Kentucky Communities and Researchers Engaging to Halt the Opioid Epidemic (CARE2HOPE)

The proposed project will build evidence-based, community-rooted public health responses to the epidemics of non-medical prescription opioid (NMPO) and heroin injecting, overdoses (ODs), and HCV, and to imminent HIV outbreaks, in 12 rural Appalachian Kentucky counties at the epicenter of these intertwined national crises. Ten of the 12 counties rank in the top 5% for HIV/HCV vulnerability. Rates of HCV, injection drug use (IDU), and ODs are high in these counties, and most are in coal country, an RFA priority. Unfortunately, these counties exemplify an extreme version of the ¡§implementation chasm,¡¨ a chasm dividing scientific knowledge from action. Evidence-based public health responses to these epidemics exist (e.g., syringe service programs [SSPs]) and are often deployed in cities. Unfortunately, these interventions have yet to be adequately deployed in these 12 hard-hit counties. In these counties, general public health infrastructure is sorely under-resourced, linkage to medication for opioid use disorder (MOUD) is lacking, and partnership between of local justice, harm reduction, and treatment programs is virtually absent. This project will bridge the implementation chasm in these 12 counties, and recognizes that bridging this chasm requires more than simply importing SSPs and other evidence-based community response projects (EB-CRPs) from cities. Guided by harm reduction principles, the Risk Environment Model, and Community/ Academic Partnerships (CAPs), in the UG3 we will: (1) Assess and enhance each community¡¦s readiness to improve the local risk environment. (2) Examine the strengths, resources, needs, and gaps of each community¡¦s risk environment. We will conduct a multi-method Community Assessment of the Risk Environment that integrates innovative, rigorous epidemiology (e.g., modeling); policy assessment; and best practices in community-based research (e.g., CAPs). (3) Select one EB-CRP that responds to local needs and strengths, using elements of Intervention Mapping. In the UH3, we will: (4) Tailor selected EB-CRP to each community¡¦s context using ADAPT-ITT. (5) Analyze the effectiveness and cost-effectiveness of each community¡¦s EB-CRP, using an innovative stepped-wedge community randomized trial and mathematical models. We will use continuous quality improvement to enhance the enhance EB-CRP implementation, reach, immediate effects, and outcomes. We propose an evidence-based, multilevel harm reduction intervention that is designed to reduce SUD and increase engagement in the SUD care cascade; reduce vulnerability to HIV, STIs, and HCV and increase engagement in the HIV, STI, and HCV care cascades; and reduce vulnerability to overdose deaths among adults who use drugs and are leaving local jails. The CARE2HOPE intervention will implement an enhanced version of START, a CDC-recognized, evidence-based, individual-level intervention designed to reduce HIV/STI/HCV risk. Enhancements will include integration of (1) the NIDA Standard HIV intervention, (2) overdose education and naloxone distribution, (3) HIV/HCV testing and post-test counseling, and (4) facilitated referral to a local network of MOUD providers, and (5) a pharmacy-based intervention to establish on-site VivitrolÆÊ administration and to increase thresholds for buprenorphine dispensing, and by local MOUD trainings to increase the number of providers waivered to prescribe buprenorphine. We will target individuals leaving jails and prioritize individuals who are not entering probation or parole, a high risk but almost entirely neglected population. We will leverage multiple existing services and partnerships to ensure success and sustainability across time. We will conduct stepped-wedge community randomized trial to determine intervention effectiveness. At the UH3's start, we will randomize each county to start date. Four counties will be randomized to start the intervention each year. In each wave, four counties will be randomized to start 6 months of enrollment into a control condition, followed by 6 months of enrollment into the intervention condition, with follow-up data collection on both extending 6 months beyond enrollment. We anticipate an average enrollment of 25 participants per county per quarter, with a total final sample size for the trial of 1200 (n=600 intervention, n=600 control).