Abstract Military veterans in the U.S. represent one of the populations most disproportionately impacted by the current opioid crisis. With historically high rates of injury and opioid analgesic use to treat chronic pain, veterans were widely prescribed opioids (often in conjunction with benzodiazepines) during the early years of the epidemic, and have been at elevated risk of opioid-related overdose and HIV/HCV infection since. Further, current data on opioid-related harms affecting veterans are likely to understate the severity of the situation, as most studies of veterans focus on the less than 50% of veterans who use VA healthcare facilities. Veterans who use opioids and are not connected to the VA healthcare system have high rates of homelessness and experience higher prevalence of comorbid substance use disorder and mental health diagnoses than their “service-connected” counterparts. Due to these vulnerabilities and the observed barriers to testing and treatment among veterans— especially substance- and mental health-related stigma, drug naiveté, and limited support networks—veterans who use opioids represent a critical target for interventions designed to mitigate overdose and HIV/HCV risk behaviors. For socially isolated veterans and veterans with limited access to healthcare, programs that work outside of formal healthcare institutions and agencies are desperately needed. This application proposes to advance scientific understanding of the most potent and efficient way to prevent opioid-related harms among veterans by achieving the following Aims: 1) Evaluate the effectiveness of a peer-delivered, community-based education, navigation and support (CENS) intervention to reduce opioid-related risk behaviors; 2) Examine factors that mediate (e.g., knowledge, self-efficacy, self-stigma) and moderate (e.g., mental health, pain/OUD severity, age) intervention effectiveness; and 3) Explore intervention participants’ and peer outreach staff perspectives on implementation as well as barriers to and facilitators of intervention effectiveness. The proposed intervention will be delivered by three veteran peer outreach workers—one dedicated to each of the three main intervention components (Education, Navigation, and Support). The study will recruit 300 veterans with opioid use disorder to participate in a randomized controlled trial. The CENS intervention will engage 150 participants in ongoing educational sessions, healthcare and treatment navigation, and social support (involving both one-on-one and group social integration protocols) designed to improve self-efficacy, reduce self-stigma, increase service and healthcare utilization, and bolster knowledge. This study stands to contribute a timely, culturally-tailored innovation to overdose and HIV/HCV prevention-as-usual that, informed by the theory of triadic influence, directly confronts the social, intrapersonal, and structural-level barriers to opioid- related risk reduction among veterans. Study findings will be of great interest to community-based and civic healthcare organizations that provide overdose and HIV/HCV risk reduction outreach, as well as to agencies committed to improving healthcare engagement among veterans.

Public Health Significance This timely, culturally-tailored intervention study has the potential to markedly improve the standards of overdose and HIV/HCV prevention among at-risk veterans. Peer-led interventions for substance use disorders have proven effective at reaching stigmatized, at-risk populations, and this intervention contributes to the evidence base for remediating the health impacts of opioid use by advancing a tripartite (education, navigation, and support) protocol to reduce risks. The products of this pragmatic trial will be of great interest to the wide range of community-based and civic healthcare organizations committed to reducing opioid-related harms while fostering social and healthcare engagement among veterans.