Novel Methods for Research on Young Rural Opioid Users at Risk of HIV, HCV & OD

Epicenters of drug use and drug-related harm in the US are shifting from cities to rural areas; rural adolescents and young adults (AYA) are bearing the brunt of these epidemiologic transitions. Fifteen years after NMPO use started rising in rural areas, we still know comparatively little about patterns of NMPO use, heroin use, or related harms or health service use in rural areas, particularly among AYA. A large body of research guided by the Risk Environment Model (REM) in urban areas, however, suggests that vulnerability and resilience to drug use and related harms are created by interplays of social, economic, political, and physical factors operating at multiple levels, including neighborhoods and settings. Despite its explanatory power, REM has not been used to understand rural NMPO use, heroin use, or related harms. Well-established features of urban risk environments may not generalize to rural areas, which have distinct histories (e.g., farming/mining crises, outmigration, isolation). Limited knowledge of patterns and multilevel predictors of rural AYA NMPO use, heroin use, and related harms and health service use undermines our ability to forecast outbreaks and develop effective interventions. These large epidemiologic shifts from cities to rural areas have presented major methodological challenges that we have yet to meet: methods used to study drug use and related harms and health service use were developed for cities and may not suit rural areas. Recruitment methods (e.g., targeted sampling, respondent-driven sampling [RDS]) are facilitated by high population densities and service-rich environments. Rural areas, however, are sparsely populated and have few services. In-person survey administration and biosample collection are feasible in high-density cities with public transportation, but may be difficult in rural areas where participants are dispersed and have poor transportation access. Also, applying REM in these populations presents methodological challenges. If, for example, salient place-based features of the risk environment differ between rural and urban areas, we may need to develop novel measures of these features to suit rural areas. Unless scientific methods evolve in response these challenges, we will miss vital opportunities to understand these emerging epidemics and develop effective interventions. The proposed mixed-methods R21 will lay the foundations for a novel program of high-impact multilevel research on how features of the risk environment influence NMPO and heroin use; transitions to and from injecting; vulnerability to HIV, HCV, and OD; and health service use among AYA in multiple US rural counties. It will do so in part by leveraging high rates of internet use among rural AYA (80% are online). Aims are: (1) To develop and validate measures of settings and activity spaces within the rural risk environment. (2) To develop and test the feasibility of using webRDS and virtual methods to screen for eligibility to create a sample of AYA opioid users in a rural epicenter of NMPO use, heroin use, and related harms (Rowan, KY). (3) To develop and pilot (a) an internet-based survey of features of the rural risk environment; drug use; injection transitions; HIV/HCV risk; OD risk and occurrence; and health service use in the full sample; and (b) a system of home-based HIV and HCV testing for a subsample. The proposed R21 will generate methodological tools to inaugurate a new program of high-impact research on the risk environment and emerging epidemics of NMPO and heroin use and related harms and health service use among AYA in multiple rural US counties.