Published August 29, 2026 | Version v1
Journal article Open

It's a Tool in the Toolbox": Public Health Approaches to Normalizing Opioid Harm Reduction

Description

This qualitative case study examines how frontline employees
within local public health units (LPHUs) interpret and implement
a video-enabled naloxone distribution intervention across
North Dakota, a largely rural state. Semi-structured interviews
were conducted with 20 representatives from 17 LPHUs that implemented
ONEboxes®, portable opioid overdose reversal kits
containing nasal naloxone, personal protective equipment, and
an embedded instructional video. Using an inductive, teambased
coding process, five primary themes were identified: impacts,
successes, challenges, promotion, education tactics, and
community reactions. Participants described ONEboxes® not
only as overdose reversal tools but also as mechanisms for community
education regarding harm reduction efforts such as naloxone
interventions, stigma reduction towards opioid use and
overdose, and empowerment of community members. The embedded
instructional video was viewed as critical in increasing
bystander confidence and reducing hesitation during emergencies.

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References

  • National Institute on Drug Abuse. (2020). North Dakota: Opioid-Involved Deaths and Related Harms. National Institute on Drug Abuse. https://nida.nih.gov/drugtopics/ opioids/opioid-summaries-bystate/ north-dakota-opioid-involved-deathsrelated- harms Cascio, M. A., Lee, E., Vaudrin, N., & Freedman, D. A. (2019). A Team-based Approach to Open Coding: Considerations for Creating Intercoder Consensus. Field Methods, 31(2), 116 -130. https://doi.org/10.1177/1525822X198382 37 Childs, E., Biello, K. B., Valente, P. K., Salhaney, P., Biancarelli, D. L., Olson, J., Earlywine, J. J., Marshall, B. D. L., & Bazzi, A. R. (2021). Implementing harm reduction in non-urban communities affected by opioids and polysubstance use: A qualitative study exploring challenges and mitigating strategies. International Journal of Drug Policy, 90, 103080. https://doi.org/10.1016/j.drugpo.2020.10 3080 Dee, S. A., Delonnay, K.-A., Bernard, D., & Jean-Baptiste, F. (2024). Identifying Provider Barriers to the Implementation of Opioid Harm Reduction Methods: An Initial Narrative Review. INQUIRY: The Journal of Health Care Organization, Provision, and Financing, 61, 00469580241276144. https://doi.org/10.1177/00469580241276 144 Eukel, H. N., Skoy, E., Werremeyer, A., Burck, S., & Strand, M. (2019). Changes in Pharmacists' Perceptions After a Training in Opioid Misuse and Accidental Overdose Prevention. The Journal of Continuing Education in the Health Professions, 39(1), 7–12. https://doi.org/10.1097/CEH.0000000000 000233 Eukel, H. N., Steig, J., Hodges, A., O'Gary, B., & Strand, M. A. (2023). Nurse delivered medication safety screening program for home care visits. Public Health Nursing (Boston, Mass.), 40(3), 410–416. https://doi.org/10.1111/phn.13178 Fischer, L. S., Asher, A., Stein, R., Becasen, J., Doreson, A., Mermin, J., Meltzer, M. I., & Edlin, B. R. (2025). Effectiveness of naloxone distribution in community settings to reduce opioid overdose deaths among people who use drugs: A systematic review and meta-analysis. BMC Public Health, 25(1), 1135. https://doi.org/10.1186/s12889-025- 22210-8 Fraimow-Wong, L., Martín, M., Thomas, L., Giuliano, R., Nguyen, O. K., Knight, K., & Suen, L. W. (2024). Patient and Staff Perspectives on the Impacts and Challenges of Hospital-Based Harm Reduction. JAMA Network Open, 7(2), e240229. https://doi.org/10.1001/jamanetworkopen. 2024.0229 Frenzel, O. C., Eukel, H., Skoy, E., Werremeyer, A., Steig, J., & Strand, M. (2020). Examining Attitudes and Beliefs that Inhibit Pharmacist Implementation of a Statewide Opioid Harm Reduction Program. Innovations in Pharmacy, 11(4). https://doi.org/10.24926/iip.v11i4.3446 Glesne, C. (2016). Becoming Qualitative Researchers: An Introduction. Pearson. Hanson, B. L., Finley, K., Otto, J., Ward, N. J., & Banik, S. (2024). Community Support for Harm Reduction and Treatment of Opioid Use Disorder. Journal of Community Health, 49(4), 724–731. https://doi.org/10.1007/s10900-023- 01278-6 Hanson, B. L., Porter, R. R., Zöld, A. L., & Terhorst-Miller, H. (2020). Preventing opioid overdose with peer-administered naloxone: Findings from a rural state. Harm Reduction Journal, 17(1), 4. https://doi.org/10.1186/s12954-019-0352- 0 Health and Human Services. (n.d.). Health data and statistics. Retrieved April 6, 2025, from https://www.hhs.nd.gov/health/data-statistics 258 WEBER ET AL. Hedegaard, H. (2021). Urban–Rural Differences in Drug Overdose Death Rates, 1999–2019 (Report No. 403). National Center for Health Statistics. Kay, E. S., Creasy, S. L., Townsend, J., & Hawk, M. (2024). A qualitative exploration of health care workers' approaches to relational harm reduction in HIV primary care settings. Harm Reduction Journal, 21(1), 97. https://doi.org/10.1186/s12954-024- 01021-x Kennedy-Hendricks, A., Barry, C. L., Gollust, S. E., Ensminger, M. E., Chisolm, M. S., & McGinty, E. E. (2017). Social Stigma Toward Persons With Prescription Opioid Use Disorder: Associations With Public Support for Punitive and Public Health- Oriented Policies. Psychiatric Services, 68(5), 462-469. https://doi.org/10.1176/appi.ps.20160005 6 North Dakota Department of Health. (n.d.). Local health units. Retrieved June 19, 2025, Local Health Units. Retrieved June 19, 2025, from https://www.ndhealth.gov/localhd/ Morgan, H. (2024). Using Triangulation and Crystallization to Make Qualitative Studies Trustworthy and Rigorous. The Qualitative Report. https://doi.org/10.46743/2160- 3715/2024.6071 U.S. Census Bureau. (n.d.). North Dakota- Census Bureau Profile. Retrieved June 19, 2025, from https://data.census.gov/profile/ North_Dakota?g=040XX00US38 North Dakota Department of Health and Human Services. (2025). Local public health sites. Retrieved February 2, 2026, from https://www.hhs.nd.gov/local-publichealthsites West Virginia Drug Intervention Institute. (n.d.). ONEbox. Retrieved February 9, 2026, from https://www.wvdii.org/onebox U.S. Department of Agriculture, Economic Research Service. (n.d.). Rural-Urban Continuum Codes. Retrieved July 9, 2025, from https://www.ers.usda.gov/dataproducts/ rural-urban-continuum-codes Saldaña, J. (2021). The Coding Manual for Qualitative Researchers. SAGE Publications. Seal, K. H., Thawley, R., Gee, L., Bamberger, J., Kral, A. H., Ciccarone, D., Downing, M., & Edlin, B. R. (2014). Naloxone distribution and cardiopulmonary resuscitation training for injection drug users to prevent heroin overdose death: A pilot intervention study. Journal of Urban Health: Bulletin of the New York Academy of Medicine, 82(2), 303–311. https://doi.org/10.1093/jurban/jti053 Sibley, A. L., Klein, E., Cooper, H. L. F., Livingston, M. D., Baker, R., Walters, S. M., Gicquelais, R. E., Ruderman, S. A., Friedmann, P. D., Jenkins, W. D., Go, V. F., Miller, W. C., Westergaard, R. P., & Crane, H. M. (2024). The relationship between felt stigma and non-fatal overdose among rural people who use drugs. Harm Reduction Journal, 21(1), 77. https://doi.org/10.1186/s12954-024- 00988-x Skoy, E., Eukel, H., Werremeyer, A., Strand, M., Frenzel, O., & Steig, J. (2020). Implementation of a statewide program within community pharmacies to prevent opioid misuse and accidental overdose. Journal of the American Pharmacists Association: JAPhA, 60(1), 117–121. https://doi.org/10.1016/j.japh.2019.09.00 3 Skoy, E., Frenzel, O., Eukel, H., Lothspeich, E., Steig, J., Strand, M., & Werremeyer, A. (2022). Evaluation of a Program to Screen Patients in Community Pharmacies for Opioid Misuse and Accidental Overdose. Preventing Chronic Disease, 19, E41. https://doi.org/10.5888/pcd19.220028 Skoy, E., Werremeyer, A., Steig, J., Eukel, H., Frenzel, O., & Strand, M. (2021). Patient acceptance of naloxone resulting from targeted intervention from community pharmacists to prevent opioid misuse and accidental overdose. Substance Abuse, 42(4), 672–677. https://doi.org/10.1080/08897077.2020.1 827126 Spector, A. L., Galletly, C. L., Christenson, E. A., Montaque, H. D. G., & Dickson- Gomez, J. (2022). A qualitative examination of naloxone access in three states: Connecticut, Kentucky, and Wisconsin. BMC Public Health, 22(1), 1387. https://doi.org/10.1186/s12889-022- 13741-5 Stake, R. E. (1995). The Art of Case Study Research. SAGE. Thomas, N., van de Ven, K., & Mulrooney, K. J. D. (2020). The impact of rurality on opioid-related harms: A systematic review of qualitative research. The International Journal on Drug Policy, 85, 102607. OPIOID HARM REDUCTION APPROACH IN A RURAL STATE 259 https://doi.org/10.1016/j.drugpo.2019.11. 015 Tsai, A. C., Kiang, M. V., Barnett, M. L., Beletsky, L., Keyes, K. M., McGinty, E. E., Smith, L. R., Strathdee, S. A., Wakeman, S. E., & Venkataramani, A. S. (2019). Stigma as a fundamental hindrance to the United States opioid overdose crisis response. PLoS Medicine, 16(11), e1002969. https://doi.org/10.1371/journal. pmed.1002969 Weiner, J., Murphy, S., & Behrends, C. (2019, May 29). Expanding Access to Naloxone: A Review of Distribution Strategies. Penn LDI. Retrieved from https://ldi.upenn. edu/our-work/research-updates/expanding- access-to-naloxone-a-review-ofdistribution- strategies/ Whipple, C. R., Kaynak, Ö., Kruis, N. E., Saylor, E., Bonnevie, E., & Kensinger, W. S. (2023). Opioid Use Disorder Stigma and Support for Harm Reduction in Rural Counties. Substance Use & Misuse, 58(14), 1818–1828. https://doi.org/10.1080/10826084.2023.2 250434 Yin, R. K. (1994). Case Study Research: Design and Methods. SAGE Publications.