BACKGROUND: Opioid agonist treatments (OAT
methadone and buprenorphine) for opioid use disorder (OUD) reduce overdose death by more than 50%. Low population-level rates of OAT are missed opportunities to reduce OUD-related mortality. OBJECTIVE: We examined county-level OAT utilization patterns to guide state-level and county-level initiatives to improve equitable access and utilization in New York State (NYS). RESEARCH DESIGN: We calculated NYS county-level methadone and buprenorphine population utilization rates per 100,000 residents by county of patient residence using NYS Office of Addiction Services and Supports and public access datasets. MEASURES: We mapped rates onto counties and conducted analyses to assess if utilization varied by county, and to identify areas of high utilization (hot spots) and low utilization (cold spots). We used t tests and Fisher exact tests to compare county-level factors. RESULTS: County-level buprenorphine and methadone utilization rates were 673.76 and 132.19 per 100,000 residents, respectively. Buprenorphine hot spot counties had significantly lower proportions of unemployed (-1.4, P-value<
0.01), and higher proportions of non-Hispanic white residents (+50.1, P value<
0.01) than counties identified as buprenorphine cold spots. Methadone hot spot counties had significantly higher proportions of unemployed (+1.0, P-value<
0.01) and lower proportions of non-Hispanic white residents (-48.1, P- value<
0.01) than counties identified as methadonecold spots. All buprenorphine cold spot counties were methadone hot spot counties. CONCLUSIONS: We found that OAT utilization rates differed by race/ethnicity and socioeconomic factors at the county level consistent with national and other state-level findings. Ensuring equitable OAT access must be part of a coordinated response to address the overdose crisis.