key: cord-0957591-6gxh61w9
authors: Joudrey, Paul J.; Kolak, Marynia; Lin, Qinyun; Paykin, Susan; Anguiano, Vidal; Wang, Emily A.
title: Assessment of Community-Level Vulnerability and Access to Medications for Opioid Use Disorder
date: 2022-04-19
journal: JAMA Netw Open
DOI: 10.1001/jamanetworkopen.2022.7028
sha: c86d6ed0e07fb2d657c0ca922edcd63832c17882
doc_id: 957591
cord_uid: 6gxh61w9

IMPORTANCE: Given that COVID-19 and recent natural disasters exacerbated the shortage of medication for opioid use disorder (MOUD) services and were associated with increased opioid overdose mortality, it is important to examine how a community’s ability to respond to natural disasters and infectious disease outbreaks is associated with MOUD access. OBJECTIVE: To examine the association of community vulnerability to disasters and pandemics with geographic access to each of the 3 MOUDs and whether this association differs by urban, suburban, or rural classification. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study of zip code tabulation areas (ZCTAs) in the continental United States excluding Washington, DC, conducted a geospatial analysis of 2020 treatment location data. EXPOSURES: Social vulnerability index (US Centers for Disease Control and Prevention measure of vulnerability to disasters or pandemics). MAIN OUTCOMES AND MEASURES: Drive time in minutes from the population-weighted center of the ZCTA to the ZCTA of the nearest treatment location for each treatment type (buprenorphine, methadone, and extended-release naltrexone). RESULTS: Among 32 604 ZCTAs within the continental US, 170 within Washington, DC, and 20 without an urban-rural classification were excluded, resulting in a final sample of 32 434 ZCTAs. Greater social vulnerability was correlated with longer drive times for methadone (correlation, 0.10; 95% CI, 0.09 to 0.11), but it was not correlated with access to other MOUDs. Among rural ZCTAs, increasing social vulnerability was correlated with shorter drive times to buprenorphine (correlation, –0.10; 95% CI, –0.12 to –0.08) but vulnerability was not correlated with other measures of access. Among suburban ZCTAs, greater vulnerability was correlated with both longer drive times to methadone (correlation, 0.22; 95% CI, 0.20 to 0.24) and extended-release naltrexone (correlation, 0.15; 95% CI, 0.13 to 0.17). CONCLUSIONS AND RELEVANCE: In this study, communities with greater vulnerability did not have greater geographic access to MOUD, and the mismatch between vulnerability and medication access was greatest in suburban communities. Rural communities had poor geographic access regardless of vulnerability status. Future disaster preparedness planning should match the location of services to communities with greater vulnerability to prevent inequities in overdose deaths.

This supplemental material has been provided by the authors to give readers additional information about their work.

The SVI is derived from 15 US Census Bureau American Community Survey variables and measures overall vulnerability of a census tract and vulnerability across four specific themes: 1) Socioeconomic status (below poverty, unemployed, income, no high school diploma), 2) Household composition and disability (aged 65 or older, aged 17 or younger, older than age 5 with a disability, single-parent households), 3) Minority status and language (minority, speak English "less than well"), and 4) Housing type and transportation (multi-unit structures, mobile homes, crowding, no vehicle, group quarters such as worker dormitories, skilled nursing facilities, or college dorms). 1 The SVI assigns each tract a score based on percentile rank (scored 0 to 1 with 1 representing the highest vulnerability). 1 The SVI was found to predict disaster related property damage and fatalities over a 12-year period among 10 southeastern states and was included within the inter-agency US Climate Resilience Toolkit to facilitate disaster preparedness planning. 2 In the context of COVID-19, increasing SVI scores were associated with increased community COVID-19 cases and deaths and lower rates of COVID-19 vaccination. [3] [4] [5] 

We modified the widely used University of Washington recommendations for RUCA urbanrural classification by first collapsing the large and small rural codes into one category and then identifying codes 3, 5.1, 7.1, 8.1, and 10.1 as rural instead of suburban. This latter change was driven by observations suggesting the traditional University of Washington approach may overestimate urban and suburban areas. We matched all zip codes assigned a RUCA code to their ZCTA. For analyses stratified by urban-rural classification, we excluded ZCTAs without an assigned RUCA code. 

CDC's Social Vulnerability Index. Place and Health

NOAA's Climate Program Office. US Climate Resilience Toolkit

County-Level Association of Social Vulnerability with COVID-19 Cases and Deaths in the USA

The Impact of Social Vulnerability on COVID-19 in the U.S.: An Analysis of Spatially Varying Relationships

County-Level COVID-19 Vaccination Coverage and Social Vulnerability -United States