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Treating Pain in Chronic Pancreatitis

October 30, 2017
With Darwin L. Conwell, MD, MS, and Timothy B. Gardner, MD, MS

Pain is the most common report among chronic pancreatitis (CP), and it is often severe, leading to detrimental effects on quality of life, Darwin L. Conwell, MD, MS, explained at the 2017 World Congress of Gastroenterology.1 CP pain “can be constant or intermittent,” Dr. Conwell told Practical Pain Management (PPM).  Dr. Conwell is the director of gastroenterology, hepatology, and nutrition, as well as the Floyd Beman Chair in Gastroenterology, at The Ohio State University Wexner Medical Center in Columbus.

CP’s prevalence is about 50 per 100,000, according to the National Institutes of Health,2 and while there are many treatment options for CP pain, the response to therapy is often unpredictable, inconsistent, and inadequate, noted Dr. Conwell. As pain specialists and other physicians are well aware, the addiction potential for opioid pain medications raises another issue, with Dr. Conwell estimating the risk at 20%.

Chronic pancreatis patient, small duct25 year-old-female, small-duct CP (Conwell D)

Understanding CP Pain

CP often presents as a complex, multi-level neuropathic pain syndrome, Dr. Conwell said. Pain levels affect the:

  • Cerebral cortex, with cortical reorganization and central sensitization (hyperalgesia and allodynia)
  • Spinal/Peripheral, with DRG and spinal cord hypersensitivity
  • Intra-pancreatic, with neuropathic mechanism and nociception.3

Most patients with CP seen at tertiary care centers have extra-pancreatic pain sources, Dr. Conwell explained. In his own study of 23 patients, the results of differential neuroaxial blockade demonstrated that 5, or 22%, had visceral pain, while 78%, or 18, had non-visceral pain. Of those, 11 experienced central pain, 4 somatosensory pain, and 3 mixed pain.4

In patients with CP, descending inhibitory pain modulation may be impaired, Dr. Conwell said. As a result, he noted that treatment should include pain modulation from supraspinal structures and CNS sensitization.

Treatment & the Pain Management Sequence

Among the standard of care treatment options are: propoxyphene with acetaminophen, tramadol, antioxidants, tricyclic antidepressants, SSRSs, combined serotonin and norepinephrine reuptake inhibitors, Pancreatic enzymes (PERT), and octreotide.1

After establishing the diagnosis of CP, Dr. Conwell advises that practitioners first tell the patient, if applicable, to stop smoking and to cease alcohol consumption. Non-narcotic management is the next step, with options including;

  • Adjunctive agents, such as pregabalin
  • Antioxidants
  • Tramadol
  • Uncoated PERT
  • Pancreatic rest (NJ feeding or TPN)

Next, narcotic analgesics may be an option, including:

  • Opiates
  • Pain therapy consultation
  • Detox or wean narcotic dose.

Pain characterization is crucial, he says, using quantitative sensor testing and nerve blockade (CPB or DNB). For duct morphology, involving the large duct, options are endoscopic or surgical therapy or thoracoscopic splanchnicectomy.

For small duct disease, more aggressive medical therapy may be tried, along with pain management referral, celiac plexus blockade, or drug trials. If these approaches fail, physicians may turn to thoracoscopic splanchnicectomy or pancreatectomy. "If you have small duct disease, it's a lot more challenging,” to treat and to diagnose, Dr. Conwell told PPM.

Dr. Conwell also recommends a multidisciplinary team, including a primary care provider, pain management specialists, psychologists, gastroenterologists, and radiologists, may be crucial to treat the CP patient. “The disease is going to change over time,” he explained. Monitoring must be done to look for increased risk of diabetes, pancreatic cancer, metabolic bone disease, and hip fracture. The risks are real, he said. Patients are also at risk for opioid addiction and must be tracked in the long term.

Those with CP and intractable pain may be referred to a pancreas center, Dr. Conwell said, noting the Pancreas Centers of Excellence designated by the National Pancreas Foundation as optimal choices.

Expert Perspective

The most important information about PC for both the PCP and the pain specialist to know is that, “It is a progressive, very debilitating, generally unremitting disease,” said Timothy B. Gardner, MD, MS, program director of the gastroenterology and hepatology fellowship program and associate professor of medicine at the Geisel School of Medicine at Dartmouth. He reviewed Dr. Conwell’s presentation for PPM.

“The idea of a fix with an intervention can often be seen with back pain or other conditions,  but is not going to be the case with CP,'” he told PPMAnd, he points out, it can be a terminal disease.

“Patients are often labeled as drug seeking or addicts,” said Dr. Gardner, ''and that is not the case at all.” The pain can be intense, yet "the only cure we have is pancreatectomy … and that is fraught with complications.”

He, too, endorses patient lifestyle changes but concedes that a practitioner must “do everything you can to avoid opiates, but in many of these patients you are going to have to use opiates.”

Drs. Conwell and Gardner reported no disclosures.

Last updated on: October 30, 2017
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