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.