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Table 1 Key questions scored independently by Guideline Development Panel

From: Priority setting for Canadian Take-Home Naloxone best practice guideline development: an adapted online Delphi method

Key questions

Mean score round 1a

Mean score round 2a

General opioid overdose response strategy

  

What is the effectiveness of Take-Home Naloxone programs?

1.6*

1.6*

Are there different rates of mortality and morbidity for persons experiencing overdose in community setting associated with:

  

 Rescue breathing in addition to naloxone administration

 Conventional CPR including rescue breathing in addition to naloxone administration

 Compression-only CPR in addition to naloxone administration

 Naloxone administration alone?

1.4*

1.8*

What should be in naloxone kits?

1.4*

1.4*

After naloxone administration, how long should people be observed to ensure the reversal was effective? What happens if people are or are not transported to the hospital?

1.6*

2.0

What aftercare should be provided for people who respond to overdose?

1.6*

1.9*

Naloxone administration methods

  

Are health outcomes different when different dosages of naloxone are used?

2.3

–

What is the effectiveness of different methods of naloxone administration, including dosage, repeat doses and titration (gradual increase in dosage), length of time before onset of action (how long until the medication starts working), and serum half-life (how long it takes for half of the dose to be eliminated from the bloodstream) of naloxone at achieving reversal of overdose?

1.5*

1.4*

Are there storage issues that impact effectiveness of naloxone in a community setting?

1.8*

1.7*

What are important safety considerations, including those for adverse reactions (unexpected or unwanted effects) and opioid withdrawal symptoms?

2.1

–

Is there a difference in preference for administration methods for different populations, e.g., between people who use drugs vs family or friends of people who use drugs, people who inject drugs vs people who inhale?

2.6

–

Naloxone distribution program strategy and implementation

  

What are the crucial factors and different possible structures for naloxone distribution programs?

1.8*

2.2

What specific program objectives and what measurable outcomes are being used to inform success (reordering of kits, population coverage/uptake, satisfaction of staff/public, mortality, consensus)?

2.0

–

What types of programs (Take-Home Naloxone (THN), Facility Overdose Response Box (FORB), others) exist or are needed?

1.8*

2.4

What distribution model gets the most kits to people who use them? How does this differ among different populations (including people who are incarcerated, rural populations, Indigenous populations)?

1.5*

1.6*

What eligibility criteria for PWUDb impact kit distribution?

2.8

–

What is the effect of overdose response training and education strategies, on primary outcomes (number of deaths due to opioid overdose avoided) and intermediate outcomes (number of kits dispensed, number of kits reported used)?

1.7*

2.2

What are the risks and benefits of provincial listings of naloxone as a Schedule II vs unscheduled drug, and what effect, if any, does it have on primary outcomes (number of deaths due to opioid overdose avoided) and intermediate outcomes (number of kits dispensed, number of kits reported used)?

1.9*

2.6

How does stigma impact how PWUDb and families and friends of PWUDb access distribution programs?

1.6*

1.5*

What are the barriers and facilitators of access to distribution programs?

1.6*

2.0

What resources are required for the effective distribution and access to naloxone?

1.7*

2.0

What policies are required for the effective distribution and access to naloxone?

1.7*

2.1

Do people prescribed opioids for pain have access to THN? Should all people prescribed opioids be routinely offered naloxone kits or should it be based on risk factors?

2.2

–

How should distribution models differ in rural vs urban settings?

2.0

–

Cost-effectiveness of program implementation

  

What is the cost-effectiveness of the intervention?

2.0

–

What evidence exists of social and economic benefits of program implementation and overdose prevention and what are economic evaluations of costs and cost–benefit ratios from health care and societal perspectives?

2.2

–

What is the relative cost-effectiveness between administration methods (nasal vs intramuscular)?

2.6

–

What is the cost-effectiveness of funding of naloxone kits, including individual doses, assembly of kits, pharmacy dispensing fees, and training fees?

2.5

–

What is the cost for implementation and running the naloxone distribution program?

2.4

–

What are the costs for data collection and program monitoring, as well as researcher/agency capacity to evaluate distribution programs?

2.9

–

Acceptability of naloxone distribution program

  

What kind of naloxone distribution program do people impacted want? Is this impacted by PWUD demographics?

1.9*

1.8*

What is the demand for and acceptability of naloxone distribution programs among people who use drugs, people who may witness an overdose, health professionals in community settings, the general public, government, and policy authorities?

2.4

–

How is the need for naloxone distribution programs communicated to the general public and how effective is that communication?

2.5

–

What are the legal or political benefits or risks of beginning or expanding programs?

3.4

–

How to make naloxone distribution easy, accessible and palatable for families of PWUD?

2.0

–

Does communication about naloxone kits/disclosure of possession/training of family impact health outcomes?

2.3

–

  1. *Scores under 2.0 which the guideline development panel identified as important to prioritize in the THN guideline
  2. aWhere 1 = strongly agree and 5 = strongly disagree that the question is important
  3. bPeople who use drugs