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Despite legislative advances, people who use drugs (PWUD) in rural settings face unique barriers to naloxone possession. This study aims to examine naloxone possession and identify its correlates among a large, geographically diverse sample of people who either use opioids or inject drugs in rural areas.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We performed a cross\u2010sectional analysis using Rural Opioid Initiative (ROI) data from rural counties of ten US states. Study sites administered a harmonized survey instrument of 3048 PWUD recruited from January 2018 to March 2020. The primary outcome was current naloxone possession. Potential correlates were identified through review of the literature. Data were collected on demographics, drug use behaviors, overdose experiences, access to care, and addiction treatment. Data were analyzed using descriptive statistics, bivariate associations, and multivariable prevalence ratios.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Findings<\/jats:title>\n                    <jats:p>Among 3008 participants included in the analysis, 36.4% reported possessing naloxone. Naloxone possession was associated with younger age, illegal income sources, past 30\u2010day opioid use, personal history of overdose, witnessing an overdose, knowing someone who died from an overdose, current injection drug use, and receiving syringes from syringe service programs (SSPs). No association was found between access to care and naloxone possession.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Only 36% of high\u2010risk rural PWUD possessed naloxone. Factors such as injection drug use, overdose history, and SSP access increased the likelihood of naloxone possession. These findings highlight the need for targeted naloxone distribution strategies in rural areas, considering the unique barriers faced by rural PWUD.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1111\/jrh.70187","type":"journal-article","created":{"date-parts":[[2026,7,25]],"date-time":"2026-07-25T07:36:47Z","timestamp":1784965007000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Correlates of Rural Naloxone Possession Among People Who Use Drugs: A Multi\u2010State Cross\u2010Sectional Analysis"],"prefix":"10.1111","volume":"42","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8281-0677","authenticated-orcid":false,"given":"P. Quincy","family":"Moore","sequence":"first","affiliation":[{"name":"Department of Emergency Medicine The Permanente Medical Group Oakland California USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0006-5149-8859","authenticated-orcid":false,"given":"L. Sarah","family":"Mixson","sequence":"additional","affiliation":[{"name":"Department of Medicine University of Washington  Seattle Washington USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2454-3109","authenticated-orcid":false,"given":"Rebecca","family":"Bolinski","sequence":"additional","affiliation":[{"name":"Department of Population Science and Policy Southern Illinois School of Medicine  Springfield Illinois USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"David C.","family":"Colston","sequence":"additional","affiliation":[{"name":"Department of Health Behavior, Gillings School of Global Public Health University of North Carolina at Chapel Hill  Chapel Hill North Carolina USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hannah L. F.","family":"Cooper","sequence":"additional","affiliation":[{"name":"Rollins School of Public Health Emory University  Atlanta Georgia USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Heidi M.","family":"Crane","sequence":"additional","affiliation":[{"name":"Department of Medicine University of Washington  Seattle Washington USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jackson","family":"Devadas","sequence":"additional","affiliation":[{"name":"Department of Health Behavior, Gillings School of Global Public Health University of North Carolina at Chapel Hill  Chapel Hill North Carolina USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4206-7214","authenticated-orcid":false,"given":"Judith","family":"Feinberg","sequence":"additional","affiliation":[{"name":"Department of Behavioral Medicine &amp; Psychiatry, School of Medicine West Virginia University  Morgantown West Virginia USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Peter D.","family":"Friedmann","sequence":"additional","affiliation":[{"name":"Department of Population &amp; Quantitative Health Sciences University of Massachusetts Chan Medical School  Worcester Massachusetts USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rachel E.","family":"Gicquelais","sequence":"additional","affiliation":[{"name":"Departments of Population Health Sciences and Medicine, School of Medicine and Public Health University of Wisconsin\u2013Madison  Madison Wisconsin USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wiley D.","family":"Jenkins","sequence":"additional","affiliation":[{"name":"Department of Public Health Sciences Clemson University  Clemson South Carolina USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dalia","family":"Khoury","sequence":"additional","affiliation":[{"name":"Center for Behavioral Health Data RTI International, Research Triangle Park North Carolina USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"P. 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