## Pain Management in Acute Pancreatitis **Key Point:** Morphine is the opioid of choice for acute pancreatitis pain management, despite older myths about sphincter of Oddi spasm. ### Why Morphine? **High-Yield:** Modern evidence shows morphine does NOT cause clinically significant sphincter of Oddi spasm in acute pancreatitis. It provides superior analgesia and is the recommended first-line opioid analgesic. **Clinical Pearl:** The old teaching that "morphine causes sphincter of Oddi spasm and worsens pancreatitis" is now considered outdated. Studies have not demonstrated worse outcomes with morphine compared to other opioids in acute pancreatitis. ### Analgesic Ladder in Acute Pancreatitis | Drug Class | Agent | Role | Notes | |---|---|---|---| | **Non-opioid** | Paracetamol | Mild pain only | Insufficient for moderate-severe pain | | **Opioid (preferred)** | Morphine | First-line opioid | Safe, effective, no sphincter spasm | | **Avoid** | Meperidine | NOT recommended | Metabolite normeperidine is neurotoxic; risk of seizures | | **Avoid** | NSAIDs | Contraindicated | May worsen inflammation and organ dysfunction | **Warning:** Meperidine accumulates toxic metabolites and is explicitly contraindicated in acute pancreatitis due to seizure risk, especially with renal impairment. ### Supportive Measures 1. NPO status (bowel rest) 2. IV fluid resuscitation (Ringer's lactate preferred) 3. Correction of electrolytes (especially calcium, magnesium) 4. Management of underlying cause (e.g., ERCP for gallstone pancreatitis) 5. Adequate analgesia with morphine ± adjuncts (regional anesthesia if severe) **Mnemonic: FARM** — **F**luids, **A**nalgesia (morphine), **R**est (NPO), **M**anage cause [cite:Harrison 21e Ch 346]
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