Table 2:

Emergent themes, subthemes, and additional supporting quotes

Theme 1: Addressing bias and stigma toward people with opioid use drugs and who use drugs.
	“The course helped me to look at each of my patients in a more human aspect, rather than generalizing them as opioid users. It also has helped me to further my understanding on the medications these patients are taking to manage their disease” (Participant 32, Washington Wave 3)
	“…the module helped to reinforce some of approaches I was already taking and was enlightening on some of the difference info I wasn’t fully aware of. Like others I found the buprenorphine info to be helpful as this often is a topic that I feel like is just brushed over and we don’t always have the time to delve deeper into with busy schedules.” (Participant 19, Oregon Wave 1)
	“Our pharmacy did not make an effort to have syringe sales available OTC and this information swayed me to take care of our community as opposed to dissuade users from purchasing syringes at our pharmacy.” (Participant 9, New Hampshire, Wave 2)
Theme 2: Familiarity and comfort with naloxone provision.
Initiating conversations about naloxone while minimizing stigma	“I am comfortable counseling on naloxone use and I am comfortable counseling on overdose prevention. As pharmacists, we are constantly asked about medications and various diseases, this is no different, these are medications that help patients” (Participant 7, New Hampshire, Wave 1)
	“I’m really open now to getting that conversation started and I’d say much better at taking any stigma out of the encounter.” (Participant 18, Oregon, Wave 2)
	“We have been offering more naloxone to patients on certain drug combos. I’ve had some great conversations with patients… My biggest goal was for my techs to not treat these patients different. I like the message meet the patient where they are at now. It was all very useful.” (Participant 15, New Hampshire, Wave 3)
Counseling patients about naloxone using intervention materials	“I use the verbiage in the binder but also just kind of let the conversation flow. The key for my team has simply been to treat everyone equally and don’t judge. We even had a random patient come by and thank us.” (Participant 27, Washington, Wave 2)
	“I’ve had a few patients come in for naloxone. I think most of them were patient that came back after purchasing needles and seeing the sticker on the bag!” (Participant 8, New Hampshire, Wave 1)
Theme 3: Perspective and practice shifts in nonprescription syringe sales.
Barrier reversal	“Although every aspect was useful, syringe sales was something that was ‘common knowledge,’ but this perspective did allow us to sell packs of 10 instead of a box of 100.” (Participant 21, Washington, Wave 2)
Dignity and Harm Reduction	“I think patients are becoming more comfortable asking for syringes knowing that we won’t question them and we will even offer a sharps container.” (Participant 14, New Hampshire, Wave 3)
Safe syringe disposal impact	“Providing sharps containers is a great idea. Used needles are frequently found in our bathroom and parking lot, which is not a pleasant experience for those who have to clean up those areas.” (Participant 32, Washington, Wave 3)
Theme 4: Structural challenges to harm reduction care in the pharmacy
Staff resistance creates barriers to access and puts pressure on one individual	“Unfortunately my colleagues are more along the notion that if the doctor didn’t prescribe it than obviously it isn’t important. So it would be a very rare instance for them to mention Narcan to a patient let alone prescribe it. Most any Narcan involvement gets defaulted to myself.” (Participant 19, Oregon, Wave 1)
Stocking issues leave stores out of stock of naloxone and preferred sizes of syringes	“Stocking. System doesn’t recognize to order specific size syringes if we don’t dispense them as rx” (Participant 3, Massachusetts, Wave 1)
	“Stocking was sometime an issue. Some days we would 3–4 [Narcan] and not have any residual stock on the shelf for the next morning” (Participant 32, Washington, Wave 3)
Cost and co-pay amount can be prohibitive and patients may want purchase to be anonymous	“Price is major factor why most patient refuse it even explaining the importance of having it on-hand” (Participant 29, Washington, Wave 3)
	“It’s difficult when patients are open to Narcan and want the product after discussing, but then the insurance won’t cover it and my patients can’t all afford various copays ranging from $8 to $130. I wish there was legislation requiring insurances to completely cover Narcan for at least high risk chronic opioid patients that they can clearly see are at higher risk.” (Participant 19, Oregon, Wave 1)