Dispenser Provision of Education or Training to Naloxone Recipients

Research SummaryPublished Dec 18, 2023

Requires pharmacists to offer education or training 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 anticipate minimal effects on all four outcomes because this requirement would increase the burdens on pharmacists already pressed for time, deterring many from dispensing naloxone, and offsetting any potential benefits of the education and training offered.
  • Experts think the public supports providing information on the proper use of all medications.
  • Experts have concerns about feasibility and affordability due to time constraints, the need to "train the trainers," and a lack of pharmacy infrastructure for confidential patient education.
  • Experts are divided on equitability: This policy could worsen equity if its onerous aspects interact with existing structural oppression and interpersonal discrimination, or the policy 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 Education has the potential to increase comfort with and effective use of naloxone by those administering it. "Might slightly increase distribution by making recipients more comfortable in having and using naloxone"
Little-to-no
(selected)
 Not likely to impact dispenser behavior sufficiently to impact naloxone pharmacy distribution. "I haven't seen major evidence of a lack of knowledge among users"
Harmful This requirement would create barriers to naloxone pharmacy distribution by increasing burdens on dispensers, who are already pressed for time. "This would put more responsibility on already busy community pharmacists and would probably result in less [naloxone] being distributed"

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 engagement with treatment and recovery services. "If the education links to treatment options then [it] may decrease prevalence"
Little-to-no
(selected)
 No credible mechanism linking naloxone education requirements and OUD prevalence. "I do not think this has an effect on the underlying prevalence of opioid use disorder on its own"
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. "Education session could help reduce stigma and lead to the identification of hidden cases"

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. "If education included about how to use safely and watch out for combo drugs, it might slightly decrease nonfatal OD [overdose]"
Little-to-no
(selected)
 No credible mechanism linking naloxone education requirements and nonfatal opioid overdoses. "People know how to use naloxone, it is very easy. Having a pharmacist explain it to a patient probably won't have any impact on these rates"
Harmful Potential for revival from overdose could have a small, indirect, and mechanistic impact on nonfatal overdoses due to increased survivorship. "Maybe slight increase in nonfatal overdoses, as slightly increased distribution facilitates opioid misuse following a nonfatal overdose"

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 effectively and increased linkages to treatment could lead to (modest) reductions in fatal overdoses. "Learning how to properly use Naloxone would lead to more nonfatal overdoses and less fatal overdoes"
Little-to-no
(selected)
 A naloxone education requirement would not impact naloxone distribution and administration sufficiently to impact fatal overdoses. "Since individuals using heroin/fentanyl are most likely to die from OD and the ones going to the pharmacy are most likely to use prescription opioids, it may have a minor effect to lower fatal OD"
Harmful N/A N/A

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. "Consultations and education on proper usage is afforded for all other prescriptions"
Moderate Depends on how burdensome and stigmatizing the education or training requirement is. "I would further highlight the risk of stigma in the pharmacy to the recipient. Pharmacists and their conditions of practice are not set up to assure high quality training, and that begins with our societal stigma, coupled with DEA [Drug Enforcement Administration] fears that the pharmacists are contending with"
Low N/A N/A

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). "As long as there is no specific requirement of what the training entails, then it is very feasible"
Moderate
(selected)
Concerns related to time constraints, the need to train pharmacists, and the lack of infrastructure at pharmacies for confidential patient education. "This takes time for pharmacists, who work on tight schedules, and is hard to monitor whether it's really being done"
Low Burdensome for communities and pharmacies to implement. "Not all pharmacies are set up or staffed to provide confidential patient education, requires pharmacist training"

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). "Using already developed tools there is limited state or community costs"
Moderate
(selected)
Concerns about pharmacist time. "This could be seen as adding significant costs, in terms of pharmacist time"
Low Concerns about pharmacist time and opportunity costs. "Not worth the cost to implement"

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. "It would mean that everyone who is given naloxone has the proper training on how to administer and use it, so would therefore increase equity"
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. "Such a requirement could reduce the likelihood that naloxone would be offered as it would add time and resource utilization. However, the policy would also provide education and knowledge that had previously been inequitably delivered to different patient populations. Any educational materials would need to reflect inclusion as well as basic language for lay people of different educational backgrounds and cognitive abilities"
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. "Equity is highly dependent on the scope of training requirements. More onerous requirements are likely to disproportionately reduce access to naloxone for people in the most marginalized circumstances (e.g. people experiencing mental illness, unhoused people, etc.)"
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Dispenser Provision of Education or Training to Naloxone Recipients, RAND Corporation, RB-A3054-4, 2023. As of October 16, 2024: https://www.rand.org/pubs/research_briefs/RBA3054-4.html
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Dispenser Provision of Education or Training to Naloxone Recipients. Santa Monica, CA: RAND Corporation, 2023. https://www.rand.org/pubs/research_briefs/RBA3054-4.html.
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