{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,13]],"date-time":"2026-10-13T20:23:57Z","timestamp":1791923037549,"version":"4.3.4"},"reference-count":40,"publisher":"Public Library of Science (PLoS)","issue":"5","license":[{"start":{"date-parts":[[2026,5,27]],"date-time":"2026-05-27T00:00:00Z","timestamp":1779840000000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100021045","name":"Massachusetts Department of Public Health","doi-asserted-by":"publisher","award":["6 NU17CE925012-03-01"],"award-info":[{"award-number":["6 NU17CE925012-03-01"]}],"id":[{"id":"10.13039\/100021045","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100004184","name":"Northeastern University","doi-asserted-by":"publisher","award":["Tier 1 Grant"],"award-info":[{"award-number":["Tier 1 Grant"]}],"id":[{"id":"10.13039\/501100004184","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:sec id=\"sec001\">\n                    <jats:title>Aims<\/jats:title>\n                    <jats:p>To examine the relationship between geographical density and opioid prescribing in a model that simultaneously accounts for both supply and demand side factors.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec002\">\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>Using the Massachusetts All-Payer Claims (MAPC) Database, we capture individual patient-level characteristics and combine this with county-level data on economic conditions and health care delivery systems to examine the relationship between geographical density and opioid prescribing.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec003\">\n                    <jats:title>Population and Setting<\/jats:title>\n                    <jats:p>Commercially insured population residing in Massachusetts between 2010 and 2014.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec004\">\n                    <jats:title>Methodology<\/jats:title>\n                    <jats:p>Using a logistic regression framework, we determine the likelihood that an individual patient with one of the three conditions (back pain, joint disease, or car accident) will receive an opioid prescription and how this varies by geographic density between patients. We also perform a two-way Blinder-Oaxaca decomposition to understand whether it is the endowments (mean levels) of these factors or the strength of the relationship (coefficients) of those factors that is more important in explaining the differences in opioid prescribing across metropolitan and non-metropolitan areas. Finally, we also explore interactions between the demand and supply side factors.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec005\">\n                    <jats:title>Findings<\/jats:title>\n                    <jats:p>We find that patients in non-metropolitan areas were 10 percentage points more likely to receive an opioid prescription. About half of this differential is attributable to the underlying health of the local population. Focusing on three prevalent conditions for which an opioid is commonly prescribed (back pain, joint disease, and car accidents), we find that a little less than half of the remaining gap can be explained by supply side factors, such as differences in the health care delivery system. On the demand side both demographics, particularly veteran status, and health insurance type were important factors. Roughly 80 percent of the difference in opioid prescribing rates can be explained by the inclusion of both sets of covariates. Allowing for the interaction of some demand-side (e.g., working in a physically demanding occupation) and supply-side (e.g., healthcare delivery system) variables further reduces this differential to be less than half of a percentage point and statistically insignificant.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec006\">\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Our findings suggest economic conditions, such as the type of working conditions that patients might experience, interact with the healthcare system in unforeseen ways and that more targeted interventions can reduce the persistent gap in opioid prescribing among more and less densely populated areas, with possible downstream impacts on overdose and mortality.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1371\/journal.pone.0349247","type":"journal-article","created":{"date-parts":[[2026,5,27]],"date-time":"2026-05-27T17:30:26Z","timestamp":1779903026000},"page":"e0349247","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":1,"title":["Why are Massachusetts opioid prescribing rates higher in rural versus urban areas?"],"prefix":"10.1371","volume":"21","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8998-3282","authenticated-orcid":true,"given":"Alicia Sasser","family":"Modestino","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gary J.","family":"Young","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Md Mahmudul","family":"Hasan","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jiesheng","family":"Shi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5353-9710","authenticated-orcid":true,"given":"Md Noor E.","family":"Alam","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2026,5,27]]},"reference":[{"key":"pone.0349247.ref001","article-title":"2022 National Survey on Drug Use and Health (NSDUH), Detailed Tables, Table 1.99B","author":"Substance Abuse and Mental Health Services Administration","year":"2023"},{"key":"pone.0349247.ref002","doi-asserted-by":"crossref","first-page":"563","DOI":"10.1186\/s12913-014-0563-8","article-title":"Opioid prescribing patterns for non-malignant chronic pain for rural versus non-rural US adults: a population-based study using 2010 NAMCS data","volume":"14","author":"JP Prunuske","year":"2014","journal-title":"BMC Health Serv Res"},{"issue":"26","key":"pone.0349247.ref003","doi-asserted-by":"crossref","first-page":"697","DOI":"10.15585\/mmwr.mm6626a4","article-title":"Vital Signs: Changes in Opioid Prescribing in the United States, 2006-2015","volume":"66","author":"GP Guy","year":"2017","journal-title":"MMWR Morb Mortal Wkly Rep"},{"issue":"3","key":"pone.0349247.ref004","first-page":"292","article-title":"Explaining spatial disparities in drug overdoses, 1970-2014","volume":"51","author":"M Davlasheridze","year":"2021","journal-title":"Review of Regional Studies"},{"key":"pone.0349247.ref005","doi-asserted-by":"crossref","first-page":"894","DOI":"10.1093\/milmed\/usz104","article-title":"Regional and Rural-Urban Variation in Opioid Prescribing in the Veterans Health Administration","volume":"184","author":"BC Lund","year":"2019","journal-title":"Mil Med"},{"issue":"2","key":"pone.0349247.ref006","article-title":"Trends in Opioid Prescriptions Among Part D Medicare Recipients From 2007 to 2012","volume":"129","author":"Y-F Kuo","year":"2016","journal-title":"Am J Med"},{"issue":"10","key":"pone.0349247.ref007","doi-asserted-by":"crossref","first-page":"988","DOI":"10.1016\/j.jpain.2012.07.007","article-title":"Geographic variation in opioid prescribing in the U.S","volume":"13","author":"DC McDonald","year":"2012","journal-title":"J Pain"},{"key":"pone.0349247.ref008","unstructured":"Massachusetts Department of Public Health. MA Prescription Monitoring Program County-Level Data Measures (2019 Quarter 1). 2019. https:\/\/www.mass.gov\/doc\/prescription-monitoring-program-pmp-data-county-overview-may-2019\/download"},{"issue":"12","key":"pone.0349247.ref009","doi-asserted-by":"crossref","first-page":"1675","DOI":"10.2105\/AJPH.2018.304673","article-title":"Estimated prevalence of opioid use disorder in Massachusetts, 2011-2015: a capture-recapture analysis","volume":"108","author":"JA Baracas","year":"2018","journal-title":"Am J Public Health"},{"key":"pone.0349247.ref010","author":"A Modestino","year":"2021"},{"key":"pone.0349247.ref011","author":"JE Wennberg","year":"1973"},{"issue":"2","key":"pone.0349247.ref012","doi-asserted-by":"crossref","first-page":"25","DOI":"10.15585\/mmwr.mm6802a1","article-title":"Opioid Prescribing Rates in Nonmetropolitan and Metropolitan Counties Among Primary Care Providers Using an Electronic Health Record System - United States, 2014-2017","volume":"68","author":"MC Garc\u00eda","year":"2019","journal-title":"MMWR Morb Mortal Wkly Rep"},{"key":"pone.0349247.ref013","article-title":"Rural America at a glance, 2018 edition. EIB-200","author":"J Cromartie","year":"2018"},{"key":"pone.0349247.ref014","article-title":"Correlates of opioid dispensing","author":"V Themula","year":"2018"},{"key":"pone.0349247.ref015","doi-asserted-by":"crossref","first-page":"319","DOI":"10.1016\/j.jrurstud.2018.12.004","article-title":"The contributions of socioeconomic and opioid supply factors to U.S. drug mortality rates: Urban-rural and within-rural differences","volume":"68","author":"SM Monnat","year":"2019","journal-title":"Journal of Rural Studies"},{"issue":"8","key":"pone.0349247.ref016","doi-asserted-by":"crossref","first-page":"1084","DOI":"10.2105\/AJPH.2019.305136","article-title":"Using Census Data to Understand County-Level Differences in Overall Drug Mortality and Opioid-Related Mortality by Opioid Type","volume":"109","author":"SM Monnat","year":"2019","journal-title":"Am J Public Health"},{"issue":"2","key":"pone.0349247.ref017","doi-asserted-by":"crossref","first-page":"182","DOI":"10.2105\/AJPH.2017.304187","article-title":"Opioid Crisis: No Easy Fix to Its Social and Economic Determinants","volume":"108","author":"N Dasgupta","year":"2018","journal-title":"Am J Public Health"},{"issue":"11","key":"pone.0349247.ref018","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0112416","article-title":"The prevalence and correlates of lifetime psychiatric disorders and trauma exposures in urban and rural settings: results from the national comorbidity survey replication (NCS-R)","volume":"9","author":"JS McCall-Hosenfeld","year":"2014","journal-title":"PLoS One"},{"key":"pone.0349247.ref019","doi-asserted-by":"crossref","first-page":"156","DOI":"10.4324\/9781315189857-14","article-title":"Suicide in Rural Areas","volume-title":"Mental Health in Rural America","author":"EG Stewart","year":"2018"},{"issue":"2","key":"pone.0349247.ref020","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1353\/eca.2017.0012","article-title":"Where Have All the Workers Gone? An Inquiry into the Decline of the U.S. Labor Force Participation Rate","volume":"2017","author":"AB Krueger","year":"2017","journal-title":"Brookings Pap Econ Act"},{"key":"pone.0349247.ref021","doi-asserted-by":"crossref","first-page":"222","DOI":"10.1016\/j.jhealeco.2017.07.009","article-title":"Macroeconomic conditions and opioid abuse","volume":"56","author":"A Hollingsworth","year":"2017","journal-title":"J Health Econ"},{"key":"pone.0349247.ref022","volume-title":"Deaths of despair and the future of capitalism","author":"A Case","year":"2020"},{"key":"pone.0349247.ref023","unstructured":"Foutz J, Artiga S, Garfield R. The role of Medicaid in rural America. https:\/\/www.kff.org\/medicaid\/issue-brief\/the-role-of-medicaid-in-rural-america\/ 2017. 2025 February 11."},{"issue":"9","key":"pone.0349247.ref024","doi-asserted-by":"crossref","first-page":"1183","DOI":"10.1002\/pds.5075","article-title":"Opioid prescribing on discharge to skilled nursing facilities","volume":"29","author":"AR Hubsky","year":"2020","journal-title":"Pharmacoepidemiol Drug Saf"},{"issue":"3","key":"pone.0349247.ref025","doi-asserted-by":"crossref","first-page":"409","DOI":"10.1016\/j.amepre.2015.02.020","article-title":"Trends in Opioid Analgesic-Prescribing Rates by Specialty, U.S., 2007-2012","volume":"49","author":"B Levy","year":"2015","journal-title":"Am J Prev Med"},{"issue":"3","key":"pone.0349247.ref026","doi-asserted-by":"crossref","first-page":"200","DOI":"10.1370\/afm.2357","article-title":"Chronic Opioid Prescribing in Primary Care: Factors and Perspectives","volume":"17","author":"ST Tong","year":"2019","journal-title":"Ann Fam Med"},{"issue":"1","key":"pone.0349247.ref027","doi-asserted-by":"crossref","first-page":"8","DOI":"10.1016\/j.pmn.2017.09.004","article-title":"Use of Self-management Interventions for Chronic Pain Management: A Comparison between Rural and Nonrural Residents","volume":"19","author":"LH Eaton","year":"2018","journal-title":"Pain Manag Nurs"},{"issue":"7","key":"pone.0349247.ref028","doi-asserted-by":"crossref","first-page":"663","DOI":"10.1056\/NEJMsa1610524","article-title":"Opioid-Prescribing Patterns of Emergency Physicians and Risk of Long-Term Use","volume":"376","author":"ML Barnett","year":"2017","journal-title":"N Engl J Med"},{"issue":"4","key":"pone.0349247.ref029","doi-asserted-by":"crossref","first-page":"533","DOI":"10.1080\/10826084.2017.1342659","article-title":"Opioid Prescribing in Rural Family Practices: A Qualitative Study","volume":"53","author":"IA Click","year":"2018","journal-title":"Subst Use Misuse"},{"issue":"1","key":"pone.0349247.ref030","first-page":"77","article-title":"The Effect of Prescription Drug Monitoring Programs on Opioid Utilization in Medicare","volume":"10","author":"TC Buchmueller","year":"2018","journal-title":"American Economic Journal: Economic Policy"},{"issue":"3","key":"pone.0349247.ref031","doi-asserted-by":"crossref","first-page":"273","DOI":"10.1080\/00952990.2019.1694536","article-title":"A systematic review of rural-specific barriers to medication treatment for opioid use disorder in the United States","volume":"46","author":"JJ Lister","year":"2020","journal-title":"Am J Drug Alcohol Abuse"},{"issue":"1","key":"pone.0349247.ref032","doi-asserted-by":"crossref","first-page":"23","DOI":"10.1370\/afm.1735","article-title":"Geographic and specialty distribution of US physicians trained to treat opioid use disorder","volume":"13","author":"RA Rosenblatt","year":"2015","journal-title":"Ann Fam Med"},{"key":"pone.0349247.ref033","unstructured":"U.S. Census Bureau. Explanation of the 2010 Urban Area to ZIP Code Tabulation Area (ZCTA) Relationship File. https:\/\/www2.census.gov\/geo\/pdfs\/maps-data\/data\/rel\/explanation_ua_zcta_rel_10.pdf"},{"key":"pone.0349247.ref034","volume-title":"Stata Statistical Software: Release 15.1","author":"StataCorp","year":"2017"},{"key":"pone.0349247.ref035","volume-title":"Dreamland: The true tale of America\u2019s opiate epidemic","author":"S Quinones","year":"2016"},{"key":"pone.0349247.ref036","article-title":"Did Medicaid expansion cause the opioid epidemic? There\u2019s little evidence that it did.","author":"A Goodman-Bacon","year":"2017","journal-title":"Health Affairs"},{"issue":"4","key":"pone.0349247.ref037","doi-asserted-by":"crossref","first-page":"947","DOI":"10.2307\/146404","article-title":"Gender Wage Discrimination Bias? A Meta-Regression Analysis","volume":"33","author":"TD Stanley","year":"1998","journal-title":"The Journal of Human Resources"},{"issue":"3","key":"pone.0349247.ref038","doi-asserted-by":"crossref","first-page":"479","DOI":"10.1111\/j.0950-0804.2005.00256.x","article-title":"A Meta-Analysis of the International Gender Wage Gap","volume":"19","author":"D Weichselbaumer","year":"2005","journal-title":"Journal of Economic Surveys"},{"key":"pone.0349247.ref039","volume-title":"Analyzing health equity using household survey data: A guide to techniques and their implementation","author":"O O\u2019Donnell","year":"2008"},{"issue":"1","key":"pone.0349247.ref040","first-page":"55","article-title":"Illness and the workplace: a study of physicians and employers","volume":"31","author":"RN Merrill","year":"1990","journal-title":"J Fam Pract"}],"container-title":["PLOS One"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0349247","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,5,27]],"date-time":"2026-05-27T17:30:34Z","timestamp":1779903034000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0349247"}},"subtitle":[],"editor":[{"given":"Junghwan","family":"Kim","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2026,5,27]]},"references-count":40,"journal-issue":{"issue":"5","published-online":{"date-parts":[[2026,5,27]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0349247","relation":{},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,5,27]]}}}