Rural and urban differences in undersupply of buprenorphine provider availability in the United States, 2018

We obtained 2018 mortality data from the Multiple Cause of Death database from Centers for Disease Control and Prevention (CDC) WONDER [3]. Drug overdose deaths were classified using the 10th revision of International Classification of Diseases, based on the underlying cause-of-death codes X40–X44 (unintentional), X60–X64 (suicide), X85 (homicide), or Y10–Y14 (undetermined intent). Deaths with the following codes were considered OODs: opium (T40.0); heroin (T40.1); natural and semisynthetic opioids (T40.2); methadone (T40.3); synthetic opioids other than methadone (T40.4); and other unspecified narcotics (T40.6). For counties with suppressed OOD counts (i.e., fewer than 10; N  = 2400), we imputed counts by summing across the non-suppressed counties within a state, subtracting the non-suppressed total from the state’s overall total (obtained from CDC WONDER published tables), and dividing the difference by the number of suppressed counties in the state.

Information on buprenorphine-waivered prescribers came from the 2018 Drug Enforcement Administration’s (DEA) Active Controlled Substances Act Registrants database. Buprenorphine provider availability relative to need in each county was defined as the number of waivered providers divided by the rate of OODs (i.e., number of OODs/1,00,000 population) in 2018. Counties with ratios in the bottom tertile of their state were classified as buprenorphine undersupplied. We classified each county as rural (micropolitan and non-core) or urban using US census definitions.

Exclusion criteria for states included having fewer than 5 non-suppressed counties (Alaska, Delaware, District of Columbia, Hawaii, Idaho, Iowa, Montana, South Dakota, and Wyoming) and lacking rural counties (New Jersey and Rhode Island) as defind above. We further excluded Maryland and Connecticut from the statistical model due to perfect prediction in the model. A total of 38 states and 2595 counties remained in the analysis.

To statistically test the association of rurality and state (independent variables) and the county classified as buprenorphine undersupplied (dependent variable), we estimated a logit model that included a county’s rural status, individual state indicators, and interaction terms indicating whether the county is in a given state and is also a rural county.

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