A Perioperative Pain Management Expert Scans His Crystal Ball for the Look of the Practice in 2050

Edward Mariano, MD, MAS, sees the growth of highly individualized pain therapy over the next quarter century as the trend that will lead to optimal outcomes for every patient in 2050. Improved preparation before surgery will account for risk factors specific to the individual that will be well-researched and included in evidence-based guidelines, Mariano said in a recent interview with Patient Care. "We also need to think about some of the other aspects of recovery that affect the perception of pain," he added, such as the impact of poor sleep, which is associated with increased pain levels.

An essential shift Mariano wants to see is "greater uptake of what we consider good pain management," that is, consistent application in practice of evidence-based principles rooted in years of research. He explains more in the short video above and a transcript of his comments follows.

The transcript has been edited for clarity and length

Patient Care. If you had a crystal ball, how do you imagine pain management will evolve in the next 10 years? And what about 25 years from now?

Mariano. Over the next decade, I envision better preoperative preparation—taking into account risk factors that may predispose patients to severe acute pain or chronic pain development. There’s tremendous potential for pre-surgical interventions that could reduce postoperative pain, which we aren’t fully utilizing yet. Identifying and optimizing pain management for patients who already have poorly controlled pain before surgery could be a game-changer. It’s similar to training for a half marathon—you wouldn’t just show up on race day without preparation. We need to adopt that mindset in surgical pain management.

We also need to address other factors influencing pain perception. For example, we know that poor sleep correlates with increased pain, yet this area remains underexplored.

Beyond the next 10 years, one of the biggest shifts I’d love to see is the widespread adoption of evidence-based pain management principles. One of the most frustrating aspects of clinical practice change is that, even after strong evidence supports a new guideline, it can take 17 years for it to be fully implemented. If we prioritize research dissemination, create incentives, and engage both medical organizations and patients in these discussions, we can accelerate the adoption of best practices.

Looking 25 years ahead, I hope we’ll have a deeper understanding of why individuals experience pain differently. If we can identify intrinsic factors that influence pain perception, we can dramatically improve preoperative evaluations. By 2050, I’d love to see a system where pain management plans are truly personalized for every surgical patient.

Edward R Mariano, MD, MAS, is a professor and vice chair in the department of anesthesiology, perioperative and pain medicine at Stanford University School of Medicine in Stanford, CA and chief of anesthesiology and perioperative care service at the Veterans Affairs Palo Alto Health Care System. Mariano pioneered the use of continuous peripheral nerve blocks for individuals having same-day surgery. He has worked on key national health care initiatives in the US including accreditation of regional anesthesiology and acute pain medicine fellowships, pain management guidelines, and hospital-based standards.