Introduction Individuals living in rural areas experience limited access to safe and effective pain management. Using insurance claims for 1.3 million Virginians, we evaluated variation in high-risk nonsteroidal anti-inflammatory drug (NSAID) prescribing by rurality during 2019-2021.

Methods We applied a difference-in-differences model to analyze the effect of the COVID-19 pandemic on high-risk NSAID prescribing rates, stratifying incidence rate ratios (IRR) by rurality.

Results Although high-risk NSAID prescribing rates decreased modesty during 2020-2021, rural areas experienced significantly higher prescribing rates throughout the study period (IRR: 1.594 [95% CI: 1.408, 1.803], p<.001).

Conclusions Context-driven efforts to de-implement high-risk NSAID prescribing in rural Virginia are needed.

The authors have declared no competing interest.

This research was funded, in part, by the Virginia Tech Libraries Collaborative Grant.

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Based on the use of de-identified data, this study was deemed non-human subjects research by the Institutional Review Board of Carilion Clinic. All data were received from the Virginia All-Payer Claims Database (APCD) https://www.vhi.org/apcd/

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