What are the recommended pain management options for pancreatitis?

Pain Management for Acute Pancreatitis

Opioids should be used as first-line treatment for pain management in acute pancreatitis, as they effectively decrease the need for supplementary analgesia without increasing the risk of pancreatitis complications. 1

First-Line Pain Management

• Opioid analgesics: The primary treatment option for acute pancreatitis pain

  • Buprenorphine appears to be more effective than NSAIDs (diclofenac), requiring significantly less rescue analgesia and providing longer pain-free intervals 2
  • Patient-controlled analgesia (PCA) with opioids is recommended when epidural analgesia cannot be used 1

• Multimodal analgesia: Adjuncts to opioid therapy

  • Paracetamol (acetaminophen)
  • NSAIDs/COX-2 inhibitors
  • These can help reduce overall opioid requirements 1

Second-Line and Advanced Pain Management Options

• Mid-thoracic epidural analgesia: Consider for severe cases

  • Provides superior pain relief compared to intravenous opioids
  • Should be continued for at least 48 hours 1

• Intravenous lidocaine infusion: May be considered as an alternative analgesic method 1

• Neurolytic coeliac plexus block:

  • Effective for treatment and prevention of pain
  • Should be considered at time of palliative surgery or by percutaneous/endoscopic approach in non-surgical patients
  • Most effective when used early rather than late in disease course
  • Produces effective palliation in approximately 70% of patients 3
  • Not recommended routinely for chronic pancreatitis pain management; only consider in selected patients with debilitating pain when other measures have failed 1

• Chemoradiation: Should be considered for severe pain, particularly when pain recurs after coeliac plexus blockade 3

Evidence Strength and Considerations

The most recent evidence (2024) strongly supports buprenorphine over NSAIDs like diclofenac. In a double-blind randomized controlled trial, patients receiving buprenorphine required significantly less rescue fentanyl (130 μg vs 520 μg), had fewer demands for additional pain medication, and experienced longer pain-free intervals (20 vs 4 hours) compared to those receiving diclofenac 2. This finding was consistent even in patients with moderately severe or severe pancreatitis.

A Cochrane review found that opioids decrease the need for supplementary analgesia compared to other analgesic options, without increasing the risk of pancreatitis complications or serious adverse events 4. A 2021 systematic review and meta-analysis confirmed that opioids were associated with a significant decrease in the need for rescue analgesia compared to non-opioids 5.

Additional Management Considerations

• Monitor for adequate pain control: Ensure pain relief is sufficient to allow mobilization out of bed 1

• Pancreatic enzyme supplements: Should be used to maintain weight and increase quality of life 3

• Neuropathic pain components: Consider gabapentin, pregabalin, nortriptyline, or duloxetine if neuropathic pain is present 1

Pitfalls and Caveats

• Avoid delaying adequate pain control due to unfounded concerns about opioid-induced sphincter of Oddi spasm; evidence shows opioids do not increase pancreatitis complications 1, 4

• Do not rely solely on pancreatic enzyme supplements for pain control; they improve quality of life but are not primary analgesics 3

• Celiac plexus block typically provides pain relief for less than 6 months, so should not be considered a permanent solution 1

• Ensure patients with severe pancreatitis have access to palliative medicine specialists for comprehensive pain management 3