Table 4 Themes for Specific Categories of NAL

Liability policies

Criminal, civil, and administrative liability are not major concerns of prescribers and dispensers

“Liability concern is not a major hindrance to prescribing/distributing naloxone” (Participant A03)

In-principle support of liability protections for nonmedical administrators of naloxone, though no meaningful impact on pharmacy naloxone distribution

“The people most at risk for naloxone related liability are other people who use drugs. I don’t think that many get naloxone from pharmacies (but I could be wrong). I don’t think this policy change would increase pharmacy based naloxone distribution very much” (Participant A12)

Broad public acceptability of protecting providers and laypersons addressing the opioid epidemic

“Highly acceptable to the public that an individual not be punished for doing what they could to assist another in good faith” (Participant B26)

Feasible and affordable due to lack of implementation challenges and costs once passed

“This is a legal protection and does not require significant labor for implementation” (Participant B18)

“Moderate equitability" because these laws do not address existing disparities of access to and biases in the healthcare system

“Would not address biases in healthcare against people with mental health issues, who experience homelessness, or who live in poverty” (Participant B04)

Education/training requirements

Onerous nature of these requirements would lead to less prescribing and dispensing of naloxone

“If burdensome training prevents prescribing of naloxone, then benefits of education/training efficacy for those with naloxone may be offset by lower naloxone access” (Participant A15)

Acceptability of receiving information about proper usage for other medications extends to naloxone

“Consultations and education on proper usage is afforded for all other prescriptions, it should be here as well” (Participant B07)

Implementability concerns related to time, reimbursement, training of trainers, and infrastructure needed to provide confidential patient education

“It’s entirely possible to offer training in flexible ways that don’t require prescribers to deliver the training (videos, websites, handouts, etc.)…"feasibility" really turns in great part on WHO is to do the training and WHAT modality is required” (Participant B09)

Equitability concerns due to disproportionate negative impact of burdens from this mandate on marginalized and underserved communities

“Could be an equalizer because education is required, but if it results in providers being more selective about who they prescribe to … then it could create inequalities given some of the research about race/ethnic differences in opioid prescribing and access to MOUD” (Participant B11)

Co-prescribing naloxone

Strong evidence that these policies expand access to naloxone through pharmacies

“I still believe the data that when higher-risk people get co-prescribed, the greatest number of naloxone will go out” (Participant A20)

Only modest decreases in mortality due to focus on populations who are prescribed opioids rather than diverted prescriptions and illicit opioids

“Although it would decrease the mortality rate, most of the OD are not from prescription opioids, they are from illicit opioids (fentanyl)” (Participant A01)

Negative reactions from patients being labelled as persons needing naloxone and providers being told what medications to prescribe and when

“Factoring pushback from providers who don’t want to be mandated to do things and from patients … who do not want to be "stigmatized" as having OUD” (Participant B05)

Concerns about the feasibility and cost of these mandates

“The U.S. still prescribes more opioids than any nation on earth, even a 25% rate of co-prescription is going to cost a lot of money” (Participant B15)

Relies on access to healthcare system for an issue (chronic pain) with documented racial and ethnic treatment disparities

“I see no reason it would address intersectional issues of equity among people of color, low income people, etc. who use drugs, especially considering people of color are less likely to be prescribed opioids” (Participant B24)

Supportive in-principle of using risk indicators beyond opioid overdose, but concerned about actual implementability in-practice

“The law may not be as concrete and well defined when determining the other factors that are considered high risk for overdose and these more squishy factors could be differentially applied across demographic groups and thus worsen health disparities for certain populations” (Participant B11)

Layperson accessibility

Greater accessibility of naloxone to anyone (regardless of opioid use status) removes barriers to naloxone pharmacy distribution

“The more people that have access to a naloxone prescription, the more people there are getting it from the pharmacy” (Participant A26)

Third party accessibility less effective on overdose mortality than OTC pharmacy supply due to reliance on physician prescriptions and targeting of laypersons not likely to be present during overdose

“For this intervention [third party accessibility] to decrease fatal OD … family and friends need to be near the individual who is injecting or using heroin or fentanyl (the most common causes of fatal OD). I’m concerned that … family might not be present when individual is using drugs” (Participant A01)

Equitability concerns about prohibitory retail costs of OTC naloxone for low-income persons

“It [OTC] makes it easier to access, but it doesn’t make it affordable for those who are most vulnerable” (Participant B07)

Expanded pharmacy access

Facilitates significant naloxone pharmacy distribution by removing the need for physician involvement

“Putting the authority to prescribe Naloxone in the hands of the pharmacist and removing the additional barrier of having to go through a doctor would increase pharmacy distribution” (Participant A26)

Publicly acceptable given several examples of successful adoption without much pushback

“This is happening all over without much pushback and other respondents seemed to share my assessment that the public is fine with this” (Participant B15)

Feasible assuming pharmacist willingness and lack of opposition from prescribers

“Fairly straightforward, though depends on pharmacist willingness” (Participant B04)

Affordable due to eliminating the costs associated with office visits with prescribers

“Reducing costs associated with seeking naloxone because it would not require an office visit, and instead someone could go to a pharmacy in the community whenever it is open” (Participant B24)

Increased equitability from removing the need to access prescribers, but remaining concerns about pharmacist bias and limited access to pharmacies

“Can reach people who do not have access or relationship with a prescriber. Can improve equitable access to naloxone through available community pharmacies. Gaps would be in places without pharmacies” (Participant B18)

Cost subsidization

Significantly facilitate naloxone pharmacy distribution by addressing out-of-pocket costs

“Cost is often an issue for patients, so breaking down this barrier would improve access for patients” (Participant A14)

Statewide free naloxone is the most equitably effective NAL but also the least acceptable to the public and affordable to the state

“Of all policies considered, this should necessarily have the largest effects. It both eliminates costs for patients and removes all supply-side barriers. Stigma will continue to put downward pressure on provision, but such a policy might even help reduce stigma over the longer term” (Participant A17)

Insurance coverage is less equitable and effective but more implementable than statewide free naloxone due to burdens falling on insurance companies

“General public sentiment is that more medications should be covered” (Participant B01)

State subsidies are less effective than statewide free naloxone and less implementable than insurance coverage because it only provides assistance with co-pays and costs fall on the state

“Opposition may come from those who wish to avoid spending taxpayer funds on PWUD, those who resent that insurance companies don’t pay the whole thing, and those who think limited funding should be directed elsewhere” (Participant B05)