Options for pancreatic cancer pain management

by Michael A. Erdek, M.D.

Pain due to pancreatic cancer most commonly manifests itself as abdominal pain which may radiate through to the back, and may be associated with the patient assuming a forward-leaning position in order to maximize his or her comfort.

Traditionally, a continuum has been followed with regard to managing pain due to pancreatic cancer. Intermittently dosed opioid medications (such as morphine or oxycodone) may be given every few hours to help control a patient’s pain. If and when the pain becomes refractory to this strategy, a long-acting or sustained release opioid (narcotic) preparation may be started.

For patients whose pain is either poorly controlled by the above modalities, or who develop dose-limiting side effects from these medications (often sleepiness or tiredness), a celiac plexus block may be employed. The celiac plexus is a group of nerve fibers in a bundle that sits just in front of the spine and the aorta at a take-off point for various blood vessels that supply the upper abdominal organs (the celiac trunk, hence its name). This celiac plexus serves most of the abdominal organs, and is an important structure in the pain associated with pancreatic cancer.

The procedure is done as an outpatient and may last up to about an hour. Sedation may be provided if necessary. The patient lies face down on an x-ray table. The physician uses radiographic guidance to help place one or two needles through the back to the area of the celiac plexus. The first step is the diagnostic block, which is done with local anesthetic to determine if this block will take away a significant amount of the patient’s pain. If so, a neurolytic block is the next step, which may or may not be done immediately following the diagnostic block. Alcohol or phenol is used to do the neurolytic block, which can interrupt this nerve transmission for on the order of 3-6 months. The block can be repeated if deemed necessary.

Many patients are able to significantly decrease their opioid intake after a successful celiac plexus neurolysis. The following article from JAMA is one of the best known on the subject and looks at celiac plexus block and neurolysis versus standard analgesic therapy.