Methadone treatment in the rural and urban United States: Geographic barriers and regional variations in Medicare-enrolled opioid treatment program availability.

INTRODUCTION: Rural older adults face unique challenges accessing medications for opioid use disorder (MOUD), especially methadone. Methadone can only be obtained from a federally certified and accredited opioid treatment program (OTP). Medicare began covering OTP services in 2020. While increasing numbers of Medicare enrollees have accessed methadone, it remains an underutilized treatment option. This study describes the availability of Medicare-enrolled OTPs in rural and urban counties.

METHODS: We conducted a cross-sectional analysis of the Centers for Medicare & Medicaid Services (CMS) database of Medicare-enrolled OTPs in June 2025. Enrolled OTPs' county locations were classified as urban or rural (micropolitan and noncore) using Urban Influence Codes. We calculated the proportions of counties with at least one enrolled OTP and ratios of enrolled OTPs per 100,000 Medicare enrollees and adult population. We compared percentages and per capita supply of enrolled OTPs across rural-urban categories, across US Census Divisions, and by county typology characteristics.

RESULTS: There were 681 counties with a Medicare-enrolled OTP (21.6% of US counties), with 46.0% of urban counties (n = 546) but only 6.9% of rural counties (n = 135) having a Medicare-enrolled OTP. Most rural enrolled OTPs were in micropolitan counties (84.2%, n = 133) while only 15.8% (n = 25) were located in noncore rural counties. About 9.3 million Medicare enrollees and 31.1 million adults live in rural counties without a Medicare-enrolled OTP. Urban counties had a higher supply of Medicare-enrolled OTPs per 100,000 Medicare enrollees and per 100,000 adults than rural counties. We observed regional variation in the availability of Medicare-enrolled OTPs: the West North Central and West South Central Census Divisions had the lowest proportions of counties with enrolled OTPs. Rural counties in these regions had fewer enrolled OTPs per capita than urban counties. Counties with low post-secondary and employment typology had a lower supply of enrolled OTPs than other counties.

CONCLUSIONS: Most rural counties in the US lack access to a Medicare-enrolled OTP, with noted regional disparities in OTP availability. Medicare enrollees living in these counties likely cannot access methadone. Policy and future research should explore additional strategies to expand methadone access in rural communities, such as primary care prescribing with pharmacy dispensing.