["Addiction, EarlyView. ", "\nAbstract\n\nAim\nWe evaluated whether community‐level naloxone distribution, medication for opioid use disorder treatment and retention and incident high‐risk opioid prescribing rates were associated with opioid overdose death rates.\n\n\nDesign\nObservational cohort conducted using 2019 to 2023 community‐level data as an exploratory analysis of the HEALing (Helping to End Addiction Long‐term®) Communities Study (HCS). Exposures included: (1) community‐level naloxone distribution, past 12‐months, categorized as ≤1000 units per 100 000 population vs. 1001–3000 units per 100 000 population vs. >3000 units per 100 000 population; (2) individuals treated with buprenorphine per 100 000 adult population in the current quarter; (3) individuals retained on buprenorphine for ≥ 180 days per 100 000 adult population in the current quarter; and (4) incident high‐risk opioid prescribing per 100 000 adult population in the current quarter.\n\n\nSetting and participants\nPopulation‐based study of 67 communities with 8.2 million adults in Kentucky, Massachusetts, New York and Ohio, USA, with required annual opioid overdose death rates of > 25 per 100 000 adult population and at least 30% rural. Across the 67 communities participating in the HCS, the adult population was 31% 18–34 years, 31% 35–54 years, 38% 55 years and over, 52% female, 73% non‐Hispanic White, 15% non‐Hispanic Black and 7.4% Hispanic.\n\n\nMeasurements\nQuarterly community‐level opioid overdose death rates from 2020 through 2023.\n\n\nFindings\nThe 2019 annual rates were 40.4 opioid overdose deaths, 1287 naloxone rescue units distributed, 977.7 people received buprenorphine treatment, 546.3 people retained for more than 180 days on buprenorphine and 1266.7 high‐risk opioid prescribing incidents per 100 000 population. In models adjusted for state, community age, sex, race/ethnicity, rurality, HCS intervention group assignment, 2019 rates of opioid overdose death, naloxone distribution, buprenorphine and high‐risk opioid prescribing, and the ratio of opioid overdose deaths involving fentanyl, an increase in 100 people treated with buprenorphine per 100 000 population was associated with a decrease of 0.92 [95% confidence interval (CI) = −1.30 to −0.55] in the quarterly opioid overdose death rate, while an increase of 100 people retained on buprenorphine for more than 180 days per 100 000 population was associated with a decrease of 1.3 (95% CI = −1.8 to −0. 76). There were no statistically significant associations between naloxone distribution or incident high‐risk opioid prescribing with change in quarterly opioid overdose death rates.\n\n\nConclusions\nIn this exploratory analysis, increases in both buprenorphine treatment and retention were statistically significantly associated with decreases in opioid overdose death rates, after adjusting for baseline rates of buprenorphine treatment and retention.\n\n"]