Types of Medications

All Prescription medications are authorized by licensed prescriber in Minnesota.  Requirements for a Valid Prescription in Minnesota outlines what the prescriber must include in a prescription. MN Statute 152.11 Prescriptions outlines the requirements for controlled substances.  

A controlled substance requires a prescription and MN Statute 121A.22 requires that a parent or legal guardian must inform the school if the drug or medicine is a controlled substance. In addition, the request of the parent may be oral or in writing.  An oral request must be reduced to writing within two school days, provided that the district may rely on an oral request until a written request is received.

The FDA has approved certain cannabinoids including, cannabidiol (Epidiolex™), dronabinol (Marinol™ and Syndros™), and nabilone (Cesamet™). These prescribed medications are not medical cannabis and should be treated in school health as all other prescribed medications with appropriate prescriber orders, storage, and administration.

Prescription medication must be supplied by the parent with a pharmacy label specific to that student.  

Prescription medications are approved by the Food and Drug Administration (FDA) which means the drug or medication is safe and effective for the intended use and it can manufacture the product to meet federal quality safety standards. The FDA provides an electronic Drug Approvals and Databases.  There are many prescribed medications that have good evidence for safe off-label use in children and adolescents.  Off-label means that the use is supported by evidence-based literature or a patient review board.  Nurses or school personnel who have questions or need clarification should contact the licensed prescriber to ensure safe medication administration as intended by the licensed prescriber.

Resources

Prescribers Digital Reference provides a full list of drug information.

RXLIST Pill Identification Tool can help identify prescription, OTC, generic and brand name pills.

FDA-Approved Drugs is tool to search for medications with FDA approval.

Pediatric research or investigational drugs are those medications currently involved in clinical trials and are undergoing formal study to determine the efficacy and safety of pediatric dosing, but they do not have full FDA approval.Research or investigational drugs are approved for the use in the FDA approved clinical trial.  

Students involved with research are involved extensively with medical providers.  Nurses and school personnel should be provided medication information on the purpose, side effects, allergy potential, administration schedule, safe dosage, storage requirements, and intended benefit for the student.

MN Statute 121A.22 Subd 2. Exclusions specifically states that drugs or medicines that are purchased without a prescription are excluded.  However, this does not mean that a school cannot choose to require both licensed provider and parent/guardian authorization for administration in school.  

State of Minnesota Office of the Attorney General Letter (February 14, 2000)

In 2000, the Attorney General was asked to provide an opinion as to whether school nurses could provide over the counter (OTC) medications to students upon a parent’s request, even without a physician’s order.  The State of Minnesota Office of the Attorney General Letter concludes, “this office concludes that school nurses do have the authority to provide over-the-counter medications to students upon a parent's request, even without a physician's order. It is important to note, however, that the school nurse has the ultimate authority and responsibility to reject a parent's request and to decline to administer an over-the- counter medication if the nurse believes that such medication is unnecessary, inappropriate, or could lead to patient harm. Further, school districts retain independent authority to implement policies that govern the administration of non-prescription drugs by school nurses. A school district, or an individual nurse, could choose to adopt a policy that requires a physician's order before a school nurse administers a non-prescription medication to a student.”

Schools should address OTC medications in policy or procedure.  OTC medications can have contraindications or interactions with prescribed medications or other OTCs.  In general, medications administered in schools should be necessary.  Many OTCs can be given at home before or after the school day. If a district chooses to administer OTC medications with or without FDA approval, the medication should be brought to school in the original container with the manufacture label and product information insert.  Parent/guardian written authorization should be specific as to when and why the medication should be taken, dosage appropriate to student and manufacturer’s label, how often and potential side effects when given.

Over the Counter Medications (FDA approved)

There are many types of over the counter (OTC) medications that may be purchased without a prescription. At one time, many of these medications did require a prescription but because the safety was well demonstrated with appropriate use, these medications were authorized as OTC.  This includes such medications for pain relief, allergy relief, indigestion, or constipation.  These medications are FDA approved and have standard labeling for indications for adult or pediatrics on why to take, dosage, frequency, and potential side effects.  

Over-the-Counter OTC / Nonprescription Drugs provides a resource to identify FDA approved OTC medications.

Over the Counter Medications (non-FDA approved)

There are many types of “medicines” that fall into this category of OTCs which could include: Complementary and Alternative Medicine (CAM), Cannabidiol (CBD) gummies/products, herbal products/remedies, vitamins, and dietary/nutritional supplements. These products are not approved by the FDA for safety, effectiveness or labeling before they are sold to the public.  There can be wide variation in ingredient contents and labeling between various manufacturers meaning the actual amount of the active ingredient can vary greatly.

Note:  Cannabidiol (CBD) is not medical cannabis. Generally, CBD products do not contain tetrahydrocannabinol (THC) which is the main psychoactive component.  However, because of limitations related to the manufacturing of OTCs, some CBD products vary in the amount of CBD as the active ingredient and could contain THC in unknown amounts.

Stock Over the Counter Medications

While well intentioned to keep students in school and “treat” minor conditions, it is generally not recommended to keep a stock supply of over-the-counter medications.  Many minor issues like headache or stomachache can be relieved with hydration, food, brief rest, or relaxation techniques.  Some considerations include:

• How will the school assess for student allergy to a specific OTC or brand, and receive up to date information on student allergies?
• How will the school know the correct dosage, route, and time for OTC medication?  The 6 Rights of Medication Administration still apply in these situations.
• How will school personnel, especially non-nurses be trained to determine the appropriateness of an OTC for a student?  Watch for side effects?  
• Can the school assume a written parent authorization, obtained annually, is up to date?  The student may have developed a new health condition, started a new medication, developed an allergy and the parent did not update the school on the changes.
• Who will maintain the OTC supply by checking for expiration dates or product recall?

The use of “standing orders” by a licensed prescriber is not addressed MN statutes for OTCs administration in schools or stock medications. “Standing orders” are essentially protocols for a specific condition and treatment with a specific OTC medication.  They are usually developed by the licensed prescriber and the school health team and renewed annually. The protocols require education and training to recognize the condition and follow the prescribed administration of that OTC. There must be strict adherence to the protocols to ensure safety and reduce risk.  While a nurse has the education and training to understand and to determine appropriate use, unlicensed assistive personnel (UAP) or non-nurses most often do not have that foundational education or training.  The MN Board of Nursing does require condition specific protocols for RNs when administering any prescription medication.  LPN’s may only use condition specific protocols for naloxone and epinephrine.  The National Association of School Nurses (NASN) School Nursing Evidence-based Clinical Practice Guideline: Medication Administration in Schools recommends that students have specific medical orders for any medication administration in schools, including OTC.

Medical Cannabis is acceptable term for what was referred to as “medical marijuana”.  MDH  Medical Cannabis  provides extensive information for patients, caregivers, health care practitioners, laws and rules, materials, and resources.  

MN Statute 152.21 to 152.37 covers medical cannabis. There are two specific references to school.    MN statute 152.23  sets forth limitations “(a) Nothing in sections 152.22 to 152.37 permits any person to engage in and does not prevent the imposition of any civil, criminal, or other penalties for:

1. undertaking any task under the influence of medical cannabis that would constitute negligence or professional malpractice;
2. possessing or engaging in the use of medical cannabis:
   1. on a school bus or van;
   2. on the grounds of any preschool or primary or secondary school;
   3. in any correctional facility; or
   4. on the grounds of any child care facility or home day care;

MN statute 152.32 Subd. 3 Discrimination prohibited provides that unless an exception applies, an individual’s status as a registered medical marijuana patient may not be used: 1) by schools as a reason to refuse enrollment; 2) by landlords as reason to refuse to lease to the person ; 3) by employers as a reason to refuse to hire or as a reason to terminate employment; or 4) as a reason to deny custody or visitation rights.  

In addition to considering MN laws, the school’s legal team will also need to consider the applicability of federal laws such as The Controlled Substances Act (2012) which does state cannabis is illegal at the federal level when developing policy and/or procedures for medical cannabis.

The MN Board of Nursing advises nurses to read the NCSBN Nursing Guidelines for Medical Marijuana and Implications for Nurses Practicing in Minnesota Providing Care for Clients Using Medical Cannabis.

MN Statute 121A.2207  Life-Threatening Allergies in Schools: Stock Supply of Epinephrine Auto-Injectors

Subdivision 1. Districts and schools permitted to maintain supply.

Notwithstanding section 151.37, districts and schools may obtain and possess epinephrine auto-injectors to be maintained and administered by school personnel to a student or other individual if, in good faith, it is determined that person is experiencing anaphylaxis regardless of whether the student or other individual has a prescription for an epinephrine auto-injector. The administration of an epinephrine auto-injector in accordance with this section is not the practice of medicine.

(b)  Registered nurses may administer epinephrine auto-injectors in a school setting according to a condition-specific protocol as authorized under section 148.235, subdivision 8. Notwithstanding any limitation in sections 148.171 to 148.285, licensed practical nurses may administer epinephrine auto-injectors in a school setting according to a condition-specific protocol that does not reference a specific patient and that specifies the circumstances under which the epinephrine auto-injector is to be administered, when caring for a patient whose condition falls within the protocol.

Subd. 2.Arrangements with manufacturers.

 A district or school may enter into arrangements with manufacturers of epinephrine auto-injectors to obtain epinephrine auto-injectors at fair-market, free, or reduced prices. A third party, other than a manufacturer or supplier, may pay for a school's supply of epinephrine auto-injectors.

This statute allows but does not require schools to stock and administer epinephrine using an auto-injector for life-threating allergies.  Implementation of stock epinephrine auto-injectors requires several components.

Emergency Response Procedure for Life Threatening Allergic Reaction (Anaphylaxis)

A procedure is a sequence of steps that should be followed to implement policies. This procedure may vary slightly by site even within a school district pending the environment and resources.

Schools are encouraged to consider the following questions for the development of the school’s procedure.

• Who is the population of students, staff, and visitors to be served?
• Where will the emergency response be delivered and where the epinephrine auto-injectors be secure, accessible, and stored per manufactures direction?
• Which school staff, at the designated location, will be trained to respond and to administer the medication when an emergency response is needed? Who else should be a part of the emergency response team, besides the person trained to the given the medication?
• Consider when the trained staff will be available to provide this emergency response. During the school day only? During other after school hour events?
• How staff will be initially trained and remain competent in the knowledge to identify a possible a life threatening allergic response, know, and administer the medication appropriately, and initiate?
• What type of communication, notification, and documentation will need to be completed as part of the emergency response and medication administration?

Epinephrine Medication

The Allergy & Asthma Network provides valuable information about epinephrine.  

An anaphylactic reaction causes life-threatening symptoms. If not quickly treated, these symptoms can lead to anaphylactic shock and death.  When epinephrine is injected, it triggers a sudden burst of adrenaline to multiple areas of the body at the same time. It works by reducing throat swelling. It opens the airways. It helps maintain heart function and blood pressure. Also, as epinephrine can help reduce hives and itching. Epinephrine will also prevent a further release of histamine, the chemical that responds to allergens and ushers in symptoms.

Epinephrine use in anaphylaxis reduces or reverses these severe symptoms immediately but the full effect may take 5-10 minutes. Epinephrine begins wearing off within 20-30 minutes. Therefore, 911 must be called because additional emergency care may be needed after administering epinephrine.

Epinephrine auto injectors are a prescribed medication and are single dose.  This means once given, the injector is empty and cannot be used again.

Epinephrine is so effective it reverses the life-threatening allergic reaction, but it is not without potential side effects.  A true allergy to epinephrine is extremely rare. Side effects may include:

• Trouble breathing
• Fast, irregular, or pounding heartbeat
• Pale skin
• Sweating
• Nausea and/or vomiting
• Dizziness
• Weakness or tremors
• Headache
• Anxiety or restlessness

Most side effects will resolve in about 30 minutes and fully disappear within a few hours.  This is another reason 911 must be called if administered.  

Recognizing Signs and Symptoms of Anaphylaxis

Anaphylaxis is diagnosed when symptoms appear on two or more body organ systems. Anaphylaxis symptoms involve:

• Skin: itching, redness, swelling, hives that are widespread across the body
• Mouth and/or throat: itching, swelling of lips or tongue
• Stomach: vomiting, diarrhea, cramps
• Respiratory: trouble breathing, shortness of breath, wheezing, coughing, chest pain and/or tightness
• Heart: weak pulse, dizziness, faintness
• Headache, nasal congestion, watery eyes, sweating
• Confusion, feeling of impending doom
• Loss of consciousness

Resources for Obtaining Epinephrine Auto-injectors

Epinephrine auto-injectors are a medication that requires a prescription.  This means that a licensed prescriber will need to provide a prescription (order) so that the school may obtain or purchase epinephrine auto-injectors.

The EpiPen™4 Schools program offers Four free EPIPEN® (epinephrine injection, USP) or EPIPEN JR® (epinephrine injection, USP) Auto-Injectors in the form of two EPIPEN 2-PAK® cartons, two EPIPEN JR 2-PAK® cartons or one 2-Pak of each kind. The school must submit a valid prescription from a licensed prescriber to qualify for this program.  

Schools may purchase epinephrine auto-injectors directly from a school health supplier or pharmacy.  The cost is substantial, so the school may wish to partner with community organizations to help cover the costs for this medication.  Schools will need a valid prescription from a licensed prescriber to purchase the medication.

Condition Specific Protocol

Condition specific protocols are required for nurses (RN and LPN) administering epinephrine auto-injectors and a best practice recommendation for all school personnel.

148.235, Subd. (8) Prescription by Protocol allows RNs to implement a protocol that results in a prescription of legend (prescription) drugs for administration, including naloxone, based on conditions (as opposed to being based on specific patients).

Subd. (8). Prescription by Protocol states, “A registered nurse may implement a protocol that does not reference a specific patient and results in a prescription of a legend drug that has been predetermined and delegated by a licensed practitioner as defined under section 151.01, subdivision 23, when caring for a patient whose condition falls within the protocol and when the protocol specifies the circumstances under which the drug is to be prescribed or administered.”

MN Statute 121A.2207  Life-Threatening Allergies in Schools: Stock Supply of Epinephrine Auto-Injectors

Subdivision 1. Districts and schools permitted to maintain supply states, “(b)  Registered nurses may administer epinephrine auto-injectors in a school setting according to a condition-specific protocol as authorized under section 148.235, subdivision 8. Notwithstanding any limitation in sections 148.171 to 148.285, licensed practical nurses may administer epinephrine auto-injectors in a school setting according to a condition-specific protocol that does not reference a specific patient and that specifies the circumstances under which the epinephrine auto-injector is to be administered, when caring for a patient whose condition falls within the protocol.”

Therefore, the nurse (RN/LPN) working with a licensed prescriber must develop and follow a condition specific protocol for anaphylaxis.

The Guidance for an Anaphylaxis Protocol in a School Setting further explains the nursing practice rationale behind the need for a condition specific protocol.

An Anaphylaxis Epinephrine auto-injector Condition Specific Protocol Template for the School Setting has been developed. Schools choosing to use this template must understand that the criteria in the template includes indications, contraindications, and side effects for administering epinephrine auto-injector. However, the criteria must be reviewed and further defined according to the licensed prescriber’s parameters who is authorizing by their signature. Additional criteria and prescribed actions may be necessary. The prescribed actions are examples and may not suit your school situation and may not include all possible actions. A licensed prescriber must review the criteria and actions and determine the appropriate action to be prescribed. It is recommended that the condition specific protocol be reviewed annually.

Many schools have a relationship with a licensed prescriber, but if not, consider connecting with a local clinic or hospital, or licensed provider who is a member of your school community.  These resources can help connect you with a provider to sign a condition specific protocol.