The Implementation of Nalmefene By a Sheriff's Office: Understanding Acceptability and Feasibility across a County Service System

Background: The opioid epidemic and subsequent fentanyl crisis has long been recognized as a nationwide issue requiring collaborative prevention efforts (White et al., 2021). In November 2023, a county Sherriff’s Office in a midwestern state trained 20 deputies in one urban substation to use the high-dose intranasal opioid overdose reversal agent nalmefene. A need for an alternative to naloxone was identified due to concerns about multiple naloxone administrations and fentanyl potency. This study evaluates the implementation of nalmefene, drawing from the experience of administrative and advocacy interlocutors across this service system.

Methods: Thirty-six semi-structured interviews were conducted across the county’s service system. Four participants represented county administrators (i.e., agency directors), five represented the county’s substance abuse service network (i.e., peer support specialists), ten represented law enforcement (i.e., deputies who carry nalmefene), and 12 represented medical services (i.e., EMS). Most were white (94%) and male (56%), ranging in age 22-68 years with varying experience in their fields (1-40 years). Interviews focused on acceptability and feasibility of nalmefene in this community. Interviews were transcribed and coded by one individual using NVivo and was guided by principles of grounded theory set forth in Creswell & Poth (2018).

Results: Findings suggest that this county was uniquely situated to pilot nalmefene given the robust service system dedicated to substance abuse treatment. Most interlocutors stated they were informed of the nalmefene pilot after implementation and felt this disorganized approach negatively impacted roll-out across the service system.

Findings also suggest that the decision to pilot nalmefene was made in consideration of potential negative impacts, including the risk of precipitated withdrawal. This concern was universal but concentrated among service providers operating in medical and advocacy spaces. This contrasts with the level of support among law enforcement and peer support specialists, who believed the introduction of another lifesaving reversal agent outweighed the risks. Many interlocutors remain skeptical, citing current anecdotal evidence does not suggest its usefulness beyond naloxone (see ACMT and AACT joint statement, 2023).

Conclusions and Implication: These findings demonstrate a dichotomy between peers with lived experience and medical professionals and advocates. These conflicting viewpoints persist alongside an uncoordinated community education process, which could contribute to disruptions in care during the overdose reversal process. Findings reflect barriers encountered during initial rollouts of naloxone distribution programming (Drainoni et al., 2016). As recommended in the joint statement by ACMT and AACT, this study, and others, should evaluate outcomes associated with the implementation of nalmefene in clinical and community-based settings.