Spatial inequities in access to medications for treatment of opioid use disorder highlight scarcity of methadone providers under counterfactual scenarios.

Access to treatment and medication for opioid use disorder (MOUD) is essential in reducing opioid use and associated behavioral risks, such as syringe sharing among persons who inject drugs (PWID). Syringe sharing among PWID carries high risk of transmission of serious infections such as hepatitis C and HIV. MOUD resources, such as methadone provider clinics, however, are often unavailable to PWID due to barriers like long travel distance to the nearest methadone provider and the required frequency of clinic visits. The goal of this study is to examine the uncertainty in the effects of travel distance in initiating and continuing methadone treatment and how these interact with different spatial distributions of methadone providers to impact co-injection (syringe sharing) risks. A baseline scenario of spatial access was established using the existing locations of methadone providers in a geographical area of metropolitan Chicago, Illinois, USA. Next, different counterfactual scenarios redistributed the locations of methadone providers in this geographic area according to the densities of both the general adult population and according to the PWID population per zip code. We define different reasonable methadone access assumptions as the combinations of short, medium, and long travel distance preferences combined with three urban/suburban travel distance preference. Our modeling results show that when there is a low travel distance preference for accessing methadone providers, distributing providers near areas that have the greatest need (defined by density of PWID) is best at reducing syringe sharing behaviors. However, this strategy also decreases access across suburban locales, posing even greater difficulty in regions with fewer transit options and providers. As such, without an adequate number of providers to give equitable coverage across the region, spatial distribution cannot be optimized to provide equitable access to all PWID. Our study has important implications for increasing interest in methadone as a resurgent treatment for MOUD in the United States and for guiding policy toward improving access to MOUD among PWID.

Methadone prescribing by addiction specialists likely to leave communities without available methadone treatment.

Methadone treatment for opioid use disorder is not available in most suburban and rural US communities. We examined 2 options to expand methadone availability: (1) addiction specialty physician or (2) all clinician prescribing. Using 2022 Health Resources and Services Administration data, we used mental health professional shortage areas to indicate the potential of addiction specialty physician prescribing and the location of federally qualified health centers (ie, federally certified primary care clinics) to indicate the potential of all clinician prescribing. We examined how many census tracts without an available opioid treatment program (ie, methadone clinic) are (1) located within a mental health professional shortage area and (2) are also without an available federally qualified health center. Methadone was available in 49% of tracts under current regulations, 63% of tracts in the case of specialist physician prescribing, and 86% of tracts in the case of all clinician prescribing. Specialist physician prescribing would expand availability to an additional 12% of urban, 18% of suburban, and 16% of rural tracts, while clinician prescribing would expand to an additional 30% of urban, 53% of suburban, and 58% of rural tracts relative to current availability. Results support enabling broader methadone prescribing privileges to ensure equitable treatment access, particularly for rural communities.

Assessment of Structural Barriers and Racial Group Disparities of COVID-19 Mortality With Spatial Analysis.

IMPORTANCE: Although social determinants of health (SDOH) are important factors in health inequities, they have not been explicitly associated with COVID-19 mortality rates across racial and ethnic groups and rural, suburban, and urban contexts. OBJECTIVES: To explore the spatial and racial disparities in county-level COVID-19 mortality rates during the first year of the pandemic. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study analyzed data for all US counties in 50 states and the District of Columbia for the first full year of the COVID-19 pandemic (January 22, 2020, to February 28, 2021). Counties with a high concentration of a single racial and ethnic population and a high level of COVID-19 mortality rate were identified as concentrated longitudinal-impact counties. The SDOH that may be associated with mortality rate across these counties and in urban, suburban, and rural contexts were examined. The 3 largest racial and ethnic groups in the US were selected: Black or African American, Hispanic or Latinx, and non-Hispanic White populations. EXPOSURES: County-level characteristics and community health factors (eg, income inequality, uninsured rate, primary care physicians, preventable hospital stays, severe housing problems rate, and access to broadband internet) associated with COVID-19 mortality. MAIN OUTCOMES AND MEASURES: Data on county-level COVID-19 mortality rates (deaths per 100 000 population) reported by the US Centers for Disease Control and Prevention were analyzed. Four indexes were used to measure multiple dimensions of SDOH: socioeconomic advantage index, limited mobility index, urban core opportunity index, and mixed immigrant cohesion and accessibility index. Spatial regression models were used to examine the associations between SDOH and county-level COVID-19 mortality rate. RESULTS: Of the 3142 counties included in the study, 531 were identified as concentrated longitudinal-impact counties. Of these counties, 347 (11.0%) had a large Black or African American population compared with other counties, 198 (6.3%) had a large Hispanic or Latinx population compared with other counties, and 33 (1.1%) had a large non-Hispanic White population compared with other counties. A total of 489 254 COVID-19-related deaths were reported. Most concentrated longitudinal-impact counties with a large Black or African American population compared with other counties were spread across urban, suburban, and rural areas and experienced numerous disadvantages, including higher income inequality (297 of 347 [85.6%]) and more preventable hospital stays (281 of 347 [81.0%]). Most concentrated longitudinal-impact counties with a large Hispanic or Latinx population compared with other counties were located in urban areas (114 of 198 [57.6%]), and 130 (65.7%) of these counties had a high percentage of people who lacked health insurance. Most concentrated longitudinal-impact counties with a large non-Hispanic White population compared with other counties were in rural areas (23 of 33 [69.7%]), included a large group of older adults (26 of 33 [78.8%]), and had limited access to quality health care (24 of 33 [72.7%]). In urban areas, the mixed immigrant cohesion and accessibility index was inversely associated with COVID-19 mortality (coefficient [SE], -23.38 [6.06]; P < .001), indicating that mortality rates in urban areas were associated with immigrant communities with traditional family structures, multiple accessibility stressors, and housing overcrowding. Higher COVID-19 mortality rates were also associated with preventable hospital stays in rural areas (coefficient [SE], 0.008 [0.002]; P < .001) and higher socioeconomic status vulnerability in suburban areas (coefficient [SE], -21.60 [3.55]; P < .001). Across all community types, places with limited internet access had higher mortality rates, especially in urban areas (coefficient [SE], 5.83 [0.81]; P < .001). CONCLUSIONS AND RELEVANCE: This cross-sectional study found an association between different SDOH measures and COVID-19 mortality that varied across racial and ethnic groups and community types. Future research is needed that explores the different dimensions and regional patterns of SDOH to address health inequity and guide policies and programs.

The impact of COVID-19 on trips to urban amenities: Examining travel behavior changes in Somerville, MA.

While there has been much speculation on how the pandemic has affected work location patterns and home location choices, there is sparse evidence regarding the impacts that COVID-19 has had on amenity visits in American cities, which typically constitute over half of all urban trips. Using aggregate app-based GPS positioning data from smartphone users, this study traces the changes in amenity visits in Somerville, MA from January 2019 to December 2020, describing how visits to particular types of amenities have changed as a result of business closures during the public health emergency. Has the pandemic fundamentally shifted amenity-oriented travel behavior or is consumer behavior returning to pre-pandemic trends? To address this question, we calibrate discrete choice models that are suited to Census block-group level analysis for each of the 24 months in a two-year period, and use them to analyze how visitors' behavioral responses to various attributes of amenity clusters have shifted during different phases of the pandemic. Our findings suggest that in the first few months of the pandemic, amenity-visiting preferences significantly diverged from expected patterns. Even though overall trip volumes remained far below normal levels throughout the remainder of the year, preferences towards specific cluster attributes mostly returned to expected levels by September 2020. We also construct two scenarios to explore the implications of another shutdown and a full reopening, based on November 2020 consumer behavior. While government restrictions have played an important role in reducing visits to amenity clusters, our results imply that cautionary consumer behavior has played an important role as well, suggesting a likely long and slow path to economic recovery. By drawing on mobile phone location data and behavioral modeling, this paper offers timely insights to help decision-makers understand how this unprecedented health emergency is affecting amenity-related trips and where the greatest needs for intervention and support may exist.