100+ Free ABPN Pain Medicine Practice Questions

Pain Pathophysiology & Assessment

Nociceptive (somatic, visceral) vs neuropathic vs nociplastic pain (IASP 2017). Ascending pathways — Adelta and C fibers, dorsal horn lamina I/II/V, spinothalamic tract, thalamus, S1/insula/ACC. Descending modulation — periaqueductal gray, rostroventromedial medulla, locus coeruleus (noradrenergic, serotonergic). Central sensitization, wind-up (NMDA), peripheral sensitization. Assessment tools — NRS 0-10, VAS, Wong-Baker FACES, FLACC (preverbal pediatric), CPOT/BPS (ICU), PAINAD (dementia), McGill Pain Questionnaire, DN4/painDETECT (neuropathic), STarT Back. Biopsychosocial model.

Acute Pain Management

Multimodal analgesia per ASA/ASRA — combine opioids with acetaminophen, NSAIDs, gabapentinoids, ketamine, regional anesthesia. Postoperative — IV PCA morphine/hydromorphone (no basal in opioid-naive), continuous epidural (bupivacaine + fentanyl) for thoracic/abdominal/major orthopedic, peripheral nerve blocks (interscalene shoulder, femoral/adductor canal knee, TAP). Acute trauma — fascia iliaca for hip fracture, serratus anterior for rib fractures. ERAS protocols. Sickle cell vaso-occlusive crisis — IV opioid q15-30 min titration, hydration, no meperidine. Burn pain — opioid + ketamine + gabapentin. Acute on chronic opioid patient — continue baseline + add multimodal.

Chronic Non-Cancer Pain

Chronic low back pain — exercise + CBT first-line per ACP 2017; imaging only with red flags (cancer, infection, cauda equina, fracture). Lumbar radiculopathy — gabapentin/pregabalin, ESI for short-term relief. Failed back surgery syndrome — SCS (PROCESS, EVIDENCE). Fibromyalgia — ACR 2016 criteria (widespread pain index + symptom severity); duloxetine, milnacipran, pregabalin FDA-approved; aerobic exercise, CBT. Complex regional pain syndrome — Budapest criteria; mirror therapy, PT, sympathetic blocks, SCS, ketamine infusion. Myofascial pain — trigger points. Osteoarthritis — acetaminophen, topical/oral NSAIDs, intra-articular steroid (short-term), duloxetine. Chronic pelvic pain, chronic abdominal pain (median arcuate, mesenteric).

Cancer Pain & Palliative Care

WHO three-step ladder (1986; updated 2018) — non-opioid → weak opioid → strong opioid; adjuvants at every step. Around-the-clock long-acting + short-acting breakthrough (10-20% of total daily dose q1-4h PRN). Methadone — NMDA antagonist + mu agonist, useful for neuropathic cancer pain; QTc and incomplete cross-tolerance (75-90% reduction when rotating from morphine equivalents). Opioid rotation for tolerance/toxicity. Bone metastases — NSAIDs, bisphosphonates/denosumab, radiation, radiopharmaceuticals (Sr-89, Sm-153, Ra-223). Bowel obstruction — octreotide, glycopyrrolate. Neurolytic blocks — celiac plexus (pancreatic, upper abdominal), superior hypogastric (pelvic), ganglion impar (perineal), intercostal. Intrathecal opioid pumps for refractory pain (Smith 2002). Hospice eligibility (<6 months prognosis).

Neuropathic Pain Syndromes

First-line per IASP/NeuPSIG — TCAs (amitriptyline, nortriptyline), SNRIs (duloxetine, venlafaxine), gabapentin, pregabalin. Second-line — topical lidocaine, capsaicin 8% patch (Qutenza). Third-line — opioids, tramadol. Postherpetic neuralgia — most common in elderly; prevent with recombinant zoster vaccine (Shingrix); treat with gabapentin/pregabalin, TCA, lidocaine 5% patch, capsaicin 8%. Painful diabetic neuropathy — duloxetine, pregabalin, gabapentin (FDA-approved). Trigeminal neuralgia — carbamazepine first-line (NNT ~2), oxcarbazepine alternative; microvascular decompression (Jannetta) for refractory. Central post-stroke pain (Dejerine-Roussy thalamic). HIV neuropathy. Chemotherapy-induced peripheral neuropathy (platinum, taxanes, vinca, bortezomib) — duloxetine (CALGB 170601). Phantom limb pain.

Headache Disorders

ICHD-3 classification. Migraine — POUND (Pulsatile, One-day, Unilateral, Nausea, Disabling); acute treatment with triptans (avoid in CAD, uncontrolled HTN, hemiplegic/basilar migraine), gepants (ubrogepant, rimegepant), lasmiditan; preventive when ≥4 days/month — propranolol, topiramate, valproate (avoid in pregnancy), amitriptyline, candesartan; CGRP mAbs (erenumab, fremanezumab, galcanezumab, eptinezumab); onabotulinumtoxinA for chronic migraine (PREEMPT, ≥15 days/month). Tension-type. Cluster headache — high-flow O2 100% 12-15 L/min via NRB, subcutaneous sumatriptan; verapamil prevention (with EKG monitoring). Medication-overuse headache — triptans/opioids ≥10 days/mo or simple analgesics ≥15 days/mo for 3 months; treat by withdrawal. Trigeminal autonomic cephalalgias — paroxysmal hemicrania (indomethacin-responsive). Occipital nerve blocks.

Opioid Pharmacology & Safe Prescribing

Mu, kappa, delta receptors. Morphine equivalent daily dose (MEDD) — 30 mg morphine = 20 mg oxycodone = 7.5 mg hydromorphone = 12 mcg/h fentanyl patch ≈ 30 mg morphine; methadone non-linear (higher MEDD = higher conversion ratio). CDC 2022 guideline (revised) — assess benefits/risks; check PDMP; nonopioid first; immediate-release before extended-release; lowest effective dose; reassess >50 MME/day; avoid concurrent benzodiazepines; counsel naloxone for ≥50 MME/day or BZD coprescription. Tapering — 10% per month for chronic use to avoid withdrawal/suicidality (HHS 2019). Specific drugs — meperidine AVOID (normeperidine seizures), tramadol (SNRI activity, serotonin syndrome, seizures), tapentadol, fentanyl patch only opioid-tolerant (≥60 MME/day for ≥1 week). Naloxone reversal 0.04-0.4 mg IV titrated. Adverse effects — constipation (universal — methylnaltrexone, naloxegol), nausea, sedation, respiratory depression, hypogonadism, hyperalgesia (OIH).

Non-Opioid Analgesics & Adjuvants

Acetaminophen — max 4 g/day (3 g/day in elderly/liver disease); hepatotoxicity from CYP2E1 NAPQI metabolite; N-acetylcysteine antidote per Rumack-Matthew nomogram. NSAIDs — nonselective COX1/2 (ibuprofen, naproxen, ketorolac max 5 days) vs COX2 (celecoxib); GI (PPI cotherapy, misoprostol), renal (avoid in CKD, heart failure), CV (naproxen lowest CV risk), antiplatelet (ASA). Ketamine — NMDA antagonist; subanesthetic infusion 0.1-0.5 mg/kg/h for refractory chronic and CRPS (ASRA 2018 consensus); psychotomimetic effects. IV lidocaine. Antidepressants — TCA (anticholinergic, QTc, orthostasis); SNRI (duloxetine for fibromyalgia, DPN, chronic LBP, OA). Anticonvulsants — gabapentin (CrCl-based dosing), pregabalin (Schedule V; weight gain, edema), carbamazepine (TN), lamotrigine. Topicals — lidocaine 5%, capsaicin, diclofenac gel.

Interventional Pain Procedures

Epidural steroid injection — interlaminar, transforaminal (preferred for radicular), caudal; particulate (triamcinolone, methylprednisolone) AVOID transforaminal cervical (vertebral artery embolic stroke risk per FDA 2014); use dexamethasone (non-particulate) for cervical TFESI. Facet joint pain — diagnostic medial branch blocks (lumbar L2-S1 dorsal rami; cervical C2-C8) followed by radiofrequency ablation (RFA) lasting 6-12 months. Sacroiliac joint injection. Sympathetic blocks — stellate ganglion (upper extremity CRPS, PHN), lumbar sympathetic (lower extremity CRPS), celiac plexus (pancreatic cancer), superior hypogastric (pelvic), ganglion impar (perineal). Spinal cord stimulation — FBSS, CRPS, painful diabetic neuropathy (high-frequency 10 kHz Nevro SENZA, burst Abbott, traditional tonic); 7-day percutaneous trial >50% relief before permanent implant. Dorsal root ganglion stimulation (ACCURATE trial). Peripheral nerve stimulation. Intrathecal drug delivery — morphine, ziconotide (PRIALT — N-type Ca channel blocker, no tolerance, psychiatric AE), baclofen for spasticity. Vertebroplasty/kyphoplasty (VERTOS). Anticoagulation guidelines per ASRA 2018 for neuraxial/deep blocks.

Psychological & Behavioral Approaches

Cognitive-behavioral therapy (CBT) for chronic pain — strongest evidence; addresses catastrophizing, fear-avoidance, kinesiophobia. Acceptance and commitment therapy (ACT) — values-based action despite pain. Mindfulness-based stress reduction (MBSR), mindfulness-based cognitive therapy. Biofeedback — EMG for tension headache and pelvic floor; thermal for migraine and Raynaud's. Operant conditioning (Fordyce). Pain catastrophizing scale (PCS), Tampa Scale for Kinesiophobia, Pain Self-Efficacy Questionnaire. Multidisciplinary functional restoration programs. Hypnosis. Yoga, tai chi for chronic LBP and OA per ACP.

Addiction Medicine & Special Populations

Opioid use disorder per DSM-5 (2+ of 11 criteria, 12 months). Buprenorphine — partial mu agonist, ceiling on respiratory depression; sublingual film/tablet 4-24 mg/d; precipitated withdrawal if started <12-24 h after short-acting or <24-48 h after methadone (or use low-dose 'micro-induction'); X-waiver eliminated 2023 (MAT Act). Methadone for OUD only via federally licensed OTPs; QTc monitoring (>500 ms). Naltrexone — extended-release IM (Vivitrol) requires 7-10 days opioid-free. Aberrant behavior — opioid risk tool, urine drug screen interpretation (immunoassay vs LC-MS/MS confirmation; oxycodone often missed on opiate immunoassay). Pregnancy — methadone or buprenorphine for OUD (NOT detox); avoid valproate, topiramate; preferred analgesics — acetaminophen, opioids if needed (avoid NSAIDs after 20 weeks per FDA 2020). Geriatric — start low, go slow; avoid TCAs (Beers), meperidine, long-acting BZDs; acetaminophen first-line. Pediatric — FLACC for preverbal, weight-based dosing, avoid codeine and tramadol <12 y (FDA 2017 boxed warning, CYP2D6 ultra-rapid metabolizers).