Pain Management in Pancreatitis

Assessment and Classification

The American College of Physicians recommends that pain intensity should be regularly assessed using validated tools such as visual analog scales (VAS), verbal rating scales (VRS), or numerical rating scales (NRS) 1
Pain in pancreatitis often has both visceral and neuropathic components due to proximity to the celiac axis 2, 1
Treatment approach should be tailored based on pancreatitis severity, with mild acute pancreatitis treated with oral pain medications, moderately severe acute pancreatitis treated with IV pain medications, and severe acute pancreatitis treated with IV pain medications with potential need for advanced interventions 3

For mild pain, the American Pain Society recommends paracetamol (acetaminophen) and/or NSAIDs 1
For moderate pain, weak opioids such as codeine or tramadol in combination with non-opioid analgesics are recommended 1
For moderate to severe pain, morphine is the opioid of first choice, according to the American College of Cardiology 1
In acute pancreatitis, hydromorphone is preferred over morphine or fentanyl in non-intubated patients, as suggested by the American Thoracic Society 1

For neuropathic pain, consider adjuvant medications such as gabapentin, pregabalin, nortriptyline, or duloxetine, as recommended by the American Academy of Neurology 2, 1
When medications provide inadequate relief or cause intolerable side effects, consider celiac plexus block, according to the American Gastroenterological Association 4, 1

Laxatives must be routinely prescribed for both prevention and management of opioid-induced constipation, as recommended by the American Society of Clinical Oncology 1
Metoclopramide and antidopaminergic drugs are recommended for treatment of opioid-related nausea/vomiting, according to the National Comprehensive Cancer Network 1

All opioids should be used with caution, at reduced doses and frequency in patients with renal impairment, as suggested by the National Kidney Foundation 1
Fentanyl and buprenorphine (transdermal or IV) are the safest opioids for patients with chronic kidney disease stages 4 or 5 (eGFR <30 ml/min), according to the American College of Physicians 1

Pancreatic enzyme supplements should be used to maintain weight and increase quality of life, as recommended by the European Society for Clinical Nutrition and Metabolism 4
Patients should have access to palliative medicine specialists for comprehensive pain management, according to the American Academy of Hospice and Palliative Medicine 4