Table 3 Key barriers to implementation of naloxone training and exemplar quotes organized by CFIR Domains

Outer setting

- Stigma surrounding disclosing opioid use and seeking help for any substance use disorder

- Legal repercussions of opioid use and lack of clarification around campus policies and laws

“I think there’s a stigma that exists for students going through this problem [addiction] and it’d be hard, I think, for many students to first admit to the problem, acknowledge that it exists and then actively go and seek help for a problem they’re currently dealing with and I think that of the personal road block for individuals what I think would be the number one factor in them pursuing help or not pursuing help”—Fraternity member

Inner setting

- Decentralized student body makes communication challenging

- Competing university-wide initiatives and priorities (sexual assault prevention, higher-risk drinking prevention, etc.) and training fatigue

- Insufficient staffing and advertising for student mental health and substance use treatment

- Perceived lack of widespread knowledge about opioid use and lack of prioritization

“Sophomore year I had surgery and there really was just like a coach or two that would come up to me and say – so you’re off the painkillers now, right?…But in terms of an open supportive culture, or any mechanisms that are in place, like not really.”—Student athlete

“If you go to Columbia websites, there’s no health resources for students who are struggling. That’s not something that’s advertised…it’s never front page news. It’s always like way in the back in the classifieds.”—Recovery Coalition member

Processes

- Complexity and decentralization of University’s structure and communication

- Difficult to disseminate messages broadly to reach such a large and diverse student population

“Especially on a campus that’s this large and it really is decentralized.”—Recovery Coalition member

Individual characteristics

- Opioid use not perceived as widespread problem on campus

- Limited knowledge about naloxone and risk of overdose with drug mixing

- Lack of perceived opioid use among students/ stigma specific to opioids

- Concern about assuming responsibility for others’ lives/inappropriate or inexpert use of naloxone (low self-efficacy)

- Fear of mandatory reporting and academic consequences

“I would say that would be my one number one biggest distrust is [not] knowing when they have to report it and when they don’t.”—Student athlete

“…if you wanted to ask your RA a question, like is this dangerous or I need help with this, I feel like there’s a lot of hesitation 'cause you don’t know if they have to like report that to someone like people are just scared to be, to get in trouble too so there’s this like lack of knowledge of who you can trust and like who you can ask for like those resources”—Sorority member

“…for RAs [the] role is kind of like how do you like get trust from people based on like you can’t keep anything like confidential?”—Resident Assistant

“If somebody on campus is using drugs because they’re stressed out and maybe they just take pills to go through the day or get their homework done but when they’re not expecting it, that might be, might be the overdose, might just be…the end.”—Recovery Coalition member

Intervention characteristics

- Competing demands for students’ time due to rigorous academic and extracurricular responsibilities

- Concern that increasing naloxone access may encourage opioid use

- Limited access to kits in buildings and ability to carry kits on person

- Difficulty identifying students with greatest need for training

“I mean people are very busy, finding the time to like do anything at Columbia is kind of difficult…”—Fraternity member

“…regardless of what’s done parents usually have an adverse reaction…they’re like ‘my children just study,’ ‘my children don’t drink, they don’t do drugs, they don’t do this, this isn’t gonna happen to them’ and by you talking about it you’re promoting that idea.”—Columbia Health staff member

“Administrators might look at it at first from an issue of liability and you have to get through the liability concerns.”—Military veteran