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Background Opioid-overdose deaths and opioid prescriptions have increased substantially within the past decade, leading to examinations of urban-rural differences for these opioid-related outcomes, and whether annual trends differ by urban-rural status. Most investigations have examined differences using national data, whereas few studies have identified patterns in hard-hit regions. Therefore, we examined urban-rural differences for opioid-related outcomes in Michigan, a state with overdose death and prescribing rates above the nati