Background

Naloxone distribution, a key global strategy to prevent fatal opioid overdose, has been a recent target of legislation in the U.S., but there is insufficient empirical evidence from causal inference methods to identify which components of these policies successfully reduce opioid-related harms. This study aimed to examine expert consensus on the effectiveness and implementability of various state-level naloxone policies.

Methods

We used the online ExpertLens platform to conduct a three-round modified-Delphi process with a purposive sample of 46 key stakeholders (advocates, healthcare providers, human/social service practitioners, policymakers, and researchers) with naloxone policy expertise. The Effectiveness Panel (n = 24) rated average effects of 15 types of policies on naloxone pharmacy distribution, opioid use disorder (OUD) prevalence, nonfatal opioid-related overdoses, and opioid-related overdose mortality. The Implementation Panel (n = 22) rated the same policies on acceptability, feasibility, affordability, and equitability. We compared ratings across policies using medians and inter-percentile ranges, with consensus measured using the RAND/UCLA Appropriateness Method Inter-Percentile Range Adjusted for Symmetry technique.

Results

Experts reached consensus on all items. Except for liability protections and required provision of education or training, experts perceived all policies to generate moderate-to-large increases in naloxone pharmacy distribution. However, only three policies were expected to yield substantive decreases on fatal overdose: statewide standing/protocol order, over-the-counter supply, and statewide “free naloxone.” Of these, experts rated only statewide standing/protocol orders as highly affordable and equitable, and unlikely to generate meaningful population-level effects on OUD or nonfatal opioid-related overdose. Across all policies, experts rated naloxone prescribing mandates relatively lower in acceptability, feasibility, affordability, and equitability.

Conclusion

Experts believe statewide standing/protocol orders are an effective, implementable, and equitable policy for addressing opioid-related overdose mortality. While experts believe many other broad policies are effective in reducing opioid-related harms, they also believe these policies face implementation challenges related to cost and reaching vulnerable populations.

中文翻译：

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国家级纳洛酮准入政策的有效性和可实施性：来自在线修改德尔菲流程的专家共识

 背景

纳洛酮分配是防止致命的阿片类药物过量的关键全球战略，最近已成为美国立法的目标，但因果推理方法没有足够的经验证据来确定这些政策的哪些组成部分成功减少了阿片类药物相关的危害。本研究旨在检验专家对各种国家级纳洛酮政策的有效性和可实施性的共识。

 方法

我们使用在线 ExpertLens 平台对 46 个具有纳洛酮政策专业知识的关键利益相关者（倡导者、医疗保健提供者、人类/社会服务从业者、政策制定者和研究人员）进行了三轮修改德尔菲流程的有目的样本。有效性小组 ( n = 24) 评估了 15 种政策对纳洛酮药房分配、阿片类药物使用障碍 (OUD) 患病率、非致命性阿片类药物相关过量以及阿片类药物相关过量死亡率的平均影响。实施小组（ n = 22）对相同政策的可接受性、可行性、负担能力和公平性进行了评级。我们使用中位数和百分位数范围比较了不同政策的评级，并使用兰德/加州大学洛杉矶分校适当性方法百分位数范围对称调整技术来衡量共识。

 结果

专家们就所有项目达成了共识。除了责任保护和所需的教育或培训之外，专家认为所有政策都会使纳洛酮药房分销出现中到大幅增长。然而，只有三项政策预计会大幅减少致命过量用药：全州范围内的常规/协议命令、非处方药供应和全州范围内的“免费纳洛酮”。其中，专家仅将全州范围内的常规/协议命令评为高度负担得起和公平的，并且不太可能对 OUD 或非致命阿片类药物相关过量产生有意义的人口水平影响。在所有政策中，专家对纳洛酮处方的可接受性、可行性、可负担性和公平性评价相对较低。

 结论

专家认为，全州范围内的常规命令/协议命令是解决阿片类药物过量死亡问题的有效、可实施且公平的政策。虽然专家认为许多其他广泛的政策可以有效减少阿片类药物相关的危害，但他们也认为这些政策面临着与成本和覆盖弱势群体相关的实施挑战。