Community-level determinants of buprenorphine provider availability: A ZCTA-level (zip code tabulation area) analysis

Equitable access to medications for opioid use disorder (MOUD) remains a global challenge. Little is known about community geographic, demographic, and socioeconomic characteristics associated with buprenorphine provider availability following removal of the X-waiver. This study examined these associations across U.S. Zip Code Tabulation Areas (ZCTAs).

We analyzed 32,667 ZCTAs from SAMHSA, the U.S. Census, CDC WONDER, and the Missouri Census Data Center. Outcomes were provider availability (≥1 provider/ZCTA) and provider count. Independent variables included dichotomized measures of urban/rural, racial composition, median household income, educational attainment, unemployment, health insurance coverage, and continuous opioid overdose mortality. Multivariable logistic and negative binomial models were estimated.

30.2% of ZCTAs had at least one provider. Rural ZCTAs had lower provider availability (AOR=0.074, p < .001) and provider counts (IRR=0.070, p < .001). Majority non-White ZCTAs were not significantly associated with either provider availability (AOR=1.1, p = .17) or counts (IRR=1.1, p = .35). Communities with majority less than a bachelor's degree had lower provider availability (AOR=0.50, p < .001) and counts (IRR=0.53, p < .001). Higher unemployment (AOR=1.5; IRR=1.4, both p < .001), lower health insurance coverage (AOR=1.3; IRR=1.2, p < .001), and higher opioid overdose mortality (AOR=1.3; IRR=1.3, both p < .001) were associated with greater provider availability and counts. Low median household income was not associated with provider availability (AOR=1.0, p = .65) but was associated with higher provider counts (IRR=1.2, p < .001).

Despite the removal of X-waiver, the availability of buprenorphine providers remains limited and uneven. Policies should prioritize equitable distribution of providers to better align treatment capacity with community need, particularly in rural areas.