What are the principles of pain management in patients with chronic pancreatitis? Can we use strong opioids?
Miroslav Vujasinovic, MD, PhD: This is the most difficult question for me. In my everyday clinical work, I think pain management is definitely the most demanding aspect. All other topics we can discuss, debate.
Right now, we are following the World Health Organization (WHO) step-up approach, but the first step, that means paracetamol, very rarely helps, so quite fast we come to the second level.
On the second level there are nonsteroidal anti-inflammatory drugs that we absolutely try to avoid in this group of patients due to the side effects. Basically, tramadol is probably the best, and I personally had the best experience with tramadol. If it is possible, I like to manage the patient with the highest possible dose of tramadol.
Unfortunately, a lot of patients are coming to opioids, especially in the Scandinavian countries, where the frequency of prescription of opioids is very high. And that is why unfortunately we have also a lot of side effects: narcotic bowel syndrome, obstipation, dependency. Sometimes we try the top-down approach, from opioids to tramadol, but it is not very easy. It is very demanding. My personal favorite is the second level, with tramadol.