Geographic differences in buprenorphine and methadone prescribing for surgical patients with opioid use disorder

Abstract

Background

Patients with opioid use disorder (OUD) frequently present for surgery while receiving medications for OUD (MOUD), typically buprenorphine or methadone. This study evaluated MOUD use among surgical patients with OUD in a health-system spanning both urban and rural areas in Maine; a predominantly rural state with a significant opioid crisis.

Methods

We retrospectively identified adult surgical patients with OUD admitted to MaineHealth hospitals from 2014 to 2023 who were receiving MOUD prior to the day of surgery. Demographics and clinical characteristics were collected; rural designation was determined using Rural-Urban Commuting Area codes. The primary outcome was the temporal trend in proportion of surgical patients with OUD receiving methadone versus buprenorphine prior to admission. Temporal trends and geographic differences were compared using chi-square tests (p < 0.05).

Results

Of 2099 surgical patients on MOUD, 71.4 % received buprenorphine and 28.6 % methadone. Overall, rural patients were more likely to receive buprenorphine than urban patients (75.1 % vs. 68.5 %) (p < 0.001). Buprenorphine prescribing increased from 52.0 % to 84.2 % in rural areas and from 59.3 % to 72.9 % in urban areas, with corresponding declines in methadone use (both p < 0.05).

Conclusions

Temporal trends showed a significant shift in MOUD prescribing over the study period, with buprenorphine use increasing and methadone use declining in rural and urban populations. Although both medications are considered safe in hospitalized and surgical patients, perioperative management remains inconsistent. Further work is needed to evaluate how these prescribing trends influence clinical outcomes and ensure perioperative protocols support continuity of care for patients with OUD.

Highlights

• •Buprenorphine use grows as methadone declines across rural and urban areas.
• •Buprenorphine prescribing increased after expanded access.
• •Rural patients more likely to be maintained on buprenorphine than methadone.

1. Introduction

The opioid use disorder (OUD) epidemic continues to affect communities across the globe, with wide regional variations in prevalence based on age, gender, and socioeconomic status (Wang et al., 2025). Worldwide, opioid-related deaths are increasing, with patterns shaped by drug supply and healthcare access. In the United States, rates are rising fastest in rural counties, particularly in the Northeast and Midwest (Oladapo and Olapado, 2024). This disproportionate impact is driven by several factors, including disparities in access to addiction treatment (Johnson et al., 2018). Buprenorphine and methadone are effective medications for OUD (MOUD) that reduce morbidity and mortality by improving retention in treatment programs, lowering the risk of fatal overdose and decreasing the incidence of infectious complications (Ward et al., 2018). Despite these benefits, only about 25 % of eligible individuals are engaged in care, largely due to persistent barriers shaped by regulatory constraints and limited provider availability- both of which vary significantly by geographic location (Arwady et al., 2024). Currently, most primary care providers cannot prescribe methadone for addiction treatment, as treatment must occur under the supervision of a certified practitioner with adherence to initial dosing protocols that limit individualized titration (Merrill, 2002, Substance Abuse and Mental Health Services Administration, 2023a). In contrast, the 2023 Consolidated Appropriations Act removed the federal waiver requirement and prescribing caps, allowing any practitioner with a DEA license to prescribe buprenorphine (Substance Abuse and Mental Health Services Administration, 2023b). This policy change is particularly impactful for predominantly rural states with fewer specialized addiction treatment providers (Conway et al., 2022).

While much of the existing literature on MOUD utilization has focused on outpatient and primary care settings, examining MOUD use patterns in surgical populations is equally important, since these patients require specialized perioperative care to address both pain control and withdrawal prevention. Protocols for managing perioperative pain differ depending on the MOUD prescribed, as buprenorphine and methadone have distinct pharmacologic profiles with separate implications for intraoperative and postoperative analgesia (Ward et al., 2018). Buprenorphine is a potent partial-agonist at the mu receptor and is not readily displaced by full opioid receptor agonists used in conjunction for pain control (Quaye and Zhang, 2019). Because of this unique pharmacokinetic profile, while it has been established that buprenorphine should be continued perioperatively to facilitate analgesia and reduce the risk of withdrawal, whether to continue the patient’s current dose or taper them to a lower dose to facilitate analgesia remains unclear (Lembke et al., 2019). Along with variations in dosing strategies, there are also clinicians that discontinue buprenorphine perioperatively due to concerns that it will interfere with the analgesic efficacy of full agonist opioids used in conjunction. Our recent national survey reported that roughly one in seven practitioners routinely held buprenorphine perioperatively and only 36 % of institutions had a formal perioperative buprenorphine management protocol (Quaye et al., 2023). While methadone as a full opioid agonist does not have the potential to interfere with analgesic efficacy the same way buprenorphine does, there are practitioners that choose to withhold methadone since they do not recognize that it is also a pain medication and that stopping can lead to withdrawal (Coluzzi et al., 2017). Understanding how prescribing patterns for these medications are changing over time can help identify where targeted education and protocol development are most needed to support consistent, evidence-based perioperative OUD management.

Prior work has shown that rural systems tend to rely more heavily on buprenorphine and less on methadone when compared to urban settings, in part due to limited access to opioid treatment programs, fewer available providers and cost constraints (Jones et al., 2023, Wyse et al., 2023). However, to date no study has explored geographic variation in MOUD prescribing among surgical patients. Furthermore, few studies have directly examined prescribing trends for patients residing in rural compared to urban areas. Understanding this variation is important because buprenorphine and methadone require different perioperative pain management approaches and discharge planning strategies, and aligning care with locally prevalent prescribing patterns can help ensure continuity of OUD treatment. In this study, our primary objective was to evaluate temporal trends in MOUD prescribing among surgical patients with OUD within a large integrated health system in Maine, a predominantly rural state before and after legislative reforms expanded buprenorphine access. We further assessed differences in MOUD utilization between rural and urban populations to identify potential geographic disparities in care.

2. Methods

This project was reviewed as exempt by the MaineHealth Maine Medical Center Institutional Review Board. Adult surgical patients with a documented diagnosis of OUD between January, 1, 2014 and December 31, 2023 were included if they were receiving MOUD at the time of admission to MaineHealth. Surgical patients were identified as having OUD based on ICD-10 diagnostic codes. Within this cohort, a query was developed to identify individuals with an active prescription for buprenorphine (including buprenorphine/naloxone) and methadone within the 30 days prior to their procedure, excluding those prescribed transdermal or buccal formulations used for chronic pain. A random sample of charts was manually reviewed by two independent clinical researchers to confirm diagnostic accuracy and indication for MOUD use. Only the first surgical encounter was included in analysis. Those on naltrexone were excluded due to low sample size. We collected data on demographic information (age, sex, body mass index, race, ethnicity), clinical characteristics (cigarette smoking status, psychiatric comorbidities, medication use), severity of systemic illness using the American Society of Anesthesiologists Physical System Classification System (ASA) score, and type of insurance. The primary outcome was the temporal trends in MOUD type on admission (methadone or buprenorphine) over the study period. We next evaluated differences in prescribing practices by rural versus urban location, defined using Rural-Urban Commuting Area codes (RUCA) for each patient’s residential zip code. RUCA codes 4–10 were considered rural regions and RUCA codes 1–3 were considered urban as described previously (Economic Research Service, 2025).

Descriptive statistics included means and standard deviations for continuous variables and counts and proportions for categorical variables. Group comparisons were made using chi-square tests. Analyses were performed using SPSS Statistical Software version 29 (IBM SPSS INC., Armonk, NY). Statistical significance was set at p < 0.05.

3. Results

We identified a total of 2099 patients with OUD who were taking buprenorphine (1498, 71.4 %) or methadone (601, 28.6 %) on admission for surgery from 2014 to 2023. Table 1 shows the clinical and demographic characteristics of the study group, both overall and stratified by patients’ rural/urban home locations. Distributions were similar for the rural and urban groups. The mean age was 42 years; 48.5 % were male, and 96.6 % were Caucasian. Tobacco use was reported in 69.7 % of patients. Psychiatric diagnoses were common in both groups and 32.4 % were prescribed antidepressants. 50 % of patients had an ASA classification of III and most patients (75.4 %) were insured through Medicare/Medicaid. Patients residing in rural areas were more likely to be on buprenorphine compared to those from urban areas (75.1 % vs. 68.5 %) and less likely to be on methadone (24.9 % vs. 31.5 %) (p <  0.001) (Table 2).

Table 1.

Demographic characteristics of individual participants at the time of the first eligible admission for surgery, 2014–2023.

Variable	Measurementa
	Overall	Ruralb	Urbanc
N	2099	909	1190
Male sex	1019 (48.5)	447 (49.2)	572 (48.1)
Age (years)	42.2 ± 12.0	42.3 ± 12.0	42.1 ± 12.1
Body mass index (kg/m2)	28.6 ± 7.2	28.7 ± 7.2	28.5 ± 7.2
N	2027	886	1141
Race
N	2086	903	1183
White/Caucasian	2015 (96.6)	880 (97.5)	1135 (95.9)
Other	71 (3.4)	23 (2.5)	48 (4.1
Current Cigarette Smoking	951 (69.7)	393 (68.9)	558 (70.3)
N	1364	570	794
Depression/Anxiety/PTSD	1210 (57.6)	492 (54.1)	718 (60.3)
Patient taking medication on admission
Anti-depressant	681 (32.4)	301 (33.1)	380 (31.9)
Anti-psychotic	198 (9.4)	93 (10.2)	105 (8.8)
Anti-anxiety	310 (14.8)	143 (15.7)	167 (14.0)
Gabapentin	457 (21.8)	191 (21.0)	266 (22.4)
ASA Score
N	2098	908	1190
1–2	873 (41.6)	361 (39.8)	512 (43.0)
3	1048 (50.0)	467 (51.4)	581 (48.8)
4–5	177 (8.4)	80 (8.8)	97 (8.2)
Insurance type
Medicare/Medicaid/replacement	1581 (75.3)	690 (75.9)	891 (74.9)
Private	257 (12.2)	99 (10.9)	158 (13.3)
None entered/self	128 (6.1)	61 (6.7)	72 (6.0)
Otherd	133 (6.4)	61 (6.7)	72 (6.0)
Distance to care (miles)	22 [10−49]	48 [23−77]	17 [7−27]

Abbreviations: ASA, American Society of Anesthesiologists

^aData shown as n (%), median [interquartile range], or mean ± standard deviation.

^bRural-Urban Commuting Area (RUCA) codes 4–10

^cRUCA codes 1–3

^dIncludes: n = 69, workers compensation/third party liability; n = 25, military; n = 11, Maine Heart Center; n = 28, Prison Health

Table 2.

Overall MOUD management among individual participants at the time of the first eligible admission for surgery, 2014–2023, stratified by home location type.

Variable	N (%)
	Overall	Rurala	Urbanb
N	2099	909	1190	p-valuec
MOUD type at initial surgery
Methadone	601 (28.6)	226 (24.9)	375 (31.5)	< 0.001
Buprenorphined	1498 (71.4)	683 (75.1)	815 (68.5)

Abbreviation: MOUD, medications for opioid use disorder; RUCA, Rural-Urban Commuting Area

^aRUCA codes 4–10

^bRUCA codes 1–3

^cChi square test

^dIncludes buprenorphine and buprenorphine/naloxone

Temporal trends showed a significant shift in MOUD prescribing over the study period, with buprenorphine use increasing and methadone use declining in both rural and urban populations. In rural areas, buprenorphine prescribing rose from 52.0 % in 2014–84.2 % in 2023, while methadone prescribing decreased from 48.0 % to 15.8 % (p <  0.001). A similar, though less pronounced, trend was observed in urban areas, where buprenorphine use increased from 59.3 % to 72.9 % and methadone use declined from 40.7 % to 27.1 % (p= 0.018) (Fig. 1).

Fig. 1.

Change in type of MOUD prescribed over time, to individuals with opioid use disorder admitted for surgery, stratified by their home location type.^a. Abbreviations: MOUD, medications for opioid use disorder. ^a Data from MaineHealth sites other than MaineHealth Maine Medical Center became available in 2020; the data presented are limited to initial surgeries performed during the overall time period. ^b Chi square test.

4. Discussion

We found that buprenorphine was prescribed more commonly than methadone among surgical patients with OUD receiving care at MaineHealth. Rural residence was associated with a significantly higher rate of buprenorphine use; this may be related to the relative scarcity of methadone clinics in rural areas. The proportion of patients receiving buprenorphine increased substantially over time, such that by 2023, more than 70 % of patients in both rural and urban geographic regions were on buprenorphine. Notably, while methadone use remained relatively stable, the absolute number of patients receiving MOUD rose considerably, suggesting that expanded access to buprenorphine may have helped engage a growing population of patients who otherwise might not have received treatment.

These shifts in prescribing patterns mirror national trends where it is estimated that about 400,000 patients with OUD are dispensed methadone annually, while the number of patients on buprenorphine is over 900,000 (IQVIA Government Solutions Inc., 2024, Williams et al., 2023). Increases in buprenorphine access have evolved incrementally starting with changes in federal policy with the Comprehensive Addiction and Recovery Act of 2016 and the SUPPORT Act of 2018 which expanded prescriber eligibility to include nurse practitioners and physician assistants, including X-waiver eligibility (Christine et al., 2024). In April 2021, training requirements were temporarily removed and by December 2022, the X-waiver training requirement discontinued altogether and any DEA-registered clinician with Schedule III authority may prescribe buprenorphine for OUD in an office-based setting. The trends that we have observed suggest that these reforms expanding access to life saving treatment significantly impacted not just rural communities that face significant barriers to addiction treatment, due to provider shortages and geographic isolation but also urban areas where access to methadone through Opioid Treatment Programs (OTPs) is more readily available. In Maine, access to methadone remains limited with only 14 OTPs, mostly located in metropolitan or micropolitan counties. This leaves many rural regions without nearby OTPs, requiring patients to travel long distances for treatment in the form of methadone and likely contributing to greater reliance on buprenorphine in rural areas.

Beyond regulation and access, treatment decisions are also shaped by social context and individual preference. A qualitative survey on patient preferences for using buprenorphine or methadone found that patients’ prior experiences with a specific medication, including adverse side effects, short term versus long term recovery goals, and their beliefs about medication effectiveness from feedback from their peers greatly influence treatment decisions (Ridge et al., 2009). Cost is also a major factor in medication choice as methadone is generally less expensive, especially when considering buprenorphine combination formulations (Hansen et al., 2013). In terms of demographic differences, studies indicate buprenorphine is more commonly used by patients who are Caucasian, employed, and have higher incomes, while methadone is used more frequently in lower-income, minority populations (Hansen et al., 2013). As such, geographic variation in treatment patterns may reflect more than just access. It may also reflect differences in how addiction is perceived, discussed, and managed across communities.

Understanding the community prevalence of buprenorphine compared to methadone is particularly important in the surgical setting, since perioperative pain management strategies must account for the differing pharmacologic properties of the two medications. Methadone, as a full opioid agonist with a long half-life, is typically continued throughout the perioperative period to maintain OUD treatment and facilitate pain control. Additional full opioid agonists can be administered in conjunction without interfering with analgesic efficacy (Ward et al., 2018). Buprenorphine management is more complex since there are concerns that its partial agonist activity, high receptor affinity, and slow dissociation from the mu-opioid receptor may limit the effectiveness of supplemental opioids used for acute pain management, especially when buprenorphine is administered in higher doses. While prior guidelines advocated for withholding buprenorphine in the perioperative period emerging evidence supports that it should be continued at a reduced dose to facilitate opioid-based analgesia (Lembke et al., 2019, Quaye and Zhang, 2019). Unfortunately, there are still providers that routinely discontinue buprenorphine which is harmful since the risk of relapse can exceed 80 % with abrupt discontinuation (Quaye et al., 2023, Quaye and Zhang, 2019).

Given the increasing number of patients on buprenorphine undergoing surgery, it is critical that perioperative providers understand the implications of MOUD selection and remain informed about evolving best practices. Anesthesiologists, surgeons, and acute care teams must be equipped to manage patients on buprenorphine without discontinuing therapy unnecessarily. Additionally, recognizing rural- urban differences in MOUD prescribing patterns is essential for ensuring perioperative protocols and discharge planning are tailored to the prevailing regional treatment patterns in order to reduce the risk of OUD destabilization, improve postoperative outcomes, and support long-term recovery.

There are limitations to this study that are worth considering. It was conducted within a single health system dispersed across the state of Maine with a predominately Caucasian population mix which may limit generalizability to other regions with different patient populations. This is particularly important since it has been established that non-Caucasian patients- including black, Hispanic, Asian and native American groups have substantially less access to MOUD (Gibbons et al., 2024, Hollander et al., 2021). Also, the rationale behind MOUD selection, including whether it was driven by provider or patient preference and treatment access was not available, restricting our interpretation of observed prescribing patterns. Additionally, patients were identified using ICD-10 codes specific for OUD, which may underestimate the true prevalence of OUD due to under-documentation. Finally, we did not assess MOUD continuation or relapse postoperatively and so are unable to evaluate the implications of prescribing differences, however prior studies have reported that postoperative analgesia is comparable with both buprenorphine and methadone continuation (Dale et al., 2022, Quaye et al., 2024). Future analyses are planned to examine rural-urban differences in postoperative analgesic outcomes associated with the perioperative management of buprenorphine compared to methadone.

Taken together, these findings illustrate that buprenorphine prevalence is increasing in perioperative patients both in rural and urban regions. While the rising prevalence of buprenorphine likely reflects improved access, it may also be influenced by the relative difficulty of accessing methadone, especially in rural regions where OTP availability is limited. As MOUD prescribing continues to evolve, further work is needed to evaluate how these prescribing trends influence clinical outcomes and ensure perioperative protocols support continuity of care for patients with OUD.

CRediT authorship contribution statement

Janelle M. Richard: Writing – review & editing, Resources, Project administration, Investigation, Data curation. Caitlin P. Coates: Writing – review & editing, Writing – original draft, Investigation. Margaret McGlothlin Carroll: Writing – review & editing, Writing – original draft, Investigation. Wendy Y. Craig: Writing – review & editing, Writing – original draft, Methodology, Formal analysis. Quaye Aurora: Writing – review & editing, Writing – original draft, Supervision, Methodology, Investigation, Conceptualization.

Funding

This project was supported in part by services provided by the Northern New England Clinical and Translational Research Center’s National Institutes of Health grant [U54GM115516]. We also acknowledge support from National Institutes of Health grant P20 GM139745.

Declaration of Competing interest

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Wendy Craig reports financial support was provided by NIH National Institute of General Medical Sciences. Aurora Quaye reports financial support was provided by National Institutes of Health. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.