key: cord-0892318-42z1oxym authors: Joudrey, P. J.; Kolak, M.; Lin, Q.; Paykin, S.; Anguiano, V.; Wang, E. A. title: Community social vulnerability and access to medications for opioid use disorder within the continental US: A cross-sectional study date: 2021-10-01 journal: nan DOI: 10.1101/2021.09.30.21264351 sha: acc19fb14eb577f3f6c36eb0c181e5797cd6276f doc_id: 892318 cord_uid: 42z1oxym The COVID-19 pandemic, like past natural disasters, was associated with significant disruptions in medications for opioid use disorder services and increased opioid overdose and mortality. We examined the association between community vulnerability to disasters and pandemics and geographic access to each of the three medications for opioid use disorder within the continental US and if this association was impacted by urban, suburban, or rural classification. We found communities with greater vulnerability did not have greater geographic access to medications for opioid use disorder and the mismatch between vulnerability and medication access was greatest in suburban communities. Rural communities had poor geographic access to all three medications regardless of vulnerability. Future disaster preparedness planning should include anticipation of access to medications for opioid use disorder and better match the location of services to communities with greater vulnerability to prevent inequities in opioid overdose deaths. US opioid overdose deaths increased within both urban and rural communities and continue to rise in the context of the 2019 novel coronavirus (COVID- 19) pandemic. (1, 2) Treatment with the three US Food and Drug Administration approved medications for opioid use disorder (MOUD), buprenorphine, methadone, and extended-release naltrexone, can reduce opioid overdose deaths, (3) (4) (5) but they are not equivalent or interchangeable. (6) Buprenorphine is a partial opioid agonist available within office-based settings via DATA 2000 waiver. (6, 7) Methadone is a full opioid agonist but can only be provisioned at federally certified opioid treatment programs (OTP). (6, 7) Extended-release naltrexone is an opioid antagonist and is typically dispensed by a specialty pharmacy and administered by the prescriber. (6, 7) Given the differences in pharmacology and delivery, the three MOUD should be accessible in all communities to facilitate treatment individualization and maximization of treatment retention. (6) However, there is a shortage of MOUD services, disproportionately impacting rural communities and contributing to racial inequities in access. (8, 9) Most US patients with opioid use disorder (OUD) never initiate a MOUD. (6, 10) Evidence suggests COVID-19 and other recent natural disasters exacerbated the shortage of MOUD services (11) (12) (13) (14) (15) and were associated with increased opioid overdose and chronic disease mortality. (2, 12, 14, 16) All-cause mortality increased 62% in Puerto Rico following Hurricane Maria and around one third of All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 1, 2021. ; https://doi.org/10.1101/2021.09.30.21264351 doi: medRxiv preprint excess deaths were attributable to healthcare service disruptions. (16) In the context of COVID-19, US opioid overdose deaths increased 29% from November 2019 to November 2020. (2) Despite efforts to mitigate the impact of COVID-19 on MOUD services, such as increased telemedicine for OAT and relaxation of methadone take home dosing requirements, (15, 17) a reduction in locations accepting new methadone patients and long wait times to initiate a medication were observed during the pandemic. (15) With the ongoing COVID-19 pandemic and the expected increased frequency of climate change related extreme weather events, (18, 19) it is important to examine how a community's ability to respond to natural disasters and infectious disease outbreaks is associated with current access to MOUD, especially given the already uneven access to the medications. The World Health Organization and the US Substance Abuse and Mental Health Services Administration (SAMHSA) have recommended state and local agencies develop disaster plans for patients receiving methadone and buprenorphine. (20) (21) (22) But no past studies have examined the relationship between access to each medication and a community's ability to respond to disaster or infectious disease outbreaks. Identifying communities with greater vulnerability to disasters and pandemics and low access to MOUD could inform interventions and policies aiming to expand MOUD access and mitigate future disparities in mortality. Therefore, we examined the association between social vulnerability and access to each of the three MOUDs within the continental US and All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. representing the highest vulnerability).(23) The SVI was found to predict disaster related property damage and fatalities over All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. vaccination. (26) (27) (28) We measured geographic access to the three MOUD using the following data sources. The primary data source was the SAMHSA (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. 28 We used ZCTAs because they are often the smallest geographic unit available to health researchers, in contrast to tract level which may show more (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 1, 2021. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 1, 2021. We created correlation matrices among all ZCTAs and among each urban-rural strata, using Spearman's rank correlation, to examine the relationship between overall SVI and each SVI theme and access to each treatment type. For each correlation matrix, we reversed the direction of the count of treatment locations within a 30-minute drive time so that the direction of All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 1, 2021. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 1, 2021. All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 1, 2021. The association between social vulnerability and access to all three types of MOUD varied depending on urban-rural classification. Among rural ZCTAs, increasing overall social vulnerability was correlated with shorter drive times to buprenorphine (correlation -0.10, p<0.001) but overall vulnerability was not correlated with other measures of access to MOUD. Vulnerability by theme was not correlated with access among rural ZCTAs, except vulnerability due to socioeconomic All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 1, 2021. All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 1, 2021. A novel finding of this study is that the mismatch between overall social vulnerability and the location of MOUD services was greatest in suburban zip codes as compared to rural and urban zip codes and does not exist for people with end stage renal disease. In examining the specific domains of social vulnerability, living in suburban communities with lower socioeconomic status or in households with more children, seniors, or individuals with disabilities was associated with less geographic access to methadone and extended-release All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 1, 2021. ; https://doi.org/10.1101/2021.09.30.21264351 doi: medRxiv preprint naltrexone. And in contrast, geographic access was largely not associated with social vulnerability in rural zip codes because geographic access to MOUD was uniformly poor. Living in urban zip codes with greater social vulnerability due to higher proportion of residents of racial and ethnic minority status and non-English speakers was associated with greater geographic access to MOUD, suggesting that geographic access may not be as important of a barrier to MOUD treatment in these communities. One important caveat is that geography is just one dimension of access;(51) MOUD access is also impacted by stigma, affordability, accommodation, capacity, and more, and future research should examine the interaction of these factors with geographic access in vulnerable communities. We improve upon previous research by utilizing two measures of small area (zip code tabulation area) geographic access (drive time and count of near locations) to all three types of MOUD, while incorporating two sources of extended-release naltrexone location data. Our results are consistent with previous research showing communities with lower socioeconomic status have less geographic access to methadone and buprenorphine,(44) and we extend these findings to extended-release naltrexone. By examining the four SVI themes, we find that communities vulnerable due to housing type and transportation also do not have greater geographic access to MOUD and may experience increased mortality during natural disasters and pandemics. While this was also true for vulnerability due to households with children, the elderly and the disabled, its relevance for All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 1, 2021. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. OTPs alone in event of a disaster has been insufficient to ensure access to methadone, (15) We would like to thank Moksha Menghaney for assistant managing the SAMHSA data and Nathan Kim for his assistant obtaining the data on extended-release naltrexone. All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 1, 2021. ; https://doi.org/10.1101/2021.09.30.21264351 doi: medRxiv preprint Exhibit 3. Correlation between social vulnerability and access to medications for opioid use disorder and dialysis centers in the continental US in 2020. The shading depends on the magnitude of correlation coefficient, with red indicating positive correlations and blue indicating negative correlations. All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. 0.119% of MOUD and dialysis resources are located in these 20 ZCTAs, thus they were not assigned to any RUCA classification. These include 2 out of 9,103 Naltrexone locations, 15 out of 51, 191 Buprenorphine locations and 66 out of 7724 Dialysis locations. All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Urban-Rural Differences in Drug Overdose Death Rates Vital Statistics Rapid Release -Provisional Drug Overdose Data Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. 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Summary Statistics of Driving Time Access Metrics across SVI Themes Median Drive Time to the Nearest Methadone, Buprenorphine, and Naltrexone SVI Theme Rural Suburban Urban Source: We obtained 2018 Census tract social vulnerability index (SVI) data from Centers for Disease Control and Prevention Quar