Rural and urban Americans are getting the same opioid addiction medication through different doors, and the gap has practical consequences for who can start treatment and when. New federal surveillance data published in the Morbidity and Mortality Weekly Report show buprenorphine reaching rural patients mainly through retail pharmacies, while emergency departments have become an increasingly important entry point in cities.
The numbers are stark at the emergency room door. Adoption of buprenorphine, defined as administering it to at least one person during each month an opioid use disorder or overdose visit occurred, rose from 6.7 percent to 31.4 percent in urban counties between 2019 and 2025. In rural counties, it rose from 2.3 percent to 10.3 percent. By 2025, only about one in 10 rural emergency departments in the sample had adopted the practice.
That matters because an emergency visit after a nonfatal overdose is one of the few reliable moments when someone at high risk is in front of a clinician. In 2024, opioid-involved deaths accounted for 54,045 of all overdose deaths in the United States, and an estimated 4.8 million people had a diagnosed opioid use disorder. Only about one in four people with the disorder receives medication for it.
The Pharmacy Counter as Rural Infrastructure
Buprenorphine is the most prescribed of the three federally approved medications for opioid use disorder. Dispensing rates rose in both settings from 2019 to 2021 and then declined through 2025, but rural rates stayed consistently higher. In 2025, rural counties saw 51.1 prescriptions dispensed per 1,000 people compared with 42.9 in urban counties.
Pharmacy availability, measured as the share of pharmacies dispensing buprenorphine every month they operated, rose from 64.9 percent to 80.0 percent in rural counties over the period. Urban availability rose from 64.8 percent to 72.4 percent. Rural pharmacies, in other words, became more consistently stocked than urban ones.
Treatment initiation and 180-day retention were also higher in rural counties, at a median 14.2 initiations per 100,000 people and 23.1 percent retention, compared with 11.8 and 17.7 percent in urban counties. Prescription length grew in both settings, with average days' supply rising from about 17 days to about 22, after the FDA clarified that buprenorphine dosing should be individualized.
CDC researchers attribute part of the rural pattern to telehealth flexibilities introduced during the pandemic, which matter more where travel distances are long, and specialty care is scarce. They also note that opioid treatment programs are less available in rural areas, making office-based prescribing a more important pathway by default. Higher rural retention may partly reflect a selection effect, since patients who overcome steeper access barriers may be more likely to stay engaged.
Two Access Gaps Pointing in Opposite Directions
The report identifies a workforce problem that cuts the other way. Prescribers per 1,000 people rose in both settings but remained lower in rural counties, reaching 0.4 in urban areas and 0.2 in rural areas by 2025.
Prescribing also stayed concentrated. The share of buprenorphine prescriptions written by the top 10 percent of prescribers climbed from 71.1 percent to 84.8 percent in urban counties and from 65.6 percent to 81.0 percent in rural counties. Removal of the federal waiver requirement in December 2022 broadened who could prescribe, and patients per prescriber fell sharply, but a small group still writes most prescriptions.
The share of prescriptions originating in emergency medicine settings fell in both places, and fell furthest in rural counties, from 5.2 percent to 2.2 percent.
Taken together, the picture is a rural system that leans heavily on pharmacies and office-based prescribing while emergency departments contribute little, and an urban system with more prescribers and growing emergency department capacity but lower dispensing, initiation, and retention.
Reasons Rural Emergency Rooms Lag
The authors point to implementation barriers rather than clinician unwillingness. Low adoption suggests missed opportunities for treatment alongside limited behavioral health support, care coordination infrastructure, and staffing needed to run protocols for administering medication for opioid use disorder.
Where the model works, emergency department administration strengthens linkage to care by connecting patients to follow-up before discharge, providing support from trained peer recovery specialists with lived experience, and offering case management to coordinate ongoing services. Small rural hospitals frequently lack the staffing to sustain any of those three elements.
The report carries real limits. Prescriptions filled outside retail pharmacies, including mail-order and clinic-based pharmacies, were not counted, which likely underestimates total prescribing. Analyses used prescriber or emergency department location rather than patient residence, so patients crossing county lines for care could be misclassified. The hospital database is large and geographically diverse but not nationally representative. Pharmacy availability was measured using dispensing as a proxy rather than real inventory. The analysis covered only buprenorphine, not methadone or extended-release naltrexone.
Practical Consequences for Families and Communities
None of this is a reason to change a treatment plan without a clinician. For families supporting someone with opioid use disorder, the useful takeaway is about where to look for help and what to ask.
In a rural area, a local pharmacy is more likely than an emergency department to be a functioning access point, and it is reasonable to call ahead and ask whether a pharmacy regularly stocks and dispenses buprenorphine before a prescription is written. Because retention declined over time in both settings, asking a prescriber what the plan is for continuing treatment past six months is a more important question than many families think to ask.
Anyone leaving an emergency department after an overdose can ask whether medication for opioid use disorder was offered and whether a follow-up appointment was arranged before discharge. If it was not, that is a gap worth raising with a primary care clinician.
The CDC frames the policy implications as expanding pharmacy availability, using a low threshold for prescribing, supporting emergency department-based treatment particularly in rural areas, and sustaining telehealth flexibilities. Whether those flexibilities continue is not settled, and the report treats their durability as an open question.
If you or someone you know is struggling with substance use, the federal SAMHSA National Helpline at 1-800-662-4357 provides free, confidential referrals and information 24 hours a day.
Key Questions Answered
What did the CDC report find? Buprenorphine reaches rural patients mainly through retail pharmacies, with higher dispensing, initiation, and retention than urban counties, while emergency department adoption remained far lower in rural areas.
How large is the emergency department gap? Adoption rose from 6.7 percent to 31.4 percent in urban counties and from 2.3 percent to 10.3 percent in rural counties between 2019 and 2025. By 2025, only about one in 10 rural emergency departments in the sample had adopted it.
Why does emergency department access matter? A visit after a nonfatal overdose is one of the few reliable moments when a person at high risk is in front of a clinician, and starting medication there improves linkage to ongoing treatment.
Are more prescribers available now? Prescribers per 1,000 people rose in both settings after the federal waiver requirement was removed in December 2022, but the rate remained lower in rural counties, and prescribing stayed concentrated among high-volume prescribers.
What are the report's limitations? It excluded mail-order and clinic-based pharmacies, used prescriber or facility location rather than patient residence, drew on a hospital database that is not nationally representative, and covered only buprenorphine.
Where can someone find help? The SAMHSA National Helpline at 1-800-662-4357 offers free, confidential referrals and information 24 hours a day, seven days a week.
