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.

6 thoughts to “Options for pancreatic cancer pain management”

  1. I had a Whipple Aug 10, 2007 at Duke, followed by raadiation and Xeloda at JHH, 4 months of gemzar chemo at Duke-Raleigh. MRCP(June) and CT(July 30) scan were clean. Since then back pain has started, now mainly on the left at waist level, fitting your description in the first paragraph.

    My oncologist says since the scans are clean, just use the percocet and dont worry. So of course I’m worried.

    Is it possible to have this pain after the Whipple without a recurrence?

  2. Ms. Singer:

    Pain usually occurs either in the upper abdomen or mid-back regions, so waist level is somewhat less common. Although pain may indicate a recurrence, it sounds like your oncologist is watching things closely and does not suspect that.

    So in answer to your question, yes, your pain may be due to reasons other than a recurrence. A pain specialist may be able to help with the diagnosis and treatment of your pain. In the meantime, it is important to continue to follow up for oncologic care as you have been doing.

    Michael Erdek

  3. My father was diagnosed with stage IV pancreatic cancer. Thus far the only pain that he has had has been due to blood clots in his legs. Today he began with the itching, is pain just around the corner or do some people never experience the torso pain?

  4. Amy:

    Thanks for your question. Itching can be from several sources, including being a part of the process that also causes jaundice (if that is an issue with your father) or even some of the pain medicines themselves.

    It’s not really possible for us to exactly predict who will and will not develop pain from this disease. Many patients get substantial pain, and others relatively little. The important thing is that if pain does occur, that it be treated so that your father’s comfort is maximized.

    Michael Erdek

  5. I’ve recently been diagnosed with stage IV pancreatic cancer, liver metastasis, and I also have an abdominal aortic aneurism. I have not started chemo yet, but for the last day or so, I’ve suffered constant nausea (no vomiting, just feeling like I have to all the time). What is this?

  6. Ms. Wikstrom:

    I’m sorry to hear about your condition. Nausea can be due to many factors. One common cause in patients being treated for pain is from opioid (“narcotic”) medications. If you are on these types of medicines, you may want to talk with your prescribing physician about treatment options to help deal with this.

    Michael Erdek

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