Study shows rural-urban gap persists despite adjustments

A study published in The Journal of Rural Health sheds new light on the persistent and troubling disparities in chronic pain prevalence between rural and urban populations in the United States.

Among the authors are three Osher Center for Integrative Health at the University of Vermont (UVM) Affiliates—Joshua Plavin, MD, MPH, FAAP; Gail L. Rose, Ph.D., and Erika C. Ziller, Ph.D.

The study, “Rural-urban disparities in the prevalence of chronic pain in adults: Associations with demographic and socioeconomic characteristics,” was part of a project the Osher Affiliates worked on with the Maine Rural Health Research Center at University of Southern Maine.

It analyzed data from over 107,000 adults across four years of the National Health Interview Survey (2019–2021, 2023), revealing that rural adults are significantly more likely to experience chronic pain than their urban counterparts. Even after adjusting for demographic and socioeconomic factors, rural residents had 9% higher odds of chronic pain, with an adjusted prevalence of 23% compared to 22% in urban areas.

Chronic pain: A rural health crisis

These disparities are not merely statistical—they reflect real barriers to care. Rural populations are more likely to be older, have lower incomes and education levels, and face limited access to specialized pain management services. The study highlights how these structural inequities contribute to a higher burden of chronic pain and, by extension, increased risk for opioid misuse, disability, and reduced quality of life.

Plavin, the Medical Director for the Osher Center’s Comprehensive Pain Program (CPP), sees the data as a call to action. “We must collectively identify and develop new evidence-based approaches and, after studying them to prove value, scale them across diverse geographies and develop sustainable funding models to meet the needs of our region and the nation,” he said.

The Osher Center for Integrative Health at UVM is at the forefront of addressing these challenges through innovative, whole health approaches to chronic pain. The study features its CPP’s Partners Aligned in Transformative Healing (PATH), a program that exemplifies the Osher Center’s mission in action.

PATH offers a 12- to 16-week integrative health program combining evidence-based non-pharmacological therapies such as mindfulness, physical therapy, acupuncture, and behavioral health support.

“PATH equips participants with knowledge and skills to optimize self-management of their pain,” said Rose, who is also an Associate Professor of Psychiatry in the Larner College of Medicine and on the team at UVM’s Center on Rural Addiction (CORA). “We see a range of positive outcomes including physical functioning, emotional health, personal resilience, self-compassion, and a greater sense of control.”

Importantly, PATH is designed with accessibility in mind: it is delivered in-person, online, and in hybrid formats to reach rural patients who might otherwise be excluded from such care.

A key innovation of PATH is its bundled payment model, developed in collaboration with Blue Cross Blue Shield of Vermont. This model ensures that patients pay no more than a standard primary care copay, removing financial barriers and promoting equitable access to comprehensive pain care. Plavin has been instrumental in shaping the model and a Medicaid pilot project that will advance its accessibility.

“The Vermont Medicaid pilot is an exciting and fundamental step towards ensuring equitable access to high value care,” he said.

Lower costs, better health

The report’s findings underscore the urgent need for systemic change in how chronic pain is addressed—particularly in rural communities. The Osher Center’s work demonstrates that integrative health is a necessary strategy for tackling complex, chronic conditions in underserved populations. Rose clarifies the impact of the Whole Health approach in programs like CPP.

“On average,” she said, “participants in our program show reduced health care costs and number of emergency department visits.”

In fact, CPP participants have shown a 70% reduction in emergency room visits one year post program completion.

As policymakers and health care leaders are challenged with how to serve millions of Americans struggling with pain, the research and programs emerging from the Osher Center offer a scalable, compassionate, and evidence-based approach that has the potential to improve health outcomes while lowering costs. By publishing critical insights and findings about their work on issues like rural health, these Osher Affiliates play a pivotal role in ensuring that approach is equitable and accessible for all.