Characteristics of US Counties With High Opioid Overdose Mortality and Low Capacity to Deliver Medications for Opioid Use Disorder

Abstract

Importance: Opioid overdose deaths in the United States continue to increase, reflecting a growing need to treat those with opioid use disorder (OUD). Little is known about counties with high rates of opioid overdose mortality but low availability of OUD treatment.

Objective: To identify characteristics of US counties with persistently high rates of opioid overdose mortality and low capacity to deliver OUD medications.

Design, setting, and participants: In this cross-sectional study of data from 3142 US counties from January 1, 2015, to December 31, 2017, rates of opioid overdose mortality were compared with availability in 2017 of OUD medication providers (24 851 buprenorphine-waivered clinicians [physicians, nurse practitioners, and physician assistants], 1517 opioid treatment programs [providing methadone], and 5222 health care professionals who could prescribe extended-release naltrexone). Statistical analysis was performed from April 20, 2018, to May 8, 2019.

Exposures: Demographic, workforce, lack of insurance, road density, urbanicity, opioid prescribing, and regional division county-level characteristics.

Main outcome and measures: The outcome variable, "opioid high-risk county," was a binary indicator of a high (above national) rate of opioid overdose mortality with a low (below national) rate of provider availability to deliver OUD medication. Spatial logistic regression models were used to determine associations with being an opioid high-risk county.

Results: Of 3142 counties, 751 (23.9%) had high rates of opioid overdose mortality. A total of 1457 counties (46.4%), and 946 of 1328 rural counties (71.2%), lacked a publicly available OUD medication provider in 2017. In adjusted models, compared with the West North Central division, counties in the East North Central, Mountain, and South Atlantic divisions had increased odds of being opioid high-risk counties (East North Central: odds ratio [OR], 2.21; 95% CI, 1.19-4.12; Mountain: OR, 4.15; 95% CI, 1.34-12.89; and South Atlantic: OR, 2.99; 95% CI, 1.26-7.11). A 1% increase in unemployment was associated with increased odds (OR, 1.09; 95% CI, 1.03-1.15) of a county being an opioid high-risk county. Counties with an additional 10 primary care clinicians per 100 000 population had a reduced risk of being opioid high-risk counties (OR, 0.89; 95% CI, 0.85-0.93), as did counties that were micropolitan (vs metropolitan) (OR, 0.67; 95% CI, 0.50-0.90) and those that had an additional 1% of the population younger than 25 years (OR, 0.95; 95% CI, 0.92-0.98).

Conclusions and relevance: Counties with low availability of OUD medication providers and high rates of opioid overdose mortality were less likely to be micropolitan and have lower primary care clinician density, but were more likely to be in the East North Central, South Atlantic, or Mountain division and have higher rates of unemployment. Strategies to increase medication treatment must account for these factors.

Figures

Figure 1.. Opioid Overdose Death Rate per 100 000 People by US County, 2015-2017

Opioid-overdose deaths were classified using the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10), based on the ICD-10 underlying cause-of-death codes X40 toX 45 (unintentional), X60 to X65 (suicide), or Y10 to Y15 (undetermined intent). Among the deaths with drug overdose as the underlying cause, opioid overdose deaths were identified using the following ICD-10 multiple cause-of-death codes: opium (T40.0), heroin (T40.1), natural and semisynthetic opioids (T40.2), methadone (T40.3), synthetic opioids excluding methadone (T40.4), or other and unspecific narcotics (T40.6).

Figure 2.. US Counties Lacking Any Publicly Available Medication for Opioid Use Disorder (MOUD) Provider, 2017

Medication for opioid use disorder providers are defined to include publicly listed opioid treatment programs, buprenorphine-waivered clinicians, and/or extended-release naltrexone–prescribing clinicians in late 2017.

Figure 3.. Opioid High-Risk Counties With Low Rates of Medication for Opioid Use Disorder (MOUD) Treatment Providers and High Rates of Opioid Overdose Death

Low and high rates of MOUD providers defined as those below and greater than the national rate, respectively, in availability of 3 types of MOUD providers (publicly listed opioid treatment programs, buprenorphine-waivered clinicians, and extended-release naltrexone prescribers) in late 2017. Low and high rates of opioid overdose deaths defined as below and above the national rate of opioid overdose deaths, respectively, from 2015 to 2017.