A total of 83,509 death certificates collected in 2014 for the 100 NC counties were screened, yielding 4278 cases of SUD (Fig. 1). The mean incidence of SUD was greatest in highly rural counties (100/100,000), followed by mixed urban-rural counties (85/100,000) and highly urban counties (68/100,000). While the univariate regression found several variables to be associated with a high county incidence of SUD (Table 1), the multiple regression model for predicting a high county incidence of SUD only identified the following variables as significant: having a higher percent of the population age 65 or older, lower percent of African-Americans, and lower median household income. For highly rural counties only, lower median household income was significant. Furthermore, although nonmedical use of pain relievers was not initially found to be a significant predictor of SUD, an exploratory analysis found that this variable became significant when included in the state-level multiple regression model.