Rural–urban differences in opioid prescribing in the Veterans Health Administration

Abstract

Purpose: To determine whether higher rates of opioid prescribing among rural Veterans in the Veterans Health Administration (VHA), previously observed through 2016, persisted through 2023. Methods: National VHA administrative data were used to contrast opioid prescribing between urban and rural Veterans for annual veteran cohorts from 2016 through 2023. The primary prescribing metric was per capita volume expressed as morphine milligram equivalents (MME). Prescribing metrics were contrasted between urban and rural Veterans using Wilcoxon signed rank tests and odds-ratios. Findings: Per capita opioid prescribing was 35% higher among rural Veterans (1275 MME) than urban Veterans (943 MME) in 2016. While overall volume decreased markedly by 2023, opioid prescribing remained higher among rural Veterans (391 MME vs. 270 MME), by 45%. The largest difference was attributable to long-term recipients, which accounted for 325 MME of the 332 MME difference (98%) during 2016 and 118 of the 121 MME difference (98%) in 2023. Conclusions: Higher rates of opioid prescribing among rural Veterans have persisted through 2023, largely driven by differences in long-term prescribing. This may indicate a need for enhanced access to nonpharmacological management options for chronic pain among rural Veterans. Leveraging existing resources within VHA such as the Whole Health System may enhance pain care for rural Veterans.