hours or visit throughout the curriculum include safe injection sites or methadone clinics. Shadowing and volunteering at these places will allow students to directly witness the impacts of drug addiction.

● Ideas for guest speakers during the lectures include patients who have previously been addicted to opioids, patients who have gone to rehabilitation for opioid use disorder, or family members who have lost loved ones to opioid overdose.

● An alternate form of implementing opioid-related education in high schools is to create a capstone project as a graduation requirement. Students might choose a topic, such as a current event, global issue, or health-related topic, such as the current opioid epidemic. Requirements will include completing a number of community service hours relating to the topic, attendance of a guest speaker event, and a final presentation. This final project may be in the form of a powerpoint presentation, poster presentation, video, website, artwork, etc^[32-34].

● Data collection is an integral part of establishing this curriculum and gauging its success. Assessments administered to students to gauge their knowledge on opioids, future recommendations, and instructor surveys will be sent to students and faculty before and after the class.

Conclusion

Prescription opioid abuse and overdose have the potential to rapidly end lives, tear apart families, and separate communities. As a result, it is crucial to raise awareness about the dangers and negative impacts of drug addiction. Individuals must be taught how to recognize the signs and symptoms of opioid abuse and withdrawal, and be shown methods in which they can help. By implementing an opioid education and prevention curriculum for grades K-12 in areas greatly affected by the opioid epidemic such as Philadelphia, using Ohio’s HOPE Curriculum as a model, it will serve as a paradigm for other school districts in the United States. Applying the harm reduction theory to these lessons is most practical, assuming that drug use and abuse will occur regardless, so therefore instead of ignoring or condemning those actions, one can at least minimize the harmful effects. In this way, the curriculum aims to educate students of all grade levels on the proper use of opioids and provide resources for seeking help. Ultimately, this will help to both improve education on the current opioid crisis, and possibly even prevent future overdose-related deaths.

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