Phenoconversion and rural pain inequities: a precision-informed roadmap to advance equity for rural older adults

Inequities in geriatric pain management persist despite three decades of research, disproportionately affecting older adults in rural communities. Structural barriers, multimorbidity, polypharmacy, and phenoconversion that alters functional drug metabolism, contribute to variable analgesic response and medication-related harm. The underrecognized mechanism, phenoconversion, is particularly consequential for patients prescribed CYP2D6-dependent analgesics, where drug-drug-gene interactions can render enzyme-dependent opioids ineffective or precipitate toxicity. Case-based illustrations demonstrate how unrecognized phenoconversion can lead to avoidable suffering and safety risks. Additionally, an implementation vignette highlights opportunities for integrating pharmacogenomics, shared decision making, and interoperable electronic care plans into rural primary care. These tools help ensure that critical information, such as patient goals, caregiver perspectives, and functional priorities, accompany medication decisions across transitions of care where phenoconversion risks may often be raised. Building on these insights, we propose a precision-informed roadmap calling for clinical decision infrastructure, telehealth-enabled specialty access, workforce development, and system-level support. When combined with person-centered care approaches, precision health care offers a promising pathway toward safer, more effective, and more equitable pain management for rural older adults.