Discussion
Buprenorphine dispensed by retail pharmacies remained consistently higher in rural than in urban counties during 2019–2025, with larger increases in rural counties during 2019–2021. These patterns might reflect benefits of COVID-19–related telehealth flexibilities, particularly in areas with longer travel distances and more limited access to specialty care (5,6). Higher dispensing rates in rural areas might also indicate increased reliance on office-based buprenorphine, because opioid treatment programs are less available in rural areas (5). Together, these findings suggest that office-based prescribing is a particularly important treatment pathway in rural communities, where fewer specialty providers and more formidable geographic barriers might limit access to other forms of OUD care (5,6). Dispensing declined in both urban and rural counties after 2021, likely reflecting multiple factors such as changes in health care use and increasing days’ supply per prescription, whereas persistent barriers to access might have constrained the overall number of persons who received treatment (3).
Average days’ supply increased both in urban and rural counties, possibly reflecting evolving clinical practice and policy changes, including removal of previous authorization for medication for OUD in several states (7). Longer prescription durations might improve treatment continuity by reducing refill frequency, particularly in rural areas with more barriers to access (5). Higher retention in rural counties might reflect both more days’ supply and selection effects, because patients who successfully overcome more formidable access barriers might be more likely to remain engaged in care. Although treatment duration should be individualized, sustained engagement in buprenorphine treatment is associated with improved outcomes, underscoring the importance of ongoing patient-provider discussions to guide treatment duration and support continued engagement in treatment.
Average daily buprenorphine dose increased modestly, possibly reflecting increased recognition that some patients exposed to fentanyl, now the predominant opioid in the illegal drug supply, might benefit from higher buprenorphine doses (8). In 2024, FDA clarified that buprenorphine labeling does not specify a maximum dose and that dosing should be individualized based on patient need. Pharmacy availability of buprenorphine also increased in urban and rural counties and might be especially important in rural areas, where a higher reliance on pharmacies for the medication and limited access can constrain treatment across larger geographic areas.
The number of buprenorphine prescribers increased, whereas patients per prescriber and prescriptions per prescriber declined. This trend suggests broader distribution of prescribing capacity after elimination of the buprenorphine waiver requirement in December 2022 (9), although prescribing remained concentrated among high-volume prescribers. However, lower prescriber density in rural areas highlights persistent workforce shortages and the need to strengthen rural workforce capacity.
ED-administered buprenorphine increased in both urban and rural counties, likely reflecting growing awareness, supportive policies, and implementation strategies such as provider education, peer support, and clinical decision support tools (10). Despite these gains, adoption remained low, particularly in rural counties, where only one in 10 EDs in the sample had adopted buprenorphine in 2025. Low adoption suggests missed opportunities for treatment and persistent implementation barriers, such as limited behavioral health support, care coordination infrastructure, and staffing needed to implement protocols for OUD medication administration (6,10). ED-based administration can strengthen linkage to care by connecting patients directly to follow-up treatment before discharge, providing support from trained peer recovery specialists with lived experience, and offering case management to help coordinate ongoing services (10).
Limitations
The findings in this report are subject to at least six limitations. First, prescriptions dispensed outside retail pharmacies (e.g., mail-order or clinic-based pharmacies) were not included in this analysis, which might have resulted in an underestimation of buprenorphine prescribing. Second, analyses were based on prescriber or ED location rather than patient residence, which could have resulted in misclassification of urban-rural treatment patterns if patients traveled across county boundaries to receive care. Third, Premier Healthcare Database hospitals represent a large, geographically diverse sample but are not nationally representative; therefore, findings might not be generalizable to all U.S. EDs or fully reflect urban-rural differences. Fourth, the analysis was limited to buprenorphine for OUD and did not include methadone or extended-release naltrexone; therefore, the findings do not represent all medications for OUD access or prescribing practices. Fifth, pharmacy availability was based on consistent dispensing of buprenorphine as a proxy because pharmacy inventory data were not available; therefore, this measure might not represent real-time availability. Finally, the absence of prescribing indications limited insight into clinician decision-making.
Implications for Public Health Practice
Urban and rural counties showed distinct patterns of buprenorphine access. Pharmacy dispensing, initiation, and retention were higher in rural counties; however, the number of prescribers relative to the population and rates of ED-administered buprenorphine were higher in urban counties. These findings highlight opportunities to expand use of a low threshold for buprenorphine prescriptions, strengthen pharmacy availability, and, particularly in rural areas, support ED-based treatment administration and sustain telehealth flexibilities.
