Rural communities face the same biology of addiction but very different care conditions—long travel distances, limited broadband, clinician shortages, pharmacy deserts, and privacy concerns in small towns. Rural Addiction Medicine translates evidence-based SUD care into settings where resources are thin and relationships matter. We start with access: building low-barrier entry points in primary care, EMS, urgent care, and community pharmacies, and using flexible scheduling to accommodate shift work and seasonal labor. We map hub-and-spoke, mobile clinics, community paramedicine, and jail-to-community bridges, showing how each can initiate and maintain medications for opioid, alcohol, and nicotine use disorders. Equity runs through every decision—support for Indigenous communities, migrant workers, and veterans; culturally adapted counseling; and language access when bilingual clinicians are scarce. We examine safety realities—fentanyl adulteration, xylazine injury care, and overdose clusters—and how to operationalize naloxone, test strips, and rescue planning without adding stigma. Economic sustainability is addressed head-on: billing pathways, value-based contracts, and pooled staffing across counties to stabilize services. We connect clinical workflows to community assets—faith groups, agricultural co-ops, 4-H and school systems—so recovery supports are local, credible, and durable. Confidentiality in small towns requires clear messaging and options for discrete care, including after-hours visits and mail-order pharmacies. We also show how to adapt contingency management ethically and affordably, use asynchronous check-ins to cut travel, and partner with harm-reduction outreach for people not yet ready for abstinence. Finally, we align measurement with reality: retention-in-care, days of non-use, employment stability, and safety events—metrics that rural teams can track without extra staff. This session positions Rural Addiction Medicine, the practical angles you’d expect from a rural addiction conference, and technology-enabled approaches like telehealth for SUD as a single, coherent playbook for small-population catchments.