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Effectiveness
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Pharmacies are limited as a setting for naloxone distribution
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“Pharmacies themselves will tend to be a suboptimal vehicle for getting naloxone to people most likely to experience or witness an overdose” (Participant B03)
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NALs that make it easy and affordable for anyone to obtain naloxone without a prescription have more substantial impacts on pharmacy naloxone distribution
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“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)
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NALs that do not increase naloxone distribution substantially will not reduce opioid-related mortality
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“I think that the increase in distribution is likely small and thus these second order effects are likely to be even smaller” (Participant A11)
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NALs do not directly impact OUD prevalence or nonfatal opioid overdoses
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“I am not sure OUD prevalence would be affected anyway by any of these laws and provisions” (Participant A26)
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NALs may indirectly have small and acute impacts on OUD prevalence and nonfatal opioid overdoses
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“More naloxone→fewer opioid deaths→increased OUD prevalence through less loss of people, but will NOT cause new OUD” (Participant A06)
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“Largely mechanical: increased provision of naloxone→reduction in fatal opioid overdose mortality→increase in non-fatal opioid overdose mortality” (Participant A17)
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Acceptability
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“High acceptability” as evidence that states have implemented specific NALs with little blowback
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“Given how many states have done this with little blowback, it seems quite acceptable to the public” (Participant B15)
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“High acceptability” as a positive trend in recent years of public support for naloxone access
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“Naloxone prescribing and distribution faced a lot of opposition before being more commonly endorsed by public agencies in the past decade” (Participant B03)
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“High acceptability” as a lack of opposition due to a lack of public awareness of the existence of NALs
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“I think the general public would largely be unaware of such a law” (Participant B11)
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“Moderate acceptability" due to remaining stigma around naloxone and substance use
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“Public still hates people who use drugs. Many want to punish them, not treat them” (Participant B14)
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“Risk compensation, where the general public thinks giving out naloxone prescriptions encourages drug use, could reduce general public acceptability” (Participant B24)
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Feasibility
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NAL feasibility depends on levels of buy-in from stakeholders involved in implementation
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“Assuming that the stakeholders agreed on this policy, it should be relatively simple to implement” (Participant B04)
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NAL feasibility depends on existing resources and infrastructure in relevant settings
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“The infrastructure is already in place to make this happen” (Participant B07)
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“Moderate feasibility" often due to remaining stigma around naloxone and substance use
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“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)
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Affordability
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Naloxone costs significantly impact NAL affordability
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“The "policy" and the cost of the "naloxone" are two different things. The naloxone [itself] can be pricy” (Participant B09)
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Naloxone costs vary due to numerous factors (e.g., market forces on naloxone pricing, type of naloxone product)
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“Without insurance, the cost of intranasal Narcan … is cost prohibitive. In addition, many pharmacies do not carry the cheaper, generic injectable naloxone” (Participant B13)
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Who pays for naloxone significantly impacts NAL affordability
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“May cost the state/community money to pay for the naloxone” (Participant B22)
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The cost-effectiveness of NALs with significant reductions in mortality improves their affordability
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“Cost-effective due to reduced morbidity and mortality related to overdoses, first responders, and emergency room care” (Participant B06)
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Equity
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Systemic discrimination and structural oppression counter potential equitability of NALs
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“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)
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Interpersonal bias and discrimination counter potential equitability of NALs
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“Individual biases would continue to impact patient identification and delivery of naloxone” (Participant B26)
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Pharmacies are often less accessible in rural areas and to subpopulations of people who use opioids
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“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)
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Equitability is inversely related to out-of-pocket costs for naloxone
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“This policy will improve equity by reducing cost barriers to prescribed naloxone” (Participant B18)
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