Pain Treatment & Management
Significant pain associated with chronic pancreatitis can seriously reduce a patient’s quality of life. It is important to treat chronic pancreatitis as soon as it is diagnosed because repeated episodes of inflammation can cause irreversible damage, and pain relief becomes much less effective. Pain relief can be achieved with medication, often using the World Health Organization’s 3-step ladder approach to pain relief:
- Pain medication begins with nonopioids (like acetaminophen, ibuprofen, or both).
- If nonopioids do not relieve pain, mild opioids (like codeine) are given.
- If mild opioids do not relieve pain, strong opioids (like morphine) are given.
Many patients with chronic pancreatitis receive antioxidants with their pain medicine, which has been shown to help with pain relief. There are other options for pain relief, such as a celiac plexus block, which may provide another option for significant pain relief. The celiac plexus block is achieved via injection and prevents the nerves that travel from the pancreas from reporting pain signals back to the brain. If there is a narrowing of the pancreatic duct, the placement of a plastic tube called a stent into the duct can be helpful in alleviating pain symptoms.
There are many ways to treat pain. If you have mild to moderate pain, acetaminophen (Tylenol®) and/or nonsteroidal anti-inflammatory drugs (NSAIDS) may bring relief. NSAIDS may upset your stomach so be sure to check with your doctor before taking them. Ibuprofen (Motrin®, Advil®), Naproxen (Naprosyn®, Aleve®) are examples of NSAIDS. If these medications do not control your pain your doctor may suggest opioids such as Hydrocodone, Codeine, Methadone, Fentanyl, Oxycodone, Hydromorphone (Dilaudid®) or Morphine. Remember that Percocet, Vicodin and Tylenol #3 all contain acetaminophen so you should not combine them with more acetaminophen (Tylenol®). If your doctor believes that you have nerve pain there are other medications he may prescribe that help sooth the damaged nerves. These medications have been used for other reasons, but are especially helpful in controlling nerve pain. These drugs are Amitriptyline (Elavil®), Nortriptyline (Pamelor®, Aventyl®) and Desipramine.
Based on your pain and condition, you and your health-care provider will decide which medication you need, how you should take it, how much you should take and how often.
Other suggestions to manage pain are heat packs, gentle massage, relaxation techniques, distraction, laughter/humor, music, reading, prayer, visitors or just finding a comfortable position.
Limited Role of Endoscopic Retrograde Cholangiopancreatography (ERCP)
An ERCP test, in which a flexible endoscope is placed into the intestine and a catheter is used to inject dye into the pancreas, should generally not be used in chronic pancreatitis. It should never be used to diagnose chronic pancreatitis because injecting dye into the pancreas can cause pancreatitis. For more information about ERCP, please click here.
When medical therapy fails to provide relief to patients with chronic pancreatitis, surgical therapy may be an option. A lateral pancreatojejunostomy (modified Puestow procedure) can result in pain relief in up to 80% of patients.
Another surgical procedure, which can remove inflammation and masses on the head of the pancreas, is the classic Whipple procedure; however, this procedure does remove a lot of important tissue and can be associated with complications such as an increased risk of death. When possible, modified Whipple procedures are performed to save more tissue compared to the classic Whipple procedure and can be successful for pain relief and return to daily activity. To read more, please visit Whipple Procedure.
For appropriately selected patients whose pain remains incapacitating despite standard medical and surgical approaches, total pancreatectomy with islet auto-transplantation (TP-IAT) – while not a panacea – yields significant relief of symptoms. For more information on this, please visit TPIAT.
Basic and clinical evidence suggests that the development of both acute pancreatitis (AP) and chronic pancreatitis (CP) can be associated with oxidative stress. Findings show that free radical activity and oxidative stress indices are higher in the blood and duodenal juice of patients with pancreatitis. Based on these findings, the idea of using antioxidant regimens in the management of both AP and CP as a supplement and complementary in combination with its traditional therapy is reasonable. In practice, however, the overall effectiveness of antioxidants is not known, and the best mixture of agents and dosages is not clear. Currently, a trial of a mixture of antioxidants containing vitamin C, vitamin E, selenium, and methionine is reasonable as one component of overall medical management. In summation, there is no definite consensus on the dosage, length of therapy, and ultimately, the benefits of antioxidant therapy in the management of AP or CP. Further well-designed clinical studies are needed to determine the appropriate combination of agents, time of initiation, and duration of therapy.
Bilateral Thoracoscopic Splanchnicectomy
This is an option for intractable, chronic pain but it is not widely available. It is a surgical resection of one or more of the splanchnicnerves for the treatment of intractable pain. It is usually performed by a thoracic surgeon when it is done.
Pain is the body’s way of telling us something is wrong. Pain can become a concern if it continues for a long time and begins to interfere with sleeping, eating, and enjoying life in general. Pain cannot be measured like weight or blood pressure. Each person feels pain differently.
It is important when you go to the doctor to report on many things about your pain.
- Where does it hurt? Is there more than one place? Does the pain move around?
- How long have you had pain? Is it always there? Does it come and go? How bad is the pain (0=no pain, 10=worst possible pain)
- What makes your pain worse? Position, movement or activity or the time of day?
- What makes the pain better? If medication, what kind, how much and how often? Does position, rest, heat/cold, friends, television, relaxation, music help?
- How does the pain affect your life? Does it affect activity, eating, sleeping, mood? Do you have side effects from the pain medication you take such as nausea, sleeping, constipation?
- How does the pain feel to you? Is it dull, sharp, throbbing, aching, stabbing, burning, gnawing, cramping, tight, squeezing, shooting?
Pain Medication and Addiction
Patients and families are always concerned when pain medication is prescribed. Many are worried about addiction. Simply using an opioid pain medication will not result in addiction. About 3-18 % of patients using opioids for pain management will develop a problem with drug addiction. These patients often have had previous addiction problems. When you use pain medication over a long period of time, you may eventually need a higher dose or a different pain medication to get the same result. This response is called tolerance and has nothing to do with addiction. Over time a patient may become dependent on the medications. Dependence means that you will experience “withdrawal symptoms” if you stop taking medications suddenly. This happens because your body has gotten used to the medications. Withdrawal symptoms include nausea, diarrhea, sweating, anxiety, and irritability. If you need to stop a medication you should follow a doctor’s advice and slow down gradually. It is important to remember that withdrawal has nothing to do with addiction.
Medical Management of Pain in Pediatric Pancreatitis: A Collaborative Approach
Symptomatic Pain Treatment
Patients who undergo treatment for pancreatic cancer can experience different symptoms, such as significant pain, jaundice and itching, digestion problems, and depression. Your physician will treat these symptoms if they occur on a case-by-case basis, and may bring in other team members, such as pain management specialists, nutritional counselling, occupational therapy, and psychological counselling/therapy.
Alternative therapies are therapies that can be used along with medical treatment to help the patient feel better. No one should begin an alternative therapy without speaking with his or her physician.
Research has found that patients with chronic pancreatitis who practice yoga on a biweekly basis can experience an improvement in overall quality of life, symptoms of stress, mood changes, alcohol dependence and appetite.
Massage therapy involves touch and different techniques of stroking or kneading the muscles of the body. It can involve only part of the body or a full body massage. Massage may be done through one’s clothing or on the exposed skin. It can be done in specialized chairs or on a table. Massage therapy should only be done by a licensed massage therapist. Massage is used for muscle and bone discomfort, improvement of circulation, reduction in swelling, relaxation, and pain control. It can be used as a complement to other treatments and as a stress reducer and feel-good therapy. Studies have shown that massage can improve the relaxation response and the general sense of well-being.
Therapeutic Touch is a process of energy exchange in which the practitioner uses the hands as a focus to help the healing process. It is based on the idea that humans are a form of energy. When we are healthy, the energy is freely flowing and balanced. Disease, on the other hand, is believed to be an imbalance or disturbance of the energy flow. Therapeutic Touch treatment may vary from 5-30 minutes depending on the needs of the individual. Exact methods vary between practitioners, but generally, they will hold their hands 2-4 inches away from your fully clothed body, moving them from your head to toe, and over your front and back. Research has demonstrated that therapeutic touch promotes relaxation and a sense of comfort and well-being. Research has shown it to be effective in decreasing anxiety and altering the perception of pain.
Physical exercise improves the overall functioning of the body and quality of life. Exercise therapy may decrease stress, pain, nausea, fatigue and depression. Regular exercise affects your hormonal balance as well as most of your body systems. Regular participation in physical activity raises the heart rate and maintains an increased heart rate for a period of time. Depending on your physical condition, and after the advice of your physician, you may begin walking 5-10 minutes twice a day with a goal of increasing activity for 45 minutes at least three times each week. It is important that your exercise time is without interruptions. This is time for yourself. If you are unable to walk, there are other ways to exercise (i.e., stretching, and isometric exercises).
Meditation or relaxation is a state of being free from anxiety, tension, and distress. A state of relaxation can be achieved using different styles, such as, diaphragmatic breathing, progressive muscle relaxation, repetitive affirmation, prayer, yoga, and guided/visual imagery. When practiced regularly, meditation can improve sleep, concentration, and the ability to cope with stress. It can help with the management of pain, nausea, and anxiety. You may find free tapes or booklets about meditation at libraries or low-cost materials in stores. You may also choose to attend groups or work groups for no or minimal fees. Once you have learned the technique, meditation can be practiced without cost.
The term acupuncture describes a family of procedures involving the stimulation of anatomical points in the body by a variety of techniques. American practices of acupuncture incorporate medical traditions from China, Japan, Korea, and other countries. The acupuncture technique that has been most studied scientifically involves penetrating the skin with thin, solid, metallic needles that are manipulated by the hands or by electrical stimulation.