Implementing a “Naloxone Hub With Many Spokes” Model in Kentucky: Partner Agency Perspectives on Implementation Strategies

Introduction

Deaths from drug overdoses continue to be a national crisis in the United States (US), such that about 42% of American adults know someone who has died from a drug overdose (Athey et al., 2024). In Kentucky, the overdose epidemic has largely been driven by illicit opioid use. From 2018 to 2021 in Kentucky, suspected opioid overdose encounters by emergency medical services increased by 44% (Rock et al., 2024), and opioid overdose deaths rose during the COVID-19 pandemic (Blair et al., 2023; Friedman & Akre, 2021; Slavova et al., 2021). Despite a 9.8% decrease in drug overdose deaths in Kentucky in 2023 (Kentucky Injury Prevention and Research Center, 2024), there is an ongoing need to scale up evidence-based practices (EBPs) to reduce opioid overdose deaths.

Overdose education and naloxone distribution (OEND) dramatically reduces the likelihood of death from opioid overdose (Clark et al., 2014; Holmes et al., 2022; Jones et al., 2022; McDonald & Strang, 2016; Razaghizad et al., 2021). When OEND has been scaled up at the community-level, rates of opioid overdose mortality have decreased (Naumann et al., 2019; Walley et al., 2013). Despite the likely benefits of scaling up OEND, access to naloxone remains challenging in many communities (Chatterjee et al., 2022; Kinnard et al., 2021; Meyerson et al., 2021; Nolen et al., 2022; Pollini et al., 2022; Spector et al., 2022).

Intentional implementation efforts can expand OEND in communities, as evidenced by our recent work as part of the HEALing (Helping to End Addiction Long-term^®) Communities Study in Kentucky (HCS-KY), which built partnerships with community coalitions and a wide range of local organizations (HEALing Communities Study Consortium, 2020). To expand OEND, the HCS-KY team developed a set of implementation strategies (Knudsen et al., 2023), drawing on the Expert Recommendations in Implementation Change (ERIC) compendium (Powell et al., 2012, 2015) to support partner organizations across implementation phases (Aarons et al., 2011). A centralized naloxone hub was tasked with naloxone dispensing, shipping, and expiration monitoring. Naloxone was provided at no cost to agency partners, along with a computer tablet(s) for submitting anonymous distribution data. The hub provided recipient-facing educational resources, including a short video and a brochure that addressed the state's educational requirements (Kentucky Revised Statutes 217.186); these resources were translated into multiple languages. In addition, implementation facilitators worked with partner organizations to implement the delivery of OEND. During initial meetings, implementation facilitators provided information, described options for overdose education that would meet state requirements, and collaborated with the agency to design an OEND workflow. At follow-up meetings, implementation facilitators shared data on the agency's distribution efforts, worked with agencies to reconcile their naloxone inventory, and collaborated with agencies to troubleshoot challenges and revise OEND workflows. These implementation strategies resulted in an adoption rate of 69% and considerable reach, with nearly 40,822 units of naloxone (i.e., a unit equals a two-dose package) distributed by partner agencies (Knudsen et al., 2023; Oyler et al., 2024). In the larger multistate analysis of naloxone distribution, HCS intervention communities experienced significantly greater increases in naloxone distribution than control communities (Freeman et al., 2025).

Although these quantitative measures of implementation outcomes provide some indication that the implementation strategies supported OEND scale-up, they provide little insight into how partner organizations perceived the implementation strategies deployed. Qualitative methods are useful for understanding perspectives on the value and utility of implementation strategies (Holtrop et al., 2018). Previous qualitative work has predominantly focused on the perspectives of OEND recipients (Abadie, 2023; Beharie et al., 2023; Bennett et al., 2020; Collins et al., 2024; French et al., 2023; Gray et al., 2023; Kahn et al., 2022; Kano et al., 2020; Kesich et al., 2023; Kline et al., 2020; Ko et al., 2021; Lowenstein et al., 2022; Natale et al., 2023; Schneider et al., 2023; Spadaro et al., 2023; Urmanche & Harocopos, 2023; Westafer et al., 2024), with fewer studies focused on organizational stakeholders involved in delivering OEND, such as pharmacists (Ijioma et al., 2021; Irwin et al., 2024; Rawal et al., 2023), first responders (Baumgart-McFarland et al., 2022; Carroll et al., 2023; Lloyd et al., 2023; Smiley-McDonald et al., 2022), harm reduction staff (Frost et al., 2022), and medical providers (Fraimow-Wong et al., 2024; Punches et al., 2020; Sasson et al., 2023). Prior studies often describe experiences with OEND in the absence of a larger structured effort to use implementation strategies to support scaling up this EBP. Relatively little is known about which implementation strategies are most salient and valuable to organizations working to expand access to OEND. Thus, the aim of this study is to describe organizational perceptions of implementation strategies used as part of HCS-KY's efforts to expand OEND.

Method

Results

Characteristics of interviewees are presented in Table 1. In describing the factors that supported their efforts to implement OEND, partner organizations largely focused on implementation strategies that provided resources in terms of no-cost naloxone, overdose education tools, and support provided by HCS-KY staff, such as implementation facilitators and staff of the hub.

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Table 1.

Characteristics of Interviewees (n = 70).

	% (n)
Sex
Male	15.7% (11)
Female	84.3% (59)
Ethnicity
Hispanic/Latino/a/e	7.1% (5)
Non-Hispanic	92.9% (65)
Race
Asian	1.4% (1)
Black	7.1% (5)
White	90.0% (63)
Missing	1.4% (1)
Age
18–34 years of age	24.3% (17)
35–49 years of age	42.9% (30)
50–64 years of age	28.6% (20)
65–74 years of age	4.3% (3)
Educational attainment
High school degree or equivalent	1.4% (1)
Some college, no degree	8.6% (6)
Associate degree	8.6% (6)
Bachelor's degree	28.6% (20)
Master's degree	48.6% (34)
Doctoral or professional (e.g., MD, DDS) degree	4.3% (3)
Agency type
Medication for opioid use disorder (MOUD) program	52.9% (37)
Non-MOUD behavioral health program	20.0% (14)
Health department	11.4% (8)
Primary care	5.7% (4)
Emergency medical services (EMS)	5.7% (4)
Criminal legal system organization (e.g., detention center, drug court)	4.3% (3)
Agency location
Urban	61.4% (43)
Rural	38.6% (27)

Note. Due to rounding, percentages may not sum to 100%. Some programs providing MOUD also provide non-MOUD services to treat other types of substance use disorder.

Naloxone Accessibility Was a Common Barrier Prior to the Study. Many participating agencies readily acknowledged previous challenges in affording to implement OEND or of keeping naloxone on hand in quantities that enabled growth of OEND efforts. Therefore, having readily available naloxone paid for and delivered by the HCS-KY team easily fit into the short-term and long-term goals of participating organizations. One study participant highlighted the successful expansion of OEND within the population served, attributing it to their consistent access to a supply (i.e., Narcan) through HCS-KY:

“We were now going to be able to … provide the Narcan to the people that we were going out to see or the community. And it wasn't just one place, it was multiple places that, ‘Oh, you're going to come to my door and you're going to give me Narcan?’ ‘Yes, and we'll come back, and we'll give you more if that's what you need.’ And it helped for us to also have those conversations about that de-stigmatizing of the Narcan and how beneficial it could be for individuals. So, it's definitely been an earmark for our program and being able to provide that to our community members that we go see.” (01072642, urban emergency medical services (EMS) organization)

To further support overdose education and naloxone distribution, HCS-KY supplied agencies with marketing materials that encouraged carrying naloxone and raised awareness that OEND was available at the agency. These materials not only helped reduce the stigma around substance use disorders but also gave agencies an effective tool to promote this vital service within their communities.

“We were able to utilize some of HEAL's marketing and, I guess, promotional materials that we were able to co-brand. Then, we were able to add a QR code on some of these materials that would drive people to the website that they would go to in order to scan to get to the mailed naloxone.” (01131207, urban health department)

Discussion

As part of efforts to scale up OEND in communities, a bundle of implementation strategies was deployed, and this study focused on the perspectives of organizations that partnered with HCS-KY regarding these strategies. Overall, participating organizations viewed the strategies as acceptable and feasible, contributing to their ability to deliver OEND.

One dominant theme in these interviews was that the provision of no-cost naloxone by HCS-KY was critically important to OEND implementation. The purchase of naloxone was supported by grant funds as well as a financial contribution from the Kentucky Opioid Response Effort (KORE), which was established through the Substance Abuse and Mental Health Services Administration's State Targeted Response and State Opioid Response grants and is housed within the state's Department for Behavioral Health, Developmental and Intellectual Disabilities. To some degree, this finding about the importance of no-cost naloxone is not surprising given that prior research has pointed to funding challenges coupled with the cost of naloxone and, at times, supply chain issues as barriers to implementation in community distribution programs (Frost et al., 2022; Hincapie et al., 2021; Winstanley et al., 2016). Qualitative work by Rawal et al. (2023) found that the cost was a barrier to pharmacy-based naloxone dispensing by standing order, and similarly, qualitative interviews focused on first responder-based OEND programs also noted that funding was a key facilitator of implementation (Carroll et al., 2023). Nearly 88% of all partner organizations were interested in sustaining OEND by joining KORE's program that also offers no-cost naloxone through its federal funding (Knudsen et al., 2023), pointing to the longer-term viability of this approach.

The unit cost of naloxone has decreased substantially over time, including when it was only available by prescription and more recently with its transition to an over-the-counter product (Marley et al., 2024). Barriers remain for accessing naloxone, including its cost and availability in community pharmacies. In a national study of people prescribed opioids for chronic pain, a group at risk of overdose, only 54% reported being willing to pay for naloxone (Huang et al., 2024). Although many insurance plans provide some coverage for naloxone, recent work has shown that cost-sharing in commercial insurance and Medicare reduces the odds that individuals will fill a naloxone prescription (Chua et al., 2024). Pharmacy stocking is also an ongoing issue. In a recent study of North Carolina pharmacies, fewer than 60% had naloxone in-stock and available for dispensing without prescription, and the mean out-of-pocket price was nearly $63, which exceeded the manufacturer's suggested retail price of $45 (Marley et al., 2024).

Developing educational materials is an implementation strategy included in the Expert Recommendations in Implementation Change (ERIC) compendium (Powell et al., 2015), and this strategy served at least two purposes. Because naloxone was available only by prescription at the time, provision of overdose education was necessary to comply with state regulations which mandated that overdose education needed to cover seven content areas. However, overdose education was important for reasons beyond regulatory compliance, as other studies have noted the importance of educational resources for training recipients of naloxone (Drainoni et al., 2016; Fraimow-Wong et al., 2024; Punches et al., 2020; Sasson et al., 2023) as well as those who deliver OEND (Ijioma et al., 2021; Rawal et al., 2023).

Our approach to resources for overdose education evolved in response to early feedback from partner organizations that reliance on a pre-existing 20-min interactive web-based training developed by another entity was not feasible for many agencies. Concerns about the time required for OEND had been documented in prior qualitative work (Ijioma et al., 2021; Rawal et al., 2023; Sasson et al., 2023). This early feedback from partner organizations points to the importance of organizational compatibility as a facilitator of innovation adoption and complexity of innovations as a barrier (Damschroder et al., 2022; Rogers, 2003). In response, our team developed a nine-minute video, available in multiple languages, that was installed on tablets and available on YouTube (https://www.youtube.com/watch?v=lZMleZybx_Q). Some partner organizations valued this video-based option, but others still perceived that its length was a barrier to use, particularly in fast-paced environments or in settings where many individuals had previously been trained in OEND (e.g., syringe service program participants). Adding review of an OEND pamphlet helped to address this concern to some extent, but nonetheless, attention to how overdose education needs may vary between settings and allowing for flexibility in how overdose education is delivered is an important consideration when planning for implementation of this EBP.

In addition to overdose education resources, partner organizations were provided communication materials upon request to raise awareness about the availability of OEND. This strategy aligns with the ‘increase demand’ implementation strategy in the ERIC compendium (Powell et al., 2015). These communication materials included customized information about how to request OEND while typically emphasizing the brief message of ‘Save a life. Get naloxone.’ Other qualitative research has reported the need for raising awareness about OEND availability (Fraimow-Wong et al., 2024; Gray et al., 2023; Natale et al., 2023) and the value of this type of message, which frames naloxone around a shared sense of responsibility to reduce opioid fatalities (Bennett et al., 2020). Not all partner organizations requested these materials, but among those that did, there was a general sense that the communication materials were helpful.

HCS-KY staff, especially the implementation facilitators who deployed the strategy of external facilitation (Powell et al., 2015), were also viewed favorably by partner organizations, who perceived that HCS-KY staff worked collaboratively with them to overcome implementation barriers. In the context of OEND, a recent randomized trial deployed a bundle of implementation strategies in syringe service programs that relied heavily on facilitation, finding that the facilitation-based approach significantly increased naloxone reach relative to a no-facilitation condition (Lambdin et al., 2024). As has been noted by others in the field of implementation science, facilitation is vitally important for organizational change initiatives (Kitson & Harvey, 2015; Moussa et al., 2019) and has been identified as an evidence-based implementation strategy (Kirchner et al., 2014; Ritchie et al., 2024; Wang et al., 2018).

It is important to note several limitations of this study. First, these interviews were only conducted with staff from partner organizations that successfully implemented OEND in a single state. It is unknown whether the HCS-KY implementation strategies would have overcome the barriers that may have impeded the subset of agencies who declined to partner or whether perspectives on the implementation strategies would be similar in other states. However, the varying types of organizations involved may suggest that the findings would have applicability for others seeking to expand OEND. Second, agencies that did not participate in the interviews may have had negative perceptions regarding their partnership with HCS-KY or the strategies used during the study. Finally, most interviewers had provided facilitation to agency staff during the implementation phase of the study, and that prior relationship may have resulted in some staff being less candid about their experiences.

Conclusions

These qualitative data highlight the importance of multifaceted implementation strategies in the process of scaling up EBPs in communities. Partner organizations noted readily accessible naloxone, supportive overdose education and other accompanying resources, and continued implementation support as noteworthy practices during this study. Overall, the strategies developed by HCS-KY were generally viewed positively by partner organizations, and OEND was greatly expanded during the study, with growth in the rate of naloxone distribution in Kentucky's intervention communities being three times greater than waitlist communities (Freeman et al., 2025). Future efforts should continue to explore how implementation strategies can be optimized to meet the needs of diverse types of organizations seeking to implement OEND.

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