Rurality weakens the positive association between the COVID-19 pandemic and substance use treatment involving medications for opioid use disorder.

Introduction: During the COVID-19 pandemic, policies and practices were adopted to increase access to medications for opioid use disorder (MOUD), an evidence-based treatment that has lower utilization rates in rural areas compared to urban regions. However, limited attention has been given to rural-urban differences in MOUD use associated with pandemic policy and practice changes. We examine associations between the pandemic, rurality, and MOUD use in residential and outpatient treatment programs in the United States. Methods: Using 2018-2022 Treatment Episode Data Set Admissions (TEDS-A) data from residential short-term (RST), residential long-term (RLT), and outpatient treatment centers, we explored bivariate associations between MOUD as part of a treatment plan as the outcome variable and rurality and the pandemic as key independent variables. We then employed logistic regression, adjusting for multiple factors to analyze base and moderation models. Results: Findings indicated MOUD use increased across all treatment modalities in the post-COVID period with the strongest association in RLT treatment (OR = 2.298). In all treatment modalities, rurality reduced the strength of the positive relationship between the pandemic and MOUD use (interaction term ORs ranged from .441 to .91). Rural areas experienced a sharp drop in MOUD use from 2021 to 2022 in RLT and outpatient treatment. Conclusions: Gains in the use of MOUD post-pandemic appeared short-lived in rural areas, ultimately widening urban-rural disparities. Providers, policymakers, and other stakeholders should work together to sustain policies and practices that promote MOUD, particularly in rural areas.