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Abstract

Background:

Opioid-related overdoses remain a critical concern in Arkansas, where Primary Care Providers (PCPs) play a key role in overdose prevention through naloxone education and prescribing. Academic Detailing (AD) is a promising strategy to improve provider knowledge, confidence, and adoption of naloxone-related practices, yet feasibility in rural primary care remains underexplored.

Aim:

To evaluate the feasibility and impact of a brief, continuing education (CE)-accredited AD intervention on naloxone prescribing confidence and behavior among rural PCPs over 2 years.

Methodology:

The University of Arkansas for Medical Sciences (UAMS) delivered a 30-minute virtual AD session, “Preventing Opioid Overdose with Naloxone,” to 15 PCPs within a large Federally Qualified Health Center network. A matched control group of 15 PCPs was included. Implementation service outcomes (via prescribing) were assessed using repeated measures multivariate analysis of variance (MANOVA). Immediate post-session and 2-year follow-up surveys examined confidence, practice changes, and implementation experiences.

Results:

Naloxone prescribing increased in both groups; however, there was no significant group-by-time interaction. All post-session respondents reported increased confidence. At 2 years, 92% indicated the AD session continued to influence their practice. Qualitative feedback identified barriers (stigma, cost, and limited patient update) and facilitators (peer support and institutional policies) shaping prescribing.

Conclusion:

This pilot demonstrates the feasibility of delivering AD in rural primary care and provides evidence of early penetration within an FQHC network. While prescribing increases could not be attributed solely to the intervention, AD was associated with sustained improvements in provider knowledge, confidence, and perceived relevance of naloxone prescribing. These findings highlight the limitations of brief educational sessions when implemented without complementary system-level supports, underscoring the need for multilevel approaches to expand naloxone access in underserved communities.

Keywords

academic detailing naloxone prescribing primary care opioid overdose prevention rural health

Introduction

The opioid overdose epidemic continues to pose a major public health challenge in the United States, with rural communities disproportionately affected.^1
-6 Structural disadvantage, limited behavioral health access, and long emergency response times have increased overdose vulnerability in rural areas.^1,2 In Dreamland, the author describes how small towns, especially Appalachia and the South, were hit hardest by the combined forces of opioid marketing and economic decline.⁷ These conditions fostered prescription opioid overuse and heroin infiltration in rural regions.⁷ Rural populations face higher rates of nonmedical opioid use, slower emergency response times, and lower naloxone access than their urban counterparts.^2,6,8 In Arkansas, opioid-related mortality remains high, with 87 overdose deaths and 4,299 naloxone administrations reported by Emergency Medical Services in 2022 alone.⁹

Primary Care Providers (PCPs) in rural regions often serve as the primary or sole medical contact for individuals at risk of opioid overdose. In Arkansas, approximately 72% of counties are classified as rural.¹⁰ However, many PCPs lack formal training in naloxone prescribing, administration, knowledge of Act 651,¹¹ or awareness of Good Samaritan protections that shield providers and patients during overdose response.^12,13 National studies and validated tools, such as the Opioid Overdose Knowledge and Attitudes Scales, reveal continued uncertainty among providers about when and how to prescribe naloxone or counsel patients on overdose safety.¹⁴

To address these barriers, Academic Detailing (AD) has emerged as a promising strategy to promote clinical behavior change through targeted, evidence-based education delivered by trained healthcare professionals.^15,16 AD has been used to increase naloxone prescribing and opioid safety practices in urban and community pharmacy settings,^12,13 but remains underutilized in rural primary care. Few studies have evaluated AD as a continuing professional development (CPD) strategy for rural PCPs or examined its long-term impact on naloxone prescribing behavior. The pilot study assessed whether a brief, CE-accredited AD session improved PCP confidence and prescribing practices within a rural Federally Qualified Health Center (FQHC) network. We compared intervention participants to matched controls and used mixed methods to evaluate implementation experiences over 2 years.

Methodology

Study Design and Setting

This mixed-methods pilot study used a matched-group design to quantitatively and qualitatively evaluate the impact of a virtual AD session on PCP confidence and naloxone prescribing. The intervention occurred between March and September 2022 within ARcare, a Federally Qualified Health Center (FQHC) network serving rural Arkansas. The University of Arkansas for Medical Sciences (UAMS) Institutional Review Board (IRB) approved the study and deemed it exempt (IRB #275902).

Intervention PCPs self-selected (ie, volunteer sampling was used) into the study after email invitations, while matched control group providers were randomly selected from a pool of eligible PCPs within the same FQHC. Groups were matched based on baseline naloxone prescribing behavior. Because only the control group was randomly selected, the study design is considered non-randomized.

Participants and Recruitment

Sixteen PCPs were recruited through internal announcements and FQHC listservs to participate in a 1-time virtual AD session. One withdrew due to an employment change, leaving 15 intervention participants. A matched control group (n = 15) was selected using the same criteria.

Academic Detailing Education

As described in the Introduction, AD is an evidence-based strategy for influencing clinical practice. In this study, AD was operationalized as a 30-minute, continuing education (CE)-accredited session titled “Preventing Opioid Overdose with Naloxone.

Delivery

Sessions were conducted via videoconference by a multidisciplinary team that included a pharmacist, physician, and physical therapist. Framed as a CPD activity, the intervention adhered to a standardized training approach.

Content

The module emphasized 3 core components (called “key messages” in AD sessions): (1) patient eligibility for naloxone prescriptions under Arkansas law (Act 651)¹¹; (2) use of non-stigmatizing communication strategies during opioid safety counseling^17
-22; and (3) naloxone formulations, administration techniques, and billing considerations.²³ Content was tailored using county-level data on overdose rates, naloxone administrations, and opioid dispensing trends.

Outputs

Participants received CE credit, provider-facing handouts, and a naloxone kit with patient education materials. The design and description of this AD intervention were informed by the implementation science literature on AD, ensuring consistency with established principles of educational outreach.^15,16

Survey Instruments and Data Collection

Within 1 week post-intervention, PCPs completed a REDCap survey evaluating changes in knowledge, confidence, clinical behavior, and communication. In January 2025, a longitudinal follow-up survey was distributed to all PCPs still employed at ARcare (n = 12), achieving a 100% response rate.

The follow-up survey included structured and open-ended questions aligned with the Interprofessional Education Collaborative (IPEC) Core Competencies, including domains such as Values and Ethics, Roles/Responsibilities, Interprofessional Communication, and Teams and Teamwork.^24,25 In addition, the survey design and analysis were informed by the Consolidated Framework for Implementation Research (CFIR 2.0), which guided exploration of barriers, facilitators, and contextual factors influencing naloxone co-prescribing. Participants were asked to reflect on how the naloxone education delivered by the UAMS AD team influenced their collaboration with peers and team-based decision-making over time.

Participation was voluntary, and PCPs could withdraw at any time by written communication to the AD program at UAMS. To protect confidentiality, intervention group survey responses were deidentified by the AD project coordinator and presented in aggregate at the end of the intervention period, rather than shared individually with the AD team. For the 2-year follow-up survey, all responses were collected anonymously, ensuring confidentiality was maintained throughout the study.

Prescribing Data and Statistical Analysis

Naloxone prescription counts for each provider were extracted from ARcare’s electronic health record (EHR) using Practice Analytics. Prescription totals were aggregated by provider to calculate mean prescription values at baseline and follow-up. A repeated measures multivariate analysis of variance (MANOVA) tested for main effects of time and group-by-time interaction. Data were evaluated for multivariate normality. In addition to clinical and self-reported outcomes, we also examined implementation outcomes as defined by Proctor et al.’s,²⁶ including feasibility (the actual fit, utility, or suitability of the AD intervention for use in providers’ everyday rural FQHC clinics) and adoption (the uptake, initial implementation, or utilization of the AD education by PCPs within the rural FQHC system). Qualitative responses from the follow-up survey were analyzed using a Rapid Analytic Process (RAP), a structured but flexible method designed to support timely interpretation of practice-based data.^27,28

Results

Participant Characteristics

Fifteen PCPs completed the AD session: 13 advanced practice registered nurses (APRNs), 1 physician assistant (PA), and 1 physician (MD). Most identified as female (87%), and 93% practiced in Primary Care Health Professional Shortage Areas (HPSAs) with moderate-to-high HPSA scores ranging from 12 to 18.²⁹ See Table 1 for full demographic details.

Table 1.

PCP Intervention Group Characteristics.

Primary care provider (PCP) ID	Profession type	PCP employed in primary care HPSA at the time of AD education	HPSA score	Biological sex	Prescribed naloxone pre-AD session (in 2021-2022)	Prescribed naloxone post-AD session (2023-2025)
1	APRN	Yes	12	Female	No	No
2	APRN	No	N/A	Female	No	Yes
3	APRN	Yes	18	Male	No	Yes
4	APRN	Yes	12	Female	No	Yes
5	APRN	Yes	17	Female	No	Yes
6	APRN	Yes	17	Female	No	Yes
7	APRN	Yes	14	Female	No	Yes
8	APRN	Yes	18	Female	No	Yes
9	APRN	Yes	12	Female	No	Yes
10	PA	Yes	17	Female	Yes	Yes
11	MD	Yes	12	Male	Yes	Yes
12	APRN	Yes	12	Female	Yes	Yes
13	APRN	Yes	12	Female	Yes	Yes
14	APRN	Yes	14	Female	Yes	Yes
15	APRN	Yes	12	Female	Yes	Yes

Naloxone Prescribing Outcomes

Prior to AD education, 5 of 15 intervention providers (33%) had prescribed naloxone at least once. Post-intervention, 13 of 15 providers (87%) had prescribed. The matched control group (n = 15) had a slightly higher average number of naloxone prescriptions per provider than the intervention group (12.63 vs 11.07; Figure 1). While both groups showed increased prescribing over time, the difference was not statistically significant.

Figure 1.

Mean naloxone prescriptions by group and time.

Comparison of average naloxone prescriptions per provider for the intervention/experimental group (n = 15) and matched control group (n = 15) at baseline and follow-up are shown in Figure 1. Both groups demonstrated increased prescribing activity over time: the mean number of naloxone prescriptions grew from 4.88 to 12.63 in the control group and from 2.47 to 11.07 in the experimental group. However, the intervention group did not show a significant difference relative to the control group, as no significant intervention effect was demonstrated by repeated measures MANOVA (approx. F = 0.32, P = .58).

Repeated measures MANOVA did indicate a main effect of time (approx. F = 9.68, P < .05), but no significant group-by-time interaction (approx. F = 0.03, P = .87), suggesting that prescribing increased similarly in both groups. Mardia testing showed violations of multivariate normality (Skewness = 122.96, Kurtosis = 13.08, P < .05), which may limit interpretability of multivariate effects.

Provider Confidence and Implementation Outcomes

Immediately after the session, all respondents (n = 10) reported increased confidence in applying the AD key messages in clinical practice (see Supplemental Figure 1). Implementation outcomes were identified and mapped post hoc to Proctor et al.’s²⁶ taxonomy based on the nature of the data collected. Quantitative (survey-based) and qualitative feedback were examined to align with relevant constructs, including feasibility, acceptability (perceived value of the intervention and satisfaction with various aspects of the AD education), and adoption. Qualitative feedback, shared verbally by PCPs with the academic detailers, indicated that participants found the AD session engaging and the content practical and relevant to their clinical practice. Collectively, these findings demonstrate the feasibility of delivering AD in rural FQHC settings and suggest promising acceptability of the intervention. Providers’ verbal commitments to more frequently educate patients about naloxone and to prescribe it when appropriate illustrate early adoption of the AD education within their practice contexts.

Two-Year Follow-Up

In January 2025, 12 of the 15 AD-trained PCPs (80%) remained employed at ARcare and completed a voluntary follow-up survey, yielding a 100% response rate among eligible participants. Five indicated the AD education had “strongly influenced” their prescribing, 5 selected “moderately influenced,” 1 selected “slightly influenced,” and 1 had not prescribed naloxone since the session. See Supplemental Figure 2. Sustained participation by these 12 PCPs over 2 years demonstrates continued engagement with the AD intervention and suggests early maintenance across participating rural FQHC clinics.³⁰

Qualitative Insights

Open-ended questions (see Supplemental Document 3) were designed to explore naloxone implementation experiences. Qualitative responses were first inductively analyzed using RAP methods.^27,28 After themes were identified, we mapped them post hoc to relevant CFIR 2.0 domains and constructs to situate findings within an implementation science framework. Five major themes emerged, reflecting both facilitators and barriers to sustained prescribing. These are summarized in Table 2, along with representative quotations.

Table 2.

Emergent Themes From RAP Analysis Reflecting Naloxone Prescribing Behaviors, Identified Through RAP Analysis and Secondarily Mapped to CFIR 2.0 Constructs.

Theme	Summary	Illustrative quote(s)	CFIR domain: construct
Prescribing for High-Risk Medication Use	Naloxone was commonly prescribed alongside opioids and/or benzodiazepines for safety purposes.	“I prescribe almost every time with any type of benzo/pain medication just in case of accidental overdose.”“Chronic opioid use for chronic pain; with and without subsequent benzo use.”	Intervention Characteristics: Relative Advantage
Co-Prescribing for Short-Term Opioid Use	Some providers regularly issued naloxone even for short-duration opioid prescriptions.	“All my patients that I prescribe a short course of pain med to, like a broken ankle, I always send in Narcan.”“Elderly patient had broken her foot; naloxone was prescribed with 3 days of opioids.”	Characteristics of Individuals: Knowledge & Beliefs about the Intervention
Patient Uptake Challenges	Providers noted low fill rates and patient stigma but valued clinic access for emergency use.	“Most of the time my patients do not pick it up . . . but having the med. available to me in clinic has been beneficial in emergent situations at least three times.”	Outer Setting: Patient’s Needs & Resources; Inner Setting: Available Resources
Contributing Factors to Decision to Prescribe Naloxone	Naloxone prescribing was supported by Continuing Education, Academic Detailing sessions, workplace policy, and peer discussions.	(N/A: Question asked PCP to select all that apply)	Inner Setting: Learning Climate; Process: Engaging (Opinion Leaders, Champions)
Request for Additional Resources	Providers requested flyers, insurance coverage, and team training to support education and uptake.	“Staff training would be beneficial.” “More insurance coverage.” “Informational flyers for staff and patients.”	Inner Setting: Available Resources; Outer Setting: External Policy & Incentives

To situate these findings within an implementation science framework, we mapped each theme to CFIR 2.0. Table 2 shows the provider prescribing behaviors reflected in Intervention Characteristics (Relative Advantage) and Characteristics of Individuals (Knowledge and Beliefs about the Intervention). Barriers such as stigma and low uptake were aligned with the Outer Setting (Patient Needs and Resources), while availability of naloxone in clinics and requests for additional tools reflected the Inner Setting (Available Resources, Learning Climate). Institutional policies, peer influences, and AD corresponded to the Process (Engaging) domain.

Several PCPs described how CE, AD, peer mentoring, and clinic policies supported prescribing, while others noted persistent stigma, patient reluctance, and insurance coverage limitations as barriers. Themes aligned with IPEC Core Competencies, particularly Interprofessional Communication, Roles/Responsibilities, and Values and Ethics, suggesting that AD education supported both individual and team-based approaches to naloxone prescribing.^24,25

Discussion

This pilot study evaluated the impact of AD education on PCPs’ naloxone prescribing behavior, confidence, and implementation experiences within a rural FQHC system. While naloxone prescribing volume did not differ significantly between intervention and control groups, most trained PCPs (87%) prescribed naloxone at least once following the session. In the 2-year follow-up survey, 92% of respondents reported that the education had influenced their prescribing, with many adopting routine naloxone co-prescribing for high-risk patients.

These findings align with existing literature demonstrating that brief, knowledge-focused interventions can improve PCP confidence and engagement with evidence-based practices, even in the absence of statistically significant differences in prescribing volume.^13,15,16 This is also consistent with evidence that brief educational sessions alone are unlikely to produce large-scale practice change compared to system-level strategies such as EHR prompts, standing orders, or policy-driven co-prescribing mandates.^31,32 Most prior evaluations of AD have been conducted in pharmacy settings, where it has been shown to increase naloxone prescribing and opioid safety practices.^12,13 Our pilot extends this literature by adapting AD as a CPD strategy for rural PCPs within an FQHC system, addressing a critical gap in implementation contexts. Barriers such as patient stigma, pharmacy access, and insurance coverage likely contributed to prescribing variability.^12,21 Additional contextual factors, such as institutional policies, peer discussions, and statewide naloxone initiatives, may also have contributed to increased prescribing across both groups. In this context, provider behavior change is necessary but not sufficient to expand equitable naloxone access in rural communities.

Notably, 93% of PCPs practiced in designated Primary Care HPSAs, underscoring the need for scalable CPD strategies in rural regions.^29,33,34 Providers in these settings often face high patient volumes and limited access to CE-accredited, evidence-based training.^33,34 The strong engagement and positive reception of this brief AD session suggest that short, tailored CPD modules can help close persistent implementation gaps when integrated in FQHC infrastructure.^33,34

Beyond AD training engagement, qualitative reflections showed the clinical relevance of naloxone prescribing. PCPs described co-prescribing across diverse scenarios, including short-term opioid use post-injury, chronic pain management, and polypharmacy in older adults. These accounts align with the 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain, which recommends naloxone for patients at elevated overdose risk regardless of whether they meet formal criteria for opioid use disorder.^17,18,35 The lack of statistically significant differences between groups may reflect broader contextual influences (public health, institutional or state-level initiatives, EHR changes) that increased prescribing across both intervention and control participants. Interpreting these findings through the CFIR 2.0 framework demonstrates the role of Outer Setting determinants (eg, patient needs, insurance coverage), Inner Setting factors (eg, organizational supports), and Intervention Characteristics (eg, session brevity, CE credit) in shaping the adoption and sustainment of naloxone prescribing.³⁶

Overall, this pilot suggests that CPD-accredited AD can enhance rural PCPs’ naloxone-related confidence, knowledge, and engagement in overdose prevention efforts. Although clinical care outcomes were not evaluated, qualitative reflections revealed early adoption of naloxone counseling and intentions to prescribe. These findings illustrate that AD is a feasible and acceptable approach for integrating naloxone education into routine primary care within rural FQHC settings. The absence of significant group differences in prescribing helps demonstrate the complexity of translating educational gains into behavior change amid broader contextual influences, such as statewide public health initiatives and institutional policies, that shape provider practice. These insights highlight the potential of CPD-accredited AD to strengthen guideline-concordant naloxone counseling and prescribing behaviors, complementing system-level efforts to reduce opioid overdose risk in rural communities.

This study has several limitations. The small sample size and focus on a single FQHC network may limit generalizability. Only 10 of 15 PCPs (67%) completed the immediate post-intervention survey, and self-reported data may be subject to response bias. Although this study included a matched control group, the non-randomized design introduces potential self-selection bias. Prescribing increases may also have been influenced by institutional policies or external factors beyond the AD intervention (eg, state-level naloxone co-prescribing mandates, insurance coverage changes, EHR alerts, or community-distribution and public health awareness campaigns). Importantly, this pilot did not assess patient-level or clinical care outcomes, as the focus was on early implementation outcomes such as feasibility, acceptability, and adoption. Additionally, mapping qualitative themes to CFIR 2.0 constructs was interpretive and consensus-based, and some overlap across domains is possible. Despite these limitations, the mixed-methods approach and 2-year follow-up provide valuable insights into the feasibility and perceived impact of AD for opioid overdose prevention in rural primary care. Future studies should explore integration with digital platforms, inclusion of broader care teams, and assessment of patient-centered outcomes to strengthen dissemination and sustainability of AD in rural settings.

Conclusion

This 2-year pilot suggests that brief, CE-accredited AD can positively influence rural PCPs’ naloxone-related knowledge, confidence, and engagement in naloxone-related care. While prescribing volume did not differ significantly from matched controls, nearly all trained PCPs reported continued prescribing and attributed these changes to the AD intervention. Qualitative data highlighted how AD supported safer opioid practices across diverse scenarios, including polypharmacy and short-term opioid use.^17,18,35 Providers also described system-level enablers such as institutional policies and peer discussions.^24,25 These findings support the feasibility of AD as a CPD strategy in rural, HPSA areas.^15,16,33,34 Future research should explore scalability across FHQCs, integration with team-based models of care, and links to patient outcomes like naloxone uptake and opioid overdose prevention.^12,13

Supplemental Material

sj-docx-1-jpc-10.1177_21501319251391284 – Supplemental material for Academic Detailing to Advance Naloxone Prescribing in Rural Primary Care: A 2-Year Pilot Study

Supplemental material, sj-docx-1-jpc-10.1177_21501319251391284 for Academic Detailing to Advance Naloxone Prescribing in Rural Primary Care: A 2-Year Pilot Study by Leah Tobey-Moore, Meghan N. Breckling, Mohab Ali, Misha Karr, Stacie Massey and Teresa J. Hudson in Journal of Primary Care & Community Health

Supplemental Material

sj-docx-2-jpc-10.1177_21501319251391284 – Supplemental material for Academic Detailing to Advance Naloxone Prescribing in Rural Primary Care: A 2-Year Pilot Study

Supplemental material, sj-docx-2-jpc-10.1177_21501319251391284 for Academic Detailing to Advance Naloxone Prescribing in Rural Primary Care: A 2-Year Pilot Study by Leah Tobey-Moore, Meghan N. Breckling, Mohab Ali, Misha Karr, Stacie Massey and Teresa J. Hudson in Journal of Primary Care & Community Health

Supplemental Material

sj-docx-3-jpc-10.1177_21501319251391284 – Supplemental material for Academic Detailing to Advance Naloxone Prescribing in Rural Primary Care: A 2-Year Pilot Study

Supplemental material, sj-docx-3-jpc-10.1177_21501319251391284 for Academic Detailing to Advance Naloxone Prescribing in Rural Primary Care: A 2-Year Pilot Study by Leah Tobey-Moore, Meghan N. Breckling, Mohab Ali, Misha Karr, Stacie Massey and Teresa J. Hudson in Journal of Primary Care & Community Health

Footnotes

ORCID iDs

Leah Tobey-Moore

Stacie Massey

Ethical Considerations

The University of Arkansas for Medical Sciences Institutional Review Board (IRB) approved the study and deemed it exempt (IRB #275902).

Funding

The authors disclosed receipt of the following financial support for the research,authorship,and/or publication of this article: Funding for this project was awarded to the University of Arkansas for Medical Sciences by the National Association of County and City Health Officials (CDC Cooperative Agreement #5 NU380T000306-05-00) and the Arkansas Department of Health (CDC-RFA-TP-18-02 and 5 NU17CE010203-02-00),with support originating from the Centers for Disease Control and Prevention.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research,authorship,and/or publication of this article.

Supplemental Material

Supplemental material for this article is available online.

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