It's tough to make predictions, especially about the future.

– Yogi Berra

The definition of pain has changed – literally. In 1979, the International Association for the Study of Pain (IASP) published this definition for pain: “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”1 Recognizing that pain can be a symptom or a disease itself, the IASP refined the pain classification model to include chronic primary pain.2 In 2020, the IASP further revised the definition of pain as follows: “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.”1 Input from IASP members and the public that factored into this new definition of pain highlighted several important themes. The definition of pain should be simple and practical, emphasize the personal nature of the pain experience, and incorporate the biopsychosocial model of pain.1 Therefore, while seemingly minor, the amendments by insertion and deletion emphasize that pain is an individual experience and that perception is reality.

The opioid epidemic has brought significant attention to issues in contemporary pain medicine.3 Treatment of opioid use disorder is challenging, and since the onset of the COVID-19 pandemic the magnitude of the challenges has become more apparent.4 While there are many factors that contributed to the overprescribing of opioids, including the “fifth vital sign” campaign and misinformation,5,6 the current crisis provides an opportunity to reevaluate the state of pain management in the U.S. The publication of Centers for Disease Control and Prevention (CDC) guidelines7, the Pain Management Best Practices Inter-Agency Task Force report,8 and recognition of surgery as a risk factor for the development of chronic opioid use,9 has caused the medical community to respond in recent years with opioid prescribing recommendations and safety initiatives10-12 and an emphasis on multimodality as the pathway to better pain management.13 

The acceptance of pain as a potentially chronic condition defined at the level of the individual is also driving the field of pain medicine toward increased personalization. In addition, subspecialty areas in acute and transitional pain to complement the established field of chronic pain have emerged in recent years to fill existing gaps and provide comprehensive care.14,15 In looking ahead, we wish to highlight three priority areas for improvement: prediction, coordination, and implementation.

Better prediction

Our ability to deliver personalized pain medicine is hindered by our inability to predict which patients will go on to develop chronic pain. There has been significant scientific progress in understanding the mechanisms of pain using a biopsychosocial model and the transition from acute to chronic pain.16 Generally, these mechanisms involve nociceptive, inflammatory, and neuropathic pain leading to both peripheral and central sensitization.17 Certain surgeries such as limb amputation and thoracotomy have been associated with a greater incidence of persistent postsurgical pain (PPSP) that goes on to become a chronic pain condition.18 The impact of genetics on pain and its treatment is an ongoing field of research. In the case of PPSP, the combination of certain gene polymorphisms and phenotypic factors has been associated with an increased risk.17,19-21 Additional opportunities related to a better understanding of genetics include evaluating the metabolism and action of opioids,22 risk of substance use disorder,3 and potentially advanced interventional therapies for common chronic diseases such as intervertebral disc pathologies.24 We are also learning that treatment decisions related to pain management may have previously unrecognized and unanticipated long-term consequences. For example, there is growing concern that chronic opioid use may be associated with an increased risk of cancer recurrence and decreased survival in some patients.25 

Many chronic pain syndromes start in response to systemic disease, chronic health conditions, non-surgical injury, chemotherapy, and other conditions, though as with PPSP, not all patients with the same conditions develop the same chronic pain conditions. The ability to leverage the wealth of clinical data from electronic health records and imaging studies has not yet been fully realized, and there is good reason to believe that application of these data in the form of artificial or augmented intelligence (AI) may allow predictions that will improve pain prevention as well as the diagnosis and treatment of pain.26,27 

Better coordination

While the concept of acute pain services has matured with support from enhanced surgical recovery programs,28,29 a critical gap in pain care has been exposed between hospital discharge and the return to primary care.30 The use of a transitional pain service (TPS) for post-discharge follow-up and preoperative preparation of complex patients, such as those with chronic pain or opioid use, may facilitate a more coordinated approach to postoperative opioid tapering and subacute pain management and is consistent with the Perioperative Surgical Home model of care.29 Given that chronic pain costs over $600 billion per year, the need to improve pain care delivery and outcomes is unarguable. Improved predictive ability through AI may facilitate appropriate selection of TPS patients and interventions34 and the early application of effective pain therapies to assist in chronic pain prevention and treatment and aid in either avoiding opioids altogether or opioid cessation.35 In the setting of chronic pain, coordination of care and timely access to the full range of treatments to facilitate recovery are often lacking. This not only reduces treatment success but ultimately costs society on many different fronts.

Better implementation

There are many reasons why knowledge translation fails and clinical practice remains unchanged despite new evidence and guidelines.36,37 In addition, we continue to struggle to deliver timely, coordinated, and consistent care due to a multitude of factors, including insurance coverage policies, patient participation and acceptance, availability of needed care, and cost. It is also increasingly apparent that pain can be seen as a barometer of population health and that addressing pain will not be successful in the absence of addressing larger public health issues. The opioid epidemic has catalyzed collaboration between ASA and other professional societies and health care organizations to address many pain issues.13,38,39 ASA is also a member organization of the National Academy of Medicine Action Collaborative on Countering the U.S. Opioid Epidemic, which is entering its third year and represents a unique public-private partnership addressing pain management guidelines, education for the health professions, and prevention, treatment, and recovery services. These relationships represent natural routes for the dissemination of best practices in evidence-based pain management. Widespread adoption of video telehealth technology during the pandemic40 is increasing patient access to pain medicine experts and other critical health care professionals and has the potential to decrease existing disparities in pain care and improve outcomes on a much broader basis.

The future of pain medicine, in our opinion, will bring advances in personalization, coordination, and implementation that will incorporate genetic testing, AI, and innovative models of care.

However, improved patient access to high-quality pain management will require a coordinated effort by clinicians, scientists, patients and caregivers, organizations and advocacy groups, regulatory bodies, and lawmakers.

Richard W. Rosenquist, MD, Member, ASA Committee on Pain Medicine and Chairman, Department of Pain Management, Cleveland Clinic, Cleveland, Ohio.

Richard W. Rosenquist, MD, Member, ASA Committee on Pain Medicine and Chairman, Department of Pain Management, Cleveland Clinic, Cleveland, Ohio.

Edward R. Mariano, MD, MAS, FASA, Chair, ASA Committee of Regional Anesthesia and Acute Pain Medicine, and Professor, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, and Chief, Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California.

Edward R. Mariano, MD, MAS, FASA, Chair, ASA Committee of Regional Anesthesia and Acute Pain Medicine, and Professor, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, and Chief, Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California.

References

1
Raja
SN
,
Carr
DB
,
Cohen
M
,
Finnerup
NB
,
Flor
H
,
Gibson
S
,
Keefe
FJ
,
Mogil
JS
,
Ringkamp
M
,
Sluka
KA
,
Song
XJ
,
Stevens
B
,
Sullivan
MD
,
Tutelman
PR
,
Ushida
T
,
Vader
K
.
The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises
.
Pain
2020
;
161
:
1976
82
. https://doi.org/10.1097/j.pain.0000000000001939
2
Treede
RD
,
Rief
W
,
Barke
A
,
Aziz
Q
,
Bennett
MI
,
Benoliel
R
,
Cohen
M
,
Evers
S
,
Finnerup
NB
,
First
MB
,
Giamberardino
MA
,
Kaasa
S
,
Korwisi
B
,
Kosek
E
,
Lavand'homme
P
,
Nicholas
M
,
Perrot
S
,
Scholz
J
,
Schug
S
,
Smith
BH
,
Svensson
P
,
Vlaeyen
JWS
,
Wang
SJ
.
Chronic pain as a symptom or a disease: the IASP Classification of Chronic Pain for the International Classification of Diseases (ICD-11)
.
Pain
2019
;
160
:
19
27
. https://doi.org/10.1097/j.pain.0000000000001384
3
Alam
A
,
Juurlink
DN
.
The prescription opioid epidemic: an overview for anesthesiologists
.
Can J Anaesth
2016
;
63
:
61
8
. https://doi.org/10.1007/s12630-015-0520-y
4
Alexander
GC
,
Stoller
KB
,
Haffajee
RL
,
Saloner
B
.
An Epidemic in the Midst of a Pandemic: Opioid Use Disorder and COVID-19
.
Ann Intern Med
2020
. https://dx.doi.org/10.7326%2FM20-1141
5
Lanser
P
,
Gesell
S
.
Pain management: the fifth vital sign
.
Healthc Benchmarks
2001
;
8
:
68
70
, 62. https://pubmed.ncbi.nlm.nih.gov/11474948/
6
Levy
N
,
Sturgess
J
,
Mills
P
.
“Pain as the fifth vital sign” and dependence on the “numerical pain scale” is being abandoned in the US: Why
.
Br J Anaesth
2018
;
120
:
435
8
. https://doi.org/10.1016/j.bja.2017.11.098
7
Dowell
D
,
Haegerich
TM
,
Chou
R
.
CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016
.
MMWR Recomm Rep
2016
;
65
:
1
49
. https://doi.org/10.15585/mmwr.rr6501e1
8
U.S. Department of Health and Human Services (2019, May). Pain Management Best Practices Inter-Agency Task Force Report: Updates, Gaps, Inconsistencies, and Recommendations. Retrieved from U. S. Department of Health and Human Services website: https://www.hhs.gov/ash/advisory-committees/pain/reports/index.html
9
Brummett
CM
,
Waljee
JF
,
Goesling
J
,
Moser
S
,
Lin
P
,
Englesbe
MJ
,
Bohnert
ASB
,
Kheterpal
S
,
Nallamothu
BK
.
New Persistent Opioid Use After Minor and Major Surgical Procedures in US Adults
.
JAMA Surg
2017
;
152
:
e170504
. https://doi.org/10.1001/jamasurg.2017.0504
10
Lin
LA
,
Bohnert
ASB
,
Kerns
RD
,
Clay
MA
,
Ganoczy
D
,
Ilgen
MA
.
Impact of the Opioid Safety Initiative on opioid-related prescribing in veterans
.
Pain
2017
;
158
:
833
9
. https://doi.org/10.1097/j.pain.0000000000000837
11
Hill
MV
,
Stucke
RS
,
Billmeier
SE
,
Kelly
JL
,
Barth
RJ
, Jr
.
Guideline for Discharge Opioid Prescriptions after Inpatient General Surgical Procedures
.
J Am Coll Surg
2018
;
226
:
996
1003
. https://doi.org/10.1016/j.jamcollsurg.2017.10.012
12
Levy
N
,
Quinlan
J
,
El-Boghdadly
K
,
Fawcett
WJ
,
Agarwal
V
,
Bastable
RB
,
Cox
FJ
,
de Boer
HD
,
Dowdy
SC
,
Hattingh
K
,
Knaggs
RD
,
Mariano
ER
,
Pelosi
P
,
Scott
MJ
,
Lobo
DN
,
Macintyre
PE
.
An international multidisciplinary consensus statement on the prevention of opioid-related harm in adult surgical patients
.
Anaesthesia
2021
;
76
:
520
36
. https://doi.org/10.1111/anae.15262
13
Chou
R
,
Gordon
DB
,
de Leon-Casasola
OA
,
Rosenberg
JM
,
Bickler
S
,
Brennan
T
,
Carter
T
,
Cassidy
CL
,
Chittenden
EH
,
Degenhardt
E
,
Griffith
S
,
Manworren
R
,
McCarberg
B
,
Montgomery
R
,
Murphy
J
,
Perkal
MF
,
Suresh
S
,
Sluka
K
,
Strassels
S
,
Thirlby
R
,
Viscusi
E
,
Walco
GA
,
Warner
L
,
Weisman
SJ
,
Wu
CL
.
Management of Postoperative Pain: A Clinical Practice Guideline From the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council
.
J Pain
2016
;
17
:
131
57
. https://doi.org/10.1016/j.jpain.2015.12.008
14
Tighe
P
,
Buckenmaier
CC
, 3rd
,
Boezaart
AP
,
Carr
DB
,
Clark
LL
,
Herring
AA
,
Kent
M
,
Mackey
S
,
Mariano
ER
,
Polomano
RC
,
Reisfield
GM
.
Acute Pain Medicine in the United States: A Status Report
.
Pain Med
2015
;
16
:
1806
26
. https://dx.doi.org/10.1111%2Fpme.12760
15
Katz
J
,
Weinrib
A
,
Fashler
SR
,
Katznelzon
R
,
Shah
BR
,
Ladak
SS
,
Jiang
J
,
Li
Q
,
McMillan
K
,
Santa Mina
D
,
Wentlandt
K
,
McRae
K
,
Tamir
D
,
Lyn
S
,
de Perrot
M
,
Rao
V
,
Grant
D
,
Roche-Nagle
G
,
Cleary
SP
,
Hofer
SO
,
Gilbert
R
,
Wijeysundera
D
,
Ritvo
P
,
Janmohamed
T
,
O'Leary
G
,
Clarke
H
.
The Toronto General Hospital Transitional Pain Service: development and implementation of a multidisciplinary program to prevent chronic postsurgical pain
.
J Pain Res
2015
;
8
:
695
702
. https://dx.doi.org/10.2147%2FJPR.S91924
16
Chapman
CR
,
Vierck
CJ
.
The Transition of Acute Postoperative Pain to Chronic Pain: An Integrative Overview of Research on Mechanisms
.
J Pain
2017
;
18
:
359 e1
359.e38
. https://doi.org/10.1016/j.jpain.2016.11.004
17
Chen
YK
,
Boden
KA
,
Schreiber
KL
,
.
The role of regional anaesthesia and multimodal analgesia in the prevention of chronic postoperative pain: a narrative review
.
Anaesthesia
2021
;
76
Suppl 1
:
8
17
. https://doi.org/10.1111/anae.15256
18
Kehlet
H
,
Jensen
TS
,
Woolf
CJ
,
.
Persistent postsurgical pain: risk factors and prevention
.
Lancet
2006
;
367
:
1618
25
. https://doi.org/10.1016/S0140-6736(06)68700-X
19
Bortsov
AV
,
Devor
M
,
Kaunisto
MA
,
Kalso
E
,
Brufsky
A
,
Kehlet
H
,
Aasvang
E
,
Bittner
R
,
Diatchenko
L
,
Belfer
I
,
.
CACNG2 polymorphisms associate with chronic pain after mastectomy
.
Pain
2019
;
160
:
561
8
. https://doi.org/10.1097/j.pain.0000000000001432
20
Clarke
H
,
Katz
J
,
Flor
H
,
Rietschel
M
,
Diehl
SR
,
Seltzer
Z
,
.
Genetics of chronic post-surgical pain: a crucial step toward personal pain medicine
.
Can J Anaesth
2015
;
62
:
294
303
. https://doi.org/10.1007/s12630-014-0287-6
21
Vasilopoulos
T
,
Wardhan
R
,
Rashidi
P
,
Fillingim
RB
,
Wallace
MR
,
Crispen
PL
,
Parvataneni
HK
,
Prieto
HA
,
Machuca
TN
,
Hughes
SJ
,
Murad
GJA
,
Tighe
PJ
,
.
Patient and Procedural Determinants of Postoperative Pain Trajectories
.
Anesthesiology
2021
;
134
(
3
):
421
34
. https://doi.org/10.1097/ALN.0000000000003681
22
Ofoegbu
A
,
B Ettienne
E
.
Pharmacogenomics and Morphine
.
J Clin Pharmacol
April 2021: Epub ahead of print. https://doi.org/10.1002/jcph.1873
23
AshaRani
PV
,
Amron
S
,
Zainuldin
NAB
,
Tohari
S
,
Ng
AYJ
,
Song
G
,
Venkatesh
B
,
Mathuru
AS
.
Whole-Exome Sequencing to Identify Potential Genetic Risk in Substance Use Disorders: A Pilot Feasibility Study
.
J Clin Med
2021
;
10
(
13
):
2810
. https://doi.org/10.3390/jcm10132810
24
Farhang
N
,
Ginley-Hidinger
M
,
Berrett
KC
,
Gertz
J
,
Lawrence
B
,
Bowles
RD
.
Lentiviral CRISPR Epigenome Editing of Inflammatory Receptors as a Gene Therapy Strategy for Disc Degeneration
.
Hum Gene Ther
2019
;
30
(
9
):
1161
75
. https://doi.org/10.1089/hum.2019.005
25
Novy
DM
,
Nelson
DV
,
Koyyalagunta
D
,
Cata
JP
,
Gupta
P
,
Gupta
K
.
Pain, opioid therapy, and survival: a needed discussion
.
Pain
2020
;
161
(
3
):
496
501
. https://doi.org/10.1097/j.pain.0000000000001736
26
Ibrahim
SA
.
Artificial intelligence for disparities in knee pain assessment
.
Nat Med
2021
;
27
:
22
3
. https://doi.org/10.1038/s41591-020-01196-3
27
Tighe
PJ
,
Lucas
SD
,
Edwards
DA
,
Boezaart
AP
,
Aytug
H
,
Bihorac
A
.
Use of machine-learning classifiers to predict requests for preoperative acute pain service consultation
.
Pain Med
2012
;
13
:
1347
57
. https://doi.org/10.1111/j.1526-4637.2012.01477.x
28
Echeverria-Villalobos
M
,
Stoicea
N
,
Todeschini
AB
,
Fiorda-Diaz
J
,
Uribe
AA
,
Weaver
T
,
Bergese
SD
.
Enhanced Recovery After Surgery (ERAS): A Perspective Review of Postoperative Pain Management Under ERAS Pathways and Its Role on Opioid Crisis in the United States
.
Clin J Pain
2020
;
36
:
219
26
. https://doi.org/10.1097/ajp.0000000000000792
29
Zaccagnino
MP
,
Bader
AM
,
Sang
CN
,
Correll
DJ
.
The Perioperative Surgical Home: A New Role for the Acute Pain Service
.
Anesth Analg
2017
;
125
:
1394
1402
. https://doi.org/10.1213/ane.0000000000002165
30
Walters
TL
,
Mariano
ER
,
Clark
JD
:
Perioperative Surgical Home and the Integral Role of Pain Medicine
.
Pain Med
2015
;
16
:
1666
72
. https://doi.org/10.1111/pme.12796
31
Klueh
MP
,
Hu
HM
,
Howard
RA
,
Vu
JV
,
Harbaugh
CM
,
Lagisetty
PA
,
Brummett
CM
,
Englesbe
MJ
,
Waljee
JF
,
Lee
JS
.
Transitions of Care for Postoperative Opioid Prescribing in Previously Opioid-Naive Patients in the USA: a Retrospective Review
.
J Gen Intern Med
2018
;
33
:
1685
91
. https://doi.org/10.1007/s11606-018-4463-1
32
Buys
MJ
,
Bayless
K
,
Romesser
J
,
Anderson
Z
,
Patel
S
,
Zhang
C
,
Presson
AP
,
Brooke
BS
.
Opioid use among veterans undergoing major joint surgery managed by a multidisciplinary transitional pain service
.
Reg Anesth Pain Med
2020
;
45
:
847
52
. https://doi.org/10.1136/rapm-2020-101797
33
Sun
EC
,
Mariano
ER
,
Narouze
S
,
Gabriel
RA
,
Elsharkawy
H
,
Gulur
P
,
Merrick
SK
,
Harrison
TK
,
Clark
JD
.
Making a business plan for starting a transitional pain service within the US healthcare system
.
Reg Anesth Pain Med
2021
;
46
:
727
31
. https://doi.org/10.1136/rapm-2021-102669
35
Ilfeld
BM
,
Finneran
JJ
.
Cryoneurolysis and Percutaneous Peripheral Nerve Stimulation to Treat Acute Pain
.
Anesthesiology
2020
;
133
:
1127
49
. https://doi.org/10.1097/ALN.0000000000003532
36
Cabana
MD
,
Rand
CS
,
Powe
NR
,
Wu
AW
,
Wilson
MH
,
Abboud
PA
,
Rubin
HR
.
Why don't physicians follow clinical practice guidelines? A framework for improvement
.
JAMA
1999
;
282
:
1458
65
. https://doi.org/10.1001/jama.282.15.1458
37
Morris
ZS
,
Wooding
S
,
Grant
J
.
The answer is 17 years, what is the question: understanding time lags in translational research
.
J R Soc Med
2011
;
104
:
510
20
. https://doi.org/10.1258/jrsm.2011.110180
38
Brenin
DR
,
Dietz
JR
,
Baima
J
,
Cheng
G
,
Froman
J
,
Laronga
C
,
Ma
A
,
Manahan
MA
,
Mariano
ER
,
Rojas
K
,
Schroen
AT
,
Tiouririne
NA
,
Wiechmann
LS
,
Rao
R
.
Pain Management in Breast Surgery: Recommendations of a Multidisciplinary Expert Panel-The American Society of Breast Surgeons
.
Ann Surg Oncol
2020
;
27
:
4588
602
. https://doi.org/10.1245/s10434-020-08892-x
39
Barreveld
AM
,
McCarthy
RJ
,
Elkassabany
N
,
Mariano
ER
,
Sites
B
,
Ghosh
R
,
Buvanendran
A
.
Opioid Stewardship Program and Postoperative Adverse Events: A Difference-in-differences Cohort Study
.
Anesthesiology
2020
;
132
:
1558
68
. https://doi.org/10.1097/ALN.0000000000003238
40
Hunter
OO
,
Mariano
ER
,
Harrison
TK
.
Leveraging video telehealth for the transitional pain service in response to COVID-19
.
Reg Anesth Pain Med
2021
;
46
:
460
1
. https://doi.org/10.1136/rapm-2020-101742