PROJECT SUMMARY/ABSTRACT There has been wide variability in public policies implemented by the states to address the devastating public health consequences of opioid injection-related drug use, particularly in the Appalachian region of the United States. At the extreme ends of the spectrum, North Carolina has implemented progressive harm reduction approaches in three state-supported public policies that have well-recognized impacts on reducing harms associated with opioid injection: naloxone distribution programs (NAL) for opioid overdose reversal, syringe exchange programs (SEP) to reduce blood-borne diseases, and Good Samaritan Laws (GSL) that encourage people to report overdoses without fear of prosecution. Kentucky and North Carolina are strong candidates for studying opioid injection because they are at the opposite ends of the policy spectrum. This application proposes to study Appalachian states to explore how state-level health policies for preventive and treatment services for injection opioid use intersect with individual-level need for services and utilization. The study will use Anderson?s Behavioral Model for Vulnerable Populations (BMVP), a theoretical framework that can be used to identify the factors that affect to access to and utilization of services supported by NAL, SEP, and GSL, and others we identify during our research. The model identifies candidate predisposing (e.g., demographics, health beliefs, social structure, such as mining, % poverty), enabling (e.g., personal resources, family resources), and need (e.g., perceived need for the services). Specific Aim 1: To conduct an environmental scan of public health policies targeting opioid injection in the 13 Appalachian states, with particular emphasis on KY and NC. Specific Aim 2: To understand the individual-level predisposing, enabling, and service needs among opioid injectors and non-injectors in KY and NC. Specific Aim 3: To develop a policy-report that addresses recommendations to identify high areas of service need and improve service delivery. We will work with our existing Community Advisory Board, and add additional representation from state and local health departments to convene a working group of affected community members to assist in data analysis and develop a toolkit of practical strategies for clinicians, program staff, and policy makers to improve the delivery of NAL, SEP, GSL and other opioid-related programs. Study findings will ultimately yield important new information on the distribution of public health policies targeting opioid injection and its consequences, which will be not only in keenly relevant to diverse regions in Appalachia, but also to other rural communities throughout America.