The national opioid crisis continues to intensify, despite the fact that opioid use disorder (OUD) is treatable and opioid overdose deaths are preventable through first-line treatment with medications for opioid use disorder (MOUD). This study identifies and categorizes payment-related barriers that impact MOUD access and retention from both the provider and patient perspectives and provides insight into how these barriers can be addressed. We performed a critical review of the literature (peer-reviewed studies and relevant documents from the gray literature) to identify payment-related access and retention barriers to MOUD. We used the results of this review to develop an analytic framework to understand how payment impacts MOUD access and retention for both providers and patients. In addition, we reviewed action plans developed by Massachusetts communities that participated in the Healing Communities Study (HCS) to analyze which payment-related barriers were addressed through the study. We identified 18 payment-related barriers that patients or providers face when initiating or continuing MOUD with either methadone or buprenorphine in Opioid Treatment Programs (OTP) and non-OTP settings. Patient-related barriers mainly relate to health insurance coverage or the design of health plans (e.g., cost sharing, covered benefits) resulting in direct (medical and non-medical) and indirect costs that can affect both access and retention, especially as they relate to services provided in OTPs. Provider-related barriers include low reimbursement and administrative burden and are most likely to impact access to MOUD. Evidence-based strategies to expand MOUD as part of the HCS in Massachusetts targeted about half of the patient and provider payment-related barriers identified. Patients and providers face an array of payment-related barriers that impact access to and retention on MOUD, most of which relate to inadequate health insurance coverage, features of health plans, and key federal and state policies. As new regulatory policies are enacted that expand access to MOUD, such as greater flexibility in OTPs and MOUD delivered via telehealth, it will be important to align these delivery changes with payment reform involving payers, providers, and policymakers.

Social determinants of health (SDoH) are considered significant determinants of mental health. This study examines the association between SDoH and mental health status in the United States. We analyzed 2023 Behavioral Risk Factor Surveillance System (BRFSS) data from 183,318 U.S. adults using multinomial logistic regression. Several SDoH were significantly linked to the frequency of poor mental health days. After adjusting for all covariates, individuals facing difficulty paying utility bills had lower odds of experiencing episodic (vs. chronic) poor mental health (AOR = 0.47, p = 0.031). Transportation challenges were associated with lower odds of episodic distress rather than chronic mental health issues (AOR = 0.35, p = 0.026). Individuals who were unable to afford a doctor or who experienced employment loss had significantly lower odds of reporting no poor mental health days compared to reporting chronic poor mental health, with adjusted odds ratios of 0.37 and 0.84, respectively. Non-Hispanic Whites and males were more likely to report chronic poor mental health. Policies that prioritize economic stability and job security, reliable transportation, and equal access to education and healthcare are crucial for promoting mental health equity across diverse populations.

The COVID-19 pandemic coincided with worsening U.S. drug overdose mortality and widening racial and ethnic disparities. We estimated race/ethnicity-specific state-level excess overdose deaths in 2020-2023 and assessed how the burden scales with population size. Using annual overdose deaths (2014-2023) for five racial/ethnic groups in 47 states and the District of Columbia, we fit a generalized growth model to 2014-2019 and defined excess deaths as observed counts above projected pre-pandemic expectations in 2020-2023. We assessed scaling by regressing log₁₀ excess and total deaths on log₁₀ 2020 population and compared excess-death rates across groups. White populations had the largest absolute excess, peaking in 2021. Black populations had minimal excess in 2020 but rose sharply in 2021-2022, approaching White counts by 2023; Hispanic excesses were intermediate. Scaling was approximately proportional for White and Hispanic populations. For Black populations, total deaths showed sublinearly, and excess-death scaling was suggestive of sublinearity but not definitive. Rank tests indicated higher excess-death rates for Black populations than for White or Hispanic populations. These analyses highlight heterogeneous, inequitable overdose burdens in 2020-2023 and motivate equity-focused surveillance and prevention.

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. 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. 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. 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.

Purpose: The COVID-19 pandemic coincided with worsening U.S. drug overdose mortality and widening racial and ethnic disparities. We estimated race/ethnicity–specific excess overdose deaths at the state level during 2020–2023 and examined how these burdens scale with population size. Methods: We analyzed annual overdose deaths from 2014–2023 for five racial/ethnic groups in 47 states and the District of Columbia. Pre-pandemic trends (2014–2019) were fit using a generalized growth model, and deaths exceeding projections in 2020–2023 were classified as excess deaths. Scaling was evaluated by regressing excess and total deaths on 2020 state population in log–log models and relating excess-death rates to social and behavioral indicators. Results: White populations experienced the largest absolute excess, peaking in 2021. Black populations showed minimal excess in 2020 but rose sharply in 2021–2022, nearly matching White deaths by 2023; Hispanic excesses were intermediate. Scaling analyses showed sublinear growth of Black deaths with population, while White and Hispanic deaths scaled approximately proportionally. Within-state rank tests indicated higher excess-death rates for Black than for White or Hispanic populations. Conclusions: Excess-mortality and scaling analyses reveal heterogeneous and inequitable overdose burdens across racial and ethnic groups during the pandemic and can inform equity-focused surveillance and prevention efforts.