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Pain alleviation is a vital step in the management of AP. However, no guideline suggests a recommended agent due to the limitations in current evidence.

A stepped multimodal approach is recommended to be applied for pain medications in AP (Figure 9.1). Such multimodal therapy has at least two desirable effects: (i) it may decrease the use of opioids and associated side effects; and (ii) it may be a more effective pain control strategy, potentially decreasing the complications associated with suboptimal pain control.

Figure 9.1 Step‐up management of pain in acute pancreatitis. Non‐opioids such as nonsteroidal anti‐inflammatory drugs (NSAIDs) or paracetamol (PCM) are recommended to be initiated at first step. Weak opioids (e.g. tramadol) with or without non‐opioids should be considered if the pain is constant and/or not controlled with non‐opioid analgesics. If pain still persists or increases, strong opioids with or without non‐opioids can be initiated. If pain is not relieved within a given time by conventional analgesic therapy, epidural analgesia is indicated.

NSAIDs are the first choice of analgesics. Opioid medications should be considered in a patient who has constant and/or severe pain not controlled with non‐opioid analgesics. The initial choice of opioid should be a weaker, mixed agonist/antagonist or partial agonist (e.g. tramadol) before using stronger opioids (e.g. morphine, meperidine, sufentanil). Sufentanil can be recommended because it is a potent opioid with high therapeutic index. If pain is not relieved within a given time by conventional analgesic therapy, epidural analgesia is indicated. Epidural analgesia is an efficient approach to pain management and may reduce the proinflammatory state and improve the outcome of AP.