Medical Management of Pain in Chronic Pancreatitis

Pain in chronic pancreatitis: What can we do today?

The aim of this study is to illustrate the complexity of pain management in chronic pancreatitis (CP). In this context, pain represents the most common and debilitating symptom, and it deeply affects patient’s quality of life. Multiple rating scales (unidimensional, bidimensional and multidimensional) have been proposed to quantify CP pain. However, it represents the result of complex mechanisms, involving genetic, neuropathic and neurogenic factors. Considering all these aspects, the treatment should be discussed in a multidisciplinary setting and it should be approached in a stepwise manner. First, a lifestyle change is recommended and nonsteroidal anti-inflammatory drugs represent the gold standard among medical treatments for CP patients. The second step, after medical approach, is endoscopic therapy, especially for complicated CP. In case of failure, tailored surgery represents the third step and decompressive or resection procedures can be chosen. In conclusion, CP pain’s management is challenging considering all these complex aspects and the lack of international protocols.

Pain management in chronic pancreatitis

Pain in chronic pancreatitis (CP) is difficult to manage. Many patients suffer from inadequate pain relief, completely incapacitating them in their daily activities. Historically, despite their well-known adverse effects, opioids have been the pillar of treatment regimens in painful CP. The management is now gradually evolving with a better understanding of the underlying pathophysiology of CP-related pain. Clinicians should follow a holistic approach to the management of CP-associated pain, which must involve lifestyle changes that are coupled with analgesic medications and other pain-relieving interventions. Furthermore, there is no easy cure for vanquishing CP-associated pain. Each patient must be evaluated on a case-by-case basis by a multidisciplinary team to decide which treatment option is best suited for that individual.

Quality of Life and Pain in Patients With Chronic Pancreatitis

INTRODUCTION

The quality of life (QoL) of patients with chronic conditions is a function of factors associated with the illness, its natural course, and treatment as well as those related to the patient. Chronic pancreatitis (CP) is a critical public health problem. Chronic pancreatitis patients can experience chronic pain with different mechanisms, malabsorption, diabetes, and cachexia.

OBJECTIVE

Chronic pancreatitis (CP) is a critical public health problem. CP patients can experience chronic pain with different mechanisms, malabsorption, diabetes, and cachexia. The aim of the study was to assess the Quality of Life (QoL) of patients with CP and identify factors affecting QoL.

METHODS

104 patients diagnosed with CP from the hospital in Wrocław, Poland, were included. The study was conducted using our own questionnaire, the World Health Organization Quality of Life-BREF (WHOQOL-BREF) scale, the 36-Item Short Form Health Survey (SF-36), and the Visual Analog Scale (VAS).

RESULTS

The mean total SF-36 score was 47.7, with the highest mean rating for the physical functioning domain. The mean VAS pain score was 5.13. Pain intensity was significantly correlated with impairments in activities of daily living (P = 0.001), the need to reduce their duration (P = 0.001), and the performance of physical activity (P = 0.003). Comorbidities, education, and age have a significant relationship with only some domains of SF-36.

CONCLUSIONS

One aspect that has an impact on QoL impairment is pain which perception is governed by the same brain regions in which abnormalities result in depression and anxiety. QoL in CP patients also depends on the patient's age, comorbidities, and level of education.

Evaluating Outcomes and Misuse in Opioid-Dependent Chronic Pancreatitis Using a State-Mandated Monitoring System

INTRODUCTION

Patients with chronic pancreatitis (CP) often require opioids for pain control. The goal of our study was to characterize opioid use in patients with CP in a real-life practice using a state-mandated online monitoring program and to assess outcomes compared to CP patients without opioid dependency.

METHODS

CP patients seen in our Pancreas Center from 2016 to 2021 were divided into two groups-with and without chronic opioid use. Details of opioids and other controlled prescriptions were obtained by review of the Massachusetts Prescription Awareness Tool (MassPat).

RESULTS

Of the 442 CP outpatients, 216 used chronic opioids. Patients with opioid use had significantly more recurrent acute pancreatitis (76.6% vs. 52.7%), concurrent alcohol use (11.2% vs. 5.8%), tobacco use (37.8% vs. 19.7%), anxiety (22.4% vs. 16.6%), depression (43.5% vs. 23.5%) and daily pain (59.8% vs. 24.8%) (p < 0.001). They also concurrently used more benzodiazepines (43.7% vs. 12.4%), gabapentinoids (66.4% vs. 31.1%) and medical marijuana (14.9% vs. 4.19%) (p < 0.001). They had more celiac plexus blocks (22.0% vs. 6.67%), surgery (18.3% vs. 8.89%) and more hospitalizations for CP flares (3.6 vs. 1.0 visits) (p < 0.001). Less than 13% patients received opioids by means of ED visits; 81.7% patients received their prescriptions from one facility and 75% received them at regular intervals.

CONCLUSION

Opioid-dependent CP patients exhibit polypharmacy and have worse outcomes with higher resource utilization. The state-monitoring program ensures that the majority of patients receive opioids from a single facility, thereby minimizing misuse.

Psychiatric Disease Susceptibility and Pain in Chronic Pancreatitis: Association or Causation?

Pain perception in chronic pancreatitis (CP) is governed by the transmission of nociceptive inputs into the pain processing centers of the brain. These regions of the brain overlap with those that regulate and process emotions and cognition. Disorders in these regions also result in psychiatric conditions such as depression, anxiety, and posttraumatic stress disorder. The present study by Dunbar et al. evaluated 24 single nucleotide polymorphisms associated with anxiety and/or posttraumatic stress disorder and found correlations with constant and severe pain phenotypes in CP patients from a large cross-sectional cohort study. Although causation cannot be proven, the findings suggest that there may be a role for neuromodulator drugs for the treatment of pain in CP based on individual genetic susceptibility.

Progress in pharmacotherapy for alleviating pain of chronic pancreatitis

Pain is the main clinical symptom of chronic pancreatitis (CP), as well as the most common cause of patients' recurrent hospitalizations. The management regimen for CP pain needs to be formulated according to the patient's conditions. Lifestyle changes and drug treatment can usually be used as first-line therapy. Conventional analgesics, pancreatic enzymes, and antioxidants are commonly used in treating pain of CP. In recent years, the application of conventional analgesics has been further standardized. Besides, there have been more clinical studies on the treatment of CP pain with pancreatic enzymes or antioxidants. Traditional Chinese medicine has played an increasingly important role in the treatment of CP pain. New drugs such as camostat mesylate are expected to be used in CP pain, though more high-quality studies are still needed to confirm their safety and effectiveness.

Predictors, rates, and trends of opioid use disorder among patients hospitalized with chronic pancreatitis

Background

Patients with chronic pancreatitis (CP) suffer from pain and receive increased opioid prescriptions with a high risk of opioid use disorder (OUD). We studied the predictors, trends and outcomes of OUD among patients hospitalized with CP.

Methods

Records with CP (with/without OUD) were extracted from the Nationwide Inpatient Sample (NIS) 2012-2014, and the association of OUD with the burden of CP was calculated. We then charted the trends of OUD and its interaction with concomitant CP from NIS 2007-2014 (SAS 9.4).

Results

In the period 2012-2014, 4349 (4.99%) of the 87,068 CP patients had concomitant OUD, with higher risk among patients who were young, females, white vs. Hispanics, and individuals with chronic back pain, arthritis, non-opioid substance use, mental health disorders, and those hospitalized in urban centers. OUD was associated with a longer hospital stay (6.9 vs. 6.5 days, P=0.0015) but no significant difference in charges ($47,151 vs. $49,017, P=0.0598) or mortality (1.64% vs. 0.74%, P=0.0506). From 2007-2014, the average yearly rate of OUD was 174 cases per 10,000 hospitalizations (174/10,000), almost 3 times higher among CP vs. non-CP (479/10,000 vs. 173/10,000, P<0.001), and it increased from 2007 to 2014 (135/10,000 to 216/10,000, P<0.001). The yearly increase was 2.7 times higher among patients with CP vs. non-CP (29.9/10,000 vs. 11.3/10,000 hospitalizations/year, P<0.001).

Conclusions

CP is associated with higher rates and trends of OUD. Patients with CP at high risk of OUD may benefit from alternate analgesic regimens or surveillance for OUD when they are prescribed opioids.

A clinically feasible method for the assessment and characterization of pain in patients with chronic pancreatitis

BACKGROUND AND AIMS

Pain is the primary symptom of chronic pancreatitis (CP), but methods for sensory testing and pain characterization have not previously been validated for clinical use. We present a clinically feasible method for the assessment and characterization of pain mechanisms in patients with CP based on quantitative sensory testing (QST).

METHODS

This was a cross-sectional, multicenter study of 122 control subjects without pancreatic disease and another 60 patients with painful CP. All subjects underwent standardized QST assessments including a cold pressor test, a conditioned pain modulation paradigm, repetitive pin-prick stimuli (temporal summation) and pressure stimulation of the upper abdominal (pancreatic) and control dermatomes. The effects of age and gender on QST assessment parameters were investigated and normative reference values based on quartile regression were derived and implemented in algorithms to categorize patients according to their patterns of central pain processing (normal vs. segmental sensitization vs. widespread sensitization).

RESULTS

Absolute pressure thresholds were subject to clinically relevant gender effects (all p < 0.001), while the remainder of QST parameters were unaffected by age and gender. The algorithm with the best discriminatory capacity showed good separation between patients and controls (p < 0.001); 50% of patients had normal central pain processing, 23% had evidence of segmental sensitization and 27% had evidence of widespread sensitization.

CONCLUSION

We show normative reference values for a clinically feasible method for assessment and characterization of pain mechanisms in patients with CP. Application of this method streamlines the evaluation of pancreatic pain and may be used to inform treatment. CLINICALTRIALS.

GOV ID

NCT03434392.

Rising Prevalence of Opioid Use Disorder and Predictors for Opioid Use Disorder Among Hospitalized Patients With Chronic Pancreatitis

OBJECTIVES

We aimed to evaluate the prevalence, impact, and predictors of opioid use disorder (OUD) in hospitalized chronic pancreatitis (CP) patients.

METHODS

A retrospective cohort study was performed using the National Inpatient Sample database from 2005 to 2014. Patients with a primary diagnosis of CP and OUD were included. The primary outcome was evaluating the prevalence and trend of OUD in patients hospitalized with CP. Secondary outcomes were to (1) assess the impact of OUD on health care resource utilization and (2) identify predictors of OUD in hospitalized CP patients.

RESULTS

A total of 176,857 CP patients were included, and OUD was present in 3.8% of patients. The prevalence of OUD in CP doubled between 2005 and 2014. Patients with CP who had OUD were found to have higher mean length of stay (adjusted mean difference, 1.2 days; P < 0.001) and hospitalization costs (adjusted mean difference, US $1936; P < 0.001). Independent predictors of OUD in CP patients were obesity, presence of depression, and increased severity of illness.

CONCLUSIONS

Opioid use disorder-related diagnoses are increasing among CP patients and are associated with increased health care resource utilization. Our study identifies patients at high-risk for OUD whose pain should be carefully managed.