Opioid dependence in patients with pain in chronic pancreatitis an emerging problem

Chronic pancreatitis is a progressive inflammatory disorder characterized by recurrent or persistent abdominal pain. Traditionally, pain in chronic pancreatitis has been linked to anatomical factors such as ductal hypertension, parenchymal pressure and disease-related complications, including pseudocysts and biliary obstruction. However, emerging evidence supports a neurobiological model of pancreatic pain, emphasizing neuropathic mechanisms and central sensitization as key contributors. Pain management in chronic pancreatitis requires a personalized, step-wise approach that combines pharmacologic titration, endoscopic decompression and, when necessary, surgical intervention. While the World Health Organization pain ladder, originally developed for cancer-related pain, offers a conceptual framework, its applicability to chronic pancreatitis remains insufficiently validated across diverse patient populations. In difficult cases, opioids are often prescribed despite increasing global concerns about opioid use disorder. The opioid epidemic highlights the importance of adopting responsible prescribing practices, employing validated screening tools and promoting interdisciplinary collaboration to balance effective pain relief with risk reduction. Recent advances such as neuromodulators (e.g. tricyclic antidepressants, pregabalin), celiac plexus blocks, pancreatic enzyme replacement therapy and antioxidant therapy, have improved outcomes in specific patients. Nonetheless, there is a significant need for innovative strategies that tailor pain management, lessen dependence on opioids and address the psycho-social aspects of chronic pain. This review emphasizes the burden of pain in chronic pancreatitis, assesses current treatment approaches and examines the relationship between opioid stewardship and quality of life. A paradigm shift-grounded in mechanistic understanding, multidisciplinary care and adaptable therapies-is vital to enhance long-term outcomes while minimizing opioid-related risks and harm.