PROJECT SUMMARY/ABSTRACT Although social determinants of health (SDOH) have long been recognized as significant contributors to the quality of life and long-term outcomes for individuals, only recently have preventive intervention efforts begun to target poor SDOH directly as a method for achieving improved health outcomes. Little remains known about interventions that disrupt the ongoing negative effect of poor SDOH or how to intervene on malleable SDOH (e.g., employment) in the context of non-malleable SDOH (e.g., rural region). This application, Disrupting Social Determinants of Health to Improve Substance Use and Mental Health Outcomes for Parents in Rural Regions, is directly responsive to NIDA RFA DA-22-036 and seeks to test the multi-level, multi-component Families Actively Improving Relationships (FAIR) intervention to prevent “opioid use disorder, and comorbid conditions by intervening on social determinants of health (SDOH).” Leveraging a naturally occurring roll out of FAIR across five rural Oregon counties, parents (N = 250) who are referred to FAIR will be recruited to participate. Oregon is the ideal setting for this project—data released in January 2022 ranks the state as leading the nation in opioid and methamphetamine use, mental health disorders and suicide. Participating counties, though all rural, are distinct in their county health metrics, providing the opportunity to examine the influence of outside structural conditions on intervention targets and subsequent prevention outcomes. Consenting parents will report weekly on their SDOH needs for 18 months, regardless of whether they are engaged in services. When engaged, their FAIR clinician also will be probed weekly for a report of intervention strategies used to address SDOH. Interventions will not be manipulated but will be observed as they naturally occur. Parents will be assessed for opioid and methamphetamine use, including IV drug use, and mental health symptoms, including suicide (ideation, intention, attempt) at Baseline, 9-months, and 18-months. To assess longer-term prevention of IV drug use and suicide, administrative health data will be collected from the time of consent to 24-42 months post-Baseline. The intensive, longitudinal, sequencing design will allow an analysis of how FAIR components (Aim 1) disrupt individual and systemic SDOH and escalation of opioid and/or methamphetamine use and mental health disorders; (Aim 2) are impacted by external, structural SDOH; and (Aim 3) can influence the relationship between SDOH and individual and systemic outcomes on costs, from the perspective of provider clinics delivering FAIR. Outcomes will (a) inform the future scale-up of FAIR by providing an empirical basis for targeting and sequencing of parent SDOH throughout the course of treatment, and the impact of these clinical decisions on outcomes and clinic-borne costs and (b) provide generalizable knowledge of the consequences of targeting, or not, poor SDOH in the treatment of comorbid opioid and methamphetamine use and mental health disorders. The disruption of a parent’s poor SDOH has the potential for a cascade of positive outcomes across generations, and drive a significant improvement of public health.

PROJECT NARRATIVE Individuals who experience the combined effects of poor individual SDOH—such as low economic status, exposure to violence, low education, housing and food insecurity—and poor systemic SDOH—such as discriminatory treatment from service providers, limited access to health care and legal representation—are at particular risk for opioid and methamphetamine use and mental health disorders. When these individuals are parents, the negative consequences are particularly deleterious, as they permeate multiple generations. The multi-level, multi-component FAIR program will target the disruption of poor individual and systemic SDOH of parents with opioid and/or methamphetamine use comorbid with mental health disorders, with the aim of preventing an escalation to IV drug use and suicide (ideation, intent, attempt), and instead, initiate cascading positive generational effects.