**7. Medical treatment of the pain**

Chronic Pancreatitis related pain is typically among the most severe pain of all chronic diseases and has a major impact on quality of life and disability [16, 17]. That is why pain control plays a key role in the treatment of CP. Combinations of medical, endoscopic, and surgical approaches may be used to relieve abdominal pain in patients with CP [75, 76].

All patients having pain should be offered medical management. Patients with inflammatory mass, pancreatic duct obstruction due to stricture and/or main duct stones or peripancreatic complications (e.g. pseudocyst) may require additional interventions. Even in patients who tend to be suitable for endoscopic or surgical therapy, initial medical management of pain is advised to provide relief, greater understanding of the mechanism of pain, response to treatment, and if there is any significant sensitization [77].

The World Health Organization analgesic ladder for cancer pain is widely used by physicians to treat CP pain as there are no recommendations for the choice, usage and dosage of analgesics [78]. This stepwise approach recommends acetaminophen and nonsteroidal anti-inflammatory drugs (e.g., diclofenac, ibuprofen, and naproxen) as initial choice. When patient has constant and/or severe pain that

### *Current Approaches in Chronic Pancreatitis DOI: http://dx.doi.org/10.5772/intechopen.98214*

cannot be controlled with non-narcotic analgesics, narcotic medications can be used. The first option of narcotics should be a weaker, mixed agonist–antagonist or partial agonist (e.g., tramadol) prior to the use of stronger narcotics (e.g., morphine, hydrocodone and hydromorphone). If opioids are needed, they should be administered orally in a long-acting form -lancet). Physicians must be aware of their side effects (e.g., constipation, nausea, sedation, increased risk of falls, and risk of dependence and substance misuse) and capable of managing them. That is why, patients that are likely to undergo long-term narcotic analgesia for pancreatic pain are most effectively assessed and treated at a pain clinic [77].

Because of these adverse effects of opioids, co-analgesics should also be tried, and interventional therapy (such as surgery) should be considered before starting opioids. Co-analgesics such as antidepressants and anticonvulsants (gabapentin, pregabalin) have been shown to be beneficial in the treatment of chronic visceral and neuropathic pain in chronic pancreatitis and can help to minimize the need for opioids [62, 79]. Pregabalin is shown to have better efficacy in decreasing daily pain scores than placebo, however central nervous symptoms were seen in significant number of participants on pregabalin, potentially limiting its clinical usefulness [80]. Alternative analgesics such as esketamine are currently being investigated for this indication [61].

Antioxidant supplementation in may be beneficial especially for those patients with nonalcoholic-derived CP but additional trials are needed [81–83]. A randomized control study showed that pain relief significantly higher in the antioxidant group than in the placebo group [84].
