Patient Perspectives of Barriers to Naloxone Obtainment and Use in a Primary Care,Underserved Setting: A Qualitative Study

Abstract

Background

Gaps in naloxone obtainment and use are not well studied, particularly among minoritized groups.

Objective

To describe patient perspectives that serve as barriers to naloxone obtainment and the number of patients who obtained naloxone in a primarily African American population in a primary care, underserved setting.

Methods

This qualitative study conducted semi-structured interviews and included 36 adults who were prescribed naloxone at a federally qualified health center using convenience sampling. Participants answered survey questions describing naloxone acceptability, perceived risk for overdose, and barriers to naloxone use.

Results

Sixty-nine percent of the patients were Black or African American. The majority of patients attempted to fill their naloxone at a local pharmacy (69%) and reported no difficulties (88%). Five major themes revealed: overall positive views of naloxone because it saves lives; existing knowledge gaps related to indications for naloxone prescription; stigma surrounding receiving a naloxone prescription; inadequacies of the patient education provided; and the role providers play in naloxone receptivity

Conclusions

Among a majority African American population, many perceived naloxone to be lifesaving. However, stigmatizing perceptions and inability to recall patient education contribute to a perception of low overdose risk. Further research describing the impact of the opioid epidemic on underrepresented groups is necessary.

Keywords

Naloxone opioid-related disorders primary health care vulnerable populations

Introduction

In 2017, 1.7 million people suffered from substance use disorders related to prescription opioids, and almost 130 people die every day from opioid-related drug overdoses.^1,2 Consequently, the U.S. Department of Health and Human Services (HHS) declared the opioid epidemic a public health emergency.³ Even before this, increased initiatives focused on expanding community-based overdose prevention programs. Many of these initiatives aimed at providing laypersons with naloxone kits. Within the time period of 2010–2014 alone, more than three times the number of local sites started providing naloxone which resulted in more than 2.5 times the number of overdose reversals.⁴ Opioid-related overdose and death decreased in communities that have naloxone distribution programs.^5–9

In spite of the effectiveness of community naloxone distribution, opiate overdose remains a considerable cause of mortality. Importantly, the opioid epidemic is evolving and initiatives to combat it are disproportionately distributed across the nation.¹⁰ Although non-Hispanic White Americans make up the largest percentage of opioid-related overdose deaths at about 80%, non-Hispanic Black Americans experienced the largest increase in deaths from 2016 to 2017, growing by 25.2% compared to 10.9% among their White counterparts.¹⁰ Furthermore, although uninsured, unemployed, or low-income individuals are at higher risk for opioid misuse,¹¹ many do not seek treatment due to unwillingness, lack of health care coverage, fear of negative impacts on job or community opinion, or lack of transportation.¹²

Given the complexities of opioid-related deaths in the U.S., further research is necessary to better understand the impact of naloxone distribution programs among underrepresented groups.¹⁰ Existing research provides insight on patient attitudes toward naloxone prescribing in a majority non-Hispanic White patient population in primary care,¹³ and describes patient experiences with naloxone following a naloxone co-prescribing program among English-speaking patients.¹⁴ However, updated research on underrepresented groups is necessary with the evolving opioid epidemic. There is a paucity of research in minoritized and underrepresented patients, who are experiencing a faster increase in opioid-related deaths in recent years. The main objectives of this present study were to describe patient perceptions that serve as barriers to naloxone obtainment among a diverse, underserved patient population in the primary care setting, as well as quantify the percentage of patients who obtained naloxone after being offered naloxone by their primary care provider (PCP).

Methods

Setting and procedures

This study took place at a nonprofit Federally Qualified Health Center (FQHC) located in Alameda County, California that provides primary care services to underserved patients, which has an Index of Medical Underservice (IMU) score of 52.3 and a Health Professional Shortage Area (HPSA) score of 16. The Touro University California Institutional Review Board (IRB) approved this study. Participants provided verbal consent and received copies of the written consent forms by mail or email, if requested.

In June 2016, the PCPs at the clinic received naloxone training by an opioid overdose prevention provider champion. The 1-h training took place as part of an in-service presentation during a staff meeting. The training included: identifying candidates appropriate for naloxone, reviewing available naloxone products, discussing patient education points, evaluating insurance coverage, and identifying pharmacies that had naloxone readily available. A naloxone patient education “cheat sheet” was provided during the training which covered education points to discuss with patients when prescribing naloxone (see Appendix A). Following training, PCPs received standardized patient education handouts that were created by a local public health department to provide to patients.¹⁵ Electronic health record (EHR) alerts were implemented in February 2018 to identify appropriate high-risk patients who would benefit from naloxone use. Providers received the alerts each time they accessed the EHR for patients identified as high risk for opioid overdose, defined as having a history of opioid overdose, an active prescription for buprenorphine or methadone according to their medication list, or a total of 100 or greater morphine milligram equivalents (MME) for greater than 90 days, and were an active patient at the clinic (defined as completing a visit between September 2017 and January 2019). Methadone was included in MME calculations, however due to differences in the relation between dosage and overdose risk for buprenorphine, buprenorphine was not included.¹⁶ The purpose of the naloxone alert was to prompt providers to discuss naloxone with all patients who could possibly benefit from a naloxone prescription. Patients were also encouraged to schedule follow-up appointments targeted at bringing patient caregivers to clinic in order to provide naloxone administration education specifically to caregivers.

Participant recruitment

We used convenience-sampling to recruit patients for our study (see Figure 1). Patients were identified through i2iTracks Software (a platform that integrates with the EHR and creates quality management analytics to improve care coordination) if they met the following inclusion criteria: (1) age ≥18 years old, (2) had an active prescription for naloxone at the clinic from February 2018 until January 2019, and (3) were an active patient seen in the last year (this definition was consistent with identifying patients for EHR naloxone alerts). We contacted eligible patients by telephone to participate in the study. Based on the eligibility requirements we identified a total of 98 patients, but excluded one patient after a chart review revealed that they did not have a clinic visit within the specified timeframe. Patients who agreed to participate were enrolled consecutively.

Data collection

Demographic data was collected through i2iTracks Software and included age, sex, history of opioid or substance abuse, and use of buprenorphine, methadone, and/or benzodiazepines. We conducted a chart review to obtain the MME if the patient was using an opioid, as well as naloxone formulation prescribed.

One of the authors (JK), a pharmacist who provided clinical pharmacy services at the clinic, conducted all interviews by telephone on site between January to March 2019 and transcribed interviews utilizing denaturalized transcription. To include a more diverse study population, we surveyed non-English speaking patients via Language Line Solutions (Monterey, California), a telephonic interpreter service. Study enrollment continued until we made an attempt to reach all 97 patients at least three times. The research team developed an interview guide (see Appendix B) that was adapted from Behar and colleagues.¹⁴ Participants were probed to provide rationale and explanations. We omitted non-pertinent interview questions if participants stated that their PCP did not offer naloxone. Participants did not receive any compensation for study participation.

Data analysis

The interviews were both descriptive and qualitative in nature. The qualitative analysis research team composed of JK (PharmD, MPH, pharmacist) and EC (PharmD, professor). All researchers in the team had previous experience or training in qualitative research methods. Due to limited available research on the perceptions of underrepresented groups regarding naloxone prescriptions, we utilized conventional content analysis through iterative categorization to represent dominant conceptual categories.^17,18 After reviewing the transcripts multiple times, we created codes deductively and inductively to identify prevailing themes until we achieved inductive thematic saturation.¹⁹ Two investigators (JK and EC) used NViVO 10 qualitative software (QSR International, Victoria, Australia) to code all transcripts together. Both coders utilized a consistent codebook that was developed collaboratively. The research team reconciled each discrepancy through discussion to reach a consensus. The research team analyzed and categorized most frequently used codes iteratively to identify prevailing themes. Codes were grouped and regrouped, linking concepts several times into prevailing categories, from which themes developed. To ensure study rigor and reliability, the Standards of Reporting Qualitative Research (SRQR) checklist was utilized.²⁰

Results

Demographic and descriptive characteristics

This study included 36 patients (Table 1). The average age was 59.8 years (SD = 10.4) and 24 (67%) participants were female. Black or African American participants made up the majority of the population at 69%, and nine participants identified as Hispanic or Latin American (25%), which was consistent with the clinic demographic representation of African American and Hispanic patients. One participant required Spanish interpretation. Most participants were at a high risk for overdose with an average MME of 128.4 mg (SD = 138.4). Doses at or above an MME of 50 mg per day at least doubles the risk for overdose compared to the risk of taking less than 20 mg per day, and MME 90 mg per day or greater is not recommended.²¹ At the time of the study 28 participants had a prescription for an opioid on their medication list. Three participants had a current prescription for buprenorphine (one had a prescription for buprenorphine transdermal patch and two had a prescription for buprenorphine/naloxone film) and 13 participants had MME of 100 or greater for greater than 90 days at the time of the study. One participant reported prior heroin use and two participants knew of someone who experienced an opioid overdose.

Table 1

Patient characteristics.

Demographic characteristic	Study participants (n = 36)	Met inclusion criteria (n = 98)	p-Value
Age in years, mean ± SD	59.78 ± 10.40	56.19 ± 12.05	0.095
Race/ethnicity, no. (%)
Black or African American	25 (69)	63 (64)	0.58
Hispanic or Latino	9 (25)	14 (14)	0.19
White	6 (17)	14 (14)	0.74
Native American	3 (8)	3 (3)	0.30
Other	2 (6)	ND	ND
Sex, no. (%)
Female	24 (67)	52 (53)	0.15
Risk factors
Substance use, no. (%)	7 (19)	19 (19)	0.99
Benzodiazepine use*, no. (%)	6 (17)	17 (17)	0.93
Morphine Milligram Equivalents, mean ± SD	128.4 ± 138.4	118.81 ± 151.88	0.74
Insurance status, no. (%)
Private	2 (6)
Medicare	4 (11)
Medicaid	14 (39)
Medicare and Medicaid	16 (44)

ND: No data.

Benzodiazepine use is defined as having an active prescription for a benzodiazepine concurrently with an opioid.

Fifty-eight per cent of participants reported that they never heard about naloxone prior to receiving an offer for naloxone prescription (Table 2). Despite the fact that naloxone was listed as an active medication in their EHR profile, six participants reported that their PCP did not offer naloxone (17%). Of all 36 participants, 69% attempted to fill the naloxone prescription, and all participants who tried to fill the naloxone prescription were able to do so and obtain the naloxone. The majority of patients (71%) stated that they would recommend naloxone to someone they know, and would want an offer for naloxone prescription in the future if they were prescribed opioids (74%). Overall, five themes emerged: (1) general perceptions of naloxone were positive because it can save lives; (2) knowledge gaps exist regarding the indications for naloxone prescription; (3) stigma surrounding receiving a naloxone prescription were tied to substance use or misuse; (4) patient education regarding naloxone was inadequate; and (5) providers play an important role in naloxone receptivity. In the following sections, we elaborate on the complexities of each theme.

Table 2

Patient response to naloxone prescription (N = 36).

Response	No. (%)
Never heard of naloxone before obtaining prescription	21 (58)
Accepted naloxone prescription (N = 30)
Yes	27 (90)
No	1 (3)
Other	2 (7)
Opinion on naloxone offer (N = 30)
Like	17 (57)
Dislike	2 (7)
No opinion	7 (23)
Other comment	4 (13)
Attempted to fill naloxone prescription (N = 36)	25 (69)
Able to fill naloxone prescription (N = 25)	25 (100)*
Difficulties with filling naloxone (N = 25)
Cost	1 (4)
Insurance coverage	1 (4)
Device^†	1 (4)
None	22 (88)
Would recommend naloxone to someone they know (N = 35)
Yes	25 (71)
No	4 (12)
Do not know	6 (17)
Would want offer for naloxone prescription in the future if prescribed opioid medications (N = 35)
Yes	26 (74)
No	4 (12)
Do not know	5 (14)
Providers should make naloxone available to patients on long term opioids (N = 35)
Yes, all	14 (40)
Yes, some	15 (43)
Do not know	6 (17)

Results compared to the 25 participants who attempted to fill the naloxone prescription.

†

Participant was provided with the naloxone applicator at the clinic and did not receive the medication until several months after.

General perceptions of naloxone were positive because it can save lives

Participants thought that it was beneficial to have naloxone on hand to prevent an overdose. With increasing news coverage on the opioid epidemic, participants were aware of the dangers of opioid use and did not doubt the efficacy of naloxone to reverse overdoses:

All people on opioids should get naloxone automatically to have an antidote. I didn't know people could die from having too much opioids and recently heard it on the news […] There are a lot of people out there who need to know about this. You can save people's lives.

Because of its ability to save lives, participants perceived that naloxone should be accessible at a time of emergency. Participants understood that rapid reversal is necessary to mitigate opioid-related mortality, but not all participants kept naloxone accessible.

I would recommend naloxone if they needed it. I accepted the naloxone initially because I thought, who knows, might overdose or know someone who will. The problem with it is that it's a separate thing. If someone overdoses, there's the question of where did I put it, how do I use it. If you have the wherewithal to find it and administer it that's fine, however I don't know how well that works in actual emergencies. I don't know where [the naloxone] is currently, I'd have to look for it. Naloxone is great if it saves lives, I don't know what else that could be better. However, there is a question of access at the time of emergency.

However, there was dissonance when discussing personal need for naloxone. Although participants agreed that naloxone is a life-saving medication that should be accessible at the time of emergency, many denied personal need for naloxone. Consequently, these participants accepted naloxone not for personal benefit but in case they could help save someone else's life. This revealed a perception that the participant is at low self-risk for overdose: “I don't need it. I didn't want to get it but I only took it to help someone else just in case.”

Knowledge gaps exist regarding the indications for naloxone prescription

Despite a consensus that naloxone is beneficial and lifesaving, there was variation in perceptions regarding risk for overdose, personal need for naloxone prescription, as well as who is recommended to have naloxone. According to the CDC, naloxone prescriptions are recommended for: patients receiving opioids of 50 MME per day or greater; respiratory conditions that may increase risk for respiratory depression; concurrent benzodiazepine prescriptions; substance use disorder; use of heroin, illicit synthetic opioids, or misusing prescription opioids; use of other illicit substances that could be contaminated with illicit opioids; treatment for opioid use disorder; or history of opioid misuse and were recently released from a controlled setting.²² Participants cited few of the possible indications for naloxone, including those on pain medications or long-term opioids. Participants also reported that those who were older or more prone to forgetting their medications were at risk for overdose and would benefit from naloxone.

Pain medication abuse or illicit substance use was the most commonly reported indication for naloxone. Consequently, despite long-term opioid use, the chronic opioid users in this study did not feel they needed a prescription for naloxone, reflecting a low perception of personal risk for overdose. These participants perceived themselves to be careful with using opioids:

I would not recommend [naloxone] to someone I know. I have been taking opioid medications for a while, never overdosed it, don't plan to overdose, and have a couple of friends on oxycodone and they don't gobble up their pills. They just take it as prescribed. Never needed naloxone and probably never will. I don't think I will ever need the naloxone.

Additionally, the fact that participants have not needed to use their naloxone supported their belief that they did not fall into the group of individuals who are indicated for naloxone. Many participants did not recall where they placed the naloxone, or offered to bring the naloxone back to help others who they perceived to be at higher risk for overdose than themselves. Participants who initially carried naloxone with them before were no longer doing so because they have not needed to use it: “Since I'm not using it [naloxone], I'm willing to bring it back to give it to someone who will use it.”

Stigma surrounding receiving a naloxone prescription were tied to substance use or misuse

Many participants associated naloxone with substance use, using language such as “junkies,” or “dope fiend”. The term overdose was often connected to overdosing on illicit substances. This was the case despite a conscious decision for the interviewer to use the term ‘unintentional opioid poisoning’ instead of ‘overdose’ due to the possible stigma tied to the term ‘overdose’: “It's almost like they are turning people into illegitimate junkies just because they are on pain medications.” Participants also felt they were stigmatized for using pain medications: “I would recommend naloxone if they were having a serious issue. There's the assumption that all people on pain medications are using pain medications inappropriately or are junkies.” This connection with substance use persisted when participants discussed how they felt when their provider offered naloxone to them. Participants who disliked the provider's offer for naloxone reported feeling as though they were treated like an illicit substance user: “The doctor made me feel like I was a dope fiend, treated me like the street people.”

Participants who had prior experience with naloxone, either personally or through someone they knew, had complex opinions regarding naloxone. The following participant touched on a negative perception related to naloxone despite its life-saving effects: withdrawal symptoms.

I don't need the naloxone. I can see it being given to someone who has a bad disposition for taking pills or someone who can't remember to take their pills, but so far I haven't gotten there yet and I don't take pills unless I need them. I'm not crazy yet. My sister said she used it and it took everything out of her system and she felt sick after taking the naloxone. […] Because [my sister] felt sick it might have scared me about taking naloxone. I would recommend naloxone to someone I know because they might be drug addicts.

Patient education regarding naloxone was inadequate

A prominent barrier to naloxone use related to patients forgetting that they received patient education on naloxone and how to use naloxone: “No one taught me how to use the naloxone. The doctor didn't school me on what to do with it or how to do it. Only reason why I know is because my daughter knows about how to look up meds.”

One patient believed receiving periodic patient education on naloxone was necessary and helpful for keeping patients informed on their pain medications:

If they can educate patients more on how to use naloxone, make sure to inform patients on how to use it. It shouldn't be something explained one time and that's it. When you are on certain medications, a lot of times you can forget how often you're supposed to do certain things because you have so much going on like dealing with pain. Doctors should keep informed on certain patients. That would keep patients in tune with what's going on because saying it one time—patients can forget that information.

Some participants did not recall having caregivers involved when they received patient education on naloxone, and did not know that a caregiver or bystander needs to administer naloxone during overdose. Many of these participants also reported that naloxone was not helpful because it was not possible for someone who is overdosing to administer naloxone to themselves in times of unconsciousness: “I know what it's for. I have no reason to use it. If I overdose, I can't use it if I'm asleep. It's a waste of time, I need to have someone else administer it. It's ridiculous.”

Providers play an important role in naloxone receptivity

Many reported learning how to use naloxone and learning why naloxone is beneficial from their PCP, reflecting positive statements regarding their PCP.

There are cases where other people are doing other substances. I appreciated that [the PCP] told me that there are accidental overdoses. People who were doing different types of things, fentanyl getting into street drugs, if you don't know about it, you might die.

Some perceived the provider's role in naloxone obtainment to be positive and caring: “I thought she was a better doctor…made me like her more…made me think the doctor cared more about us patients. I was glad that the doctor offered [naloxone].”

The patient education provided by PCPs affected participant receptivity to the offer for naloxone. Some participants became more receptive to naloxone after gaining a better understanding of naloxone, whereas others who felt uncomfortable with the naloxone offer conceded to accepting naloxone without feeling like they truly needed it. “I kind of didn't like it [being offered naloxone], didn't think I needed it. But just in case it can help someone else that's why I took the prescription. It didn't cost anything. I gave in to the provider.”

However, some participants perceived the role of providers more negatively, particularly with regards to their role in the opioid epidemic and perception of stigma with opioid use. This revealed the complexities of the opioid epidemic and the need to establish trusting patient-provider relationships to address these complexities and to clarify that risk mitigation strategies are intended for patient safety:

Doctors over-prescribed [pain medications] for years, now they under-prescribe and put everyone in one cubbyhole. Whether it's useful or not, they [providers] can't prescribe controlled substances anymore, things that can be taken recreationally. It is a backlash to over-medicated patients so that patients who don't abuse meds, who are well enough versed in pharmacology, don't overdose, are not able to get pain meds.

Discussion

Although naloxone distribution programs have been associated with reduced opioid-related mortality, there is limited knowledge regarding patient follow through with obtaining naloxone and patient perceptions regarding naloxone among underrepresented, minoritized populations.^5–9,14 Our results show that 69% of the underserved patients at our clinic who were at high risk for opioid overdose attempted and were able to fill naloxone after being offered a prescription by their provider. The majority of patients did not report any difficulties with filling naloxone. Although most participants stated that they would recommend naloxone to someone they knew and that they would want their provider to offer a prescription for naloxone if they are prescribed opioids in the future, the qualitative analysis revealed additional perspectives regarding overall positive views of naloxone because it can save lives; existing knowledge gaps related to the indications for naloxone prescription; stigma surrounding receiving a naloxone prescription; inadequacies of the patient education provided; and the role providers play in naloxone receptivity.

Previous research assessing patient experience with naloxone found that almost all chronic pain patients (82%) who were prescribed naloxone in an underserved setting attempted to fill the prescription after receiving an intervention on naloxone co-prescribing, which shows that naloxone co-prescribing initiatives can effectively increase naloxone obtainment.¹⁴ The lower percentage of naloxone obtainment found in our study, with 69% of patients attempting to fill their naloxone prescription, reveals that targeted efforts on naloxone education are necessary. Many patients did not remember receiving patient education on naloxone, which further illustrates another barrier to naloxone use and obtainment. Surprisingly, 17% of patients had naloxone listed as an active medication on their medication profile but endorsed never being offered naloxone. Similarly, a study assessing patient experience with naloxone in safety-net clinics reported that 25% of patients who were prescribed naloxone could not recall receiving naloxone.¹⁴ It is possible that this reflects the additional barriers that exist among underserved patients. Although not assessed in this study, limited health literacy is more common among Hispanic (66%), Black (58%) and Native American (48%) populations, as well as among individuals who have less education, did not speak English prior to starting school, and fall below the poverty level.²³ Implications of low health literacy on medication use include difficulty identifying medications as well as misunderstanding medication directions.²³ This finding stresses the need to address health literacy in all aspects of care, including naloxone prescribing.

Prior research assessing patient attitudes toward naloxone prescribing in a primary care setting showed that few patients could recall risk discussions with their medical providers regarding opioid medications.¹³ This greatly impacts the results of our study, and reveals a profound gap in the naloxone cascade. Although initiatives can effectively increase naloxone obtainment, the utility of naloxone is lost if patients cannot recall information surrounding its indication and use, as well as the need for bystander assistance. Logistical and systems barriers such as busy clinic schedules and insufficient clinical follow-up hinder adequate patient education and naloxone prescribing.²⁴ Additionally, attitudes and concerns such as a fear of offending patients may serve as a barrier to naloxone prescribing.²⁴ This highlights the need to establish trusting patient-provider relationships, especially among populations that may have greater medical mistrust due to a history of discriminatory treatment.²⁵ Initiatives to provide naloxone education to providers may improve providers’ acceptability of prescribing naloxone and, in turn, encourage providers to educate patients on naloxone utilization and potential for overdose.^26–28 The findings support the need for continuous patient education on the risks of opioids throughout the course of treatment.¹³ Moreover, our findings support the need for further initiatives engaging caregivers, family members, or friends to facilitate naloxone use and administration.^{26,27,29–32}

Our study found distinctions in patient perceptions regarding naloxone compared to prior research. Although prior research also connected naloxone with implied opioid addiction and misuse, the consequences of this implication vary in different populations. Our participants described opioid misuse with terms often used in the context of non-opioid-specific illicit substances (e.g., “junkies,” “dope fiend,” or “street people”). A previous study on a majority White population revealed that the main consequence of being seen as an opioid abuser was that it delegitimized their pain and need for opioids.¹³ In contrast, our study reveals that, among a majority Black population, the stigma of substance abuse itself can be a major consequence of being seen as an opioid abuser. In literature, stigma is often noted throughout the process of obtaining naloxone, spanning from patients’ personal stigma on the implications of opioid overdose at the individual level, to stigma experienced at pharmacies and from providers at the societal level.^{13,24,33–36} However, it is necessary to understand the shades of stigma that different groups experience. Particularly with regards to the opioid epidemic, racialized differences between heroin and prescription opioid control have affected underrepresented populations and their barriers to overdose-reversing medications like naloxone.³⁷ Strategic educational messaging around naloxone and overdose risk may help dismantle stigma, help patients understand the utility of naloxone, and serve as an area of future research.^13,38

Previous studies on patient attitudes toward naloxone revealed that many patients have a perception of low risk of overdose and dismissed personal risk because they thought that they take their medications as prescribed.^13,14 Personal experience with overdose or intravenous drug use may impact whether or not this dissonance is present.^39,40 Our results are not only consistent with prior research, but also touch on the possible repercussions of this low perceived overdose risk. Many of our participants misplaced naloxone or did not keep it accessible, which greatly limits the utility of naloxone in times of emergency. However, we also show that patients acknowledge the role that providers play in the process of naloxone obtainment and in the complexities of the opioid epidemic. Participants who remembered receiving patient education on naloxone had a better understanding of naloxone. Accordingly, providers can help fill this gap in the naloxone cascade. These findings highlight the need for future training on the importance of providing patient education on overdose risk at this clinic. Further studies can leverage the role PCPs play in providing naloxone and discussing overdose prevention by utilizing appropriate messaging as well as empowering, non-judgmental communication practices.¹³

There were a number of limitations to this study. The study took place in a single institution and findings may not be generalizable to other settings. Furthermore, the study population was predominately Black or African American, which is not reflective of the U.S. population which is 13.4% Black or African American.⁴¹ This limits the external generalizability of the study results. However, as opioid-related deaths increase at a faster pace in Black populations and few studies assess naloxone use in a this population, our study helps fill a gap in knowledge on patient perceptions regarding naloxone and the opioid epidemic in a underrepresented population.^10,14 Although the study took place in a FQHC, no uninsured participants were included in this study. Consequently, this limits the ability to assess important barriers to obtaining naloxone that are present for those who lack insurance. Additionally, the in-service naloxone training was offered in June 2016, however the EHR alerts were not implemented until February 2018 and interviews were not conducted until January 2019. Because of this, in addition to the study relying on the ability of participants to recall naloxone prescriptions that may have been offered months to a year ago, it is possible that some of the participants in this study could not recall being offered naloxone. It is also possible that prescribers did not discuss with patients prior to prescribing naloxone, however a systematic way of documenting the naloxone patient education offered was not implemented to conclusively identify if this occurred. Consequently, specific details surrounding the provider's offer for naloxone and initial perceptions on naloxone may not be accurately described in the interviews, and were not systematically documented in the EHR. However, the primary objective of this study was to assess current patient perceptions regarding naloxone as the opioid epidemic evolves, which is distinct from initial perceptions on naloxone. Future naloxone prescribing efforts can include developing a standardized charting template that highlights necessary components to discuss with patients, such as how to prevent an overdose, risk of overdose, and the need to engage caregivers or family members. Additionally, providing regular booster training sessions for providers can help mitigate gaps in provider training that may result from the high turnover of providers observed in FQHCs, which was seen at our clinic. Patient education can be improved by tailoring the education based on the patient's history of illicit opioid use and should be revised to include important information such as the need to place individuals experiencing overdose in a recovery position. Future studies on providing culturally sensitive naloxone education to patients and on providing PCPs with training regarding the impact of the opioid epidemic on underrepresented groups can help fill in gaps in naloxone distribution. Engaging creative approaches, such as partnering with community- and faith-based organizations or respected community leaders, can help address stigma surrounding naloxone.

Overall, most patients perceive naloxone to be life-saving, but barriers such as stigmatizing perceptions and gaps in patient education may contribute to a low perception of personal risk for overdose and need for naloxone. Thus, although patients may keep naloxone accessible soon after filling their naloxone prescription, many patients eventually misplace the naloxone and do not perceive it is necessary. Providers can play an important role in dismantling stigma and providing education to reduce gaps in knowledge, which may improve patient understanding of the utility of naloxone for preventing unintentional opioid poisonings. As the opioid epidemic is ever changing, further research to better understand its impact on underrepresented groups is necessary.

Footnotes

Acknowledgments

The authors would like to acknowledge Coffin and colleagues for approving our adaptation of their survey utilized to assess patient experience with naloxone prescription. Additionally, the authors would like to thank Drs. Michelle Healy and Jean Marsters for creating the materials and delivering the naloxone training at the clinic. The authors would also like to thank the study participants as well as the clinic staff for their support.

Author contributions

J.K. was principal investigator on this study, helped develop the study protocol, enrolled subjects, conducted interviews, coded transcripts, reconciled coded transcripts, conducted theme extraction and analysis, and contributed to and revised the final manuscript. E.C. helped develop the study protocol, coded transcripts, reconciled coded transcripts, conducted theme reconciliation, and contributed to and revised the final manuscript. S.D. helped develop the study protocol and contributed to and revised the final manuscript.

Naloxone patient education cheat sheet

Points to cover for patient education (can provide either verbally or by video): 1.

Naloxone is a safe antidote for opioid overdose for adults and children.

It is safe to give to someone who is overdosing even if you don't know what they used.

Good Samaritan laws in CA protect lay-people who are using it for others in your community.

What you learn today you will need to teach to the people around you and let them know where it's kept.

The signs of opioid overdose: the person is hard to wake up, lips and fingers can be blue, breathing is shallow, labored or absent.

How to administer the naloxone formulation that they receive. Show a demo kit.

Call 911.

Overview of rescue breathing.

Stay with the patient until the ambulance arrives.

10.

If the person doesn't get better in 3–5 min, give a second dose of naloxone.

11.

Naloxone can wear off in 30–60 min and the person can stop breathing again, so emergency care is required.

12.

Ask if they have questions.

13.

Give patient written naloxone information sheet to keep with kit.

14.

Opioid overdose can happen with prescription or illicit opioid use, sometimes even when following recommended dosing.

15.

Review of risk of mixing alcohol, anxiety medications, sleeping pills, muscle relaxants or sedatives with opiates.

16.

How gaps in opiate use can lead to your tolerance being lower.

17.

If you use illicit opiates, use them with a buddy who can help you.

18.

Storage temperatures.

Modified: 07.13.16

Survey questions and interview guide

As we discussed, you were referred to us because your doctor offered you a prescription for naloxone, sometimes also known as “Narcan,” the opioid antidote. We're conducting these interviews to learn how to improve medication safety among our patients. Please remember that all of your answers are confidential and you may refuse to answer any question. Your care providers (doctors, nurses, treatment providers, case managers, or anyone else) will not have access to any information you share with me today.

We'll start with some questions about you.

Interview Guide 1.

What best describes your ethnic identity?

Hispanic or Latino/a

Not Hispanic or Latino/a

Don't Know

Refuse to answer

What best describes you racial identity (check all that apply)?

Black or African-American

White

Asian or Pacific Islander

South Asian, Indian, or Pakistani

Middle Eastern

Native American

Other (please specify ________________________)

Don't know

Refuse to answer

Have you ever had naloxone to carry with you before? If no, have you heard of naloxone before you received this prescription?

Did your doctor offer you a prescription called naloxone?

Yes [skip to question 6]

I don't know

Refuse to answer

[If no] Did you wish your doctor had prescribed you naloxone? [SKIP to #15]

Yes

I don't know

Refuse to answer

Did you like or dislike it when your doctor offered you naloxone?

Dislike

No opinion

Refuse to answer

___________________

What was the main reason why you (liked/disliked) being offered naloxone?

Did the doctor's offer for naloxone change your relationship with the doctor in any way?

Did you accept the doctor's offer for the naloxone prescription?

No [SKIP to # 15]

Yes

Refuse to answer

10.

Did you try to get the naloxone prescription filled at the pharmacy?

No, didn't try [SKIP to # 15]

Yes, did try

Refuse to answer

11.

Why did you try to fill the naloxone prescription?

12.

Was the pharmacy able to fill the naloxone prescription?

No, was not able to [SKIP to #16]

Yes, was able to

Refuse to answer

13.

What, if any, difficulties did you have filling the naloxone prescription?

14.

Was there anything done that helped make the process of getting naloxone easier? [Prompts: Was it like getting other medications? Did clinic staff help you with the process? Did someone show how to use it?

15.

[If didn't try to accept/fill prescription] Was there a reason you didn't want the medication?

16.

[If tried but unable to fill prescription] Why were you unable to fill the naloxone prescription?

17.

Would you recommend naloxone to someone you know? Why or why not?

18.

In the future, if you were prescribed opioid medications, would you want your provider to offer you a naloxone prescription? Why or why not?

19.

Do you think your provider should make naloxone available to patients on long-term prescription opioids? Why or why not?

20.

Are there any other comments or thoughts you'd like to share about risk of unintentional opioid poisoning or bad reaction, medication safety?

Thank you for your participation in this study.

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