Table 3 Overall themes for specific categories of the evidence-to-decision framework

Effectiveness

Pharmacies are limited as a setting for naloxone distribution

“Pharmacies themselves will tend to be a suboptimal vehicle for getting naloxone to people most likely to experience or witness an overdose” (Participant B03)

NALs that make it easy and affordable for anyone to obtain naloxone without a prescription have more substantial impacts on pharmacy naloxone distribution

“When naloxone is in the hands of people who use drugs and their communities, and is accessible free and in a low-barrier way that can eliminate stigma, hassle, insurance concerns, people will access it” (Participant A08)

NALs that do not increase naloxone distribution substantially will not reduce opioid-related mortality

“I think that the increase in distribution is likely small and thus these second order effects are likely to be even smaller” (Participant A11)

NALs do not directly impact OUD prevalence or nonfatal opioid overdoses

“I am not sure OUD prevalence would be affected anyway by any of these laws and provisions” (Participant A26)

NALs may indirectly have small and acute impacts on OUD prevalence and nonfatal opioid overdoses

“More naloxone→fewer opioid deaths→increased OUD prevalence through less loss of people, but will NOT cause new OUD” (Participant A06)

“Largely mechanical: increased provision of naloxone→reduction in fatal opioid overdose mortality→increase in non-fatal opioid overdose mortality” (Participant A17)

Acceptability

“High acceptability” as evidence that states have implemented specific NALs with little blowback

“Given how many states have done this with little blowback, it seems quite acceptable to the public” (Participant B15)

“High acceptability” as a positive trend in recent years of public support for naloxone access

“Naloxone prescribing and distribution faced a lot of opposition before being more commonly endorsed by public agencies in the past decade” (Participant B03)

“High acceptability” as a lack of opposition due to a lack of public awareness of the existence of NALs

“I think the general public would largely be unaware of such a law” (Participant B11)

“Moderate acceptability" due to remaining stigma around naloxone and substance use

“Public still hates people who use drugs. Many want to punish them, not treat them” (Participant B14)

“Risk compensation, where the general public thinks giving out naloxone prescriptions encourages drug use, could reduce general public acceptability” (Participant B24)

Feasibility

NAL feasibility depends on levels of buy-in from stakeholders involved in implementation

“Assuming that the stakeholders agreed on this policy, it should be relatively simple to implement” (Participant B04)

NAL feasibility depends on existing resources and infrastructure in relevant settings

“The infrastructure is already in place to make this happen” (Participant B07)

“Moderate feasibility" often due to remaining stigma around naloxone and substance use

“There is a "not in my lobby" mentality… toward people who use drugs. Some [providers] think that if they do not offer MAT, naloxone… they will deter patients who use drugs from their facility/site. These stigmas may mean despite the policy, pharmacies refuse to participate in practice” (Participant B24)

Affordability

Naloxone costs significantly impact NAL affordability

“The "policy" and the cost of the "naloxone" are two different things. The naloxone [itself] can be pricy” (Participant B09)

Naloxone costs vary due to numerous factors (e.g., market forces on naloxone pricing, type of naloxone product)

“Without insurance, the cost of intranasal Narcan … is cost prohibitive. In addition, many pharmacies do not carry the cheaper, generic injectable naloxone” (Participant B13)

Who pays for naloxone significantly impacts NAL affordability

“May cost the state/community money to pay for the naloxone” (Participant B22)

The cost-effectiveness of NALs with significant reductions in mortality improves their affordability

“Cost-effective due to reduced morbidity and mortality related to overdoses, first responders, and emergency room care” (Participant B06)

Equity

Systemic discrimination and structural oppression counter potential equitability of NALs

“Mandates that do not consider racial or other socioeconomic factors are anticipated to be equitable. However … the law itself is equitable, but subject to the foundational inequities of our society and healthcare system” (Participant B26)

Interpersonal bias and discrimination counter potential equitability of NALs

“Individual biases would continue to impact patient identification and delivery of naloxone” (Participant B26)

Pharmacies are often less accessible in rural areas and to subpopulations of people who use opioids

“That seems about as easy access as possible unless you live somewhere with no pharmacies within a reasonable distance and/or a person didn’t have transportation or access to transportation to actually get to a pharmacy” (Participant 17)

Equitability is inversely related to out-of-pocket costs for naloxone

“This policy will improve equity by reducing cost barriers to prescribed naloxone” (Participant B18)