Overdose Education and Naloxone for Patients Prescribed Opioids in Primary Care: A Qualitative Study of Primary Care Staff

Abstract

BACKGROUND:The rate of fatal unintentional pharmaceutical opioid poisonings has increased substantially since the late 1990s. Naloxone is an effective opioid antidote that can be prescribed to patients for bystander use in the event of an overdose. Primary care clinics represent settings in which large populations of patients prescribed opioids could be reached for overdose education and naloxone prescription. OBJECTIVE: Our aim was to investigate the knowledge, attitudes and beliefs about overdose education and naloxone prescription among clinical staff in primary care. DESIGN: This was a qualitative study using focus groups to elucidate both clinic-level and provider-level barriers and facilitators. SETTING: Ten primary care internal medicine, family medicine and infectious disease/HIV practices in three large Colorado health systems. METHODS: A focus group guide was developed based on behavioral theory. Focus group transcripts were coded for manifest and latent meaning, and analyzed for themes using a recursive approach that included inductive and deductive analysis. RESULTS: Themes emerged in four content areas related to overdose education and naloxone prescription: knowledge, barriers, benefits and facilitators. Clinical staff (N= 56) demonstrated substantial knowledge gaps about naloxone and its use in outpatient settings. They expressed uncertainty about who to prescribe naloxone to, and identified a range of logistical barriers to its use in practice. Staff also described fears about offending patients and concerns about increased risk behaviors in patients prescribed naloxone. When considering naloxone, some providers reflected critically and with discomfort on their own opioid prescribing. These barriers were balanced by beliefs that prescribing naloxone could prevent death and result in safer opioid use behaviors. LIMITATIONS: Findings from these qualitative focus groups may not be generalizable to other settings. CONCLUSION: In addition to evidence gaps, logistical and attitudinal barriers will need to be addressed to enhance uptake of overdose education and naloxone prescription for patients prescribed opioids for pain.

Attitudes Toward Naloxone Prescribing in Clinical Settings: A Qualitative Study of Patients Prescribed High Dose Opioids for Chronic Non-Cancer Pain

“…Several barriers identified by participants in our study correspond with previously identified provider barriers, 14 such as the prohibitive cost of naloxone and potentially stigmatizing aspects of naloxone. While providers expressed concern that prescribing naloxone may be considered stigmatizing, 14 patient participants suggested that naloxone could be prescribed using a patient-centered approach that is empowering and non-judgmental.…”

“…Using the theoretical models that informed our interview guide content and our prior findings, we created an a priori template of codes. 14,20 Using this template as a guide, two analysts (S.K. and S.M.)…”

“…The interdisciplinary research team, consisting of clinicians, an anthropologist and health services researchers, developed a semi-structured interview guide informed by the findings of prior clinician focus groups, 14 the Theory of Planned Behavior 18 and the Health Belief Model 19 (see sample questions in the Online Appendix). The primary interviewer was a doctoral student with training in qualitative methods (S.M.…”

Twenty years of take-home naloxone for the prevention of overdose deaths from heroin and other opioids—Conception and maturation

“…US primary care providers described insufficient time during patient appointments and inability to follow up with patients as main organizational barriers to THN (Binswanger et al, 2015). Canadian primary care providers considered existing naloxone guidelines inadequate and identified the lack of user-friendly naloxone devices, sufficient funding and training as central barriers to THN provision (Leece et al, 2015).…”

Capsule Commentary on Binswanger et al., Overdose Education and Naloxone for Patients Prescribed Opioids in Primary Care: A Qualitative Study of Primary Care Staff

“…4 In their qualitative study of focus groups involving 56 providers discussing naloxone rescue kits, Biswinger found several important themes. 5 First, providers are not prepared or trained to help their patients understand how and when to use naloxone, or even to identify patients at risk. Second, there are logistical barriers such as how and whom to train in naloxone rescue use, since the patient is likely to be incapacitated.…”