Availability of Medication-Assisted Treatment in Rural Michigan: A Comparison of Non-Metropolitan and Metropolitan Counties

Background and Purpose. Overdose-related deaths have increased dramatically since the early 2000s, continuing to rise in recent years. The state of Michigan saw significant increases in 2015 and 2016, now having the 15^th highest overdose-related death rate of all states. Nationally, overdose-death rates in non-metropolitan areas surpassed metropolitan areas. This is concerning for rural residents who more commonly face limited availability of evidence-based practices (EBPs). The gold-standard EBP to treat opioid use disorder is medication-assisted treatment (MAT), which involves medications like buprenorphine (BUP) to suppress opioid cravings. Typically, patients access MAT at opioid-specialty clinics or from waivered BUP practitioners at non-specialty clinics. However, it is unclear whether there are differences in MAT availability based on urbanicity or other factors (county-level income). This study is the first to examine these relationships, and the first to do so with representative data for an entire Midwestern state.

Methods. In March 2018, we extracted data for two levels of MAT: 1) opioid-specialty clinics, and 2) BUP practitioners in Michigan (SAMHSA Treatment Locator Tool) and county-level income (U.S. Census Bureau). We assessed county-level availability of both levels of MAT dichotomously (yes/no) and continuously. Rural Urban Continuum Codes were used to categorize county-level urbanicity as metropolitan or non-metropolitan. We assessed county-level income using a median split ($43,373) of all Michigan counties. Bivariate analyses examined urbanicity differences in MAT availability and county-level income, and county-level income differences in MAT availability. We conducted two separate logistic regression analyses examining the association of urbanicity to any opioid-specialty clinic(s) and any BUP practitioner(s), controlling for county-level income.

Results. There were 42 opioid-specialty clinics and 769 waivered BUP practitioners across Michigan’s 83 counties (non-metropolitan: n=57, 68.7%). Bivariate analyses highlighted non-metropolitan counties as less likely (than metropolitan) to have any opioid-specialty clinic(s) (p<.001), fewer opioid-specialty clinics (p<.001), any BUP practitioner(s) (p<.001), and fewer BUP practitioners (p<.001). Further, non-metropolitan counties were more likely to be low-income counties (p<.01), and low-income counties were less likely (than high-income) to have any opioid-specialty clinic(s) (p<.01), fewer opioid-specialty clinics (p<.01), any BUP practitioner(s) (p<.001), and fewer BUP practitioners (p<.001). Logistic regression analyses (controlling for county-level income) demonstrated that non-metropolitan counties were 35.6 and 12.2 times less likely (than metropolitan) to have any opioid-specialty clinic(s) (p<.001) or BUP practitioners (p<.05), respectively. County-level income was not significantly associated with opioid-specialty clinic availability, though low-income counties were 5.9 times less likely (than high-income) to have any BUP practitioner(s) (p<.01).

Conclusions and Implications. Our study highlights a relative shortage of opioid-specialty clinics and BUP practitioners among non-metropolitan Michigan counties. Results were consistent when accounting for county-level income. There are sufficient challenges that undermine the feasibility of expanding the availability of opioid-specialty clinics (burdensome staffing requirements, high infrastructural costs). By comparison, expanding the availability of BUP practitioners represents a cost-effective, feasible solution to address MAT shortages for low-income, non-metropolitan counties. Therefore, we suggest approaches that engage practitioners in non-specialty settings (family medicine) to provide BUP, and recommend initiatives encouraging rural practitioners interested in delivering BUP to consult via telemedicine with experienced practitioners.