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Background Ohio's opioid epidemic continues to progress, severely affecting its rural Appalachian counties-areas marked by high mortality rates, widespread economic challenges, and a history of extreme opioid overprescribing. Substance use may be particularly prevalent in the region due to interactions between community and interpersonal trauma. Purpose/Objectives We conducted qualitative interviews to explore the local context of the epidemic and the contributing role of trauma. Methods Two interviewers conducted in-depth interviews (n