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AHSR 2021 Abstract Title: Rural-urban trends in the availability of methadone maintenance therapy during the beginning of the national opioid crisis Authors: Amanda G. Sharp, PhD, MPH, Daniel J. Sullivan, PsyD, Amity E. Quinn, PhD, Constance M. Horgan, ScD, Cindy Parks Thomas, PhD, Timothy B. Creedon, PhD Words: 324/350 Background: After two decades, the U.S. has yet to implement adequate treatment and policy solutions to address the opioid overdose epidemic. This is despite the existence of multiple forms of effective treatment, including methadone maintenance therapy (MMT), which had demonstrated effectiveness for decades before the epidemic began. To better understand the origins of the epidemic, we investigated early trends in the availability of MMT, placing emphasis on communities with the highest OUD treatment need: rural areas with high opioid mortality and misuse rates. Methods: We conducted secondary analysis of N-SSATS, CDC WONDER, and NSDUH data merged at the state-year level. We analyzed repeated measures N-SSATS data on nearly all substance abuse treatment facilities in the U.S. between 2004-2011. Primary outcomes were if facilities offered MMT and, for comparison, buprenorphine in each study year. Key explanatory variables were facility location (urban/rural), year, and a rural-year interaction. We controlled for state-level opioid mortality and misuse rates and a range of facility-level characteristics. Generalized linear mixed models estimated differential trends accounting for clustering. Results: Among N=96,047 facility-year observations, 21.6% were rural. MMT was available in 9.8% of facilities in 2004 and 11.3% in 2011 (buprenorphine: 7.3%, 2004; 19.1%, 2011; both: 2.4%, 2004; 6.1%, 2011). In model-based analyses, rural facilities were significantly less likely to offer methadone than urban facilities (-5.2 pts., p<0.001) and were slower to add MMT over time (-0.2 pts/year, p=0.005). Buprenorphine was more available in areas with higher opioid mortality rates (0.8 pts, p<0.001), but methadone was less available (-1.0 pts., p<0.001). Conclusions: At the beginning of the opioid epidemic, MMT was least available where it was needed most: rural communities with higher opioid mortality rates. Between 2004 and 2011, there was a promising near tripling of buprenorphine availability, but MMT availability did not meaningfully change. To help determine what reforms are needed to avert future public health crises, further research should investigate the role of federal, state, and local health policies in these trends.
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