The United States (U.S.) is experiencing a national epidemic of opioid- and stimulant- use and overdose-related deaths. The situation has worsened with the dramatic rise in availability and use of opioids, particularly synthetic opioids (primarily illicitly manufactured fentanyl (IMF)) (1, 2). Based on the most recent provisional data from the Centers for Disease Control and Prevention (CDC), the number of drug overdose deaths that occurred during the year ending in April 2022 (108,174) is over 6 times the number that occurred in 1999 (16,849) (3, 4). Seventy-six percent (81,692) of those 108,174 deaths involved opioids, 89% of which involved synthetic opioids (4). City, county, state, and national-level data support that the COVID-19 pandemic exacerbated (or at least maintained) the pre-existing upward trend of opioid-related overdoses and resultant deaths (4–10), with the number of opioid-related and synthetic opioid-related overdose deaths increasing by 52% and 79%, respectively, between the years ending in March 2020 and in April 2022 (4). A number of factors likely contributed to this exacerbation, including social isolation, job loss, worsening mental health, and lack of widespread access to mental healthcare, opioid use disorder (OUD) treatment, and harm reduction services (2, 5, 8, 10–15).
Young adults are a priority population in the opioid overdose epidemic (16–18). College-aged adults (18–25) are more likely than other age groups to misuse opioids generally (e.g., misuse of prescription pain relievers or use of heroin) and IMF specifically, and have worse OUD treatment outcomes (e.g., higher rates of 24-week relapse than older adults) (13, 19, 20). Based on national CDC data, between 1999 and 2018 opioid-only and polysubstance-involved opioid overdose deaths (primarily involving synthetic opioids and cocaine) among adolescents and young adults ages 13–25 increased by 384% and 760%, respectively (21). After remaining consistent from 2010 through 2019, the number of drug overdose deaths among adolescents ages 14–18 increased from 492 (2.36 per 100,000) to 954 (4.57 per 100,000) between 2019 and 2020 and rose to 1146 deaths (5.49 per 100,000) in 2021, 77% of which involved fentanyl (22).
Among college students in particular, prescription opioid misuse (e.g., “use without a medical prescription or the use for something other than directed by a prescribing healthcare provider” (23)) is associated with suicidality, depression, anxiety, other forms of psychological distress, and other substance use (23–27), and illicit opioid use (e.g., heroin) is associated with relationship problems like intimate partner violence (24). A recently published systematic review (2013–2019) found that lifetime prescription opioid misuse prevalence among college students in the U.S. ranged from 4–19.7% (23). Recent data from the American College Health Association-National College Health Assessment (n = 90,503 students across 162 colleges) found that 4.8% of college students reported prescription opioid misuse within the past year (28). Importantly, research indicates that college students have limited knowledge around what constitutes an opioid (e.g., lack of recognition of fentanyl), causes of opioid overdose, signs and symptoms of opioid overdose and withdrawal, and the importance of naloxone as an opioid antagonist to reverse opioid overdose (29). Similarly, research supports that there is a low perceived risk of opioid overdose death among adolescents and young adults, who may not change use patterns even after personally experiencing an overdose (30).
Naloxone training programs that provide information about opioid overdose prevention, recognition, and response have broadly shown effectiveness across a range of settings in improving overdose knowledge and response skills and reducing stigma (e.g., see Razaghizad and colleagues’ recent review of 6 systematic reviews published 2014–2019 that include 87 studies published 1996–2018) (31). Additionally, such programs have documented successful overdose reversals involving peer-administered naloxone, few adverse consequences, and reductions in population-level opioid-related mortality (31). There is growing evidence of the value of community-based distribution of naloxone to laypersons and recent legislation and national efforts to expand naloxone access (32, 33).
College campuses are an important but underutilized, understudied setting where implementation of evidence-based public health strategies for providing education and training around opioid use and naloxone are needed, particularly given the substantial reach (of young adults) and infrastructure they provide for large-scale implementation efforts nationally. Training students and staff/faculty may prevent overdoses not only on campus, but in surrounding communities, as well as in communities to which students go home during breaks and after graduating (34). Such training fills a critical need and is part of a broader, comprehensive, multi-pronged public health approach, as many opioid overdose deaths occur in the presence of bystanders who are not prepared to respond (1, 35, 36).
In recent years, the American College Health Association Guidelines “Opioid Prescribing in College Health” has recommended stocking naloxone and training health center staff about its use (37). Nationally, universities have differed in their perspective about naloxone, specifically regarding who should be trained and what protocols are established for overdose prevention and response. To date, opioid overdose prevention and naloxone training programs have primarily been offered to medical, pharmacy, and undergraduate/graduate nursing students (38–52), with few examples implemented for undergraduate students generally (34, 53–56). As one example, in 2016, the University of Texas at Austin Schools of Pharmacy and Social Work launched Operation Naloxone, an interprofessional collaboration between students and faculty aimed at combating the opioid overdose crisis through a multi-pronged approach that addressed knowledge gaps in substance use safety and overdose prevention and ensured that communities were prepared with naloxone and other resources to prevent overdoses and overdose deaths. This approach included a service learning component for all students on campus (54). University of Southern California implemented a program modeled after Operation Naloxone and is offering training online to improve accessibility during the pandemic (55). Emerging literature suggests that online naloxone training models may be as effective as in-person training (e.g., in knowledge improvement) (38, 39, 52). Importantly, though there are several examples of training programs emerging in the gray literature, there are significant gaps in routine delivery and evaluation of implementation of such training on college campuses nationally (53, 55, 57–60).
As evidence of the importance and impact of naloxone programs continues to grow as an essential part of overdose prevention efforts (53, 61), it is important to understand challenges and facilitators to planning and implementing such programs on college campuses nationally. To address these gaps and understand the potential acceptability and feasibility of implementation in this understudied setting, we conducted research to assess key barriers and facilitators to the delivery of opioid overdose prevention and naloxone training programs on college campuses. Specifically, we use an implementation science framework (The Consolidated Framework for Implementation Research (CFIR) (62); see Fig. 1) to inform qualitative data collection and analysis among students and staff at Columbia University’s undergraduate campus. This paper seeks to help advance understanding of multi-level factors that may impact the routine, widespread delivery of naloxone and opioid education and training on college campuses.
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