Buprenorphine Dispensing Declined After 2021 Despite Gains in Access and Emergency Department Use
August 31, 2026
Key Points
- Pharmacy dispensing of buprenorphine increased from 2019 through 2021 but declined from 2021 through 2025 in both rural and urban US counties.
- The number of buprenorphine prescribers increased, while the number of patients and prescriptions managed per prescriber decreased.
- Pharmacy availability of buprenorphine increased from approximately 65% of counties in 2019 to 80% of rural and 72.4% of urban counties in 2025.
- Emergency department (ED) adoption of buprenorphine increased substantially between 2019 and 2025, but overall adoption remained relatively low.
- Treatment initiation and 180-day treatment retention were higher in urban than rural counties.
- The findings suggest persistent geographic and health-system barriers to treatment for opioid use disorder (OUD), particularly in rural communities.
Study Overview
Buprenorphine dispensing through US pharmacies increased between 2019 and 2021 but subsequently declined through 2025, according to an analysis published in the Morbidity and Mortality Weekly Report.
The study, led by Gery P. Guy Jr., PhD, a health scientist at the Centers for Disease Control and Prevention, and colleagues, examined changes in buprenorphine access and use between 2019 and 2025. The researchers evaluated both pharmacy-dispensed buprenorphine and buprenorphine administration in emergency departments, with particular attention to differences between rural and urban counties.
The analysis comes amid a substantial ongoing burden of opioid-related disease in the United States. According to the researchers, 54,045 deaths involving opioids occurred in 2024, while approximately 4.8 million people were estimated to have OUD.
Despite the availability of effective medication treatment, the investigators noted that:
โBuprenorphine remains underused.โ
The researchers suggested that geographic differences in access may contribute to this treatment gap.
โGeographic variation in access might contribute to underuse, reflecting differences in prescriber and pharmacy availability and health system capacity.โ
Data Sources and Study Design
Guy and colleagues analyzed prescribing and treatment data from 2019 through 2025 using information from IQVIA and the Premier Healthcare Database.
The analysis included several measures of buprenorphine access and utilization, including:
- Pharmacy dispensing
- Number of prescribers
- Patients per prescriber
- Prescriptions per prescriber
- Average prescription supply
- Pharmacy availability
- Treatment initiation
- 180-day treatment retention
- ED adoption of buprenorphine
- Rates of ED-administered buprenorphine
The researchers compared these measures between rural and urban counties.
Pharmacy Dispensing Trends
Pharmacy dispensing of buprenorphine increased from 2019 to 2021. The increase was particularly pronounced in rural counties.
During this period, the annual percent change (APC) in dispensing was approximately 7% in rural counties, compared with 0.7% in urban counties.
After 2021, however, dispensing declined in both geographic settings.
Although dispensing decreased more rapidly in rural areas, the researchers reported that dispensing rates remained higher in rural counties.
โRates remained higher in rural counties despite decreasing more rapidly in rural counties.โ
Buprenorphine Pharmacy Dispensing Trends
| Period | Rural counties | Urban counties |
|---|---|---|
| 2019-2021 | Increased; APC, 7% | Increased; APC, 0.7% |
| 2021-2025 | Decreased | Decreased |
| Overall pattern | Higher dispensing despite subsequent decline | Lower dispensing than rural counties |
The pattern indicates that the increase in access observed before and during the early COVID-19 period was not sustained through 2025.
Prescription Supply Increased
Although dispensing declined after 2021, the average amount of medication supplied with each prescription increased over the entire 2019-2025 period.
In rural counties, the average prescription supply increased from 17.4 days to 22.2 days.
In urban counties, the average prescription supply increased from 17.6 days to 22.6 days.
Average Prescription Supply
| County type | 2019 | 2025 | Change |
|---|---|---|---|
| Rural | 17.4 days | 22.2 days | +4.8 days |
| Urban | 17.6 days | 22.6 days | +5.0 days |
Thus, the decline in the number of dispensed prescriptions should be interpreted alongside the increase in the duration of medication supplied per prescription.
Growth in the Number of Prescribers
The number of buprenorphine prescribers per 1,000 population increased between 2019 and 2025.
In urban counties, the number increased from 0.1 to 0.4 prescribers per 1,000 people.
In rural counties, the corresponding increase was from 0.1 to 0.2 per 1,000 people.
Prescribers per 1,000 Population
| County type | 2019 | 2025 |
|---|---|---|
| Urban | 0.1 | 0.4 |
| Rural | 0.1 | 0.2 |
Despite the increase in prescriber availability, the overall volume of patients and prescriptions managed by individual prescribers declined.
Patients and Prescriptions per Prescriber
Between 2019 and 2025, the number of patients per prescriber decreased substantially.
In urban counties, patients per prescriber declined from 48.7 to 25.7.
In rural counties, the number decreased from 60.1 to 36.3.
The number of prescriptions per prescriber also decreased.
In urban counties, prescriptions per prescriber fell from 312.8 to 116.
In rural counties, the corresponding decline was from 469.2 to 195.8.
Prescriber Workload Measures
| Measure | Urban, 2019 | Urban, 2025 | Rural, 2019 | Rural, 2025 |
|---|---|---|---|---|
| Patients per prescriber | 48.7 | 25.7 | 60.1 | 36.3 |
| Prescriptions per prescriber | 312.8 | 116.0 | 469.2 | 195.8 |
These changes occurred despite growth in the number of prescribers, suggesting that increasing the number of clinicians alone did not necessarily translate into sustained increases in buprenorphine utilization.
Pharmacy Availability Improved
The proportion of counties with pharmacies dispensing buprenorphine increased from 2019 to 2025.
In rural counties, pharmacy availability increased from 64.9% to 80.0%.
In urban counties, availability increased from 64.8% to 72.4%.
Pharmacy Availability
| County type | 2019 | 2025 | Absolute increase |
|---|---|---|---|
| Rural | 64.9% | 80.0% | 15.1 percentage points |
| Urban | 64.8% | 72.4% | 7.6 percentage points |
The improvement was therefore greater in rural counties.
Treatment Initiation and Retention
Despite higher pharmacy dispensing rates in rural counties, treatment initiation and longer-term retention were higher in urban areas.
Median monthly treatment initiation was:
- 14.2 per 100,000 people in urban counties
- 11.8 per 100,000 people in rural counties
The difference was also evident in 180-day treatment retention.
Retention at 180 days was:
- 23.1% in urban counties
- 17.7% in rural counties
Treatment Initiation and Retention
| Measure | Urban counties | Rural counties |
|---|---|---|
| Median monthly treatment initiation | 14.2 per 100,000 | 11.8 per 100,000 |
| 180-day treatment retention | 23.1% | 17.7% |
These findings demonstrate that availability of medication does not necessarily translate into equivalent treatment initiation or sustained treatment retention across geographic settings.
Emergency Department Use of Buprenorphine
One of the more substantial changes identified during the study period was the increase in ED adoption of buprenorphine.
Among rural counties, ED adoption increased from 2.3% in 2019 to 10.3% in 2025, corresponding to an average annual percent change (AAPC) of 23.3%.
In urban counties, adoption increased from 6.7% to 31.4%, corresponding to an AAPC of 30.3%.
ED Adoption of Buprenorphine
| County type | 2019 | 2025 | AAPC |
|---|---|---|---|
| Rural | 2.3% | 10.3% | 23.3% |
| Urban | 6.7% | 31.4% | 30.3% |
Although adoption increased substantially, the researchers emphasized that overall ED adoption remained low, particularly in rural communities.
ED-Administered Buprenorphine
The rate at which EDs administered buprenorphine also increased during the study period.
The AAPC was:
- 6.9% in rural counties
- 18.4% in urban counties
The researchers suggested that this growth may reflect increasing awareness of buprenorphine treatment as well as policies and implementation strategies designed to facilitate its use.
They specifically identified interventions such as:
- Provider education
- Peer support
- Clinical decision-support tools
The researchers wrote that these factors likely contributed to the increasing use of buprenorphine in ED settings.
ED Buprenorphine Administration
| County type | Trend, 2019-2025 | AAPC |
|---|---|---|
| Rural | Increased | 6.9% |
| Urban | Increased | 18.4% |
Why Rural Dispensing May Have Been Higher
The researchers proposed several possible explanations for the relatively higher dispensing rates observed in rural counties.
One possibility was the effect of COVID-19-related telehealth policies and flexibilities. These changes may have been particularly important in rural areas where patients often face longer travel distances and fewer specialty-care options.
The investigators wrote:
โHigher dispensing rates in rural areas might reflect benefits of COVID-19-related telehealth flexibilities, particularly in areas with longer travel distances and more limited access to specialty care.โ
Another explanation relates to the limited availability of opioid treatment programs in rural communities.
The authors noted:
โHigher dispensing rates in rural areas might also indicate increased reliance on office-based buprenorphine, because opioid treatment programs are less available in rural areas.โ
They therefore suggested that office-based prescribing may have an especially important role in rural OUD treatment.
โTogether, these findings suggest that office-based prescribing is a particularly important treatment pathway in rural communities, where fewer specialty providers and more formidable geographic barriers might limit access to other forms of OUD care.โ
Persistent Barriers to ED-Based Treatment
Despite the marked increase in ED adoption, the investigators concluded that buprenorphine use in emergency departments remained relatively limited.
They characterized this as evidence of:
โmissed opportunities for treatment and persistent implementation barriersโ
Potential barriers identified by the researchers included:
- Limited behavioral health support
- Inadequate care-coordination infrastructure
- Insufficient staffing
- Difficulties establishing standardized OUD medication-administration protocols
These barriers can prevent emergency departments from consistently initiating medication treatment even when clinicians recognize the need for OUD care.
Potential Role of the Emergency Department in Treatment Linkage
The researchers emphasized that ED-based buprenorphine administration can do more than provide an initial medication dose.
Initiating treatment before discharge can potentially establish a direct connection between emergency care and continuing OUD treatment.
The authors wrote:
โED-based administration can strengthen linkage to care by connecting patients directly to follow-up treatment before discharge, providing support from trained peer recovery specialists with lived experience, and offering case management to help coordinate ongoing services.โ
This approach could integrate medication treatment with behavioral health services, peer support, and longitudinal care coordination.
Overall Findings
The study demonstrates several simultaneous trends in US buprenorphine treatment between 2019 and 2025.
Pharmacy dispensing increased during the earlier part of the study period but subsequently declined. At the same time, the number of prescribers increased, prescription durations became longer, and pharmacy availability expanded.
Emergency department adoption of buprenorphine also increased considerably, particularly in urban counties.
However, important geographic differences persisted. Rural counties had higher dispensing rates but lower treatment initiation and 180-day retention compared with urban counties.
Summary of Major Findings
| Indicator | Rural counties | Urban counties |
|---|---|---|
| Pharmacy dispensing, 2019-2021 | Increased; APC, 7% | Increased; APC, 0.7% |
| Pharmacy dispensing, 2021-2025 | Decreased | Decreased |
| Average prescription supply | 17.4 โ 22.2 days | 17.6 โ 22.6 days |
| Prescribers/1,000 population | 0.1 โ 0.2 | 0.1 โ 0.4 |
| Patients/prescriber | 60.1 โ 36.3 | 48.7 โ 25.7 |
| Prescriptions/prescriber | 469.2 โ 195.8 | 312.8 โ 116.0 |
| Pharmacy availability | 64.9% โ 80.0% | 64.8% โ 72.4% |
| Monthly treatment initiation | 11.8/100,000 | 14.2/100,000 |
| 180-day retention | 17.7% | 23.1% |
| ED adoption | 2.3% โ 10.3% | 6.7% โ 31.4% |
| ED adoption AAPC | 23.3% | 30.3% |
| ED administration AAPC | 6.9% | 18.4% |
Clinical and Public Health Implications
The findings suggest that improving OUD treatment access requires more than simply increasing the number of clinicians authorized or available to prescribe buprenorphine.
Although prescriber numbers and pharmacy availability increased, pharmacy dispensing declined after 2021. In addition, rural areas experienced lower treatment initiation and retention despite having higher dispensing rates.
The findings highlight several potentially important components of OUD treatment infrastructure:
- Prescriber availability โ expanding the number of clinicians able to provide buprenorphine.
- Pharmacy access โ ensuring that prescriptions can be filled consistently.
- Telehealth โ maintaining mechanisms that reduce geographic barriers to treatment.
- ED initiation โ starting treatment during acute-care encounters when appropriate.
- Care coordination โ ensuring patients have follow-up after ED initiation.
- Peer support โ incorporating trained individuals with lived experience into treatment pathways.
- Behavioral health integration โ addressing the broader needs of patients with OUD.
- Long-term retention strategies โ improving continuation of treatment beyond initial medication initiation.
Conclusion
From 2019 through 2025, the US buprenorphine treatment landscape showed both progress and persistent gaps. Pharmacy availability and the number of prescribers increased, prescription supplies became longer, and ED adoption of buprenorphine expanded substantially.
However, pharmacy dispensing declined after 2021, and treatment initiation and 180-day retention remained lower in rural than urban counties. ED adoption, although markedly higher in 2025 than in 2019, remained relatively limited overall.
The findings suggest that improving access to buprenorphine will require attention not only to medication availability but also to geographic barriers, treatment initiation, continuity of care, behavioral health resources, care coordination, staffing, and implementation infrastructure.
For rural communities in particular, the study suggests that office-based prescribing and telehealth may remain important mechanisms for overcoming geographic and specialty-care limitations, while ED-based initiation may provide an additional opportunity to connect patients with ongoing OUD treatment.
