What painkillers are used to treat acute pancreatitis?

Pain Management in Acute Pancreatitis

For acute pancreatitis pain, use hydromorphone (Dilaudid) as the preferred opioid in non-intubated patients, with morphine as an acceptable alternative for severe pain; NSAIDs should be avoided in patients with acute kidney injury. 1

Stepwise Analgesic Approach Based on Pain Severity

Mild Pain

• Start with paracetamol (acetaminophen) and/or NSAIDs as first-line therapy 2, 3
• Critical caveat: NSAIDs must be avoided if acute kidney injury is present 1
• NSAIDs themselves can rarely cause acute pancreatitis, so monitor closely for symptom worsening 4, 5

Moderate Pain

• Add weak opioids (codeine or tramadol) in combination with non-opioid analgesics 2, 3
• This represents an escalation when paracetamol/NSAIDs alone provide inadequate relief

Severe Pain

• Hydromorphone (Dilaudid) is preferred over morphine or fentanyl in non-intubated patients 1, 2, 3
• Morphine is the first-line opioid if hydromorphone is unavailable 2, 3
• Recent high-quality evidence shows buprenorphine is more effective than diclofenac (an NSAID), requiring significantly less rescue analgesia (130 μg vs 520 μg fentanyl; P < .001) and providing longer pain-free intervals (20 vs 4 hours; P < .001) 6

Multimodal Analgesia Strategy

Patient-Controlled Analgesia (PCA)

• Integrate PCA with any analgesic strategy to optimize pain control 1
• Allows patients to self-titrate within safe parameters

Epidural Analgesia

• Consider epidural analgesia as an alternative or adjunct to intravenous opioids, particularly for patients requiring high opioid doses for extended periods 1
• Especially valuable in severe acute pancreatitis cases

Neuropathic Pain Components

• Pain in pancreatitis often has both visceral and neuropathic components due to proximity to the celiac axis 2, 3
• Add gabapentin, pregabalin, nortriptyline, or duloxetine when pain has neuropathic characteristics 2, 3

Mandatory Side Effect Management

Opioid-Induced Constipation

• Laxatives must be routinely prescribed for both prevention and management of opioid-induced constipation 2, 3
• This is not optional—constipation is expected with opioid use

Nausea and Vomiting

• Use metoclopramide and antidopaminergic drugs for opioid-related nausea/vomiting 2, 3

Special Populations and Considerations

Renal Impairment

• Use all opioids with caution at reduced doses and frequency in patients with renal impairment 2, 3
• For chronic kidney disease stages 4-5 (eGFR <30 ml/min), fentanyl and buprenorphine (transdermal or IV) are the safest opioid choices 3
• Morphine should be used cautiously due to accumulation of active metabolites 7

Biliary Tract Considerations

• Morphine may cause sphincter of Oddi spasm, which is a theoretical concern in acute pancreatitis 7
• However, this has not been shown to worsen clinical outcomes in practice, and pain relief remains the priority 1
• Fentanyl also carries this warning for biliary tract disease 8

Interventional Options for Refractory Pain

• Reserve celiac plexus block for cases where medications provide inadequate relief or cause intolerable side effects 2, 3
• Do not use as first-line intervention—it has a 40-50% failure rate 3

Evidence Quality and Practical Considerations

The 2019 World Society of Emergency Surgery guidelines provide the most current recommendations, emphasizing that no restrictions on pain medication are warranted, with the primary goal being adequate pain control 1. The evidence comparing opioids to NSAIDs shows opioids decrease the need for rescue analgesia (OR 0.25,95% CI 0.07-0.86) 9, though both are effective in mild pancreatitis 9.

Common pitfall: Withholding adequate analgesia due to unfounded concerns about masking abdominal findings or causing sphincter of Oddi spasm. Pain control is a clinical priority and should be addressed promptly 1, 10.