Rural-Urban Disparities in SUD Treatment Marked by Rising Inpatient Care

While substance abuse escalates in rural America, a new study revealed that limited access to substance use disorder treatment has propelled rural adults into court-ordered inpatient care more frequently than urban residents, spotlighting rural-urban disparities.

Substance abuse has struck rural America hard, precipitating a spike in overdose deaths. Over 20 million individuals in rural United States counties grapple with SUD involving opioids, alcohol, stimulants, or a mix thereof.

In 2020, urban counties saw a drug overdose death rate of 28.6 per 100,000 standard population, while in rural counties, it was 26.2, according to Centers for Disease Control and Prevention data.

While there have been attempts to improve SUD treatment, these vary across regions and have proven insufficient to handle the problem. This rural-urban divide reflects structural barriers and limited access to SUD prevention and treatment services, often resulting in increased inpatient hospital utilization.

The study conducted by East Tennessee State University/NORC examined potential differences between rural and urban residents' hospital inpatient stays using 2018 all-payer claims data from seven states.

The findings showed that about 86 percent of both rural and urban SUD hospital admissions emerge from emergency departments or urgent care settings. However, rural patients were vastly overrepresented when it comes to law-enforced or court-ordered inpatient stays for SUD treatment, with rates 4.5 times higher than their urban counterparts.

Additionally, urban areas witness higher inpatient admission rates coming from non-medical facilities than rural areas.

The combination of more court-ordered inpatient stays plus fewer admissions from community-based facilities indicates that there’s a dearth of mental and behavioral healthcare options for people in rural areas, the researchers indicated.

“Our research found that accessible mental health resources are crucial in reducing inpatient needs for individuals with SUDs, underscoring the vital role of healthcare resources and outpatient treatment options,” Craig Holden, a senior research scientist with the NORC Walsh Center for Rural Health Analysis, said in a press release. “While all areas of the country face a SUD epidemic, rural areas have been hit hardest and currently have limited resources to address the crisis.”

The study found that rural inpatients were over nine times more likely to live in areas without access to physicians licensed to prescribe buprenorphine—a key medication in medication-assisted treatment (MAT) that mitigates withdrawal and curbs cravings associated with opioid use disorder.

Experts have long pointed out that the limited amount of authorized buprenorphine prescribers presents significant hurdles to patient care access. Additionally, even among those prescribers, not all were fully filling their patient quota. Said otherwise, they were treating fewer patients than they were authorized to.

“Most people with substance use disorder are able to resolve it over time. Their chances are greatly improved with access to high-quality treatment,” said Robert Pack, director of the ETSU/NORC Rural Health Equity Research Center. “This study further highlights the importance of attention to those who live in rural areas and the urgency to bring equitable health resources to them.”

Researchers found that in rural areas, the bulk of inpatient hospital stays for SUD treatment are covered by Medicare and Medicaid. These public programs finance over 68 percent of such hospital stays compared to 60 percent in urban areas, where private insurance plays a more significant role.

“Substance use disorders, including alcohol, take too many lives in rural areas and contribute to the decrease in life expectancy in rural communities,” said Alana Knudson, director of the NORC Walsh Center. “If prevention and treatment resources were more accessible in rural areas, it would improve lives and increase economic opportunities for rural residents.”