Prescriber Provision of Education or Training to Naloxone Recipients

Research Brief

Requires prescribers of naloxone to offer education or training to prevent overdose to the recipient of a naloxone prescription.

A panel of experts rated how they expect this type of policy to affect four outcomes: naloxone distribution through pharmacies, opioid use disorder (OUD) prevalence, rates of nonfatal opioid overdose, and opioid overdose mortality. Another panel of experts rated the policy on four implementation criteria: acceptability to the public, feasibility of implementation, affordability from a societal perspective, and equitability in health effects.

Policy Recommendations According to Expert Ratings

Oppose Uncertain Support
No
Yes
No

Summary of Expert Ratings

Outcomes Effect Rating
Harmful Little-to-no Beneficial
Naloxone Pharmacy Distribution
No
Yes
No
OUD Prevalence
No
Yes
No
Nonfatal Opioid Overdose
No
Yes
No
Opioid Overdose Mortality
No
Yes
No
Criteria Implementation Rating
Low Moderate High
Acceptability
No
No
Yes
Feasibility
No
Yes
No
Affordability
No
Yes
No
Equitability
No
Yes
No

Summary of Expert Comments

  • Experts expect this policy to have minimal effects on all four outcomes because this requirement would increase the burdens on busy prescribers, deterring many physicians from prescribing naloxone, thereby offsetting any potential benefits of the education or training.
  • Experts think the public supports providing information on the proper use of all medications.
  • Experts have concerns about feasibility and affordability primarily due to time constraints, reimbursement for training and education, and the need to “train the trainers.”
  • Experts are divided on equitability: This policy could worsen equity if its onerous aspects interact with existing structural oppression and interpersonal discrimination, or it could improve equity among those who previously have been underserved in terms of medical education.

Outcome Summaries

Naloxone Pharmacy Distribution

Amount of naloxone dispensed through retail pharmacies (e.g., chain pharmacy stores, independent community pharmacies).

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial More patients may pick up naloxone prescriptions at pharmacy. “A more educated recipient may fill prescriptions more routinely and may place a higher value on naloxone, potentially leading to a small increase in distribution”
Little-to-no

(selected)
Not likely to impact prescriber behavior sufficiently to impact naloxone pharmacy distribution. “Mandating provision of education on how to use naloxone is probably unlikely to have an effect on prescribing”
Harmful This requirement could create barriers to naloxone pharmacy distribution by increasing burdens on prescribers, who are already pressed for time. “Adds additional substantial barrier especially to large majority of prescribers who may not feel confident about their knowledge though at same time training is very simple”

Opioid Use Disorder Prevalence

Percentage of the general population with a pattern of opioid use leading to clinically and functionally significant impairment, health problems, or failure to meet major responsibilities.

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial Could facilitate better patient-provider relationships, as well as engagement with treatment and recovery services. “Folks with OUD would be able to have a relationship with their prescriber via the offered education and potentially learn of other resources for recovery”
Little-to-no

(selected)
No credible mechanism linking a naloxone education requirement and OUD prevalence. “Unclear what the mechanism of change would be here”
Harmful Potential for revival from overdose could have a small, indirect, and mechanistic impact on OUD prevalence due to increased survivorship and screening for OUD. “The increase in naloxone prevalence will increase the amount of people with OUD because of a potential decrease in OUD mortality due to increased prevalence of naloxone (which is a good thing). While I believe the effect size will be small, I do not think it will be negligible or insignificant”

Nonfatal Opioid Overdose

Per capita rates of nonfatal overdose related to opioids, including opioid analgesics (e.g., oxycodone), illegal opioids (e.g., heroin), and synthetic opioids (e.g., fentanyl).

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial Education could reduce riskier behaviors and facilitate engagement with treatment and recovery services. “Would expect education to potentially decrease overdose rates if good treatment options were provided”
Little-to-no

(selected)
No credible mechanism linking a naloxone education requirement and nonfatal opioid overdoses. “I doubt that education on naloxone use will have meaningful effects on individuals’ behavior”
Harmful Potential for revival from overdose could have a small, indirect, and mechanistic impact on nonfatal overdoses due to increased survivorship. “Possible that better training prevents fatality in overdoses that would otherwise be fatal”

Opioid Overdose Mortality

Per capita rates of fatal overdose related to opioids, including opioid analgesics (e.g., oxycodone), illegal opioids (e.g., heroin), and synthetic opioids (e.g., fentanyl).

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial Better knowledge about how to administer naloxone and increased linkages to treatment could lead to (modest) reductions in fatal overdoses. “Could have a mortality benefit if good linkage to treatment was provided and safe use practices were provided”
Little-to-no

(selected)
A naloxone education requirement would not impact naloxone distribution and administration sufficiently to impact fatal overdoses. “Doubtful that education of [patients] on how and when to use naloxone will have very significant effects if any on overall opioid od mortality rate”
Harmful Potential to increase fatal overdoses if the education requirement creates barriers to naloxone pharmacy distribution by increasing burdens on prescribers. “If training requirements reduce naloxone distribution, then opioid overdose mortality could increase”

Implementation Criteria Summaries

Acceptability

The extent to which the policy is acceptable to the general public in the state or community where the policy has been enacted.

Implementation Rating Summary of Expert Opinion Representative Quotations
High

(selected)
Agreement among the general public to provide information on the proper use of all medications. “I think the general public agrees with provision of education about proper medication use”
Moderate Depends on how burdensome and stigmatizing the education or training requirement would be. “People benefit from knowing how to use naloxone, but the training requirements can be overly burdensome and can be streamlined”
Low Stigmatized beliefs about naloxone persist. “There will be stigmatized beliefs related to any distribution of naloxone, and the added measure could be welcomed by those who are less knowledgeable regarding the actual risks and benefits”

Feasibility

The extent to which it is feasible for a state or community to implement the policy as intended.

Implementation Rating Summary of Expert Opinion Representative Quotations
High Education or training can be offered in flexible approaches and via streamlined technology (e.g., free, readily available videos and handouts). “There are many available educational materials and modalities available for use so these do not need to be created de novo, which improves feasibility for prescribers”
Moderate

(selected)
Concerns related to time constraints and the need to train prescribers. “Feasibility really turns in great part on WHO is to do the training and WHAT modality is required”
Low Burdensome for communities and providers to implement. “At the state level mandating this educational campaign should be simple. However, at the community level providers who serve people in need of naloxone are often some of the most resource-poor healthcare settings. High level of burden for communities and providers”

Affordability

The extent to which the resources (costs) required to implement the policy are affordable from a societal perspective.

Implementation Rating Summary of Expert Opinion Representative Quotations
High Education or training can be offered in cost-effective approaches that use technology (e.g., free, readily available videos and handouts). “Non-active forms of training (like a video), should they be made widely available, can be more cost effective”
Moderate

(selected)
Concerns about provider time, opportunity costs, enforcement costs, and reimbursement for training and education. “It depends on how costs are calculated. However, this will be a significant time and therefore financial burden for providers → health systems → payers. Who will be training prescribers? This will also impact costs”
Low Concerns about provider time and opportunity costs. “Opportunity costs outweigh any benefits”

Equitability

The extent to which the policy is equitable in its impact on health outcomes across populations of people who use opioids.

Implementation Rating Summary of Expert Opinion Representative Quotations
High Improves equity among those who previously have been underserved in terms of medical education. “Not receiving education and training will hurt people from low [socioeconomic status] backgrounds more than it will middle class people who have more education and more ways to get the information elsewhere”
Moderate

(selected)
Depends on balance of reduced access due to onerous aspects of the mandate versus improved equity among those who previously have been underserved in terms of medical education. “Unclear how this might impact health disparities. In some cases, it could be an equalizer because education is required, but if it results in providers being more selective about who they prescribe to because of the additional time it takes to conduct education, then it could create inequalities given some of the research about race/ethnic differences in opioid prescribing and access to [medication for OUD]”
Low Onerous aspects of this mandate could interact with the structural oppression and interpersonal discrimination faced by many people and communities affected by these policies. “The variability in training accessibility as well as the associated reduction in access to the medication would almost certainly disproportionately disenfranchise racial minorities and individuals with lower socioeconomic status. The greater the resources required, the more these communities are harmed in almost every instance”

Research conducted by

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