Rural chronic pain patients know a kind of math most healthy people never have to learn. One appointment can mean two hours on the road, $40 in gas, a missed shift, a stiff back, swollen knees, and the quiet fear that the pharmacy still won't have the prescription ready when the drive is over.
Access looks good on paper when a clinic technically exists somewhere in the region. Real life, however, is different: rural patients often travel long distances for care, especially specialty care, and the burden includes travel time, cost, missed work, and unreliable transportation.
Chronic pain makes every mile heavier; sitting too long turns a manageable day into a flare, and standing in line can undo whatever rest the person saved up for the trip.
Then comes the appointment treadmill. Many pain patients don't get a simple yearly checkup and a refill. They get monthly visits, medication agreements, urine screens, insurance delays, pharmacy calls, and follow-up messages through communication portals that may not get quickly answered.
Those pain patients don't only manage their pain; they manage a small bureaucracy built around pain.
The CDC's 2022 opioid prescribing guideline says pain care should be individualized, patient-centered, and not treated as a rigid rulebook. It also warns against abrupt or poorly supported changes for patients already receiving opioid therapy. From the CDC:
Four key areas are covered in this clinical practice guideline for prescribing of opioid pain medication for patients aged ≥18 years for pain, excluding pain management related to sickle cell disease, cancer-related pain treatment, palliative care, and end-of-life care. These areas are 1) determining whether or not to initiate opioids for pain; 2) selecting opioids and determining opioid dosages; 3) deciding duration of initial opioid prescription and conducting follow-up; and 4) assessing risk and addressing potential harms of opioid use. In addition, five guiding principles were identified to inform implementation across recommendations. These guiding principles focus on 1) the appropriate treatment of pain; 2) flexibility to meet the care needs and clinical circumstances of each patient; 3) a multimodal and multidisciplinary approach to pain management; 4) avoiding misapplication of the clinical practice guideline beyond its intended use; and 5) vigilance in attending to health inequities and ensuring access to appropriate, affordable, diversified, coordinated, and effective nonpharmacologic and pharmacologic pain treatment for all persons.
A central tenet of this clinical practice guideline is that acute, subacute, and chronic pain needs to be appropriately and effectively treated regardless of whether opioids are part of a treatment regimen. Clinicians should select nonpharmacologic or pharmacologic treatment modalities, or both, that maximize patient safety and optimize outcomes in pain, function, and quality of life. A multimodal and multidisciplinary approach to pain management that considers the biologic, psychological, and social characteristics of each person is critical (6). The care provided needs to be individualized and person centered (6). Clinicians and patients should work together to identify treatment goals, including functional goals, and tailor an approach that considers both the benefits and risks of available options (6). Progress should be monitored over time and treatment protocols adjusted accordingly. Health systems and payers can work to ensure multimodal treatment options are available, accessible, and reimbursed for patients. Public and private payers can support a broader array of nonpharmacologic interventions such as exercise, multidisciplinary rehabilitation, mind-body interventions, cognitive behavioral therapy, and certain complementary and integrative medicine therapies (e.g., acupuncture and spinal manipulation) that increasingly are known to be effective (9). Reimbursement often is cited as a principle barrier to why these nonpharmacologic treatments are not more widely used (9).
Rural patients need that flexibility even more because one extra appointment or one delayed prescription means another drive, another lost day, and another night spent wondering whether the system sees them as sick or suspicious.
The pharmacy trip is another fight. A prescription sent at 9 a.m. may not be filled until late afternoon. The local pharmacy may have closed; the medication may be out of stock; the pharmacist may need clarification from the doctor; or the insurer may want prior authorization.
For pain patients living in or near cities, frustration may mean another stop after work, while for rural patients, it means another county, another tank of gas, and another drive while hurting.
Pharmacy access is getting harder in many places. Research published in 2024 found 15.8 million Americans live in pharmacy deserts.
Pharmacies are important health care access points, but no national map currently exists of where pharmacy deserts are located. This cross-sectional study used pharmacy address data and Census Bureau surveys to define pharmacy deserts at the census tract level in all 50 US states and the District of Columbia.
We also compared sociodemographic characteristics of pharmacy desert vs non-pharmacy desert communities. Nationally, 15.8 million (4.7%) of all people in the United States live in pharmacy deserts, spanning urban and rural settings in all 50 states.
On average, communities that are pharmacy deserts have a higher proportion of people who have a high school education or less, have no health insurance, have low self-reported English ability, have an ambulatory disability, and identify as a racial or ethnic minority.
While, on average, pharmacies are the most accessible health care setting in the United States, many people still do not have access to them. Further, the people living in pharmacy deserts are often marginalized groups who have historically faced structural barriers to health care.
This study demonstrates a need to improve access to pharmacies and pharmacy services to advance health equity.
Question Can areas in the US at risk of becoming pharmacy deserts be better identified by developing a pharmacy vulnerability index?
Findings This cross-sectional study of the US population (321.3 million people) found that 17.7% resided in pharmacy deserts, and an additional 8.9% relied on a single pharmacy for access. Notably, individuals in small rural areas were particularly at risk for pharmacy access issues.
Meaning These results suggest that targeted policy interventions are essential to prevent further inequities in pharmacy access, particularly in small rural areas, by ensuring the financial sustainability of pharmacies that are the sole source of pharmacy services in an area.
Chronic pain patients lose more than convenience when pharmacies close: they lose a lifeline.
Rural patients also know the fear that follows them into the exam room. They rehearse symptoms on the drive; they worry about sounding too desperate; they worry about not sounding desperate enough; and they try to explain burning nerves, damaged joints, failed surgeries, bad sleep, and shrinking daily function without sounding dramatic.
A pain patient can spend all morning trying to look stable enough to be trusted, then spend all afternoon paying for the effort.
Appointments should help patients explain function, not perform innocence. Can the patient sleep? Drive? Work? Cook? Sit through church? Stand in line at the grocery store? Make the pharmacy run without needing two days to recover?
A pain score from one to ten can't capture the cost of living 70 miles from the only doctor to treat the condition.
Families get pulled into the miles, too. A spouse takes time off to drive; adult children rearrange schedules; gas money comes out of groceries; and everybody watches the patient brace for the appointment, the pharmacy, and the phone call that may or may not come.
AARP and the National Alliance for Caregiving reported in 2025 that 63 million Americans provide care to another adult or child. Rural chronic pain turns that care into logistics, money, fatigue, and worry.
Pain care isn't access when help is hours away. A clinic on a map doesn't mean much when the patient can barely sit in a car. A prescription in a database doesn't mean much when the pharmacy is closed, out of stock, or another long drive down the road.
Rural patients need doctors who understand distance, pharmacies that communicate quickly, insurers that stop turning refills into scavenger hunts, and policies built for the lives patients actually live.
A livelong condition shouldn't come with a monthly road test. Rural pain patients aren't asking for special treatment; they're asking for care that doesn't punish them for their ZIP code, their mileage, or the simple fact that pain doesn't politely wait while paperwork moves.
I want to hear from you!
These chronic pain columns exist because people are willing to speak honestly in a system that often punishes honesty.
Read My Chronic Pain Series here.
If you're living with chronic pain and have had to learn to stay quiet just to survive care, your experience matters. Whether your story is long or short, clinical or personal, it helps expose what life inside the system actually looks like.
If you choose to share, you grant PJ Media permission to edit, publish, and use your submission without compensation. Any edits will be limited to grammar and clarity, never substance or meaning.
To submit, visit the Contact Us page and put “Dave Manney: Chronic Pain” in the subject line.
You may request anonymity or use a first name only. A few honest paragraphs about your condition, care, and how your life has been reshaped are more than enough.
Remember: Silence protects broken systems; your voice helps challenge them.
Rural chronic pain patients don’t just fight pain. They fight miles, gas costs, pharmacy shortages, insurance delays, and monthly appointments that can consume an entire day. PJ Media VIP helps keep stories like these in front of readers, and right now, get 60% off with promo code FIGHT.
"Dirty Harry writes for PJ Media, apparently." - Redstater in a Blue Apocalypse
David Manney writes for PJ Media with the outlook of someone who has spent nearly sixty years watching the world with both eyes open. He leans on plain language, lived experience, and a stubborn belief that character still matters, even when no one is paying attention. A former graphic designer, marketing content specialist, marketing professional, journalist, and technical writer, he tries to sort truth from noise and share what he sees without theatrics.
He lives in the Midwest with his wife, who is smarter than he is and far more graceful about it, along with their two dogs, Watson and Mabel. Manney often jokes that he has never faked sarcasm in his life, and most days his columns prove it. Follow him on X here.
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