Introduction: Opioid prescribing is heterogenous across the US, where 3- to 5-fold variation has been observed across states or other geographical units. Residents of rural areas appear to be at greater risk for opioid misuse, mortality, and high-risk prescribing. The Veterans Health Administration (VHA) provides a unique setting for examining regional and rural-urban differences in opioid prescribing, as a complement and contrast to extant literature. The objective of this study was to characterize regional variation in opioid prescribing across Veterans Health Administration (VHA) and examine differences between rural and urban veterans.

Materials and methods: Following IRB approval, this retrospective observational study used national administrative VHA data from 2016 to assess regional variation and rural-urban differences in schedule II opioid prescribing. The primary measure of opioid prescribing volume was morphine milligram equivalents (MME) dispensed per capita. Secondary measures included incidence, prevalence of any use, and prevalence of long-term use.

Results: Among 4,928,195 patients, national VHA per capita opioid utilization in 2016 was 1,038 MME. Utilization was lowest in the Northeast (894 MME), highest in the West (1,368 MME), and higher among rural (1,306 MME) than urban (988 MME) residents (p < 0.001). Most of the difference between rural and urban veterans (318 MME) was attributable to differences in long-term opioid use (312 MME), with similar rates of short-term use.

Conclusion: There is substantial regional and rural-urban variation in opioid prescribing in VHA. Rural veterans receive over 30% more opioids than their urban counterparts. Further research is needed to identify and address underlying causes of these differences, which could include access barriers for non-pharmacologic treatments for chronic pain.