What is the role of morphine in acute pancreatitis and biliary (gallstone-related) pancreatoopathy?

From the Guidelines

Morphine should not be the first choice for analgesia in acute pancreatitis, including biliary pancreatitis, due to the preference for other opioids like dilaudid in non-intubated patients, as suggested by recent guidelines. The management of pain in acute pancreatitis is a clinical priority, and all patients should receive some form of analgesia within the first 24 hours of hospitalization to maintain their quality of life 1. According to the 2019 WSES guidelines for the management of severe acute pancreatitis, dilaudid is often preferred over morphine or fentanyl in non-intubated patients, indicating a shift away from morphine as the primary analgesic option 1.

Some key points to consider in the management of acute pancreatitis pain include:

• The use of epidural analgesia for patients with severe and acute critical pancreatitis who require high doses of opioids for an extended period 1.
• Adherence to the most current acute pain management guidelines in the perioperative setting, given the uncertainty about the preferred analgesic and method of administration 1.
• The importance of multimodal pain control, which may incorporate acetaminophen and potentially NSAIDs if not contraindicated, to achieve adequate pain relief without relying solely on opioids.

Given the current evidence and guidelines, the best approach is to follow the most recent acute pain management guidelines and consider alternatives to morphine as the first line of treatment for acute pancreatitis, ensuring that pain control is optimized while minimizing potential risks and complications 1.

From the FDA Drug Label

Morphine causes a reduction in motility and is associated with an increase in tone in the antrum of the stomach duodenum. Gastric, biliary and pancreatic secretions are decreased by morphine. Morphine can cause a marked increase in biliary tract pressure as a result of spasm of the sphincter of Oddi.

The role of morphine in Acute Pancreatitis is not directly supported by the provided drug labels. However, morphine may exacerbate biliary pancreato issues due to its effects on the:

• Sphincter of Oddi: causing spasm, which may increase biliary tract pressure
• Biliary and pancreatic secretions: decreasing secretions, which may worsen the condition
• Gastrointestinal motility: reducing motility, which may prolong the obstruction 2 In patients with biliary surgery or disorders of the biliary tract, morphine sulfate injection may cause spasm of the sphincter of Oddi and diminish biliary and pancreatic secretions 2. Therefore, morphine should be used with caution in these patients.

From the Research

Role of Morphine in Acute Pancreatitis and Biliary Pancreato

• Morphine is a commonly used opioid for pain management in acute pancreatitis, but its effectiveness and safety have been debated 3, 4.
• A systematic review and meta-analysis of randomized controlled trials found that opioids, including morphine, were associated with a decrease in the need for rescue analgesia in patients with mild acute pancreatitis 3.
• Another study found that morphine may be of more benefit than meperidine in acute pancreatitis, offering longer pain relief with less risk of seizures 5.
• However, a review of the data on narcotic analgesic effects on the sphincter of Oddi found that all narcotics, including morphine, increase biliary pressure and interfere with sphincter of Oddi peristalsis 5.

Comparison with Other Analgesics

• A study comparing intravenous hydromorphone patient-controlled analgesia with intramuscular pethidine found that hydromorphone was not superior to pethidine in relieving pain in acute pancreatitis patients and may have worse clinical outcomes 6.
• Another study found that opioids, including morphine, were equally effective as non-steroidal anti-inflammatory drugs (NSAIDs) in decreasing the need for rescue analgesia in patients with mild acute pancreatitis 3.

Management of Biliary Acute Pancreatitis

• The management of biliary acute pancreatitis varies according to its severity, and cholecystectomy should be performed during in-hospital stay for mild cases 7.
• For moderately severe and severe cases, treatment is based on resuscitation, early enteral continuous feeding, and management of complications, with interval cholecystectomy performed at a later stage 7.
• Endoscopic retrograde cholangiopancreatography with sphincterotomy may be performed in emergency cases or as a delayed emergency procedure 7.