Who Bears the Burden? Structural Patterning of Chronic Musculoskeletal Pain across Social and Economic Determinants In a Nationally Representative Sample

Background and Purpose: Chronic musculoskeletal pain affects more than 137 million U.S. adults and is the leading cause of disability in the United States, yet social work scholarship remains strikingly sparse. Existing research has documented pain disparities but largely examined social and economic determinants in isolation, obscuring the structural conditions that shape who suffers, how severely, and whether their pain is believed and treated. Understanding how chronic pain is distributed across race, gender, poverty, disability, and age is a social justice imperative. This study examined how chronic musculoskeletal pain prevalence and frequency were distributed across demographic, social, and economic characteristics in a nationally representative U.S. adult sample, establishing the population-level empirical foundation for intersectional chronic pain inquiry in social work.

Methods: This study used secondary data from the 2023 National Health Interview Survey (NHIS), a cross-sectional, nationally representative survey, The analytic sample included adults with chronic musculoskeletal pain (n = 16,210; N = 137,081,129). Complex Samples crosstabulations and Rao-Scott adjusted chi-square tests examined the distribution of pain frequency (categorized as some days, most days, or every day) across age, gender, race/ethnicity, sexual orientation, disability status, educational attainment, income-to-poverty ratio, employment status, and depression and anxiety frequency.

Results: Within the analytic sample, 20.7% of adults reported daily chronic pain, and more than one-third reported pain most days or every day. Significant bivariate associations with pain frequency were observed for all characteristics examined (all p < .001) except household region (p = .184), indicating that chronic pain is structured by social and economic stratification not geography. Employment status demonstrated a clear gradient; adults not employed full time reported daily pain at more than double the rate of those employed full time (14.0% vs. 6.8%; χ² = 473.008, p < .001). Age demonstrated a strong gradient, with daily pain rising from 1.4% among adults 18–30 to 5.2% among those 61–70 (χ² = 814.592, p < .001). Disability status showed one of the strongest associations (χ² = 1,439.254, p < .001), with disabled adults disproportionately concentrated in the daily pain category. Depression (χ² = 758.993, p < .001) and anxiety (χ² = 557.998, p < .001) frequency were also strongly associated with pain frequency, consistent with prior evidence (Zajacova et al., 2021).

Conclusions and Implications: Chronic musculoskeletal pain is not randomly distributed; it follows the contours of structural inequality across employment, age, disability, income, and affective distress. The sole non-significant finding redirects analytic attention toward social stratification as the primary organizing force behind pain disparities. These findings have direct implications for equitable health; when pain burden is systematically concentrated among those already most marginalized, chronic pain becomes a social justice issue demanding structural responses. Social workers are positioned to lead intersectional, population-level pain research and to advocate for policies addressing the upstream determinants — poverty, unemployment, and disability exclusion — that drive these disparities. This study advances social work's empirical contribution to health equity scholarship and establishes a rigorous, nationally representative foundation (Macgregor et al., 2023; Booker et al., 2023).