Buprenorphine Access in Urban and Rural Counties, 2019–2025

In 2024, 54,045 people in the United States died of opioid-involved overdoses — 68.1% of all overdose deaths — and an estimated 4.8 million people had a diagnosed opioid use disorder (OUD). Medications for OUD reduce opioid use, overdose risk and death, yet only about one in four people with OUD receives one.

Buprenorphine is the most prescribed of the three medications the Food and Drug Administration (FDA) has approved for OUD. It can be prescribed in clinics and filled at retail pharmacies, and emergency departments (EDs) can give it after a nonfatal overdose or an OUD-related visit to connect people to treatment. A CDC team looked at how access differed between urban and rural counties from 2019 through 2025.

Data

• Pharmacies: IQVIA data covering about 94% of U.S. retail pharmacy prescriptions, used to measure dispensing, prescribers, how many new patients started (no buprenorphine in the prior 180 days) and how many stayed on it (a continuous 180-day supply with no gap over 7 days).
• Emergency departments: the Premier Healthcare Database, about 86 million outpatient visits and 8 million inpatient admissions a year from about 1,400 hospitals. An ED counted as having adopted buprenorphine if it gave it to at least one person in every month with an OUD or overdose visit.
• Counties were classed urban or rural by the Census Bureau's 2020 definitions, using the prescriber's or ED's location.

Pharmacies: more dispensing in rural counties

• Dispensing rose from 2019 to 2021, much faster in rural counties (annual percent change 7.0 vs 0.7), then fell in both through 2025. Rural rates fell faster but stayed higher.
• Longer prescriptions: the average supply rose from 17.6 to 22.6 days in urban counties and from 17.4 to 22.2 in rural ones. Prescriptions of 15 days or more went from 45.1% to 65.2% (urban) and from 30.7% to 53.7% (rural). Average daily doses rose modestly.
• More prescribers, fewer patients each: prescribers per 1,000 people rose from 0.1 to 0.4 in urban counties and from 0.1 to 0.2 in rural ones. Patients per prescriber fell from 48.7 to 25.7 (urban) and 60.1 to 36.3 (rural). Yet prescribing grew more concentrated: the top 10% of prescribers wrote 84.8% of urban and 81.0% of rural prescriptions by 2025, up from 71.1% and 65.6%.
• Starting and staying on treatment: median monthly starts were higher in rural counties (14.2 per 100,000 people vs 11.8), as was 180-day retention (23.1% vs 17.7%). Starts declined slightly in urban counties and held steady in rural ones. Retention rose in both through July 2020, then declined — in urban counties until September 2023, when it stabilized, and in rural counties through June 2025.
• Pharmacy availability — pharmacies dispensing buprenorphine every month they were open — rose from 64.8% to 72.4% in urban counties and from 64.9% to 80.0% in rural ones.

Buprenorphine initiation (A) and retention (B) by month, urban and rural. CDC figure.

Emergency departments: growing, but behind in rural areas

By 2025, only one in 10 rural EDs in the sample had adopted buprenorphine.

Pharmacy availability (A) and ED adoption (B) by year, urban and rural. CDC figure.

What may explain the patterns

• Rural dispensing may reflect COVID-19-era telehealth flexibilities, which helped most where travel is long and specialty care scarce, and heavier reliance on office-based prescribing, because opioid treatment programs are less available in rural areas.
• The post-2021 decline likely has several causes, including changes in health care use and longer supplies per prescription, while access barriers may have limited how many people got treatment.
• Longer supplies may reflect changing practice and policy, including several states dropping prior authorization for OUD medication. Fewer refills may help people stay in treatment.
• Higher doses may reflect recognition that some patients exposed to fentanyl — now the main opioid in the illegal supply — benefit from more. In 2024 the FDA clarified that buprenorphine labeling sets no maximum dose and that dosing should be individualized.
• More prescribers suggests capacity spread after the buprenorphine waiver requirement ended in December 2022, though lower prescriber density in rural areas points to workforce shortages.
• Low ED adoption points to missed chances and barriers such as limited behavioral health support, care coordination and staffing. ED treatment can link patients to follow-up care before discharge, peer recovery specialists and case management.

Limitations

The data left out mail-order and clinic pharmacies, used prescriber or ED location rather than where patients lived, and relied on hospitals that are not nationally representative. Methadone and naltrexone were not included, pharmacy availability was inferred from dispensing rather than stock, and the reasons for each prescription were unknown.

What the authors recommend

Lower the threshold for prescribing buprenorphine, strengthen its availability in pharmacies, and — especially in rural areas — support ED-based treatment and keep telehealth flexibilities.

Sources

• Guy GP Jr, Chen Y, Zhang K, et al. "Buprenorphine Dispensed by Pharmacies and Administered in Emergency Departments in Urban and Rural Areas — United States, 2019–2025." Morbidity and Mortality Weekly Report 75(33), Centers for Disease Control and Prevention.