The first international guidelines on pain management in acute pancreatitis suggest potent opioids in severe cases of pain are superior relievers to non-opioid alternatives and should be considered despite safety concerns.
A multidisciplinary group, led by UK pancreatic surgeon Professor Sanjay Pandanaboyana and Danish gastroenterologist and pain researcher Professor Asbjorn Mohr Drewes, developed the guidance due to “highly variable” practice in the space, with clinicians often extrapolating from general acute pain management principles.
Pancreatology and pain expert Professor Asbjorn Mohr Drewes.
The guidelines, published in the United European Gastroenterology Journal [link here], had input from eight European specialist groups and used the Delphi method with agreement of 80% or higher to reach consensus on recommendations.
Among the key recommendations, the group makes a case for strong opioids like buprenorphine to be used over non-opioid medications for hospitalised cases of severe acute pancreatitis pain, with evidence suggesting they provide superior pain relief and decrease the need for rescue analgesia.
“Recent randomised trials have found decreased need for rescue analgesia and prolonged pain‐free intervals with buprenorphine and pentazocine that are mixed opioid agonists‐antagonists, over NSAIDs (diclofenac),” the authors say.
They acknowledge that while opioids are widely recognised treatments for severe pain, concerns about potential adverse effects on gut dysmotility, impaired gut permeability, and the sphincter of Oddi spasms have led to hesitation over their use.
They stress there is no consistent evidence of harm and safety concerns should not delay their timely use to ensure adequate analgesia. However, they also recognise there is a lack of high-level evidence from large studies.
“When opioid therapy is required, a clear follow‐up plan should be in place to minimise the risk of prolonged and harmful use,” the guidelines state.
Meanwhile, the guidance says the role of NSAIDs in acute pancreatitis remains debated, and potential anti‐inflammatory benefits must be balanced against gastrointestinal, cardiovascular, and renal risks in a population prone to organ failure. It also makes a weak recommendation for COX‐2 inhibitors, which may reduce the risk of progression to severe disease.
For the first time, specific recommendations have been provided for the use of epidural analgesia – with the guidance noting its safety and efficacy profile in pain management for severe cases where local expertise is available – and for complementary treatments such as acupuncture and Chinese herbal medicine.
Despite some positive but limited evidence for complementary therapies, the group warn that traditional Chinese medicine and acupuncture might not be feasible outside of China due to “a lack of regulatory approvals, implementation barriers and definite lack of proven efficacy from randomised controlled trials”.
The guidelines also touch on pain management in the paediatric population and during pregnancy, with the type of analgesic (opioid versus non‐opioid) not appearing to affect children’s length of stay or intensive care admission.
The authors say a multidisciplinary approach that includes the use of simple analgesics, opioids, interventional procedures, and behavioural pain management interventions should be considered for pain management in children.
The guidance calls for the development of a specific acute pancreatitis pain assessment tool and more quality randomised controlled trials on opioid safety.