Applying the Consolidated Framework for Implementation Research (CFIR) to understand college health administrator perceptions on adopting and implementing opioid overdose education and naloxone distribution (OEND) programs among universities nationally

Background: The United States opioid epidemic’s reach is expanding. Rapidly scaling opioid education and naloxone distribution (OEND) programs is essential within a multipronged public health response. Universities offer infrastructure with potential to support routine, widespread OEND implementation among adolescents and young adults nationally, a priority population who could disseminate to broader networks and geographic communities. This important setting is underutilized, and critical gaps remain in understanding university-based OEND program adoption/implementation. Methods: We conducted semi-structured, in-depth interviews (n=21) among a purposively selected national sample of college health administrators to understand their perceptions of barriers/facilitators of implementing OEND programs at their universities and among universities nationally. The Consolidated Framework for Implementation Research guided data collection and inductive-deductive thematic analysis. Results: Regarding Relative Priority ( Inner Setting ), High/Mid-Level Leaders (Individuals), and Rationale for the Intervention (emergent code in the Innovation domain), participants described the need for compelling justification to adopt, implement, and prioritize university-based OEND programs. The key justification for administration was student opioid overdose and mortality events. Absent these events and regarding Assessing Needs ( Implementation Process ), participants described the need for student opioid misuse data to justify investment. Regarding Local Conditions ( Outer Setting ) and Tension for Change ( Inner Setting ), participants indicated that a university’s level of community obligation and integration determined which opioid overdoses and misuse data administration deemed relevant to justify adoption. Regarding Partnerships & Connections ( Outer Setting ), Relational Connections ( Inner Setting ); Planning , Engaging , and Teaming ( Implementation Process ), participants described external/internal collaborators’ key roles in OEND program adoption/implementation. Regarding Local Attitudes ( Outer Setting ), participants described the need to manage political risk, implicating stigma against harm reduction programming. Regarding Culture and Available Resources ( Inner Setting ), participants illustrated a trajectory in which their institutions prioritized recovery programming for years before prioritizing harm reduction programming (e.g., OEND programs). Conclusions: Our findings underscore the complexity of university-based OEND program implementation while providing actionable insights to support its national scale-up. Building on identified distinctions between non-implementing and implementing universities, future research should establish OEND programming implementation phase among universities nationally, advance understanding of implementation determinants and strategies distinguishing each phase, and establish core components and best practices.