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Pain Medicine
Board Review
This page intentionally left blank
 Pain Medicine
Board Review

Anna Woodbury, MD
Department ofAnesthesiology
Emory University School ofMedicine
Veterans Afiairs Medical Center
Atlanta, Georgia

Boris Spektor, MD
Department ofAnesthesiology
Emory University School ofMedicine
Atlanta, Georgia
Vinita Singh, MD
Department ofAnesthesiology
Emory University School ofMedicine
Atlanta, Georgia
Brian Bobzien, MD
Department ofAnesthesiology
Emory University School ofMedicine
Grady Memorial Hospital
Atlanta, Georgia
Trusharth Patel, MD
Department ofAnesthesiology
Emory University School ofMedicine
Atlanta, Georgia
Jerry Kalangara, MD
Department ofAnesthesiology
Emory University School ofMedicine
Veterans Aflairs Medical Center
Atlanta, Georgia

ELSEVIER
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PAIN MEDICINE BOARD REVIEW ISBN: 978—0—823—4481 1—6

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Names: Woodbury, Anna, author.

Title: Pain medicine board review / Anna Woodbury, Boris Spektor, Vinita Singh, Brian Bobzien,
Trusharth Patel, Jerry Kalangara.
Description: First edition. | Philadelphia, PA : Elsevier, [2018] | Includes index.
Identifiers: LCCN 2017007004 | ISBN 9780323448116 (pbk. : alk. paper)
Subjects: | MESH: Pain Management—methods | Examination Questions
Classification: LCC RB127 | NLM WL 18.2 | DDC 616/.0472076—dc23 LC record
available at https://1ccn.loc.gov/2017007004

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Jose Avila-Calles, MD, PhD
Assistant Professor, Department of Anesthesiology (Pain
Medicine),Jackson Stephens Spine Center, University
of Arkansas for Medical Sciences
Brian Bobzien, MD
Assistant Professor, Department of Anesthesiology (Pain
Medicine), Emory University School of Medicine,
Director of Pain Services, Grady Memorial Hospital,
Atlanta, Georgia
Eashwar Balu Chandrasekaran, MD, MSc
Clinical Assistant Professor, Department of Emergency
Medicine, IUH Methodist Palliative Care Services,
Indiana University School of Medicine, Indianapolis,
Indiana
Shivang Vinod Desai, MD
Associate, Departments of Interventional Pain and
Anesthesiology, Geisinger Clinic
Danville, Pennsylvania
Lisa Guo Foster, MD
Associate Professor, Department of Orthopedics, Emory
Orthopaedics 8c Spine Center, Atlanta, Georgia
Lynn Marie Fraser, MD
Pain Medicine Fellow, Department of Anesthesiology,
University of North Carolina School of Medicine,
Chapel Hill, North Carolina
Jerry Kalangara, MD
Assistant Professor, Department of Anesthesiology (Pain
Medicine), Emory University School of Medicine,
Veterans Affairs Medical Center, Atlanta, Georgia
Brian H. Keogh, Jr., MD
Banner Health Interventional Pain and Spine
Management Clinic, Greeley, Colorado
Zachary Leuschner, MD
Pain Management Physician, Baylor Scott 8c White Health,
Marble Falls, Texas
Contributors
Daniel P. Loren, MD
Interventional Pain Management Specialist and
Anesthesiologist, Orlando, Florida
Joshua Meyer, MD
Interventional Pain Medicine, Dothan, Alabama
Preeti Narayan, MBBS
Regional Anesthesia and Acute Pain Fellow, Department
of Anesthesiology, Emory University, Atlanta, Georgia
Trusharth Patel, MD
Assistant Professor, Department of Anesthesiology (Pain
Medicine), Emory University School of Medicine,
Atlanta, Georgia
Joshua Scott Powers, MD
Bain Complete Wellness, Tampa, Florida
Moises Adrian Sidransky, MD
Interventional Pain Management, East Texas Medical
Center, Tyler, Texas
Vinita Singh, MD
Assistant Professor, Director of Cancer Pain Services,
Department of Anesthesiology (Pain Medicine), Emory
University School of Medicine, Atlanta, Georgia
Boris Spektor, MD
Program Director, Emory Pain Fellowship, Assistant
Professor, Department of Anesthesiology (Pain Medicine),
Emory University School of Medicine, Atlanta, Georgia
Liliana Viera—Ortiz, MD
Palliative Medicine, Trauma Hospital, University of
Puerto Rico, Medical Center, San Juan, Puerto Rico
Anna Woodbury, MD, C.Ac
Assistant Program Director, Emory Pain Fellowship,
Assistant Professor, Department of Anesthesiology (Pain
Medicine), Emory University School of Medicine,
Division Chief, Veteran’s Affairs Medical Center, Atlanta,
Georgia
Preface
The field of pain medicine is an ever-developing and expand-
ing field with an inherently multidisciplinary nature. The
field continues to advance with research into newer, safer,
and more comprehensive techniques for the management of
pain. In the face of a widespread opioid epidemic, physicians
from a variety of fields have become intensely interested in
nonnarcotic management of acute and chronic pain condi-
tions and learning how to appropriately assess opioid risk. As
those who study pain know, there are many varieties of pain
and many ways to target these individual pain sources and
interrupt their mechanisms of development.
This question book highlights some key concepts in the
pathophysiology and treatment of pain. It was compiled by
physicians from specialties and subspecialties including An—
esthesiology, Emergency Medicine, Pain Medicine, Pallia-
tive Care, Physical Medicine and Rehabilitation, and Re-
gional Anesthesia/Acute Pain, and it also includes editors
with expertise and special interests in Cancer Pain, Integra-
tive Medicine, and Pediatric Pain. Questions were written
primarily by fellows during their subspecialty training at
Emory University School of Medicine and reviewed/ edited
by their attendings. Editors represent four separate institu-
tions associated with Emory University School of Medicine,
bringing with them a wide range of backgrounds and exper-
tise with diverse patient populations.
vi
This question book is not intended as a stand-alone re-
source, but as an aid to guide studying and highlight key
points in pain management. It is a companion book to Prac—
tical Management of Pain, edited by Honorio Benzon et al.
Practical Management of Pain stands out as a comprehensive
resource for those interested in the study of pain; it is ap—
propriate both for those seeking board certification as well
as for those who simply wish to gain a deeper understanding
of pain and its various treatments. Healthcare practitioners
from a variety of fields would benefit from information
found in these books. In assessing currently available books
regarding pain medicine for our fellows to use for self-study
and board review, we found that most books on the market
were inadequate and inherently flawed. We therefore en—
couraged them to read Practical Management of Pain and, as
a group interested in furthering education and understand-
ing regarding pain medicine, came together (fellows and
faculty) to develop a question book based off of this com-
prehensive text. As such, this question book should be used
as an adjunct to specifically target areas in need of further
study, whether for board preparation or simply as a “test
your knowledge” guide to accompany Practical Management
ofPain.

The editors would like to acknowledge helpful discussions
and input from their colleagues in multiple departments at
Emory University School of Medicine. The multidisciplinary
pain fellowship at Emory and the development of this book
could not exist without the willingness and enthusiasm to
teach that has come from the cohesive groups of individuals
within these departments. These departments include Anes-
thesiology, Emergency Medicine, Hematology 8c Oncology,
Interventional Radiology, Neurology, Palliative Care, Physical
Medicine and Rehabilitation, Primary Care, Psychiatry, Psy-
chology, Radiology, and many others. Specific individuals de—
serving of thanks for their support and their commitment to
medical education include Laureen Hill (Chair, Department
of Anesthesiology), Anne Marie McKenzie—Brown (Director,
Center for Pain), Colette Curtis (Acute Pain), Tammie Quest
(Emergency Medicine & Palliative Care), Paul Desandre
Acknowledgments
(Emergency Medicine 8: Palliative Care), Lynn O’Neill
(Geriatrics, Internal Medicine & Palliative Care), Michael
Silver (Neurology), Taylor Harrison (Neurology 8c Electrodi—
agnostics), Natalie Strickland (Pediatric Pain), Jennifer
Steiner (Pain Psychology), Nadine Kaslow (Pain Psychology),
Howard Levy (Physical Medicine 8c Rehabilitation), William
Beckworth (Physical Medicine & Rehabilitation),]ose Garcia
(Physical Medicine 8c Rehabilitation), Randy Katz (Occupa—
tional Medicine & Physical Medicine 8c Rehabilitation), Scott
Firestone (Psychiatry), Walter Carpenter (Radiology). And of
course, the field would not advance without the aid of those
who have dedicated themselves to advancing research in
pain and neural networks, including Paul Garcia, Wei Huang,
Vitaly Napadow, Bruce Crosson, Ling Wei, and Shan Ping Yu.
Anna Woodbury, MD
vii
 GENERAL CONSIDERATIONS
The History of Pain Medicine
QUESTIONS
1. Which of the following anesthetics was administered for
labor pain to Queen Victoria in 1874 and subsequently
cited as legitimizing analgesia during labor?
A. Chloroform
B. Nitrous oxide
C. Cocaine
D. Morphine
E. Procaine
2. Which of the following theories combines both physical
and psychological aspects of pain perception and is
credited with revolutionizing pain research?
A. Pattern Theory
B. Sensory Interaction Theory
C. Gate Control Theory
D. The Fourth Theory of Pain
E. Specificity Theory
ANSWERS
I. A. Queen Victoria was given chloroform byjames Simp-
son in 1847 for the delivery of her eighth child, at
which point it became widely accepted that labor pain
should be medically managed. Prior to this, it was con—
sidered against Christian beliefs to provide or accept
analgesia during labor.
2. C. The Gate Control Theory, developed by Melzack
and Wall in 1965, states that nonnociceptive signals
can override nociceptive signals, and, as a result, the
perception of pain is reduced or eliminated. Interven-
tions such as peripheral nerve stimulators, TENS units,
and spinal cord stimulators, as well as biofeedback
3. Which of the following organizations is multidisci-
plinary, with members including but not limited to
physicians, dentists, psychologists, nurses, and physical
therapists?
A. The American Academy of Pain Medicine (AAPM)
B. The International Association for the Study of Pain
(IASP)
C. The International Spine Intervention Society
(SIS, formally ISIS)
D. The American Society of Interventional Pain
Physicians (ASIPP)
E. The American Society of Regional Anesthesia
(ASRA)
techniques, are based on the Gate Control Theory.
This theory is cited as ending the debate regarding
whether or not the cerebral cortex plays a role in pain.
Development of imaging such as PET, fMRI, and
SPECT later added credibility to this theory by demon—
strating the activation of the cerebral cortex in
response to pain.
3. B. The International Association for the Study of Pain
(IASP) is the largest multidisciplinary international as-
sociation, with a goal of furthering pain research by in-
tegrating professionals with different backgrounds and
disciplines.
 2 Taxonomy and Classification
of Chronic Pain Syndromes

QUESTIONS
1. The International Association for the Study of Pain D. Serves to exclude new syndromes such as those
(LASP) classification focuses on chronic pain; however, involving painful legs and moving toes
it includes syndromes that are not acute in nature, E. Is entirely psychogenic in nature
including which of the following?
A. Acute herpes zoster . Migraines fall under which of the following diagnostic
B. Burns with spasm categories?
C. Pancreatitis Pain Disorder, Somatoform Persistent

£115.09”?
D. Prolapsed intervertebral disk Pain Disorder, Psychological Origin
E. All of the above Pain Disorder, Malingering
Pain Disorder, Neuropathic
. The classification of chronic pain specifies five axes for Psychological or Behavioral Factor Associated with
describing pain. The second axis is the system most re- Disorders or Disease Classified Elsewhere
lated to the cause of the pain. Which of the following
are systems identified? 7. While defining pain, it is important to recognize that
A. The central, peripheral, and autonomic nervous pain is always a subjective state related to which of the
systems and special senses following?
B. Psychological and social function of the nervous Emotional state
PLUGS”?

system Physical state

C . Respiratory and vascular systems Psychiatric state
D. The musculoskeletal system and connective tissue Psychological state
E. All of the above Social state

3. Which of the following is NOT part of the diagnosis of 8. According to the IASP Taxonomy Committee, chronic
complex somatic symptom disorder? pain is defined as pain that has been present for what
A. Emotional disturbances length of time?
B. Health anxiety 3 months
HUGE”?

C. Excessive amount of time devoted to health concerns 12 months

D. Symptoms and concerns must have lasted 12 months 6 months
E. None of the above 24 months
None of the above
. Based on the ICD—lO classification, a predominant
complaint that is persistent, severe, and distressing that . Consensus generally exists on the meaning or
cannot be explained fully by a physiologic process or definition of which of the following terms?
physical disorder is categorized as: A. Condition
A. Pain Disorder, Somatoform Persistent B. Disease
B. Pain Disorder, Psychological Origin C. Disorder
C. Pain Disorder, Malingering D. Symptom
D. Pain Disorder, Neuropathic E. Syndrome
E. Psychological or Behavioral Factor Associated with
Disorders or Disease Classified Elsewhere 10. All of the following are listed by the IASP as relatively
generalized pain syndromes except:
. The definition of complex regional pain syndrome A. Fibromyalgia
(type 1): B. Phantom Pain
A. Is related to the sympathetic nervous system C. Complex Regional Pain Syndrome
B. Is defined by its clinical phenomena D. Pain of Psychological Origin
C. Is defined solely for research purposes E. Radicular Pain
 CHAPTER 2 — Taxonomy and Classification of Chronic Pain Syndromes
ANSWERS
l. E. The LASP (International Association for the Study of
Pain) focuses on the classification of chronic pain syn-
drome, but includes some acute syndromes for compar-
ison (and because these acute conditions can often be-
come chronic). Acute herpes zoster, burns with spasm,
pancreatitis, and prolapsed intervertebral disk are all
examples of acute pain syndromes that are included.
. E. The classifications are divided into five axes: (l) ana-
tomic, (2) system, (3) temporal characteristics and pat-
tern, (4) intensity, (5) etiology. The second axis systems
include (a) central, peripheral, and autonomic nervous
and special senses; (b) psychological and social function;
(c) respiratory and vascular; (d) musculoskeletal and
connective tissue; (e) cutaneous and subcutaneous tissue
and glands, gastrointestinal, genitourinary, and other
organs/viscera; and (g) unknown systems.
. D. To be diagnosed with complex somatic symptom
disorder by DSM-IV criteria, patients must report at
least one distressing somatic symptom as well as at least
one of “emotional/ cognitive/behavioral disturbances:
high levels of health anxiety, disproportionate and
persistent concerns about the medical seriousness of
the ‘symptoms’ and an excessive amount of time and
energy devoted to the symptoms and health concerns,”
for at least 6 months’ duration.
4. A. Persistent Somatoform Pain Disorder is persistent,
severe, distressing pain that cannot be explained fully
by physiologic mechanisms. Pain during schizophrenia
or depression is not included.
. B. The name of CRPS was changed from RSD based on
the advice of a special subcommittee. Steps taken have
(1) defined CRPS type 1 by its clinical phenomena and
(2) developed identifying diagnostic criteria for clinical
agreement as well as for more stringent research pur-
poses. The classification has also helped in understand-
ing relatively new syndromes. The old name, RSD, was
3
based on a theoretical relationship to the sympathetic
nervous system.
E. Pain that is due to known or inferred psychophysio-
logic mechanisms, such as muscle tension pain or mi—
graines, but is believed to have a psychogenic cause
falls under the ICD-lO classification of Psychological or
Behavioral Factor Associated with Disorders or Disease
Classified Elsewhere.
D. The definition of pain by the IASP is “an unpleasant
sensory and emotional experience associated with ac-
tual or potential tissue damage or described in terms of
such damage.” This addresses the situation of patients
who appear to have pain but do not have obvious tissue
damage and acknowledges that pain is always subjective
and psychological, regardless of tissue damage.
. C. Chronic pain is pain that persists beyond the normal
healing process. Although the timeframe for this may
differ in practice and many types of pain become
chronic or persistent at 3 months, the 6—month division
was chosen for scientific purposes by the IASP as a
good entry to the patient population treated by pain
physicians.
. D. The words “disorder,” “syndrome,” and “disease”
are all in dispute regarding whether they reflect the
true phenomena that physicians treat. However, the
word “symptom” is not in dispute.
10. E. Relatively generalized syndromes include diffuse or
widespread pain that is poorly localized, such as rheu-
matoid arthritis, fibromyalgia, polymyalgia rheumatica,
pain of psychological origin, syringomyelia, central
pain, CRPS, phantom pain, stump pain, and periph-
eral neuropathy. Localized syndromes are divided by
the area affected (head, neck, limbs, thorax, abdomen,
spinal/ radicular) .
 Organizing an Inpatient Acute
Pain Service
QUESTIONS
1. Which of the following factors is likely to influence
postoperative opioid requirements?
A. Preoperative pain sensitivity
B. Presurgical opioid tolerance or a history of drug
abuse
C. Psychological factors, including catastrophizing and
anxiety
D. Age
E. All of the above
2. Which is the best intervention for inhibition of surgical
stress responses?
A. Neuraxial steroids
B. Neuraxial local anesthetics
C. Perineural local anesthetics
D. Systemic steroids
E. None of the above
. Postoperative pain is identified as one of the major
fears of patients undergoing surgery. What percentage
of patients consider it to be their primary fear?
A. 30%—40%
B. 40%—50%
ANSWERS
l. E. Achieving satisfactory acute pain management can be
challenging. It is often difficult to estimate a patient’s
postoperative analgesic requirements. The following
factors may influence postoperative opioid require—
ments: preoperative pain sensitivity, coexisting medical
conditions and associated multiple drug administration,
presurgical opioid tolerance or a history of drug abuse,
psychological factors (including catastrophizing and
anxiety), age, and type of surgery.
. B. Surgical stress responses are best inhibited by neur-
axial administration of local anesthetics; the adminis-
tration of other agents—systemically, neuraxially, or
perineurally—appears to contribute little additional
reduction of the endocrine (metabolic and catabolic)
stress response following operative procedures.
. C. Inadequacy of pain relief has been highlighted as a
quality-of—care measure and a focus of patients’ con-
cern. In a questionnaire survey, 57% of patients identi-
fied pain after surgery as their primary fear.
C. 50%—60%
D. 60%—70%
E. 80%—90%
. All of the following are examples of multimodal
analgesia EXCEPT:
A. Neuraxial block and music therapy
B. IV morphine and fentanyl patch
C. PCA morphine and thoracic epidural
D. Acupuncture and TENS
E. Femoral nerve block and stress reduction
. Which is an important first step in organizing an inpa-
tient acute pain service?
A. Enlisting the support of hospital administration and
defining resources
B. Assessment of need
C. Definition of service
D. Financing and business plan
E. Nursing education
4. B. A time-, energy—, and cost-effective acute pain pro-
gram should optimally provide multimodal and multidis-
ciplinary interventions, including systemic and regional
pharmacologic treatments, stress reduction, transcuta—
neous electrical nerve stimulation, music therapy, and
acupuncture. Extracting and integrating the relevant
expertise from multiple health care disciplines often
allows individualized and optimized pain management.
Disciplines commonly involved include psychology,
pharmacy, physical therapy, and nutrition.
5. A. Enlisting the support of hospital administration and
defining resources are a Vital first step in organizing an
inpatient acute pain service. Once the challenge of or—
ganizing an acute pain service is accepted, assessment
of need is mandatory. Once the mission statement has
been formulated in response to the perceived institu-
tional and community needs, it is necessary to define
the resources that will be required. The next step in the
process of organizing an inpatient acute pain service is
to construct the business plan.
 Measurement-Based
Stepped Care Approach to
Interdisciplinary Chronic
Pain Management

QUESTIONS
1. Which of the following is FALSE regarding the World 5. All of the following are aberrant drug behaviors
Health Organization cancer pain analgesic ladder? EXCEPT:
A. It is focused on the relief of intensity of cancer pain. A. Self-induced oversedation
B. It incorporates relief of suffering of the cancer pain B. Continuing medication despite report of feeling
patient. intoxicated
C. It emphasizes treating the intensity of pain even at C. Early refill requests
the expense of function. D. Calling the office to report worsening pain
D. It includes three steps in its analgesic strategy. E. Self-directed dose increase
E. The goal of the ladder is complete freedom from
pain. . The 2006 Trends and Risks of Opioid Use for Pain
(TROUP) study found opioid use to be higher in pa-
. Which the following pain treatment domains should tients with mental health disorders and what other
ideally be included in a measurements-based stepped health problem?
care pain treatment algorithm? A. Chronic pelvic pain
A. Physical and emotional function B. Substance use disorders
B. Quality of sleep C. Chronic back pain
C. Risk for chemical dependency D. Postsurgical patients
D. Self-reported quality of life E. Patients with whiplash history
E. All of the above
. All of the following are validated opioid risk scales
. The Patient Health Questionnaire 4 (PHQ—4) is a EXCEPT:
screening tool for depression and anxiety. Which of the A. ORT
following is NOT assessed on this questionnaire? B. COMM
A. Feeling nervous, anxious, or on edge C. SOAPP—R
B. Not being able to stop or control worrying D. DIRE
C. Feeling down, depressed, or hopeless E. DOLOPLUS
D. Having little interest or pleasure in doing things
E. Feeling better off dead 8. Which of the following is true about patient access to
pain specialists?
4. Which of the following is true about daily morphine A. There is an overabundance of pain care providers in
equivalent dose (MED) and relative risk of mortality in the United States today.
patients on chronic opioid therapy? B. There is currently a significant shortage in pain
A. As daily morphine equivalent dose increases, providers relative to the number of people with
mortality risk also increases in tandem. chronic pain.
B. As daily morphine equivalent dose increases, C. The number of patients with chronic pain is cur-
mortality risk tends to plateau. rently well matched to the number of board-certified
C. As daily morphine equivalent dose increases, providers in pain care.
mortality risk decreases. D. In the United States, fewer than 1000 physicians
D. The 50—100 mg morphine equivalent dose has the were board-certified in pain care between 2000 and
highest risk for mortality. 2009.
E. Using between 20 and 50 mg morphine equivalents E. The current shortage in pain care expertise leaves
per day does not increase mortality risk relative to more than 100,000 people with chronic pain for
less than 20 mg daily. every pain specialist in the United States.
6 PART 1 — GENERAL CONSIDERATIONS
. Obstructive sleep apnea risk is thought to increase
with the dose of opioid used. Which of the following
is NOT an additional risk factor for obstructive sleep
apnea based on STOP-BANG criteria?
. Hypertension
mvow>
. Snoring
. BMI greater than 35
. Age less than 50
. Male gender
10. According to the model of measurement—based
stepped care, referral to a behavioral health specialist
is indicated when all of the following are present
EXCEPT:
PHQ—Q 2 15
FCC???
PHQ—4 2 5
Suicidal ideation
PTSD
Anxiety
11. A 28-year-old male with chronic pain presents to your
clinic. Opioid risk screening reveals a personal and
family history of cocaine use as well as a psychological
history of anxiety. According to the stepped care
model, he should be referred to see:
A. Pain physician
B. Physiatrist
C. Behavioral health specialist
D. Addiction medicine specialist
E. Sleep medicine specialist
12. A primary care physician is treating a 26-year-old
female with chronic diffuse pain of unclear etiology,
unresponsive to 3 months of conservative management
including opioid escalation. According to the stepped
care model, she should be referred to see:
A. Pain physician
B. Physiatrist
ANSWERS
1. B. The WHO cancer pain analgesic ladder is focused
strictly on alleviating the intensity of pain and does not
incorporate suffering of the cancer pain patient in its
analgesic strategy. Other answer choices listed are true
statements regarding the ladder.
2. E. All of the listed pain treatment domains should
ideally be included in a stepped care pain treatment
algorithm.
3. E. The question regarding suicidality comes from the
PHQ—Q screening tool rather than the simpler PHQ—4
questionnaire.
4. A. Relative risk of mortality with chronic opioid therapy
increases in parallel with escalating morphine equiva-
lent dose.
5. D. Contacting the office to report worsening pain is
considered appropriate behavior meriting reevaluation.
C. Behavioral health specialist
D. Addiction medicine specialist
E. Sleep medicine specialist
13. The concept of “adverse selection” in relation to
substance use disorders and chronic pain opioid
prescribing argues which of the following:
A. The patients at highest opioid risk are being
prescribed the highest opioid doses.
B. The patients with highest socioeconomic status are
being prescribed the highest opioid doses.
C. The patients with lowest opioid needs are being
prescribed the lowest opioid doses.
D. The patients at highest opioid risk are being
prescribed the lowest opioid doses.
E. The patients at lowest opioid risk are being
prescribed the highest opioid doses.
14. What is the morphine equivalent dose (MED) that
prompts a referral to a pain specialist according to
the stepped care model?
A. 0—19 mg MED
B. 20—49 mg MED
C. 50—79 mg MED
D. 80—119 mg MED
E. Greater than 120 mg MED
15. Physical medicine and rehabilitation referral is
prompted by all of the following EXCEPT:
A. Disability greater than 4 weeks
B. On-the—job pain interference
C. Ineffective return—to—work plan
D. Roland Morris > 12/ 24
E. Obesity
6. B. Presence of substance use disorder in addition to
mental health disorders predisposed patients to higher
opioid use in the TROUP study.
7. E. The first four options are validated opioid risk
screening tools: Opioid Risk Tool (ORT), the Screener
and Opioid Assessment for Patients with Pain—Revised
(SOAPP—R) ; the Current Opioid Misuse Measure
(COMM); and the Diagnosis, Intractability, Risk, and
Efficacy (DIRE). The DOLOPLUS scale, though vali-
dated, is used for behavioral pain assessment in elderly
with verbal communication problems, not for opioid
risk screening.
. B. There is currently a significant shortage of
board-certified pain physicians in the United States
relative to the number of patients with chronic pain.
. D. Age greater than 50 is a risk factor for OSA per the
STOP-BANG criteria.
 CHAPTER 4 — Measurement-Based Stepped Care Approach to Interdisciplinary Chronic Pain Management

10. E. While anxiety is often associated with chronic pain,
its presence alone is not considered sufficient for psy-
chiatrist referral according to the stepped care model
unless deemed poorly controlled despite conservative
measures.
11. D. This patient has an opioid risk tool score 28 and
thus merits referral to an addiction medicine specialist.
13. A. The patients at highest opioid risk are being
prescribed the highest opioid doses.
14. E. Greater than 120 mg MED.
15. E. All are true except obesity, which is one of the risk
factors for sleep medicine referral.

12. A. This patient merits referral to a pain medicine

specialist for further evaluation.
 5 The Health Care Policy
of Pain Management
QUESTIONS
1. Which of these statements is part of the International
Association for the Study of Pain (IASP) Declaration of
Montreal?
A. Only pain that has been objectively verified must be
treated.
B. Pain must be treated by a medical doctor specialty-
trained in pain management.
C. Patients should receive analgesia based on their
ability to pay.
D. Access to effective pain management is a basic
human right.
E. Patients must have a history negative for substance
abuse to qualify for opioids.
2. Which of the following phases of the Food and Drug
Administration Center for Drug Evaluation and Re—
search (FDA CDER) approval process focuses on the
ANSWERS
I. D. The Declaration of Montreal, published in 2010, states
that effective pain management is a basic human right.
It underscores the importance of government to enact
legislature that promotes access to pain management
for all. It consists of three articles, including:
0 Article I: The right of all people to have access to
pain management without discrimination.
0 Article 2: The right of people in pain to have their
pain acknowledged and to be informed about how
it can be assessed and managed.
0 Article 3: The right of all people with pain to have
access to appropriate assessment and treatment
of the pain by adequately trained health care
professionals.
2. B. The phases of the FDA CDER approval process are
tiered as follows:
0 Preclinical IND application: Animal data used to
justify testing of the drug in humans.
0 Phase I: Basic safety profile and pharmacokinetics of
the drug in 50—100 human subjects.
0 Phase II: Drug dosage, efficacy, and safety in 100—500
human subjects.
basic safety profile and pharmacokinetics of the drug
in human subjects?
A. Preclinical Investigational New Drug (IND) application
B. Phase I
C. Phase II
D. Phase III
E. Phase IV
3. Which of the following is NOT identified as a barrier to
access to pain treatment around the world?
A. Education of patient population
B. High cost of treatment
C. Lack of government policy on pain treatment and
drug supply
D. Poor training of health care workers
E. Fear among health care workers of legal action
0 Phase III: Confirmation of the safety and effective-
ness of the drug, its dosages, and drug interactions
in 1000—4000 human subjects.
0 Phase IV: New or expanded use for patient population
and long—term risks vs. benefits.
. A. Access to appropriate pain management worldwide
remains largely inadequate. Seventy-eight percent of
morphine consumed in 2010 went to only six countries.
Inexpensive oral medications are unobtainable in many
countries. Reasons cited include:
0 Failure of governments to put functioning drug supply
systems in place.
0 Failure to enact policies on pain treatment and
palliative care.
0 Poor training of health care workers.
0 Existence of unnecessarily restrictive drug control
regulations and practices.
0 Fear among health care workers of legal sanctions
for legitimate medical practice.
0 Unnecessarily high cost of pain treatment.
 Quality Assessment and 6
Improvement and Patient
Safety in the Pain Clinic

QUESTIONS
1. The majority of errors that take place in health care are C. Lack of evidence-based benchmarks or national “best
due to which of the following? practices”
A. Patient factors D. Lack of cooperation from patients
B. System defects E. Lack of government regulation to support such
C. Provider carelessness programs
D. Equipment malfunction
E. Resource misallocation 3. Which of the following tools has been shown to signifi-
cantly lower the death rate, reduce patient complica-
2. Which of the following is identified as the biggest hurdle tions, and is especially helpful in emergencies?
to establishing Continuous Quality Improvement (CQI) A. E-conferencing/ telecommuting
in pain medicine? B. Speech recognition software
A. Lack of additional reimbursement to justify higher C. Electronic prescriptions
quality care D. Safety checklist
B. Lack of support from hospital administration E. Patient portals

ANSWERS
1. B. According to the Institute of Medicine (IOM), a ma-
jority of errors in health care are more likely attributable
to system defects (as opposed to individual errors).
2. C. Because evidence available in peer-reviewed litera-
ture is insufficient for chronic pain interventions, estab-
lishing a CQI in the field of pain medicine largely relies
on consensus expert opinion instead.
3. D. Using a checklist has been shown to reduce patient
complications, which is thought to be due to decreases
in human error. Data shows that simply implementing a
safety checklist can substantially reduce patient mortality
rates. Checklists are critical in emergency situations,
such as local anesthetic toxicity, where a checklist/
protocol should be readily available.
 Education, Training, and
Certification in Pain Medicine
QUESTIONS
1. Which of the following describes the design of current
pain medicine training programs?
Comprehensive and multidisciplinary
cow?
. Emphasis on pharmacologic-only treatment
Centered around principles from anesthesiology
. Incorporating multidisciplinary principles from three
specialties including anesthesiology, psychiatry, and
neurology
E. Focus on objective physical exam findings
2. Which of the following is a consequence of the Food
and Drug Administration’s (FDA) 510(k) “substantially
similar device” process?
A. There must be data from >1000 patients demonstrat-
ing device efficacy.
B. There must be data from >1000 patients demon—
strating device safety.
C. Guideline stringency hinders device innovation.
ANSWERS
1. A. The original fellowship training programs in pain
medicine were extensions of the department of anesthe-
siology. Since that time, there has been a broadening
of specialties seeking training in pain medicine. In an
effort to standardize and ensure quality of pain medi-
cine training programs, four specialties have agreed to
ACGME requirements for fellowship programs, includ-
ing anesthesiology, neurology, physical medicine and
rehabilitation, and psychiatry, since 2007. This collabo-
ration between specialties echoes the views of the
American Academy of Pain Medicine and the American
Board of Pain Medicine, emphasizing a multidisciplinary
and multimodal approach to pain medicine.
. D. In order to expedite innovation and the introduc-
tion of new technology, devices can be cleared for
10
D. Introduction of devices to the market often outpaces
practitioner familiarity.
E. Creation of new devices becomes cost prohibitive for
manufacturers.
3. Which of the following is a problem in using interven-
tional techniques in pain medicine?
A. The procedures are only suitable for a small subset
of patients.
B. Randomized, controlled clinical trials are still lacking
for many interventional treatments.
C. There is a lack of patient cooperation with adhering
to the schedule of frequency required.
D. The complications from most of the procedures are
such that the risk outweighs the benefit.
E. Patients are unwilling to try novel procedures.
market if the FDA deems the risks and benefits are
comparable to a device that has been previously ap-
proved. The FDA’s 510(k) “substantially similar device”
process can require little additional efficacy data. In
some cases, practitioners are overwhelmed with new
technology available and are not able to keep pace with
the skills and knowledge required to use the device.
3. B. The trend in medicine favoring evidence—based therapy
has highlighted a relative lack of randomized controlled
trials in the pain medicine subspecialty to validate treat-
ments. At the same time, patients with chronic pain re-
quire treatment and are often willing to try novel proce—
dures. Practitioners must monitor their own outcomes to
aid in making decisions in patient care as well as use best
judgment of risk vs. benefit for each individual patient.
 BASIC CONSIDERATIONS

Pain Pathways: Peripheral,

Spinal, Ascending, and
Descending Pathways

QUESTIONS
1. What is the primary termination site for sensory integra- 5. Prolonged membrane hyperpolarization has what effect
tion in the pain pathway? on the role of GABA—B receptors?
A. Thalamus A. Change from inhibition to more inhibition
B. Medulla B. Change from inhibition to excitation
C. Basal ganglia C. Change from excitation to inhibition
D. Dorsal columns D. Increased threshold for depolarization
E. Frontal cortex E. No effect

. What are the small unmyelinated axonal fibers with slow 6. Which of the following is the primary afferent excitatory
conduction velocities that relay noxious input from the neurotransmitter?
skin and other tissues to the central nervous system? A. Substance P
A. A-delta fibers B. CGRP
B. A—beta fibers C. IL—I
C. C fibers D. Glutamate
D. Free nerve endings E. Norepinephrine
E. Dorsal root ganglia
. Noxious cutaneous input is relayed by which of the
The dorsal horn is anatomically organized in laminae. following lamina projection neurons as the crossed
Small unmyelinated fibers terminate in laminae , spinothalamic tract pathway traveling in the lateral
while large myelinated fibers terminate in laminae and ventrolateral white matter en route to the VPL?
A. II—III, IV—V
B. I—II, III—V
C. III—V, I—II
D. II—IV, I—III
E. V, I—II

. The substantia gelatinosa is associated with which of the . The gray matter of the dorsal horn includes the following
following lamina? Rexed laminae:
A. Lamina I A. I—IV
B. Lamina II B. I—VI
C. Lamina III C. II—IV
D. Lamina IV D. II—VI
E. Lamina V E. I—X

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