Qualitative study of opioid overdose education and naloxone access strategies in community health center primary care settings: opportunities for expanding access and saving lives
Clark, Michele N.
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BACKGROUND: Naloxone, an opioid antagonist, offers a powerful tool for preventing opioid overdose deaths. Because studies have shown opioid overdose education and naloxone distribution (OEND) programs to be a safe, feasible, and effective intervention, several policymakers and public health agencies have advocated for broader access to this life-saving medication. Community health centers (CHCs) are a promising location for expanding naloxone access. This investigation examined the experience of CHC-based HIV primary care teams with a variety of overdose education and naloxone access (OENA) strategies in order to inform future dissemination efforts. METHODS: A mixed methods study was conducted with eight CHCs located in Massachusetts communities experiencing high opioid overdose fatality rates. Individual and group interviews with 29 clinic staff members; clinic and participant surveys; and document review were used to elucidate the OENA strategies. The Consolidated Framework for Implementation Research guided the data collection process and subsequent analysis, which revealed several factors supporting or hindering implementation of OENA activities in CHC primary care settings. RESULTS: Operating in a facilitative state policy environment, the CHCs utilized a mix of approaches to OENA: providing clinic-based services, issuing prescriptions, utilizing pharmacy standing orders, and making referrals to existing community-based OEND programs. With prescribers having limited time and competing priorities, nurses, health educators, and other staff played a prominent role in OENA. Pharmacies also served as important access points for patients and community residents. Several strategies were used to engage patients, including active outreach, partnerships with external organizations, and efforts to destigmatize substance use disorders. Clinic staff participation was enhanced through leadership support for harm reduction approaches, ongoing training, peer modeling, and information sharing. CONCLUSIONS: This study demonstrated that OENA can be integrated into CHC primary care services, adapted to the clinic context, and modified as needed. Successful implementation required a systems-level response, grounded in a team-based care model and a consideration of patient needs. The process for naloxone reimbursement needs to be determined to minimize CHC or patient barriers and ensure sustainability. Clinic training and technical assistance plans should be customized according to the staff members’ potential roles and their stage of readiness.