100+ Free ABR Pain Medicine Practice Questions

Image-Guided Interventional Procedures

Fluoroscopy and ultrasound technique, sterile prep, contrast confirmation under live fluoroscopy. Particulate (triamcinolone, methylprednisolone, betamethasone) vs non-particulate (dexamethasone) steroids — non-particulate REQUIRED for cervical and thoracic transforaminal injections to avoid catastrophic embolic spinal cord/brainstem infarct. Epidural steroid injections (interlaminar, transforaminal — Kambin's triangle, caudal). Facet joint injections and medial branch blocks (cervical/thoracic/lumbar) — diagnostic blocks require ≥80% pain relief on two separate occasions before proceeding to radiofrequency ablation. SI joint injection. Sympathetic blocks: stellate ganglion (C6-C7 anterior tubercle, C7 transverse process for ultrasound — for upper extremity CRPS, herpes zoster, hyperhidrosis), lumbar sympathetic (L2-L3 paravertebral for lower extremity CRPS), celiac plexus (T12-L1, transcrural or anterocrural; for pancreatic and upper abdominal cancer), superior hypogastric (L5-S1 anterior to vertebral body for pelvic cancer), ganglion impar (sacrococcygeal junction for perineal pain). Trigger point injections, peripheral nerve blocks (greater/lesser occipital, suprascapular, intercostal, ilioinguinal/iliohypogastric, lateral femoral cutaneous, genitofemoral, pudendal). Vertebral augmentation (vertebroplasty, kyphoplasty for osteoporotic VCF), epidural blood patch for PDPH (15-20 mL autologous blood).

Opioid Pharmacology & Prescribing Safety

Mu/kappa/delta opioid receptor pharmacology, full agonists (morphine, hydromorphone, oxycodone, fentanyl) vs partial agonists (buprenorphine — ceiling effect on respiratory depression but high mu affinity displaces full agonists). Morphine metabolites: M3G (neuroexcitatory, accumulates in renal failure causing myoclonus/hyperalgesia), M6G (active analgesic). Codeine — CYP2D6 prodrug; ultra-rapid metabolizers risk fatal respiratory depression (FDA boxed warning, contraindicated <12 yr and breastfeeding mothers). Tramadol (mu agonist + SNRI, lowers seizure threshold, serotonin syndrome risk), tapentadol (mu + NRI). Methadone — NMDA antagonism, QTc prolongation (baseline ECG, monitor at 30 days then annually), long variable half-life (8-59 hr), biphasic elimination, conversion ratios INCREASE at higher morphine equivalents (4:1 at <100 mg, up to 12:1 at >300 mg morphine). Fentanyl transdermal — onset 12-24 hr, lasts 72 hr, contraindicated opioid-naive. CDC 2022 guideline (no specific MME threshold; emphasize individualized risk-benefit, naloxone co-prescribing at MME ≥50 or with benzo co-use, PDMP query at every prescription). Urine drug screens — immunoassay screens followed by GC/MS confirmation; oxycodone, fentanyl, methadone, buprenorphine require specific assays (don't cross-react with standard opiate immunoassay). Opioid-induced hyperalgesia (paradoxical worsening with dose escalation), opioid-induced constipation (PAMORAs — methylnaltrexone, naloxegol, naldemedine).

Chronic Non-Cancer Pain

Low back pain — axial mechanical, facet-mediated (paramedian, worse with extension, relieved with flexion), discogenic (positive provocative discography — controversial), SI joint (Fortin finger test, multiple positive provocation tests), radicular (dermatomal, positive SLR), failed back surgery syndrome (epidural fibrosis, recurrent disc, adjacent segment disease, foraminal stenosis). Complex regional pain syndrome (Budapest criteria — 4 categories: sensory, vasomotor, sudomotor/edema, motor/trophic; ≥1 symptom in 3 categories AND ≥1 sign in 2 categories at evaluation; type I no nerve injury, type II with nerve injury). Fibromyalgia (2016 ACR criteria — Widespread Pain Index ≥7 + Symptom Severity ≥5, OR WPI 4-6 + SSS ≥9; symptoms ≥3 months; central sensitization, increased substance P, decreased descending inhibition). Myofascial pain with trigger points and twitch response. Osteoarthritis (knee, hip, hand). Chronic abdominal/pelvic pain (endometriosis, IBS, interstitial cystitis). Post-amputation phantom limb pain (mirror therapy, gabapentin, TCAs, peripheral/central techniques). Post-thoracotomy (intercostal neuritis), post-mastectomy (intercostobrachial nerve).

Pain Pathophysiology & Assessment

Nociceptive pain (somatic — well-localized; visceral — vague, referred), neuropathic pain (lesion of somatosensory system — burning, electric, allodynia, hyperalgesia), nociplastic pain (altered nociception without tissue damage — fibromyalgia, IBS). Peripheral sensitization (lower threshold of nociceptors), central sensitization (NMDA-mediated, wind-up, secondary hyperalgesia, allodynia). Ascending spinothalamic tract (lateral — discriminative; anterior — affective via medial thalamus to ACC and insula). Descending modulation (PAG → RVM → dorsal horn; serotonergic and noradrenergic — basis for TCA/SNRI efficacy). Gate control theory (Melzack-Wall). IASP 2020 revised definition: 'unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.' Assessment scales: NRS 0-10, VAS, Verbal Rating, Faces Pain Scale Revised (3-7 yr), FLACC (preverbal/nonverbal), PAINAD (advanced dementia), CPOT/BPS (ICU intubated). Neuropathic screening: DN4 (≥4/10), LANSS, painDETECT. Multidimensional: Brief Pain Inventory (BPI severity + interference), McGill Pain Questionnaire, PROMIS pain measures.

Acute Pain Management

Postoperative multimodal analgesia (PROSPECT recommendations) — scheduled acetaminophen 1 g q6h, NSAIDs (ketorolac, ibuprofen, celecoxib), gabapentin/pregabalin (controversial — modest opioid-sparing but increased sedation in elderly per recent ASA guidance), low-dose ketamine infusion (0.1-0.5 mg/kg/hr), IV lidocaine infusion (1-2 mg/kg bolus then 1-3 mg/kg/hr), dexmedetomidine. Enhanced Recovery After Surgery (ERAS) — minimize opioids, regional techniques, early mobilization. Patient-controlled analgesia (PCA) — basal infusions in opioid-naive INCREASE respiratory depression risk; lockout intervals, 1-hr and 4-hr limits. Regional anesthesia: TAP (T10-L1 dermatomes for lower abdominal surgery), erector spinae plane (paraspinal at T5 for thoracic/breast surgery), PECS I/II (breast surgery), fascia iliaca/femoral (hip/knee surgery), brachial plexus (upper extremity), thoracic paravertebral. Neuraxial: epidural analgesia (continuous infusion or PCEA), intrathecal morphine for cesarean. Acute on chronic pain in opioid-tolerant patients (continue baseline opioid, add multimodal, increase PRN doses 50-100% above baseline). Sickle cell vaso-occlusive crisis — IV opioids within 30 min, hydration, NSAIDs unless contraindicated.

Neuropathic Pain

Postherpetic neuralgia (>90 days after herpes zoster rash; vaccine prevention with Shingrix recombinant zoster vaccine ≥50 yr — 90% effective). Diabetic peripheral neuropathy (length-dependent, stocking-glove, burning). Chemotherapy-induced peripheral neuropathy (CIPN): platinum (cisplatin, oxaliplatin — acute cold-triggered with oxaliplatin), taxanes (paclitaxel), vincristine (early-onset), bortezomib. Trigeminal neuralgia (V2/V3 most common, neurovascular conflict — superior cerebellar artery; carbamazepine first-line, oxcarbazepine alternative; refractory — microvascular decompression, gamma knife radiosurgery, percutaneous balloon/glycerol/RF rhizotomy). Painful HIV neuropathy. Central post-stroke pain (Dejerine-Roussy syndrome, thalamic). Spinal cord injury pain (above-level, at-level, below-level). Phantom limb pain. IASP/NeuPSIG algorithm — first-line: TCA (amitriptyline, nortriptyline — anticholinergic risk in elderly), SNRI (duloxetine, venlafaxine), gabapentinoids (gabapentin titrated to 1800-3600 mg/day; pregabalin 150-600 mg/day); second-line: lidocaine 5% patch (focal — PHN), capsaicin 8% patch (focal — PHN, painful diabetic peripheral neuropathy of the feet, HIV neuropathy), tramadol; third-line: opioids, botulinum toxin A (focal).

Cancer Pain Management

WHO analgesic ladder — Step 1: non-opioid (acetaminophen, NSAID) ± adjuvant; Step 2: weak opioid (codeine, tramadol) ± non-opioid ± adjuvant; Step 3: strong opioid (morphine, hydromorphone, oxycodone, fentanyl, methadone) ± non-opioid ± adjuvant. Recent revision considers Step 4 (interventional). Opioid rotation indicated for inadequate analgesia, intolerable side effects, opioid-induced hyperalgesia — use equianalgesic table and reduce by 25-50% for incomplete cross-tolerance (50-90% reduction for methadone). Methadone conversion ratios increase at higher morphine doses. Breakthrough pain — rapid-onset opioids (transmucosal fentanyl — buccal Fentora, sublingual Abstral, intranasal Lazanda; oral transmucosal Actiq lozenge); typically dosed at 10-20% of total daily morphine equivalent. Bone pain — NSAIDs, bisphosphonates (zoledronic acid IV q4 weeks), denosumab (RANK-L inhibitor), external beam radiation, bone-seeking radiopharmaceuticals (Sr-89, Sm-153 EDTMP, Ra-223 dichloride for castration-resistant prostate metastases). Intrathecal drug delivery (PACC guidelines — first-line morphine, ziconotide [non-opioid N-type calcium channel blocker, no tolerance, but psychiatric/cognitive side effects]; combinations with bupivacaine, clonidine, hydromorphone). Neurolytic blocks: celiac plexus (alcohol or phenol — pancreatic, upper abdominal), superior hypogastric (pelvic), ganglion impar (perineal). Cordotomy (anterolateral thoracic for unilateral lower-body cancer pain — historic). Palliative care integration.

Non-Opioid Analgesics & Adjuvants

Acetaminophen — 4 g/day max (3 g in chronic alcohol use, malnutrition, hepatic impairment); hepatotoxicity via NAPQI (treated with N-acetylcysteine). NSAIDs — nonselective COX-1/COX-2 inhibition; cardiovascular risk highest with diclofenac and rofecoxib (withdrawn), lowest with naproxen; GI risk (PPI co-prescription, avoid in active PUD), renal risk (avoid in CKD, volume depletion, ACE/ARB/diuretic co-use), cardiovascular contraindications (recent MI, CHF). Selective COX-2 (celecoxib) — lower GI risk, similar CV risk. Ketamine — non-competitive NMDA antagonist; sub-anesthetic infusion (0.1-0.5 mg/kg/hr) for acute, chronic, and CRPS; intranasal esketamine for treatment-resistant depression; dissociative side effects (emergence reactions, hallucinations, cystitis with chronic use). IV lidocaine infusion (1-2 mg/kg/hr) — perioperative and chronic neuropathic pain. Alpha-2 agonists — clonidine (oral, transdermal, intrathecal, epidural), tizanidine, dexmedetomidine (perioperative). Muscle relaxants — cyclobenzaprine (TCA-related, anticholinergic), baclofen (GABA-B agonist; oral and intrathecal for spasticity/dystonia — abrupt withdrawal causes severe rebound spasticity, hyperthermia, rhabdomyolysis), methocarbamol, tizanidine. Cannabinoids — CBD, dronabinol (THC), nabilone; modest evidence for chronic pain. Low-dose naltrexone (1.5-4.5 mg) — off-label for fibromyalgia and chronic pain. IV/oral magnesium.

Headache & Facial Pain

ICHD-3 classification — primary (migraine, tension-type, trigeminal autonomic cephalalgias, other) vs secondary. Migraine — with/without aura; chronic migraine ≥15 days/month for ≥3 months with ≥8 migraine days. Acute treatment: triptans (5-HT1B/1D — sumatriptan, rizatriptan, eletriptan; contraindicated in CAD, uncontrolled HTN, basilar/hemiplegic migraine), DHE, gepants (rimegepant, ubrogepant — CGRP receptor antagonists, no vasoconstriction), lasmiditan (5-HT1F — no vasoconstriction). Prophylaxis: beta-blockers (propranolol), TCAs (amitriptyline), topiramate, valproate, candesartan, CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab). Cluster headache — unilateral periorbital, autonomic features, circadian; acute: 100% O2 12-15 L/min via non-rebreather, subQ sumatriptan, intranasal zolmitriptan; prophylaxis: verapamil (high-dose with ECG monitoring), lithium, galcanezumab. TACs — paroxysmal hemicrania (indomethacin-responsive — diagnostic), SUNCT/SUNA, hemicrania continua (indomethacin-responsive). Trigeminal neuralgia — carbamazepine first-line (HLA-B*1502 screening in Asian patients for SJS risk). PREEMPT protocol for chronic migraine — onabotulinumtoxinA 155 units across 31 sites in 7 head/neck muscles q12 weeks. Medication overuse headache — withdraw offending agent (triptans, opioids, butalbital, NSAIDs). Occipital nerve stimulation, sphenopalatine ganglion block.

Psychological, Behavioral & Rehabilitation

Cognitive-behavioral therapy (CBT) for chronic pain — strongest evidence; targets catastrophizing, fear-avoidance, activity pacing, cognitive restructuring. Acceptance and commitment therapy (ACT) — psychological flexibility, values-based action despite pain. Mindfulness-based stress reduction (MBSR — Kabat-Zinn 8-week program). Biofeedback (EMG, thermal — for tension headache, migraine), hypnosis (IBS, procedural pain), relaxation training, guided imagery. Pain Catastrophizing Scale (PCS — rumination, magnification, helplessness). Fear-avoidance model (Vlaeyen) — pain-related fear leads to avoidance, deconditioning, disability. Tampa Scale for Kinesiophobia. Depression and anxiety comorbidities (PHQ-9, GAD-7) — bidirectional relationship with pain. Sleep disturbance (insomnia worsens pain via central sensitization). Pain self-efficacy (PSEQ). Physical therapy — graded activity, McKenzie method (directional preference), aquatic therapy. Manipulative therapy. Acupuncture (evidence for chronic LBP, knee OA, headache). TENS (high-frequency conventional gate control vs low-frequency endorphin-mediated). Interdisciplinary functional restoration programs (Mayday/Texas model — strongest evidence for chronic disabling LBP).

Neuromodulation & Advanced Techniques

Spinal cord stimulation (SCS) — indications include failed back surgery syndrome, painful diabetic neuropathy (SENZA-PDN trial — 10-kHz HF), CRPS, refractory angina, peripheral vascular disease. Trial period 5-7 days percutaneous lead with ≥50% pain relief required before permanent implant. Waveforms: tonic (paresthesia-based, traditional), burst (DeRidder — sub-perception), high-frequency 10-kHz (Nevro Senza — sub-perception, dorsal column), DTM (differential target multiplexed), closed-loop (Saluda Evoke — measures evoked compound action potentials, autoadjusts amplitude). MRI conditional considerations (1.5T or 3T conditional with manufacturer programming). Dorsal root ganglion stimulation (DRG-S — Abbott Proclaim) for focal lower extremity neuropathic pain (CRPS lower extremity, post-herniorrhaphy, post-knee/foot surgery — ACCURATE trial). Peripheral nerve stimulation (PNS) — temporary 60-day systems (SPRINT) and permanent implants (StimRouter, Bioness). Radiofrequency ablation: conventional thermal 80°C × 90 sec for medial branches (cervical TON, lumbar/thoracic), genicular nerves (knee OA — superior medial, superior lateral, inferior medial), SI joint lateral branch (L4 dorsal ramus, L5 dorsal ramus, S1-S3 lateral branches); pulsed RF 42°C (DRG, peripheral nerves — non-neurodestructive); water-cooled RF (larger lesions for SI joint). Cryoablation. Intrathecal drug delivery (programmable pumps — Medtronic SynchroMed, Flowonix Prometra) — PACC guidelines: first-line morphine and ziconotide; combinations include hydromorphone, bupivacaine, clonidine. Vertebroplasty/kyphoplasty for VCFs (VAPOUR trial — early intervention <6 weeks).

Addiction Medicine & SUD

DSM-5 substance use disorder criteria — 11 items across impaired control, social impairment, risky use, pharmacological criteria; severity: mild 2-3, moderate 4-5, severe ≥6. Distinguish tolerance (decreased effect with same dose), physical dependence (withdrawal on cessation — both expected with chronic opioids), and addiction (compulsive use, loss of control, continued use despite harm). Buprenorphine — partial mu agonist with high affinity, ceiling effect on respiratory depression; sublingual/buccal (Suboxone with naloxone, Subutex mono), transdermal (Butrans 5-20 mcg/hr for chronic pain), buccal film (Belbuca for chronic pain), monthly extended-release injection (Sublocade). DEA X-waiver ELIMINATED December 2022 (MAT Act in CAA 2023) — standard DEA registration sufficient to prescribe buprenorphine for OUD. Induction during mild-to-moderate opioid withdrawal (COWS ≥8-12) to avoid precipitated withdrawal; new low-dose/microdosing/Bernese method allows induction without withdrawal. Methadone for OUD restricted to federally certified opioid treatment programs (OTPs). Extended-release injectable naltrexone (Vivitrol IM monthly) — opioid antagonist; requires 7-10 days opioid-free, naloxone challenge. Naloxone — IM 0.4 mg, intranasal (Narcan 4 mg, Kloxxado 8 mg), autoinjector (Evzio); short half-life (30-90 min) often shorter than opioid, repeat dosing/infusion. Treating pain in patients on MOUD — split buprenorphine dosing, add short-acting opioids at higher than usual doses (mu antagonism), regional/multimodal preferred. Stimulant, alcohol (CIWA, benzodiazepines, naltrexone, acamprosate), benzodiazepine (gradual taper) use disorders.

Special Populations & Ethics

Pediatric pain — age-appropriate scales (FLACC <7 yr or nonverbal, Faces Pain Scale-Revised 3-7 yr, NRS ≥7 yr), weight-based dosing. FDA boxed warning: codeine and tramadol CONTRAINDICATED in <12 yr (and <18 yr for tonsillectomy/adenoidectomy) due to ultra-rapid CYP2D6 metabolism deaths; codeine contraindicated in breastfeeding. Intranasal fentanyl, intranasal/IM ketamine, sucrose for neonatal procedures, EMLA topical anesthetic, regional blocks (caudal, ilioinguinal). Geriatric pain — Beers criteria 2023: AVOID meperidine (normeperidine seizures), skeletal muscle relaxants (cyclobenzaprine, methocarbamol — anticholinergic), barbiturates, indomethacin, ketorolac >5 days; use lower acetaminophen dose; NSAIDs increase GI/renal/cardiac risk; gabapentinoid + opioid co-prescription increases respiratory depression. Pregnancy — acetaminophen first-line; AVOID NSAIDs after 30 weeks (premature ductus arteriosus closure, oligohydramnios; FDA 2020 warning at 20 weeks for renal effects); opioids increase risk of neonatal abstinence syndrome (NAS — Finnegan scoring, treat with morphine or methadone); MOUD in pregnancy — methadone or buprenorphine preferred over abstinence. Lactation — most opioids excreted in breast milk; codeine contraindicated; small doses of morphine, hydrocodone, oxycodone may be acceptable monitoring infant. Renal failure — AVOID morphine and codeine (M3G/M6G accumulation, normeperidine seizures with meperidine); preferred opioids include fentanyl, hydromorphone, methadone, buprenorphine. Hepatic failure — reduce dose/frequency of all opioids and acetaminophen. Sickle cell disease, end-of-life care, informed consent for chronic opioid therapy and high-risk interventions, controlled substance agreements.