What is the recommended pain reliever for pancreatitis?

Pain Management in Pancreatitis

Opioids are the recommended first-line pain relievers for moderate to severe pain in pancreatitis, with morphine being the preferred choice, while NSAIDs and paracetamol can be used for mild pain or as adjuncts. 1

Pain Management Algorithm

Acute Pancreatitis

• For mild pain: Paracetamol (acetaminophen) and/or NSAIDs are effective first-line options 1, 2
• For moderate pain: Weak opioids such as codeine or tramadol in combination with non-opioid analgesics 1
• For moderate to severe pain: Morphine is the opioid of first choice 1, 2
• In non-intubated patients with acute pancreatitis, hydromorphone is preferred over morphine or fentanyl 1, 2

Chronic Pancreatitis

• Regular scheduled analgesics rather than "as needed" dosing is recommended 1
• Individual titration using immediate-release morphine administered every 4 hours plus rescue doses for breakthrough pain 1
• Recent evidence suggests buprenorphine may be more effective than NSAIDs like diclofenac for pain management in pancreatitis, with less need for rescue analgesia 3

Special Considerations

Renal Impairment

• All opioids should be used with caution, at reduced doses and frequency in patients with renal impairment 1, 2
• For patients with chronic kidney disease stages 4 or 5 (eGFR <30 ml/min), fentanyl and buprenorphine are the safest opioid options 1, 2

Neuropathic Pain Components

• For neuropathic pain components, consider adjuvant medications such as gabapentin, pregabalin, nortriptyline, or duloxetine 1, 2
• Pain in pancreatitis often has both visceral and neuropathic components due to proximity to the celiac axis 1, 2

Advanced Interventions

Celiac Plexus Block

• When medications provide inadequate relief or cause intolerable side effects, consider celiac plexus block (CPB) 4, 1
• CPB appears to be safe and effective for pain reduction in patients with pancreatic cancer, with significant advantage over standard analgesic therapy for up to 6 months 4
• Neurolytic blocks should be limited to patients with short life expectancy as they typically produce a block lasting 3-6 months 1

Other Interventional Approaches

• EUS-guided celiac plexus neurolysis (CPN) is effective for pain in pancreatic cancer (80% pain relief) but less effective in chronic pancreatitis (59% pain relief) 4
• EUS-CPN is not recommended as first-line treatment for pain arising from chronic pancreatitis due to limited efficacy 4

Managing Adverse Effects

• Laxatives must be routinely prescribed for both prevention and management of opioid-induced constipation 1, 2
• Metoclopramide and antidopaminergic drugs are recommended for treatment of opioid-related nausea/vomiting 1, 2
• Patient-controlled analgesia (PCA) should be integrated with analgesic strategies when appropriate 1

Evidence Quality and Controversies

• A meta-analysis of 12 studies (699 patients, 83% mild acute pancreatitis) found that NSAIDs and opioids are equally effective in decreasing the need for rescue analgesia in mild acute pancreatitis 5
• The optimal analgesic strategy for patients with moderately severe and severe acute pancreatitis remains less well-defined due to limited high-quality studies 5
• Recent research (2024) comparing buprenorphine to diclofenac showed buprenorphine was more effective with similar safety profile, even in moderately severe/severe pancreatitis 3

Pitfalls and Caveats

• Avoid NSAIDs in patients with acute kidney injury or at high risk for renal complications 1
• In chronic pancreatitis, pain processing becomes abnormal and may resemble neuropathic pain disorders, making traditional pain management approaches less effective 6
• A multimodal approach combining different analgesic classes often provides better pain control with fewer side effects than single-agent therapy 1