Tracking Opioid Prescribing Metrics in Washington State (2012-2017): Differences by County-Level Urban-Rural and Economic Distress Classifications

J Rural Health. 2020 Mar;36(2):152-166. doi: 10.1111/jrh.12400. Epub 2019 Oct 4.


Purpose: High-risk opioid prescribing is a critical driver of prescription opioid-related morbidity and mortality. This study explored opioid prescribing patterns across urban-rural and economic distress classifications. Secondarily, this study explored the urban-rural distribution of relevant health services, economic factors, and population characteristics.

Methods: County-level opioid prescribing metrics were based on quarterly Washington State Prescription Monitoring Program data (2012-2017). Counties were classified using the 2013 National Center for Health Statistics Urban-Rural Classification Scheme for Counties, and Washington State unemployment-based distressed areas. County-level measures from Area Health Resources Files were used to describe the urban-rural continuum.

Findings: Persistent economic distress was associated with higher-risk opioid prescribing. The large central metropolitan category had lower-risk opioid prescribing metrics than the other 5 urban-rural categories, which were similar to each other and not ordered by degree of rurality. High-risk prescribing declined over time, without notable trend divergence by either urban-rural or economic distress classifications.

Conclusions: The most striking urban-rural differences in opioid prescribing metrics were between large central metropolitan and all other categories; thus, we recommend caution when collapsing urban-rural categories for analysis. Further research is needed regarding geographic and economic patterning of opioid prescribing practices, as well as the dissemination of guidelines and best practices across the urban-rural continuum. Finally, the multiple intertwined burdens faced by rural communities-higher-risk prescribing practices, higher opioid morbidity and mortality rates, and fewer resources for primary care, mental health care, alternative pain treatment, and opioid use disorder treatment-must be addressed as an urgent public health priority.

Keywords: inappropriate prescribing; opioids; prescription drug monitoring programs; rural; unemployment.

Publication types

  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Analgesics, Opioid* / therapeutic use
  • Benchmarking
  • Humans
  • Practice Patterns, Physicians'
  • Rural Population*
  • Urban Population
  • Washington / epidemiology


  • Analgesics, Opioid