Rural and Western Region Veterans Prescribed More Opioids Than Urban, Other Regions

BACKGROUND:
Opioid prescribing is heterogeneous across the US, where 3 to 5-fold variation has been observed across states or other geographical units. Residents of rural areas appear to be at greater risk for opioid misuse, mortality, and high-risk prescribing. Having placed emphasis both on serving rural Veterans and monitoring opioid prescribing, VA provides a valuable setting to complement and contrast extant research. This retrospective observational study sought to characterize regional variation in opioid prescribing across VA and examine prescribing differences between rural and urban Veterans. Using VA administrative data, researchers identified a primary cohort of Veterans who had received at least one outpatient prescription in 2016 and determined those who had received an opioid (n=800,479). Regionality and rural or urban residence was determined via Veteran zip code. The primary measure of opioid prescribing volume was morphine milligram equivalents (MME) dispensed per capita.

FINDINGS:

• There was substantial rural-urban variation in VA opioid prescribing, with rural Veterans receiving over 30% more opioids than their urban counterparts.
• National VA per capita opioid utilization in 2016 was 1,038 MME. Utilization was lowest in the Northeast (894 MME) and highest in the West (1,368 MME).
• Opioid prescribing was substantially higher for rural (1,306 MME) compared to urban (988 MME) Veterans, with most of the difference attributable to long-term use.
• Mean days' supply dispensed at initiation was higher for rural veterans (15 vs. 13) and the proportion prescribed an initial 30 days' supply was 23% for rural vs. 19% for urban Veterans.
• The prescribing gap between urban and rural Veterans in the South was 33% vs. 13% in the Northeast, and similar in the West and Midwest.

IMPLICATIONS:
Both urban and rural opioid prescribing rates in VA have declined, but a rural-urban prescribing gap persists, as do regional variations. Higher rates of opioid prescribing among rural compared to urban Veterans are driven mostly by higher rates of long-term use, indicating a need for interventions to improve access to non-pharmacologic treatment for chronic pain among rural Veterans.

LIMITATIONS:

• This study cannot provide comprehensive and definitive explanations for why rural Veterans are prescribed more opioids, or why those in certain regions receive 5-fold more opioids than others.
• This study did not observe opioids dispensed from non-VHA sources which could be more likely among rural residents and only considered opioid prescribing vs. illicit opioid use or opioid related harms including overdose.

AUTHOR/FUNDING INFORMATION:
All authors are part of HSR&D's Center for Access & Delivery Research and Evaluation (CADRE) in Iowa City, IA.

Lund B, Ohl M, Hadlandsmyth K, Mosher H. Regional and Rural-Urban Variation in Opioid Prescribing in the Veterans Health Administration. Military Medicine. May 21, 2019;epub ahead of print.