The most appropriate additional treatment is pregabalin, a gabapentinoid. Pain can be difficult to treat in patients with chronic pancreatitis. In the absence of a local anatomic cause of pain, a stepwise approach to analgesia is appropriate starting with simple analgesics such as NSAIDs or acetaminophen. Non–enteric-coated pancreatic enzymes, which theoretically limit stimulation of the pancreas by inhibiting the cholecystokinin feedback loop, can be tried for pain control. They seem to be most effective in patients with idiopathic pancreatitis. For patients with persistent pain despite the use of simple analgesics, initiating opioids is a reasonable consideration while developing a pain management program that includes adjunctive agents to minimize chronic narcotic use, which can create addiction and gastrointestinal side effects. Most experts begin with tramadol, a nonopioid with opioid actions that provides analgesia comparable to other opioid analgesics in patients with chronic pancreatitis but causes fewer gastrointestinal side effects. Pregabalin (or a low-dose tricyclic antidepressant) may be offered adjunctively, as part of a step-up approach to pain management, after an initial trial of acetaminophen, ibuprofen, and/or tramadol. According to a recent randomized controlled trial, the gabapentinoid pregabalin used as adjuvant treatment reduced constant pain in chronic pancreatitis but has an unclear durability of action and may cause central nervous system side effects in up to 30% of patients.

Celiac plexus blockade (using glucocorticoids) or neurolysis (using ethanol) can be performed percutaneously or via endoscopic ultrasonography, but any relief from this procedure tends to be short lived and is associated with risks of diarrhea, postural hypotension, and rarely paraplegia. Adding pregabalin as adjuvant therapy is a more reasonable and less invasive next therapeutic step for this patient.

Extracorporeal shock wave lithotripsy can be used to break up stones obstructing pancreatic ducts and improve ductal drainage and relieve pain. Extracorporeal shock wave lithotripsy is not appropriate for this patient because she does not have an intraductal pancreatic duct stone and dilated main pancreatic duct.

Surgical management of chronic pancreatitis is reserved for patients in whom conventional medical management is unsuccessful. Surgical management is categorized into operative resection (pancreaticoduodenectomy or distal pancreatectomy) and drainage procedures (lateral pancreaticojejunostomy), and the choice of surgery is dependent on the clinical situation.