Project Summary/Abstract Rural communities in the U.S. have been tremendously impacted by the overdose and addiction crisis and face unique rural-specific factors (e.g., heightened stigma, limited treatment access, distance to care). We have a continuum of effective prevention interventions that reduce risks of non-medical substance use to harm reduction interventions that reduce consequences (e.g., overdose education, naloxone, sterile supplies). To implement these strategies, it is also critical to address addiction stigma and to reduce long-existing health disparities in rural communities, including in socioeconomically marginalized people, Veterans and others, who have some of the highest overdose rates. This spectrum of interventions, from prevention to harm reduction, implemented alongside stigma reduction in partnership with diverse rural persons with lived experience (RPWLE), have tremendous potential to save lives, but the vast majority of rural areas currently lack access We propose to develop and test a novel Hub and Spoke Model/intervention called Coalition for Harm Reduction and Prevention (CHRP, `chirp') to help rural outpatient clinics (primary care and behavioral health) adopt effective prevention and harm reduction services, with a cross-cutting focus on reducing disparities. Hub and Spoke models have been developed for opioid use disorder (OUD) and other conditions and are a cost- effective way to sustainably increase adoption of effective interventions and improve patient outcomes in rural areas. Models vary substantially, but hub sites can help train clinicians/staff in spoke sites and deliver clinical interventions via telehealth to patients. Other potential components include a virtual learning collaborative, tele- mentoring to provide individualized support and patient-specific tele-consultations. However, this model has not been robustly leveraged to implement prevention or harm reduction strategies. We propose to develop and test CHRP across rural communities in Michigan with elevated overdose rates in response to RFA-DA-24-036's Rural Community-Centered Prevention and Harm Reduction Research. We are addiction community and academic leaders including in Michigan's largest health systems caring for rural populations. Our proposal builds on prior work building/testing effective prevention and harm reduction interventions and leading state/national programs that have trained thousands of health professionals and increased OUD care across Michigan. During the R61 developmental phase, with the CHRP Advisory Board including community partners, we will help refine the intervention, develop an Intervention Toolkit and conduct focused usability testing. In the R33, we will conduct a type I hybrid effectiveness‐implementation trial with a stepped-wedge design, across rural spoke clinics. This project will have high public health impact by co- designing with key community partners and testing a highly pragmatic and sustainable model that can be implemented in rural clinics to implement the continuum of effective prevention to harm reduction interventions.

We have a spectrum of effective substance use prevention to harm reduction interventions that can improve outcomes and save lives, but the vast majority of rural communities lack access. This study builds on our team’s long history of community-partnered work building/testing a continuum of effective prevention and harm reduction interventions and leading pragmatic and sustainable programs training health professionals to deliver substance- related care. The overall goal of this project is to apply a user-centered design approach with rural community partners to co-develop a novel hub and spoke model/intervention specifically to help rural clinics adopt multiple prevention and harm reduction services, and test in a stepped wedge effectiveness-implementation trial.