Pancreatitis Discharge FAQs
Q: How do I treat pain?
A: First determine if you are treating acute or chronic pancreatitis.
Severe acute pancreatitis
Patients often need continued narcotics post discharge for several weeks due to ongoing inflammation and drain site pain. Pain medication needs should be assessed regularly in the ambulatory setting as weaning can often start a week or two post discharge, even if it is in very slow increments. Complications and flares are also common and may necessitate increased pain medications for a short duration. Assessment should include the patient’s ability to perform ADL’s and daily ambulation. If a patient is unable to ambulate due to pain, complications can ensue, namely respiratory complications that can lead to fluid in the lungs, atelectasis and pneumonia.
Repeated bouts of inflammation and injury leads to permanent damage to the pancreas resulting in chronic pain and pain episodes. There are two common forms of pain in chronic pancreatitis patients: one is persistent pain with flare-ups or exacerbations of pain; the other is relatively pain free durations with flare-ups and exacerbations. Management of chronic pancreatitis can be very challenging. The average patient gets only 30 percent reduction in pain over the long term and there is no data to suggest an improvement in function with opioid management.
Useful Guidelines in Treating Pancreatitis Pain
- Abstinence from alcohol is imperative as it is one of the leading causes of chronic pancreatitis.
- Abstinence from smoking is equally imperative as it is an independent risk factor, resulting in pancreatic damage and functional impairment.
- Begin with a single pain medication. If possible, non-narcotic pain medications should be trialed before introducing narcotics. Tricyclic antidepressants have been shown to effectively manage pancreatitis pain. This is most effective if combined with non-pharmacological approaches such as yoga, meditation and massage.
- If non-narcotic medication is not working, moving to a narcotic is sometimes necessary. A weaker narcotic should be trialed first. A decision to use opioids needs to balance risk and efficacy. Risks can include: depression, decreased bowel function, sex hormone suppression and addiction.
- If adding a second pain medication is warranted, it is suggested that a weaker narcotic medication is coupled with a non-narcotic agent.
- For more severe pain, a long acting narcotic may be warranted and may also require a second medication for breakthrough pain. Again, it is best to trial a non-narcotic agent first, followed by a weaker narcotic and if not successful, a low dose short-acting narcotic. If possible, the low-dose, narcotic should be weaned as soon as possible.
- Other pain treatment modalities include:
- Smoking and alcohol cessation
- Non-enteric pancreatic enzymes
- The use of mindfulness
- Cognitive Behavioral Therapy
- ERCP with stenting
- Celiac Plexus block
Q: When is a good time to start weaning from opioids?
A: There are many circumstances that might prompt weaning, such as patient not benefitting, patient with aberrant use, etc. Generally a weaning schedule might start at a couple of weeks post-procedure, especially if the typical patient would be off or significantly tapering opioids at that juncture.
Q: Is there a general guideline for weaning patients off opioids?
A: There is no clear best practice. Most guidelines suggest a slow taper is 10 percent of starting dose per week. In a post-procedure setting when pain is actually better, weaning back toward baseline can go faster, for example starting at two-to-three weeks and return to baseline by six weeks.
Q: How should I treat new onset DM in patients that had new insulin needs while in the hospital?
A: Education is key. Many patients can feel overwhelmed with a new diagnosis of diabetes, especially after having just been through the physical and emotional stressors of pancreatitis. These patients will likely need insulin at least for some time post discharge, if not for life. Close monitoring of blood sugars/insulin and educational needs should continue regularly in the outpatient setting.
Q: Will my patient need antibiotics at discharge?
A: Patients who have infected pseudocyst/infected necrotic fluid collections may need to complete a course of antibiotics after discharge. Usually these patients have an infectious disease doctor following them in hospital and many need post hospital follow up by infectious disease.
Q: My patient went home on tube feeds, now what?
A: The need for tube feeds for some period of time is not uncommon in pancreatitis patients and requires coordination of care by the provider and the specialty infusion services company managing the equipment and nutrition. Registered dietitians (RD), pharmacists and home health RNs provide expert care to the patient and serve as a valuable resource for the ambulatory provider. Recommendations for care based on ongoing assessment of the patient’s nutritional status and needs is communicated to the ambulatory provider who is responsible for signing the orders. Malfunctions of the percutaneous endoscopic gastrostomy (PEG) tube, other than a clogged tube, is usually addressed by the gastroenterologist.
Q: Do smoking and alcohol contribute to pancreatitis?
A: Alcohol is one of the leading causes of pancreatitis. Formal alcohol cessation programs are often warranted and patients will need continued support and specific resources. MSWs are a great resource and patients benefit from daily support from family, friends and organized support groups.
Smoking is an independent risk factor for pancreatitis and can lead to functional impairment and pancreatic damage. Quitting smoking is very challenging for many patients and not every method works for every patient. Despite their willingness and motivation to quit, relapse is common and requires continued discussion and support.
Do you have other questions about best practices for pancreatitis patient care? What knowledge gaps in caring for pancreatitis patients after discharge can we help answer? Send us your questions and we'll do our best to answer them.