BACKGROUND: Naloxone, an opioid antagonist, offers a powerful tool for preventing opioid overdose deaths. Because studies have shown opioid overdose education and naloxone distribution (OEND) programs to be a safe, feasible, and effective intervention, several policymakers and public health agencies have advocated for broader access to this life-saving medication. Community health centers (CHCs) are a promising location for expanding naloxone access. This investigation examined the experience of CHC-based HIV primary care teams with a variety of overdose education and naloxone access (OENA) strategies in order to inform future dissemination efforts. METHODS: A mixed methods study was conducted with eight CHCs located in Massachusetts communities experiencing high opioid overdose fatality rates. Individual and group interviews with 29 clinic staff members; clinic and participant surveys; and document review were used to elucidate the OENA strategies. The Consolidated Framework for Implementation Research guided the data collection process and subsequent analysis, which revealed several factors supporting or hindering implementation of OENA activities in CHC primary care settings. RESULTS: Operating in a facilitative state policy environment, the CHCs utilized a mix of approaches to OENA: providing clinic-based services, issuing prescriptions, utilizing pharmacy standing orders, and making referrals to existing community-based OEND programs. With prescribers having limited time and competing priorities, nurses, health educators, and other staff played a prominent role in OENA. Pharmacies also served as important access points for patients and community residents. Several strategies were used to engage patients, including active outreach, partnerships with external organizations, and efforts to destigmatize substance use disorders. Clinic staff participation was enhanced through leadership support for harm reduction approaches, ongoing training, peer modeling, and information sharing. CONCLUSIONS: This study demonstrated that OENA can be integrated into CHC primary care services, adapted to the clinic context, and modified as needed. Successful implementation required a systems-level response, grounded in a team-based care model and a consideration of patient needs. The process for naloxone reimbursement needs to be determined to minimize CHC or patient barriers and ensure sustainability. Clinic training and technical assistance plans should be customized according to the staff members’ potential roles and their stage of readiness.

The ongoing opioid crisis presents a significant public health challenge particularly for people who use opioids (PWUO). Naloxone is an opioid antagonist crucial to reducing opioid overdose mortality. Inconsistencies exist among PWUO in obtaining, carrying, discussing, and administering naloxone. Using sequential mixed methods, this study was aimed at investigating the use of implementation intentions on naloxone use among PWUO. Semi-structured interviews were conducted with 83 PWUO to gather individual experiences with using naloxone and contextual details regarding its use. An essentialist thematic analysis with inductive coding revealed valuable insights into where, for whom, and when naloxone is implemented. The analysis identified major themes such as caring for others' needs, knowledge gaps, reinforcement through overdose experiences, duality of overdose and compassion, and stigma. Minor themes related to syringe services program implementation and drug use were identified. Building on these qualitative findings a quantitative analysis determined the impact of implementation intentions on naloxone implementation. Participants were randomly assigned to develop implementation intentions or goal intentions for the use of naloxone. Follow-up surveys assessed changes in participants' intentions to obtain, carry, discuss, and administer naloxone and their actual implementation over a 6-month period. At the 3-month follow-up the experimental condition exhibited statistically significant positive intentions to obtain naloxone and engage in discussions about naloxone in social contexts of drug use. Changes in the magnitude of naloxone implementation were observed at the 3- and 6-month timepoints. Specifically, the self-reported discussion of naloxone showed noticeable changes in implementation frequency over time. This suggests that while implementation intentions may not have statistically significant effects on the use of naloxone it had some influence on the frequency of discussing naloxone prior to drug use. This work makes a valuable contribution to the existing literature because of its attempt to apply the Theory of Planned Behavior and implementation intentions in a novel way. Though the experimental hypothesis was not supported statistically significant observations were made for some behaviors at the 3-month follow-up. The pragmatic nature of the setting enhances the relevance of the findings and provides valuable insights for future interventions supporting PWUO. / Doctor of Philosophy / The ongoing crisis of opioid addiction poses a significant public health challenge particularly for individuals who use opioids. Naloxone is a medication that can reverse opioid overdoses and it plays a crucial role in saving lives. People who use opioids often face difficulties in accessing, carrying, discussing, and using naloxone consistently. This study was aimed at investigating the use of naloxone by employing qualitative and quantitative methods. We conducted interviews with 83 individuals who use opioids to explore their experiences and gather insights into naloxone use. These interviews provided valuable information about when, where, and for whom naloxone is used. Several important themes emerged including the significance of helping others, knowledge gaps, the influence of personal experiences, the conflict between the fear of overdose and caring for others, and the stigma associated with drug use. We investigated the impact of a specific approach called "implementation intentions" in improving naloxone use. Participants were randomly assigned to create specific plans or general goals for naloxone use. Through surveys conducted over a 6-month period we examined changes in participants' intentions and actions related to naloxone use. Although the specific approach did not yield significant improvements, we observed changes in how people discussed naloxone over time. This study contributes to the existing research by introducing innovative ideas to support positive behavioral changes among individuals who use opioids. The real-world setting in which the study took place enhances the applicability of the findings and offers valuable insights for future programs supporting individuals who use opioids.