Understanding Clinician Knowledge,Attitudes,and Practices Relating to Nonpharmaceutical Fentanyl and Harm Reduction

Abstract

Background:

Nonpharmaceutical fentanyl (NPF) is driving the national epidemic of opioid overdose deaths. Clinicians can play a role in fostering awareness of this growing risk and delivering interventions to reduce mortality. However, there is limited research assessing clinician knowledge, attitudes, and practices relating to NPF and harm reduction strategies.

Methods:

A 34-question survey was designed to assess knowledge, attitudes, and practices related to NPF and harm reduction strategies of adult and pediatric hospital-based and emergency clinicians at a single academic medical center. Results were summarized using descriptive statistics. Chi square and Fishers exact tests were used to compare groups.

Results:

There were 136 survey responses. The majority (88%) of respondents correctly answered a question on NPF potency. Most respondents were aware that NPF exposure was very (84%) or somewhat likely (10%) for someone using illicit opioids and very (44%) or somewhat likely (46%) for nonopioid drugs. Respondents viewed overdose prevention as highly important for patients using illicit opioids (93%) and nonopioid drugs (86%) but few (21%) were very/extremely familiar with overdose prevention strategies and just over half (57%) were comfortable/very comfortable counseling about overdose prevention. There was wide variability in utilization of harm reduction/treatment strategies (7.3% frequently providing fentanyl test kits to 70% frequently prescribing naloxone). Higher levels of comfort and familiarity with overdose prevention were associated with more frequent counseling on harm reduction strategies. Pediatric-only clinicians had less familiarity (5% very/extremely familiar) and comfort (35% comfortable/very comfortable) with overdose prevention, and limited use of harm reduction strategies (0%-31% using each strategy frequently).

Conclusions:

While clinicians had knowledge and awareness of NPF and rated overdose prevention as highly important, utilization of harm reduction and treatment strategies was variable. This study highlights opportunities for education and system-based support to improve clinician-driven harm reduction practices for patients at risk of overdose.

Keywords

fentanyl opioid overdose harm reduction

Highlights

While clinicians rated overdose prevention as highly important, use of harm reduction strategies to reduce overdose risk when caring for at-risk patients was variable and often limited.

Clinicians’ limited levels of comfort and familiarity with overdose prevention points to opportunities for interventions to increase utilization of harm reduction and treatment strategies.

Given the rising rates of adolescent overdoses, it is particularly important to highlight the gap in pediatric clinician familiarity, comfort, and utilization of overdose prevention strategies. Future initiatives should target this population for intervention.

Introduction

Nonpharmaceutical fentanyl (NPF), an illicitly manufactured high-potency synthetic opioid, is currently the main driver of the national epidemic of opioid overdose deaths. In 2021, the age-adjusted rate of overdose deaths involving NPF was twice as high as any other opioid or stimulant drug.¹ NPF has largely replaced heroin in the illicit drug market and can be found in other drugs, including stimulants and counterfeit prescription medications.^2,3 Accidental ingestion of NPF has led to increasing overdoses among pediatric and adolescent populations, and adolescent overdose mortality has increased more than 200% between 2019 and 2021.^4,5 Understanding the unique risks associated with NPF and being able to effectively communicate harm reduction strategies, which encompasses several measures to prevent overdose including carrying naloxone, using fentanyl test kits, reducing illicit drug use, and not using alone, is key to decreasing overdose deaths.

Clinicians can play a role in fostering awareness of harm reduction strategies to prevent opioid overdoses. The Substance Abuse and Mental Health Services Administration advises clinicians to provide overdose prevention education, prescribe naloxone to patients at risk of opioid-related harms, and offer treatment to patients with opioid use disorder (OUD).⁶ However, these interventions are often not provided to people who use drugs (PWUD) seeking healthcare.^7,8 People at high risk of overdose are often not prescribed naloxone despite contact with healthcare systems, and clinician naloxone prescribing is variable even for patients identified to be at high risk of overdose.^9-12

Despite the increased risk that NPF poses, clinician knowledge and practices related to NPF are not well described. To leverage provider capacity to reduce overdose deaths, it is important to uncover clinician-level factors contributing to low uptake of overdose prevention interventions. It is also vital to identify how clinicians have adapted their practices when treating PWUD in the setting of rising overdose deaths and NPF prevalence. Through a survey of adult and pediatric clinicians in various practice settings, this study aimed to describe clinician knowledge of and attitudes toward NPF and overdose prevention as well as current approaches to managing patients at risk of overdose.

Methods

Survey Development

A 34-question survey was designed to assess clinician knowledge, attitudes, and practices related to NPF and harm reduction strategies that can reduce the risk of death from opioid overdose. The survey development was informed by the Precede-Proceed implementation science framework and a review of the literature on the characteristics of NPF, experiences of PWUD with fentanyl, and clinician knowledge and attitudes toward OUD treatment, naloxone prescribing, and overdose prevention.^11,13-22 Survey questions were iteratively refined through input from local clinicians with subject matter expertise and pilot testing.

Respondents and Procedures

The survey was conducted at a large, urban academic medical center in the Midwest from May to June 2023. Surveys were distributed to attending physicians and advanced practice providers from the sections of hospital medicine, emergency medicine, pediatric hospital medicine, and pediatric emergency medicine. Resident physicians from the internal medicine, emergency medicine, medicine-pediatrics, and pediatric residency programs were also eligible to complete the survey. Anonymous surveys were distributed by email, at educational conferences, and in workrooms. Data were collected and managed using REDCap.^23,24 The study was determined to be exempt by the Institutional Review Board.

Measures

The survey instrument (Supplemental Material 1) evaluated provider knowledge of NPF and the impact of NPF on clinical practice. The survey assessed attitudes toward overdose prevention, asking respondents to rate the importance of overdose prevention, familiarity with overdose prevention strategies, and comfort discussing overdose prevention on 5-point Likert scales. To assess clinician practices, respondents reported their use of harm reduction (naloxone, fentanyl test kits, safer drug use counseling) and treatment (initiation of buprenorphine, initiation of methadone, referral to substance use disorder (SUD) treatment) strategies when caring for patients they determine to be at risk of overdose on a 5-point Likert scale of frequency. Demographic information and practice characteristics were collected and included questions on frequency of clinical exposure to opioid overdose and patients with OUD.

Statistical Analysis

Likert scale responses were dichotomized for the following measures: importance of overdose prevention (low importance = not at all/slightly/somewhat important, high importance = very/extremely important), familiarity with overdose prevention strategies (low familiarity = not at all/slightly/somewhat familiar, high familiarity = very/extremely familiar), comfort discussing overdose prevention (low comfort = very uncomfortable/uncomfortable/neutral, high comfort = comfortable/very comfortable), harm reduction/treatment strategy use (infrequent = never/rarely/sometimes, frequent = often/always; responses of “not relevant to my clinical practice” were excluded from analysis). The sample was first characterized using descriptive statistics. Chi square test or Fishers exact test were used to test differences between groups. Analyses were performed using R version 4.0 (R Core Team, 2020).²⁵

Results

Of 417 eligible respondents, 136 (33%) completed the survey. Residents made up 53% of responses (N = 72, response rate = 30%), attending physicians 32% (N = 43, response rate = 32%), and advanced practice providers 14% (N = 19, response rate = 48%). Fifteen percent of respondents (N = 20, response rate = 20%) cared for only pediatric patients. Twenty-one percent (N = 29) primarily practiced in the emergency department. Sixty-five percent (N = 89) cared for patients with OUD more than once per week (high clinical exposure to OUD). Twenty-four percent (N = 32) cared for patients more than once per week who presented after an opioid overdose (high clinical exposure to overdose; Table 1).

Table 1.

Survey Respondent Demographics (N = 136).

Type of clinician, n (%)
Advanced practice nurse	12 (8.9)
Physician assistant	7 (5.2)
Resident	72 (53.3)
Fellow	1 (0.7)
Attending physician	43 (31.9)
Medical specialty, n (%)
Emergency medicine	22 (19)
Internal medicine	67 (57.8)
Medicine-pediatrics	6 (5.2)
Pediatrics	19 (16.4)
Other	2 (1.7)
Years in practice, n (%)
≤5	88 (65.7)
6-10	27 (20.1)
11-15	9 (6.7)
>15	10 (7.5)
Practice setting, n (%)
Emergency department (all/most of clinical practice)	29 (21.3)
Non-emergency department	107 (78.7)
Patient population, n (%)
Adult patients only	93 (68.4)
Pediatric patients only	20 (14.7)
Adult and pediatric patients	23 (16.9)
Care for patients with OUD, n (%)
More than once a week	89 (65.4)
Less than once a week	44 (32.4)
Don’t know	3 (2.2)
Care for patients following an opioid-related overdose, n (%)
More than once a week	32 (23.5)
Less than once a week	102 (75)
Don’t know	2 (1.5)

Abbreviation: OUD, opioid use disorder.

Almost all respondents (88%) knew that NPF is more potent than heroin. Sixty percent responded that overdoses involving NPF may require more naloxone and 40% responded that NPF use may make buprenorphine inductions more difficult (46% answered “don’t know”). Respondents perceived there to be a high risk of exposure to NPF for someone using illicit opioids with 84% rating exposure as very likely. There was a lower perceived risk of exposure to NPF for someone using illicit nonopioid drugs, 44% rating it very likely and 46% somewhat likely.

Respondents largely rated overdose prevention as highly important for patients using illicit opioids and nonopioid drugs, 93% and 86%, respectively. Just over half of the respondents (57%) reported being comfortable discussing preventing overdose with patients. Fewer respondents (21%) reported high familiarity with overdose prevention strategies (Table 2).

Table 2.

Attitudes Toward Overdose Prevention (N = 136).

How important is it to discuss overdose prevention strategies with patients who are using illicit opioids? n (%)
Very/extremely important (high importance)	126 (92.6)
Not at all/slightly/somewhat important (low importance)	10 (7.4)
How important is it to discuss overdose prevention strategies with patients who are using illicit nonopioid drugs? n (%)
Very/extremely important (high importance)	116 (85.9)
Not at all/slightly/somewhat important (low importance)	19 (14.1)
How familiar are you with overdose prevention strategies? n (%)
Very/extremely familiar (high familiarity)	28 (20.6)
Not at all/slightly/somewhat familiar (low familiarity)	108 (79.4)
How comfortable are you talking to patients about preventing overdose? n (%)
Very comfortable/comfortable (high comfort)	77 (56.6)
Very uncomfortable/uncomfortable/neutral (low comfort)	59 (43.4)

The most frequently used harm reduction or treatment strategy when caring for patients at risk of overdose was naloxone prescribing. For patients at risk of overdose, 70% of clinicians frequently (often/always) prescribed naloxone, 59% frequently counseled about naloxone use, and 30% frequently recommended over-the-counter naloxone. Twenty-nine percent of respondents frequently counseled about strategies for safer drug use and 12% frequently recommended using fentanyl test kits (Figure 1). Twenty-three percent frequently initiated buprenorphine, and 18% of inpatient clinicians frequently initiated methadone. Forty-nine percent of respondents answered that a patient testing positive for fentanyl would make them more likely to utilize harm reduction strategies and 34% responded that it would not change the likelihood. Of those who responded that it would not change the likelihood, 90% frequently prescribed naloxone and 71% frequently counseled on naloxone. The most common barriers to utilizing harm reduction strategies were lack of time (70%), lack of knowledge (56%), lack of comfort (35%), and patient acceptability (41%).

Figure 1.

Clinician use of harm reduction and treatment strategies for patients at risk of overdose (N = 136).

Increased comfort and familiarity with overdose prevention were associated with more frequent implementation of harm reduction and treatment strategies. Clinicians with high levels of comfort discussing overdose prevention used several strategies more frequently than those with lower comfort levels: counseling on strategies for safer use (44% vs 6%, P < .001), counseling about naloxone use (73% vs 40%, P < .001), recommending over-the-counter naloxone (37% vs 20%, P = .04), and referring patients to substance use treatment (60% vs 37%, P = .009; Table 3). Higher reported familiarity with overdose prevention strategies was associated with more frequent counseling on strategies for safer drug use (54% vs 21%, P < .001) and counseling about naloxone use (79% vs 54%, P = .02; Table 3). High clinical exposure to OUD was associated with increased naloxone prescribing (77% vs 54%, P = .01) but no other interventions. There was no association between clinical exposure to opioid overdose and utilization of harm reduction or OUD treatment interventions.

Table 3.

Association Between Clinician Comfort/Familiarity With Overdose Prevention and Frequent Use of Harm Reduction and Treatment Strategies (N = 136).

Harm reduction/treatment strategy	High comfort (N = 77)	Low comfort (N = 59)	P-value	High familiarity (N = 28)	Low familiarity (N = 108)	P-value
Frequent (often/always) use of harm reduction and treatment strategies, n (%)
Counsel patients about strategies for safer use	33 (44)	3 (5.9)	<.001	15 (53.6)	21 (21.4)	<.001
Counsel patients about carrying and using naloxone	54 (73)	21 (39.6)	<.001	22 (78.6)	53 (53.5)	.02
Prescribe naloxone	54 (74)	33 (63.5)	.2	20 (71.4)	67 (69.1)	.8
Recommend over the counter naloxone	27 (37)	10 (20)	.04	11 (39.3)	26 (27.4)	.2
Counsel patients about fentanyl test kits	12 (16.4)	3 (5.9)	.1	6 (22.2)	9 (9.3)	.07
Provide patients with fentanyl test kits	6 (8.1)	3 (6)	.7	2 (7.1)	7 (7.3)	1
Initiate buprenorphine	21 (28.8)	7 (14)	.06	8 (28.6)	20 (21.1)	.4
Initiate methadone	14 (19.4)	5 (10)	.2	5 (18.5)	14 (14.7)	.6
Refer patients to SUD treatment	44 (60.3)	19 (36.5)	.009	18 (64.3)	45 (46.4)	.1

Counts and percentages represent the respondents in each group who reported using each strategy frequently (often/always) when caring for patients at risk of overdose, excluding those who responded that the strategy was not relevant to their clinical practice.

Among respondents who care only for pediatric patients, familiarity and comfort with overdose prevention strategies were limited. Only 5% reported having high levels of familiarity with overdose prevention strategies and 35% had high levels of comfort counseling on overdose prevention. Thirty-one percent of pediatric clinicians counseled on naloxone use and 8% prescribed naloxone frequently for patients at risk of overdose. An additional 35% to 45% of pediatric clinicians reported that each strategy was not relevant to their clinical practice. The most frequently reported barrier among pediatric clinicians was lack of knowledge (60%).

Discussion

Emergency and hospital-based clinicians had general knowledge and awareness of NPF and viewed overdose prevention strategies as important, but their utilization of harm reduction and treatment strategies was variable. Among pediatric clinicians, comfort, familiarity, and utilization of harm reduction strategies were low.

The only harm reduction or treatment strategy utilized consistently by clinicians in this study was prescribing and counseling on naloxone. Rates of reported naloxone prescribing were higher than seen in published literature,^11,21 possibly because of temporal trends of increasing awareness among clinicians, as well as local interventions to increase naloxone prescribing including an electronic health record alert. There is widespread consensus that naloxone distribution to patients at risk of experiencing or witnessing an overdose is critical to reduce opioid-related mortality. Clinicians who treat these patients should be distributing naloxone routinely. System-based interventions such as improving ease of naloxone prescribing or offloading screening and counseling to nonclinician staff,^26,27 could be impactful given that 30% of respondents prescribed it infrequently. Clinicians infrequently provided counseling on or access to fentanyl test kits, highlighting an opportunity for this intervention to detect fentanyl presence in illicit nonopioid drugs that increasingly contain NPF. Strategies for safer drug use (eg, not using drugs alone, using less, using more slowly) are infrequently used by PWUD^14,28 and there is an opportunity for clinicians to raise awareness about these harm reduction interventions. However, clinician counseling on these strategies was infrequent.

Consistent with the reported experiences of PWUD,^14,29-31 the vast majority of respondents perceived there to be a high likelihood of NPF exposure for someone using illicit opioids. Despite this and the belief that overdose prevention is highly important in the context of high regional rates of overdose,¹ implementation of harm reduction strategies beyond naloxone prescribing was limited and inconsistent. Limited clinician knowledge, for example, on topics like the impact of NPF use on buprenorphine induction, may contribute to their infrequent implementation of interventions. This study identifies a need for broader and more advanced education and systems to support the many ways clinicians can impact patients at risk for overdose. To close this gap, targeted education should aim to improve familiarity and comfort among clinicians who recognize the importance of harm reduction but practice evidence-based strategies less frequently. Clinicians also frequently reported lack of time as a barrier. This highlights the need to improve knowledge of harm reduction among all staff so clinicians are able to more effectively provide education in limited time and other members of the clinical team are also equipped to offer education on overdose prevention strategies.

Interventions are especially needed for pediatric clinicians, as they care for adolescents, a group experiencing a rapid increase in overdose mortality. Since 2020 adolescent overdose mortality has increased at a rate greater than that of the overall population.^4,5 Despite believing that overdose prevention was very important, few pediatric clinicians in this study frequently prescribed naloxone or counseled on strategies to reduce overdose risk. Many reported that the strategies were not relevant to their clinical practice, perhaps reflecting a lack of awareness. Pediatric clinicians had low levels of familiarity and comfort with overdose prevention and frequently reported lack of knowledge as a barrier, consistent with previously reported barriers to pediatric resident naloxone prescribing.³² Limited education on overdose prevention in pediatric training may also contribute to these findings.³³ In the context of rising adolescent overdoses, it is important to address these barriers for pediatric clinicians.

Limitations of this study include survey distribution at a single institution and response rate. Clinicians who found the topic of the survey less relevant may have chosen not to respond, creating a selection bias by eliminating respondents with less exposure to the management of OUD and opioid overdoses. This is particularly relevant for pediatric clinicians, who responded at a lower rate than clinicians who care for adult patients. Most respondents cared for patients with OUD relatively frequently, which may limit the generalizability of the data. The cross-sectional nature does not allow identification of causal relationships, and self-report measures may not reflect the actual practices of clinicians. Measures were dichotomized from Likert scales, which may cause a loss of variability. Finally, while the survey was pilot tested and iteratively refined, survey measures were not formally tested for validity or reliability.

Conclusions

This study described ED- and hospital-based clinician knowledge, attitudes, and practices relating to NPF and harm reduction strategies. We identified a gap between the clinician perceived importance of overdose prevention and the implementation of overdose reduction strategies. These results highlight opportunities for education and system-based support to improve clinician comfort and familiarity needed to practice harm reduction and reduce patient risk due to NPF.

Supplemental Material

sj-docx-1-saj-10.1177_29767342241266421 – Supplemental material for Understanding Clinician Knowledge, Attitudes, and Practices Relating to Nonpharmaceutical Fentanyl and Harm Reduction

Supplemental material, sj-docx-1-saj-10.1177_29767342241266421 for Understanding Clinician Knowledge, Attitudes, and Practices Relating to Nonpharmaceutical Fentanyl and Harm Reduction by Elena Whitney, George Weyer, Molly Perri, Sarah Dickson, Angela Kerins, Andrea Justine Landi, P. Quincy Moore, John P. Murray, Geoff Pucci and Mim Ari in Substance Abuse

Footnotes

Author Contributions

All authors contributed to the study design. EW and MA performed the data collection and analysis. EW, MA, and GW contributed in the data interpretation and writing of the manuscript. All authors provided critical revisions to the manuscript. All authors provided final approval of the version to be published.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the University of Chicago Pritzker School of Medicine.

Compliance,Ethical Standards,and Ethical Approval

The study was determined to be exempt by the University of Chicago Institutional Review Board.

ORCID iD

Elena Whitney

Supplemental Material

Supplemental material for this article is available online at the SAJ website .

References

Spencer

Warner

Cisewski

, et al. Estimates of Drug Overdose Deaths Involving Fentanyl, Methamphetamine, Cocaine, Heroin, and Oxycodone: United States, 2021. National Center for Health Statistics (U.S.); 2023. doi:10.15620/cdc:125504

Jones

Bekheet

Park

Alexander

GC.

The evolving overdose epidemic: synthetic opioids and rising stimulant-related harms. Epidemiol Rev. 2020;42(1):154-166. doi:10.1093/epirev/mxaa011

Green

Gilbert

Counterfeit medications and fentanyl. JAMA Intern Med. 2016;176(10):1555-1557. doi:10.1001/jamainternmed.2016.4310

Friedman

Godvin

Shover

Gone

Hansen

Schriger

DL.

Trends in drug overdose deaths among US adolescents, January 2010 to June 2021. JAMA. 2022;327(14):1398. doi:10.1001/jama.2022.2847

Gaither

JR.

National trends in pediatric deaths from fentanyl, 1999-2021. JAMA Pediatr. 2023;177:733-735. doi:10.1001/jamapediatrics.2023.0793

Substance Abuse and Mental Health Services Administration. SAMHSA Opioid Overdose Prevention Toolkit. Published online 2018.

Wood

Solomon

Hadland

Universal precautions for people at risk of opioid overdose in North America. JAMA Intern Med. 2023;183(5):401. doi:10.1001/jamainternmed.2023.0116

Mauro

Gutkind

Annunziato

Samples

Use of medication for opioid use disorder among US adolescents and adults with need for opioid treatment, 2019. JAMA Netw Open. 2022;5(3):e223821. doi:10.1001/jamanetworkopen.2022.3821

Follman

Arora

Lyttle

Moore

Pho

MT.

Naloxone prescriptions among commercially insured individuals at high risk of opioid overdose. JAMA Netw Open. 2019;2(5):e193209. doi:10.1001/jamanetworkopen.2019.3209

10.

Chua

Dahlem

CHY

Nguyen

, et al. Naloxone and Buprenorphine prescribing following US emergency department visits for suspected opioid overdose: August 2019 to April 2021. Ann Emerg Med. 2022;79(3):225-236. doi:10.1016/j.annemergmed.2021.10.005

11.

Calcaterra

Binswanger

Edelman

McNair

Wakeman

PG.

O’Connor

The impact of access to addiction specialist on attitudes, beliefs and hospital-based opioid use disorder related care: a survey of hospitalist physicians. Subst Abuse. 2022;43(1):143-151. doi:10.1080/08897077.2020.1748169

12.

Deanna Wilson

Berk

Matson

, et al. A cross-sectional survey using clinical vignettes to examine overdose risk assessment and willingness to prescribe naloxone. J Gen Intern Med. 2019;34(4):507-509. doi:10.1007/s11606-018-4733-y

13.

Somerville

O’Donnell

Gladden

, et al. Characteristics of fentanyl overdose—Massachusetts, 2014-2016. MMWR Morb Mortal Wkly Rep. 2017;66(14):382-386. doi:10.15585/mmwr.mm6614a2

14.

Latkin

CarlA

Dayton

Davey-Rothwell

Tobin

. Fentanyl and drug overdose: perceptions of fentanyl risk, overdose risk behaviors, and opportunities for intervention among people who use opioids in Baltimore, USA. Subst Use Misuse. 2019;54(6):998-1006. doi:10.1080/10826084.2018.1555597

15.

Shuey

Lee

Ugalde

, et al. Evaluation of resident physicians’ knowledge of and attitudes towards prescribing buprenorphine for patients with opioid use disorder. J Addict Med. 2021;15(3):219-225. doi:10.1097/ADM.0000000000000750

16.

Peckham

Niculete

Steinberg

Boggs

DL.

A Survey of prescribers’ attitudes, knowledge, comfort, and fear of consequences related to an opioid overdose education and naloxone distribution program. J Public Health Manag Pract. 2018;24(4):310-317. doi:10.1097/PHH.0000000000000668

17.

Varshneya

Thakrar

Hobelmann

Dunn

Huhn

AS.

Evidence of buprenorphine-precipitated withdrawal in persons who use fentanyl. J Addict Med. 2022;16(4):e265-e268. doi:10.1097/ADM.0000000000000922

18.

Comer

Cahill

CM.

Fentanyl: Receptor pharmacology, abuse potential, and implications for treatment. Neurosci Biobehav Rev. 2019;106:49-57. doi:10.1016/j.neubiorev.2018.12.005

19.

Wakeman

Pham-Kanter

Donelan

Attitudes, practices, and preparedness to care for patients with substance use disorder: results from a survey of general internists. Subst Abuse. 2016;37(4):635-641. doi:10.1080/08897077.2016.1187240

20.

Reed

Murali

Sarpoulaki

Zavodnick

Hom

Rising

KL.

Hospitalist perspectives on buprenorphine treatment for inpatients with opioid use disorder. Drug Alcohol Depend Rep. 2022;5:100106. doi:10.1016/j.dadr.2022.100106

21.

Wilson

Spicyn

Matson

Alvanzo

Feldman

Internal medicine resident knowledge, attitudes, and barriers to naloxone prescription in hospital and clinic settings. Subst Abuse. 2016;37(3):480-487. doi:10.1080/08897077.2016.1142921

22.

Green

Kreuter

MW.

Health Promotion Planning: An Educational and Ecological Approach. 3rd ed. Mayfield Publishing Company; 1999.

23.

Harris

Taylor

Thielke

Payne

Gonzalez

Conde

JG.

Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377-381. doi:10.1016/j.jbi.2008.08.010

24.

Harris

Taylor

Minor

, et al. The REDCap consortium: building an international community of software platform partners. J Biomed Inform. 2019;95:103208. doi:10.1016/j.jbi.2019.103208

25.

R Core Team. R: A Language and Environment for Statistical Computing. R Foundation for Statistical Computing; 2020. Accessed December 8, 2023. https://www.R-project.org/

26.

Jennings

Ward

Pekar

, et al. The effectiveness of a noninterruptive alert to increase prescription of take-home naloxone in emergency departments. J Am Med Inform Assoc. 2023;30(4):683-691. doi:10.1093/jamia/ocac257

27.

Moore

Cheema

Follman

, et al. Medical student screening for naloxone eligibility in the emergency department: a value-added role to fight the opioid epidemic. MedEdPORTAL J Teach Learn Resour. 2021;17:11196. doi:10.15766/mep_2374-8265.11196

28.

Rouhani

Park

Morales

Green

Sherman

SG.

Harm reduction measures employed by people using opioids with suspected fentanyl exposure in Boston, Baltimore, and Providence. Harm Reduct J. 2019;16(1):39. doi:10.1186/s12954-019-0311-9

29.

Silverstein

Daniulaityte

Martins

Miller

Carlson

RG.

“Everything is not right anymore”: buprenorphine experiences in an era of illicit fentanyl. Int J Drug Policy. 2019;74:76-83. doi:10.1016/j.drugpo.2019.09.003

30.

Bass

Kelly

PJA

Pandit-Kerr

, et al. “It’s my frenemy”: a qualitative exploration of knowledge and perceptions of fentanyl use during the COVID-19 pandemic in people who use drugs at a syringe services program in Philadelphia, PA. Front Public Health. 2022;10:882421. doi:10.3389/fpubh.2022.882421

31.

Gryczynski

Nichols

Schwartz

Mitchell

Hill

Wireman

Fentanyl exposure and preferences among individuals starting treatment for opioid use disorder. Drug Alcohol Depend. 2019;204:107515. doi:10.1016/j.drugalcdep.2019.06.017

32.

Wilson

Berk

Adger

Feldman

Identifying missed clinical opportunities in delivery of overdose prevention and naloxone prescription to adolescents using opioids. J Adolesc Health. 2018;63(2):245-248. doi:10.1016/j.jadohealth.2018.05.011

33.

Allen

Michelson

O’Donnell

Bagley

Earlywine

Hadland

SE.

Training in adolescent substance and opioid misuse in pediatric residency programs. Pediatrics. 2022;149(5):e2021053423. doi:10.1542/peds.2021-053423

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.87 MB