Pain Managment

1
Pain Managment
2
A 40-year-old male with chronic hepatitis C has
osteoarthritis in his knees that is beginning to
limit his activity. He asks you if he can take
acetaminophen for the pain.Which of the
following would be appropriate advice? (Mark all
that are true.)Acetaminophen overdose is a
leading cause of fulminant liver failure in
adultsAcetaminophen is excreted through the
biliary systemHe can safely take up to 3 grams of
acetaminophen per dayNSAIDs are preferred over
acetaminophen in patients with chronic liver
disease
3
Answer

• Acetaminophen overdose is a leading cause of
  fulminant liver failure in adults

4
Acute acetaminophen overdose is a very common
problem in the United States, and when
unrecognized can lead to fulminant hepatic
failure. In healthy adult nondrinkers,
acetaminophen is safe taken chronically in doses
up to 4 g/day. Adults who drink excessively,
those with chronic liver disease, and those with
malnutrition are at increased risk for toxicity.
Acetaminophen should be limited to 2 g/day in
these persons (B level recommendation). It
appears safe at this dosage, and is preferred
over NSAIDs in patients with chronic liver
disease. Acetaminophen is metabolized in the
liver and excreted by the kidneys.
5
A 40-year-old male has had low back pain for 2
years. He asks your advice concerning physical
therapy.Which of the following would be
appropriate advice? (Mark all that are
true.)Prescribed exercise programs are the most
efficacious physical modality for chronic back
painTranscutaneous Electrical Nerve Stimulation
(TENS) units produce modest benefits in pain
reductionRegular massage therapy often produces
lasting benefitsWhile expensive,
multidisciplinary rehabilitation programs are
clearly beneficialHydrotherapy is ineffective
for chronic back pain
6
Answer

• Prescribed exercise programs are the most
  efficacious physical modality for chronic back
  painWhile expensive, multidisciplinary
  rehabilitation programs are clearly
  beneficialHydrotherapy is ineffective for
  chronic back pain

7
It is difficult to analyze the evidence for the
efficacy of physical therapy, because improvement
is affected by a patient's effort and motivation,
as well as the personal attention one gets from
the physical therapist. Randomized, controlled
trials are difficult to perform and compare. On
this subject, systematic reviews and
meta-analyses do not always agree.A review of
physical modalities for chronic back pain
published in 2004 looked not only at efficacy,
but also at the clinical significance of the
effect. Only exercise programs and
multidisciplinary rehabilitation programs (which
can cost thousands of dollars) were shown to be
effective and clinically beneficial. Laser
therapy, spinal manipulation, and massage were
shown to be mildly effective with little lasting
clinical benefit. Using the same criteria, TENS,
magnets, ultrasound, hydrotherapy, and traction
were ineffective. There was too little evidence
to rank acupuncture, back schools, and lumbar
supports.Physical therapists not only
administer modalities but also provide functional
assessments, patient evaluations, and patient
education. Therapists can specialize in areas
such as neurologic rehabilitation, wound
management, or sports training.
8
Two weeks ago, a 30-year-old female with a
history of lymphoma underwent her sixth and last
cycle of chemotherapy before radiologic
reevaluation. She has had chronic
lymphoma-related back pain for the past six
months, adequately controlled by
oxycodone/acetaminophen (Percocet), 5 mg/325 mg,
one to two tablets orally every 4 hours as
needed. During her last chemotherapy cycle she
became neutropenic, and was treated with
filgrastim (Neupogen).The patient comes to your
office today for regular follow-up of
prednisone-induced hyperglycemia, and complains
of severe bilateral lower extremity pain. The
pain started about 2 weeks ago and is mostly over
her shins. She tells you it is a constant, sharp
pain, and that the Percocet is not relieving her
pain anymore. What is the most likely cause of
her new pain? Pain secondary to increased
cytokines from chemotherapy-related
tumorlysis Neuropathic pain related to her
prednisone-induced hyperglycemia Osteoporosis-rel
ated pain from high-dose prednisone Bone pain
from increased bone marrow activity resulting
from treatment with filgrastim Tolerance to
Percocet secondary to chronic use
9
Answer

• Bone pain from increased bone marrow activity
  resulting from treatment with filgrastim

10
Filgrastim is used to treat neutropenia from
chemotherapy or bone marrow transplantation. It
stimulates granulocyte and macrophage
proliferation and differentiation. One of its
most common side effects is bone pain (30 of
patients) that usually starts in the first 3 days
of treatment.Although tumor lysis can cause
pain from increased circulating cytokines, this
pain is usually diffuse. Long-lived hyperglycemia
does cause neuropathic pain that is usually
described as burning, shooting, "pins and
needles," and "painful numbness." The onset is
very rarely acute, however. Osteoporosis does not
cause pain. Tolerance does not occur abruptly.
Any pain escalation should be thoroughly
investigated before a diagnosis of tolerance is
made, especially when the pain has an acute onset.
11
You decide to use a pain rating scale to help
guide the management of a 77-year-old female with
peripheral neuropathy who has daily pain. True
statements regarding these scales include which
of the following? (Mark all that are true.)They
are simple and easy to administerThey eliminate
embellishment of painThe emotional state of the
patient can influence the ratingThere are valid
scales which are useful in children
12
Answer

• They are simple and easy to administer
• The emotional state of the patient can influence
  the rating
• There are valid scales which are useful in
  children

13
Pain rating scales are used by many physicians to
measure intensity of pain and monitor the effect
of therapy. (C level recommendation, evidence
level II) They can be administered in a matter of
minutes and are easy to score. These scales can
be adapted for any age group by substituting
words and/or pictures. Most children understand
that 10 is greater than 2 and can use the simple
1-10 scale.There are four scales in wide use
numeric rating scales, verbal rating scales,
visual analog scales, and pain drawings. Some
clinicians use pain diaries to further enhance
the rating's accuracy and provide information on
function. One drawback is that the scales allow
for embellishment and can be skewed one direction
or the other by someone with little pain
experience (Evidence level III). A teenager who
is naive to pain might rate the pain of a sore
throat as a 10, or a patient seeking sympathy or
additional treatment might overrate the amount of
pain he or she is having. Emotions affect the
pain experience and can also affect the rating.
While there is some controversy about how
accurate these scales are, most clinicians have
learned to use them for assessment and management
of pain.
14
40-year-old nurse presents with neck pain. He has
no history of specific injury. His symptoms are
intermittent and seem worse when turning his head
to the left. The pain radiates into the left
thumb and index finger. At times it can be
severe.Which one of the following is true
regarding this problem? The irritated nerve root
is most likely C5 Diagnostic imaging would be
helpful Flexion of the neck is likely to worsen
the pain The most common cause is osteophytes
15
Answer

• Diagnostic imaging would be helpful

16
Cervical radiculitis is quite common and results
from irritation of the cervical nerve as it
leaves the spinal cord. The location of the
symptoms may help to identify the irritated
nerve. A C5 root irritation will cause pain in
the shoulder but without radiation into the arm.
The pain is generally made worse by extension, a
maneuver that decreases the space for the nerve
root. Flexion may actually help the pain. The
pain is generally also made worse by turning
toward the side of the compression. Reflexes
decrease as the duration of the compression
lengthens.The most common cause of cervical
nerve root compression is either an acute disc
herniation or a degenerative disc. Osteophytes
may cause no impingement. Diagnostic imaging is
helpful and should start with plain films of the
cervical spine with oblique views (C level
recommendation). An MRI is the most definitive
imaging test, but should be used to confirm the
diagnosis since there is a fair amount of
asymptomatic cervical pathology (Evidence level
II).
17
Which one of the following agents provides the
greatest analgesic effect when compared milligram
to milligram? Oxycodon(OxyContin) Morphine(MSCon
tin) Codeine Hydromorphone(Dilaudid) Hydrocodon
e
18
Answer

• Hydromorphone (Dilaudid)

19
True statements regarding the management of
vertebral compression fractures in the elderly
include which of the following? (Mark all that
are true.)These fractures are normally unstable,
making surgical treatment idealIf conservative
treatment is selected, a minimum of 4 weeks of
bed rest is requiredIn the elderly, NSAIDs are
safer than opioidsCalcitonin-salmon (Miacalcin)
nasal spray can be used for treatment of
painPercutaneous vertebroplasty can be helpful
in managing the pain when conservative treatment
failsAfter the fracture heals, returning to a
normal exercise program may still be dangerous
20
Answer

• Calcitonin-salmon (Miacalcin) nasal spray can be
  used for treatment of painPercutaneous
  vertebroplasty can be helpful in managing the
  pain when conservative treatment fails

21
Compression fractures of the vertebral body are
common, especially in older adults. Vertebral
compression fractures usually are caused by
osteoporosis, and range from mild to severe. More
severe fractures can cause significant pain,
leading to the inability to perform activities of
daily living, and life-threatening decline in the
elderly patient who already has decreased
reserves. While the diagnosis can be suspected
from the history and physical examination, plain
radiographs are often helpful for determining the
diagnosis and prognosis. Occasionally, it may
also be helpful to obtain CT or MRI.The
physician must first determine if the fracture is
stable or unstable. A stable fracture will not be
displaced by physiologic forces or movement.
Fortunately, compression fractures are normally
stable as a result of their impacted nature.
Traditional treatment is non-operative and
conservative. Patients are treated with a short
period (no more than a few days) of bed rest.
Prolonged inactivity should be avoided,
especially in elderly patients. Oral or
parenteral analgesics may be administered for
pain control, with careful observation of bowel
motility. If bowel sounds and flatus are not
present, the patient may require evaluation and
treatment for ileus. Calcitonin-salmon nasal
spray can be used for treatment of pain. Muscle
relaxants, external back braces, and physical
therapy modalities also may help (Evidence level
B). NSAIDs have been shown to significantly
increase gastrointestinal bleeding in the elderly
and must be used with caution (Evidence level A,
randomized controlled trial).Patients who do
not respond to conservative treatment or who
continue to have severe pain may be candidates
for percutaneous vertebroplasty. This involves
injecting acrylic cement into the collapsed
vertebra to stabilize and strengthen the fracture
and vertebral body. This procedure does not,
however, restore the shape or height of the
compressed vertebra. Kyphoplasty, where cement is
injected into a cavity created by a high-pressure
balloon, is being evaluated for use and may be
successful in restoring height to the collapsed
vertebra.Most patients can make a full recovery
or at least significant improvements within 6-12
weeks, and can return to a normal exercise
program after the fracture has fully healed. A
well-balanced diet, regular exercise program,
calcium and vitamin D supplements, smoking
cessation, and medications to treat osteoporosis
(such as bisphosphonates) may help prevent
additional compression fractures. Age should
never preclude treatment.There is now good
evidence that diagnosing and treating
osteoporosis does indeed reduce the incidence of
compression fractures of the spine (Evidence
level A). Regular activity and muscle
strengthening exercises have been shown to
decrease vertebral fractures and back pain.
Measures to prevent falls must be initiated by
patients and their caregivers.Family physicians
can help patients prevent compression fractures
by diagnosing and treating predisposing factors,
identifying high-risk patients, and educating
patients and the public about measures to prevent
falls.
22
You are seeing a colleague's patient for a
follow-up visit. The patient has been taking
opioids for 12 months for chronic low back pain.
After reviewing his chart you notice numerous
phone messages from the patient asking for early
refills, as he has been using his opioids more
frequently than prescribed. During the encounter,
the patient admits to borrowing pain medications
from his wife.In the absence of other aberrant
behavior, this is highly indicative
of dependence addiction pseudoaddiction drug
trafficking
23
Answer

• pseudoaddiction

24
The suspicion of opioid addiction in chronic pain
sufferers is often triggered by the occurrence of
what have been called aberrant drug-related
behaviors. Ambiguities inherent in this approach
affect patient care adversely. Rather than
consistently signifying abuse or addiction, these
behaviors are often motivated by undertreated
pain.The term pseudoaddiction was coined in
1989 to describe chronic pain victims mistakenly
diagnosed as suffering from opioid addiction when
undertreated pain led to certain drug-related
behaviors. Simply stated, pseudoaddiction is a
misdiagnosis that results from undertreatment of
chronic pain. Patients are frequently harmed by
the misdiagnosis of addiction and these behaviors
should prompt an aggressive search for
undertreatment of pain. Unfortunately, this
usually does not happen. Instead, when a patient
displays certain behaviors, he or she is
typically threatened with termination of
treatment, rather than questioned about its
effectiveness.Undertreatment of chronic pain
should be considered first on the list of
differential diagnoses when considering the cause
of worrisome drug-related behaviors. Some of
these behaviors includeborrowing another
patient's drugsobtaining prescription drugs from
nonmedical sourcesunsanctioned dosage
escalationsaggressive complaining about the need
for higher dosesdrug hoarding during periods of
reduced symptomsrequesting specific
drugsacquisition of similar drugs from medical
resources(Evidence level III)The diagnosis of
opioid addiction should be based on observation
of deteriorating function, which can be directly
attributed to opioid abuse, rather than inferred
from an anecdotal set of behavioral criteria
derived from medical folklore. Behaviors
suggestive of opioid addiction include injection
of substances prescribed for oral use, concurrent
use of related illegal drugs, and selling
prescription drugs (Evidence level III).When
patients are obtaining opioids from more than one
medical source, the primary physician must
reevaluate the pain syndrome. Factors to consider
include whether the patient is undermedicated,
whether the syndrome is misdiagnosed, and whether
the patient is abusing or diverting
drugs.Physicians must work with chronic pain
patients to adequately evaluate and treat their
pain. In turn, physicians must expect patients to
use only one source to obtain opioid
prescriptions. A written opioid use agreement is
recommended.
25
Mind-body therapy (MBT), such as relaxation,
(cognitive) behavioral therapies, meditation,
imagery, biofeedback, and hypnosis, is used for
several common clinical conditions. There is good
evidence to support which of the following
statements about MBT? (Mark all that are
true.)MBT is more effective for decreasing pain
intensity than for improving functional status
associated with low back pain MBT has NO
significant effect in the symptomatic treatment
of arthritisStress management training can be as
effective as tricyclic antidepressants in the
management of chronic tension-type headacheThe
combination of relaxation training and thermal
biofeedback is the preferred behavioral treatment
for recurrent migraine disorder
26
Answer

• MBT is more effective for decreasing pain
  intensity than for improving functional status
  associated with low back pain Stress management
  training can be as effective as tricyclic
  antidepressants in the management of chronic
  tension-type headacheThe combination of
  relaxation training and thermal biofeedback is
  the preferred behavioral treatment for recurrent
  migraine disorder

27
Multimodal mind-body therapy (MBT) treatments
typically include some combination of relaxation,
biofeedback therapy, cognitive strategies (e.g.,
for coping with pain), and education. Narrative
reviews suggest that the Arthritis
Self-Management Program (ASMP) might be a
particularly effective adjunct in the management
of arthritis (Evidence level III). This
community-based program consists of education,
cognitive restructuring, relaxation, and physical
activity to reduce pain and distress and
facilitate problem solving. Using this program,
reductions in pain were maintained 4 years after
the intervention, and physician visits were
reduced by 40 (Evidence level II).A review of
the efficacy of MBTs in chronic low back pain
concluded that there was strong evidence (defined
as generally consistent findings in multiple
high-quality randomized, controlled trials) that
MBTs, when compared with wait-list controls or
usual medical care, have a moderate positive
effect on pain intensity and only small effects
on functional status and behavioral outcomes
(Evidence level I, Cochrane review).A review of
the efficacy of relaxation and biofeedback in
recurrent migraine headache showed a 43
reduction in headache activity in the average
patient compared with a 14 reduction with
placebo medication and no reduction in
unmedicated subjects (Evidence level II). A more
recent narrative review concluded that a
combination of relaxation training and thermal
biofeedback is the preferred behavioral treatment
for recurrent migraine disorder (C level
recommendation). Recent evidence indicates that
stress management training is as effective as
tricyclic antidepressants in the management of
chronic tension-type headache, suggesting that
combining these two therapeutic approaches might
be more effective than using either one alone
(Evidence level I).
28
True statements regarding dysmenorrhea include
which of the following? (Mark all that are
true.)Leiomyomata can cause secondary
dysmenorrheaOral contraceptives will not help
primary dysmenorrheaNSAIDs can be used on an
intermittent basis to help with
dysmenorrheaProstaglandins play a principal role
in dysmenorrhea
29
Answer

• Leiomyomata can cause secondary
  dysmenorrheaNSAIDs can be used on an
  intermittent basis to help with
  dysmenorrheaProstaglandins play a principal role
  in dysmenorrhea

30
Dysmenorrhea is pain that occurs during the
menses and is crampy in nature. It is commonly
classified as either primary or secondary.
Primary dysmenorrhea is a condition unto itself
that is not a symptom of another disorder.
Secondary dysmenorrhea can be caused by
leiomyomata or by other pelvic pathology.
Prostaglandin release is the understood
pathophysiology for primary dysmenorrhea. Oral
contraceptives provide relief for primary
dysmenorrhea by suppressing ovulation and thereby
reducing the release of prostaglandins (Evidence
level II). NSAIDs that inhibit prostaglandin
synthetase provide relief in most patients and
are usually initiated for 2-5 days, just before
and during the menses (Evidence level I). In some
recalcitrant cases the NSAIDs could be used
continuously, with proper attention to the risks
of chronic NSAID use.
31
A 34-year-old female presents with intermittent
facial pain. The pain occurs in brief episodes
and always on the left side of her face. She
reports that the pain is like an electric shock.
The episodes may be evoked by smoking, talking,
or washing her face. There are times, however,
where there is no inciting stimulus. Between
episodes she is pain free and there are no
sensation deficits on her face.True statements
regarding this problem include which of the
following? (Mark all that are true.)Facial
sensory loss associated with facial pain should
prompt cerebral imagingThis may be the first
manifestation of multiple sclerosisA large
proportion of cases are caused by compression of
the nerve by a blood vesselCarbamazepine
(Tegretol) is first-line medical
managementPatients not responding promptly to
pharmacotherapy should be offered referral for
interventional therapy
32
Answer

• Facial sensory loss associated with facial pain
  should prompt cerebral imagingThis may be the
  first manifestation of multiple sclerosisA large
  proportion of cases are caused by compression of
  the nerve by a blood vesselCarbamazepine
  (Tegretol) is first-line medical
  managementPatients not responding promptly to
  pharmacotherapy should be offered referral for
  interventional therapy

33
Trigeminal neuralgia (TGN) is a painful condition
which affects one side of the face. It is
characterized by brief shock-like pain limited to
the distribution of one or more divisions of the
trigeminal nerve. The pain may be stimulated by
such actions as washing, shaving, smoking,
talking, or brushing the teeth, but may also
occur spontaneously. It begins and ends abruptly,
and may remit for varying periods.Loss of
facial sensation or any suspected involvement of
a cranial nerve should prompt appropriate
cerebral imaging (C level recommendation). In the
last three decades, evidence has been mounting
that in a large proportion of cases, compression
of the trigeminal nerve root at or near the
dorsal root entry zone by a blood vessel is a
major causative or contributing factor (Evidence
level III). Of the known etiologic factors, the
association of multiple sclerosis (MS) with TGN
is well established. MS is seen in 2-3 of
patients with TGN. Conversely, TGN is diagnosed
in 1-5 of patients with MS. In a small
proportion of patients with MS, TGN is the first
manifestation of the disease.Pharmacotherapy
remains the mainstay of treatment of TGN.
Unfortunately, only a few randomized, controlled
trials have been conducted. Carbamazepine
(Evidence level I), oxcarbazepine (Evidence level
II), phenytoin (Evidence level III), lamotrigine
(Evidence level II), and baclofen are commonly
used to treat TGN. Patients with TGN are often
willing to consider surgery as a first-line
treatment in anticipation of a permanent cure.
Numerous interventional procedures (e.g.,
cryotherapy, alcohol blocks, radiofrequency
lesions) and operations (e.g., microvascular
decompression) are available to treat TGN. Each
is associated with complications and recurrences.
Patients should be provided a realistic view and
balanced information regarding treatment choices.
34
A 52-year-old male is admitted to the hospital
with abdominal pain and dehydration, and is
diagnosed with inoperable pancreatic cancer. He
chooses to return home with hospice care. While
in the hospital, he has been using
patient-controlled analgesia (PCA). His PCA is
set to deliver 1 mg of intravenous morphine on
demand, with a 10-minute lockout. There is no
basal rate. He reports his pain is well
controlled. Over the past 3 days, his morphine
use has been 28 mg/day, 32 mg/day, and 29
mg/day.You wish to send the patient home on
sustained-action opioids to help control his
pain. Based on his PCA usage, which one of the
following would be an appropriate starting dosage
of a sustained-action morphine (MS Contin)? 15
mg orally twice daily 30 mg orally twice
daily 45 mg orally twice daily 60 mg orally
twice daily
35
Answer

• 45 mg orally twice daily

36
While there is some variability, 10 mg of
parenterally administered morphine is
approximately equivalent to 30 mg orally
(Evidence level I). On average, this patient has
used 29.7 mg of intravenous morphine per day.
This would be approximately equivalent to 90 mg
of oral morphine per day. An appropriate dosage
of sustained-action oral morphine would be 45 mg
twice daily, or 30 mg three times daily.
Milligram-to-milligram, oxycodone is about 50
more powerful than morphine.
37
Important concepts for assessing pain in older
adults with cognitive impairment include which of
the following? (Mark all that are
true.)Observing for changes in normal
functioningAsking about pain using synonyms,
such as discomfort, aching, and sorenessFraming
questions in the present tense (e.g., "Are you
hurting now?")Understanding that elderly
patients are less sensitive to painRecognizing
that persistent pain is likely to affect physical
and psychosocial functioningUsing the 0-10 pain
scale, as it works well for nearly all older
adultsAllowing extra time for the patient to
assimilate the questions
38
Answer

• Observing for changes in normal
  functioningAsking about pain using synonyms,
  such as discomfort, aching, and sorenessFraming
  questions in the present tense (e.g., "Are you
  hurting now?")Recognizing that persistent pain
  is likely to affect physical and psychosocial
  functioningAllowing extra time for the patient
  to assimilate the questions

39
Persistent pain is common in older adults,
particularly among the frail elderly, in whom
cognitive impairment is more common. Age-related
changes in pain perception are probably not
clinically significant. Functional changes, both
psychosocial and physical, are common sequelae to
chronic pain and may be the first indicators of
pain in cognitively impaired patients. A
substantial portion of older adults (with and
without cognitive impairment) have difficulty
using the 0-10 pain scale. Many other scales have
demonstrated their validity in this population
(Evidence level II). Many cognitively impaired
older adults deny pain, but may be able to report
distress when synonyms such as "aching" and
"soreness" are used. Focusing on assessment of
current symptoms (e.g., asking "Are you hurting
right now?") may also help those with short-term
memory deficits.Validated pain rating systems
for the cognitively impaired focus on facial
expressions, posture, vocalizations, appetite,
and interactivity (Evidence level II). Clinicians
should choose one tool and use it consistently to
ensure uniformity among health care providers (C
level recommendation).
40
A 40-year-old female with three children has
chronic low back pain and frequent tension
headaches. In addition, she was recently treated
for shoulder pain. Her neighbor has suggested
that she look into acupuncture and she asks you
if acupuncture is safe and effective.Which of
the following would be accurate advice? (Mark all
that are true.)In a randomized study of chronic
headache, those treated with acupuncture in
addition to usual therapy had fewer headaches
than controlsThe addition of acupuncture to
diclofenac (Voltaren) in patients with shoulder
pain improves function more than diclofenac
aloneStudies that looked at more than 60,000
acupuncture treatments showed no serious adverse
events
41
Answer

• In a randomized study of chronic headache, those
  treated with acupuncture in addition to usual
  therapy had fewer headaches than controlsStudies
  that looked at more than 60,000 acupuncture
  treatments showed no serious adverse events

42
Acupuncture has been practiced for thousands of
years and has been used for hundreds of different
ailments. Studies of the method use sham
treatments or minimal treatments as controls.
Studies often show conflicting results or small
clinical effects. Acupuncture is quite safe, with
no serious adverse effects reported in two
studies including more than 60,000 treatments.
Infection is minimized by using disposable
needles and aseptic technique. Serious bleeding
is very rare.In a meta-analysis of chronic back
pain studies, acupuncture proved to be more
effective than sham acupuncture or no treatment.
For short-term pain relief in these patients it
does not appear to be superior to other active
therapies. It was not particularly effective in
acute back pain (Evidence level I). As an
adjunct to usual therapies, acupuncture has
proven effective in randomized studies of chronic
headache and osteoarthritis of the knee (Evidence
level I). It is used as an adjunct in cancer pain
management. One randomized, controlled trial of
auricular acupuncture showed a positive effect in
decreasing cancer pain when used with routine
analgesics.
43
A new patient comes to your office for evaluation
of pain. The patient history should include which
of the following? (Mark all that are
true.)Identification of possible pain
generatorsA worker's compensation and litigation
historyA history of the onset and progression of
the painA complete medication historyA
substance abuse history
44
Answer

• Identification of possible pain generatorsA
  worker's compensation and litigation historyA
  history of the onset and progression of the
  painA complete medication historyA substance
  abuse history

45
In the evaluation of pain, the history may be
more valuable than the physical examination. An
important goal of the encounter is to identify
the pain generator when possible, and the history
may be the most illuminating part of the
evaluation in this regard (C level
recommendation). Often the specific pain
generator cannot be identified. History taking
requires very active listening, with interplay
between what the patient is saying and the
physician's interpretation and clarification.Obt
aining a history of the onset and progression of
the pain is of great importance. It can tell the
physician whether this is an acute process and if
immediate action is needed (C level
recommendation). It also provides clues as to the
amount of additional history that will be needed
to sort out previous treatment successes and
failures. A history of legal action related to
pain, for example, is associated with a worse
prognosis.The medication history is a very
important part of the initial evaluation. Rather
than just a list of medications the patient is
taking, it should include a discussion of
efficacy, tolerability, and economics (C level
recommendation). It might also provide some idea
of the patient's attitudes toward medicines and
expectations for efficacy. A history of substance
abuse must be elicited because it has important
implications in the treatment plan and the need
for safeguards.
46
A 30-year-old brick mason presents to your office
with mid-back pain. On examination you note that
his rhomboid muscles are in spasm, and he jumps
when you touch three discrete points in the
muscles.He is concerned that he may be
developing fibromyalgia like his mother. True
statements regarding the differentiation between
myofascial pain syndrome and fibromyalgia include
which of the following? (Mark all that are
true.)The tender points of fibromyalgia are
different from the trigger points seen with
myofascial pain syndromeMuscle spasm is most
often associated with fibromyalgiaA jump/twitch
response is most often associated with myofascial
pain syndromeThe tender points in fibromyalgia
patients tend to be distributed
asymmetricallyMyofascial pain tends to be
regional
47
Answer

• The tender points of fibromyalgia are different
  from the trigger points seen with myofascial pain
  syndromeA jump/twitch response is most often
  associated with myofascial pain
  syndromeMyofascial pain tends to be regional

48
The trigger points seen with myofascial pain
syndrome are different from the tender points
seen with fibromyalgia. Trigger points are
discrete, focal, hyperirritable spots located in
a taut band of skeletal muscle. Compression of
these points is painful and can produce referred
pain, referred tenderness, motor dysfunction, and
autonomic phenomena. Trigger points may be single
or multiple, and are usually asymmetric. Pressing
them may elicit a twitch in the muscle or a jump
response from the patient. Trigger points are
associated with regional pain syndromes. Patients
with fibromyalgia exhibit multiple tender points
symmetrically distributed along the axial
skeleton, and have constitutional symptoms such
as fatigue, sleep disturbance, and depressed
mood.No single modality stands out as the best
for long-term treatment of trigger points and
myofascial pain. However, trigger point
injections are widely accepted and recommended
for providing short-term relief (C level
recommendation).Dry-needle techniques usually
result in more soreness the next day than
injection of local anesthetic. The addition of
corticosteroids and other medications to local
anesthetics is unnecessary for efficacy and may
cause muscle damage. The technique for trigger
point injection is well described in the
reference article.
49
Common adverse effects of NSAIDs include which of
the following? (Mark all that are true.)Renal
toxicityGastrointestinal bleedingPeripheral
edemaIncreased systolic blood pressure
50
Answer

• Renal toxicityGastrointestinal
  bleedingPeripheral edemaIncreased systolic
  blood pressure

51
NSAID use is associated with renal toxicity,
gastrointestinal bleeding and ulcers, peripheral
edema, and increased systolic blood pressure
(median 5 mm Hg) (Evidence level I).
52
A 30-year-old female at 38 weeks gestation comes
to the hospital with irregular contractions. Her
membranes ruptured spontaneously while she was at
home. She has a history of sciatica, and
underwent back surgery 2 years ago. Since then
she has been taking opioids for pain control. She
is currently on sustained-release morphine, 15 mg
three times daily, and acetaminophen/oxycodone
(Percocet), 5 mg/325 mg every 4-6 hours as needed
for breakthrough pain.The patient complains of
low back pain with contractions but refuses
epidural anesthesia. The resident on call orders
nalbuphine (Nubain), 10 mg intravenously every 3
hours as needed for pain. After the first dose,
the pain worsens and the resident approves a
repeat dose. The patient develops severe low back
pain, nausea, vomiting, and tremors, and starts
feeling very anxious.What is the most likely
cause of the patient's worsening
symptoms? Underdosing of nalbuphine, as the
patient is tolerant to opioids Increased
intensity of labor contractions Overdosage due
to giving a repeat dose of nalbuphine too
soon Decreased opioid effect resulting from
fetal absorption Withdrawal symptoms caused by
nalbuphine antagonizing µ receptors
53
Answer

• Withdrawal symptoms caused by nalbuphine
  antagonizing µ receptors

54
Nalbuphine is an agonist/antagonist opioid
medication. It has an agonist effect on ?
receptors. This is the reason it seems to work
better for women, as they respond better to ?
receptor-agonists. Men respond better to µ
receptor-agonists for pain control. Nalbuphine
has an antagonist effect on µ receptors, which is
why it should not be used to treat pain when
patients are on chronic opioid therapy such as
morphine (C level recommendation), which is a µ
receptor-agonist. Nalbuphine's action is similar
to that of naloxone, and it will cause opioid
withdrawal symptoms such as nausea, vomiting,
diarrhea, goose bumps, excessive yawning,
tremors, runny nose, high blood pressure, and
anxiety.
55
Cultural aspects of pain include which of the
following? (Mark all that are true.)The dominant
culture of pain in the United States honors the
stoical personThe meaning and expression of pain
is influenced by the patient's culturePersons
from cultures different from that of their
treating physician often receive inadequate pain
managementPain behaviors can be predicted
reliably by understanding a patient's cultureTo
minimize bias, physicians must be aware of their
own pain experiences and culture
56
Answer

• The dominant culture of pain in the United States
  honors the stoical personThe meaning and
  expression of pain is influenced by the patient's
  culturePersons from cultures different from that
  of their treating physician often receive
  inadequate pain managementTo minimize bias,
  physicians must be aware of their own pain
  experiences and culture

57
Culture is the framework that directs human
behavior in a given situation. The meaning and
expression of pain are influenced by people's
cultural background. Pain is not just a
physiologic response to tissue damage, but also
includes emotional and behavioral responses based
on individuals' past experiences and perceptions
of pain. However, not everyone in every culture
conforms to a set of expected behaviors or
beliefs, so trying to categorize a person into a
particular cultural stereotype will lead to
inaccuracies. On the other hand, knowledge of a
patient's culture may help to better understand
their behavior. Studies have shown that
patients from ethnic minorities and cultures
different from the health care professionals
treating them receive inadequate pain management
(Evidence level II). Each of us has the
impression that people from distinct cultures are
more or less likely to express their pain
experience in a manner that is somewhere between
quietly enduring (stoical) or very expressive.
While the physician should attempt to treat the
expressive patient and the stoical patient alike,
physicians from a stoical culture are likely to
be more attentive to the patient who is stoical.
The culture of pain in mainstream American
culture tends to teach the hurting person to be
stoical and the attending person to honor that
stoicism.For the physician, even more important
than understanding the culture of others is
understanding how his or her own upbringing
affects attitudes about pain (C level
recommendation). It is important to overcome the
belief that one's own reaction to pain is
"normal" and that other reactions are "abnormal."
Even subtle cultural and individual differences
between patient and physician, particularly in
nonverbal, spoken, and written language, can
affect care.
58
List three chronic conditions that may be
effectively treated by spinal cord stimulation.
59
Spinal cord stimulation, also known as dorsal
column stimulation, was introduced in 1967. It
has been applied successfully to a number of pain
disorders including angina, tumors, brachial
plexus injuries, spinal cord injuries, phantom
limb pain, complex regional pain syndrome/reflex
sympathetic dystrophy, ischemic limb pain,
multiple sclerosis, peripheral vascular disease,
arachnoiditis, and failed back surgery syndrome.
Success rates are variable. While spinal cord
stimulation has been utilized for a number of
pain conditions, there are a limited number of
randomized trials regarding its use (Evidence
level I, Cochrane review). More trials are
necessary to confirm that spinal cord stimulation
is an effective treatment for certain types of
chronic pain.Success Rates for Spinal Cord
StimulationDiagnosis SuccessFailed back surgery
syndrome/low back leg pain62Ischemic limb
pain77Complex regional pain syndrome I and
II84Peripheral neuropathy67Spinal cord
injury57Postherpetic neuralgia82Stump (phantom
limb) pain62Adapted from Cameron T Safety and
efficacy of spinal cord stimulation for the
treatment of chronic pain A 20-year literature
review. J Neurosurg 2004100(3 suppl
Spine)264.Spinal cord stimulation is a late
resort for chronic intractable pain conditions.
The risks and costs of spinal cord stimulation
may outweigh the benefits for many patients.
60
A 58-year-old female with metastatic breast
cancer has bone involvement. She is undergoing
active treatment and is still working despite her
pain. She also has nausea from the
chemotherapy.True statements regarding this
situation include which of the following? (Mark
all that are true.)As many as 80 of cancer
patients with advanced or terminal cancer disease
have bone metastasesBone pain is usually sharp,
and worsens with restingProstaglandin is thought
to be involved in cancer-related bone
painIrradiation is not effective in the relief
of bone pain from metastasesRelief of bone pain
by irradiation, if achieved, is short-term in
effect
61
Answer

• As many as 80 of cancer patients with advanced
  or terminal cancer disease have bone
  metastasesProstaglandin is thought to be
  involved in cancer-related bone pain

62
Metastatic bone pain is troublesome to patients
trying to live and work with their disease. As
many as 84 of advanced or terminal cancer
patients have bone metastases (Evidence level
III). The pain is aching in quality and worse
with moving or bearing weight. Prostaglandins are
thought to be involved in the pain, accounting
for the surprisingly good results with
irradiation. About 80 of patients treated with
irradiation will have complete or substantial
relief of their pain (Evidence level I, Cochrane
review). Two-thirds of those will remain pain
free in the irradiated area for the rest of their
lives. The role of prostaglandins is also the
reason for the often surprising effectiveness of
NSAIDs for relief.
63
A 52-year-old female with type 2 diabetes sees
you for a routine follow-up. Her diabetes is
controlled with diet, exercise, and oral
antihyperglycemics. While her diabetes has not
always been under good control, her last
hemoglobin A1c was 6.3. Her cholesterol is under
good control and a recent stress test was
negative.At todays visit, she describes a
painful numbness in her toes bilaterally. She has
been able to continue working but the pain is
beginning to interfere with her sleep. After
performing a physical examination, you decide to
treat her symptoms.True statements regarding
this situation include which of the following?
(Mark all that are true.)A low dose of a
tricyclic antidepressant is the preferred initial
therapySSRIs would be an appropriate first-line
therapy if depression were also presentThe
efficacy of gabapentin is similar to that of
amitriptylineOpioids, alone or in combination
with antidepressants, would be effective
64
Answer

• A low dose of a tricyclic antidepressant is the
  preferred initial therapyThe efficacy of
  gabapentin is similar to that of
  amitriptylineOpioids, alone or in combination
  with antidepressants, would be effective

65
Meta-analyses consistently show that tricyclic
antidepressants (TCAs) are effective for
neuropathic pain (Evidence level I, Cochrane
review). They can be of particular benefit where
insomnia, anxiety, or depression is present.
SSRIs are not considered first-line therapy for
diabetic neuropathy because the evidence of their
effectiveness is limited (Evidence level I).
Duloxetine and venlafaxine have demonstrated
efficacy in treating neuropathic pain (Evidence
level II). An estimated 2.6 patients must be
treated with TCAs and 6.7 patients with SSRIs to
have one patient with more than 50 pain relief.
Gabapentin has a demonstrated efficacy in
treating neuropathic pain (Evidence level I,
Cochrane review). It is an alternative to TCAs
where side effects or contraindications prevent
their use. A small randomized, controlled trial
showed that gabapentin had an efficacy and
tolerability similar to that of amitriptyline
(Evidence level II). The efficacy of opioids in
the treatment of neuropathic pain has been
consistently demonstrated in randomized,
controlled trials, but they typically require
greater caution than other options (Evidence
level I).
66
A 70-year-old male has significant osteoarthritis
in his knees. After failing conservative
measures, he is evaluated for bilateral knee
replacement and expects to undergo surgery in the
next few weeks. For pain management, you have
prescribed acetaminophen, 1000 mg orally four
times daily, but the patient is still having
significant pain. You wish to improve his pain
control with the use of an acetaminophen/opioid
or NSAID/opioid combination.True statements
regarding these medications include which of the
following? (Mark all that are true.)Combination
medications may improve pain control while
limiting the side effects associated with a
higher dose of a single agentPropoxyphene/acetami
nophen (Darvocet N-100) provides pain control
similar to that of acetaminophen aloneCodeine
may be ineffective in up to 10 of
African-American patients, due to a cytochrome
P450 enzyme deficiencyWhen the maximum dosage of
the acetaminophen or NSAID component is reached
without sufficient pain relief, adding a pure
opioid to the nonopioid is recommendedUnsupervise
d use of over-the-counter medications along with
combination medication increases the risk of
adverse events
67
Answer

• side effects associated with a higher dose of a
  single agentPropoxyphene/acetaminophen (Darvocet
  N-100) provides pain control similar to that of
  acetaminophen aloneUnsupervised use of
  over-the-counter medications along with
  combination medication increases the risk of
  adverse events

68
The agents in combination medications operate
through different mechanisms. Their use in
combination can reduce the side effects of a
higher dosage of a single agent. A meta-analysis
of 26 trials involving 2,231 patients compared
the combination of acetaminophen and propoxyphene
(Darvocet) to acetaminophen alone and found that
the combination provided little benefit over
acetaminophen (Evidence level I). To become
active, codeine is metabolized to morphine it
may not be metabolized in up to 10 of
Caucasians, due to a cytochrome P450 deficiency.
Combination medications are limited by their
NSAID or acetaminophen content. When the maximum
dosage is reached, switching to non-combination
medications is recommended (C level
recommendation). Without express warnings,
patients may use over-the-counter medications
that contain acetaminophen or NSAIDs.
Unsupervised use of these medications increases
the risk of adverse events.
69
Many acute care and office procedures require
anxiety control and/or pain control. True
statements regarding sedation and pain control
for procedures include which of the following?
(Mark all that are true.)Reported allergy to
lidocaine (Xylocaine) is usually due to the
preservative methylparabenTo decrease injection
pain, lidocaine should be buffered 101 with 8.4
sodium bicarbonateThe pain of injection can be
decreased by using the smallest possible needle
and injecting slowlyDiphenhydramine 1
(Benadryl) provides anesthesia comparable to that
produced by lidocaine
70
Answer

• Reported allergy to lidocaine (Xylocaine) is
  usually due to the preservative methylparabenTo
  decrease injection pain, lidocaine should be
  buffered 101 with 8.4 sodium bicarbonateThe
  pain of injection can be decreased by using the
  smallest possible needle and injecting
  slowlyDiphenhydramine 1 (Benadryl) provides
  anesthesia comparable to that produced by
  lidocaine

71
Guidelines for procedural sedation emphasize that
the qualifications of the physician handling the
procedure is the most important criterion when
deciding whether to use procedural sedation. The
physician must have an understanding of the
medications administered, must be able to monitor
the patient's response to the medications, and
must have the skills necessary to manage all
potential complications (C level
recommendation).True allergy to the amine
anesthetic lidocaine is rare, and a reaction is
most likely due to the preservative methylparaben
(Evidence level III). This can be circumvented by
using preservative-free lidocaine there is
evidence that injection of 1 diphenhydramine
(Benadryl) solution gives anesthesia comparable
to lidocaine injection, although it takes a bit
longer to work. Topical anesthetics can be used
to reduce the pain on initial local anesthetic
injection, or topical anesthetics can be used in
place of injection. Pain can also be reduced by
using the smallest needle that will work (30
gauge if possible), injecting very slowly, and
lightly pinching the skin around the wound before
and during the injection.Regional nerve blocks
are performed by using landmarks to guide the
injection of local anesthetic in the potential
spaces around the nerve supplying the area to be
numbed. To avoid systemic toxicity, one must
avoid injecting into the arteries and veins in
these spaces. Depending on the size of the nerve
and the anesthetic used, it can take 5-20 minutes
for a block to become effective. Epinephrine can
be used for local infiltration and field blocks,
but never for nerve blocks. Using a longer-acting
anesthetic such as bupivicaine in the nerve block
will make it last longer, but it will take a few
minutes longer to work. The blocked region should
be tested before beginning to incise, suture, or
cauterize (C level recommendation).
72
A 37-year-old male presents to your office with a
burn. While helping his wife with dinner
yesterday, he tripped on a dog bone and put his
left hand on a hot stovetop burner. When you
examine the hand, you note that the wound covers
the entire palm, is red and blistered, and
blanches under pressure. He took acetaminophen 2
hours ago, but still rates his pain as 8 on a
scale of 10. He seems very uncomfortable.After
cleaning and dressing his wound, which one of the
following would be most appropriate? No pain
medication, because the affected nerve was
destroyed Cold packs applied to the burn over
the next 24-36 hours Aloe as needed and
acetaminophen 4 times daily A neural blockade to
stop the pain An opioid such as
oxycodone/acetaminophen (Percocet)
73
Answer

• An opioid such as oxycodone/acetaminophen
  (Percocet)

74
Critique for this questionThis patient has a
partial thickness burn causing acute somatic pain
that is unresponsive to acetaminophen. An opioid
such as oxycodone/acetaminophen will provide more
potent analgesia and is suitable for this pain
profile (C level recommendation). In order to
best treat a burn victim, it is necessary to
distinguish the different levels of burns. This
patient has a superficial partial thickness burn.
These burns typically are red and blistered,
although blisters may not appear for 12 hours
after the injury. The skin will be pink and moist
under the blister, and the wound surface blanches
with pressure.Superficial burns can be treated
with aloe and acetaminophen for pain. Neural
blockade is generally used for neuropathic pain
management. Although cold packs are initially
good to keep swelling down, they are not suitable
for extended pain management of larger partial
thickness burns.
75
Which one of the following is true regarding the
use of glucosamine and chondroitin sulfate in the
management of chronic osteoarthritis
pain? Treatment with chondroitin sulfate is
associated with a significant decrease in the
incidence of joint swelling, effusion, or
both Glucosamine and chondroitin sulfate in
combination works as fast as celecoxib
(Celebrex) Glucosamine increases the risk of
ischemic cardiovascular events for patients with
diabetes mellitus The use of glucosamine and
chondroitin sulfate is more beneficial for mild
osteoarthritis pain than for moderate to severe
pain
76
Answer

• Treatment with chondroitin sulfate is associated
  with a significant decrease in the incidence of
  joint swelling, effusion, or both

77
The dietary supplements glucosamine and
chondroitin sulfate have been advocated,
especially in the lay media, as safe and
effective options for the management of symptoms
of osteoarthritis. Glucosamine and chondroitin
sulfate are the most widely used dietary
supplements for osteoarthritis, with estimated
sales in 2004 approaching 730 million.Several
studies have evaluated the efficacy of
glucosamine and chondroitin sulfate. Some of
these studies have shown that these supplements
are effective, but have been criticized as having
flaws such as failure to adhere to the
intention-to-treat principle, enrollment of small
numbers of patients, potential bias related to
sponsorship of the study by the manufacturers of
the dietary supplements, and inadequate masking
of the study agent.The Glucosamine/Chondroitin
Arthritis Intervention Trial (GAIT) was a
randomized, double-blind, controlled, multicenter
trial sponsored by the National Institutes of
Health. It was designed to rigorously evaluate
the efficacy and safety of glucosamine and
chondroitin sulfate, separately and in
combination, in the treatment of pain due to
osteoarthritis of the knee. Both placebo and
celecoxib were used as control agents.The GAIT
trial showed that glucosamine and chondroitin
sulfate, alone or in combination, did not reduce
pain effectively in the overall group of patients
with osteoarthritis of the knee. Exploratory
analyses suggested that the combination of
glucosamine and chondroitin sulfate may be
effective in the subgroup of patients with
moderate to severe knee pain (Evidence level
I). Treatment with chondroitin sulfate was
associated with a significant decrease in the
incidence of joint swelling, effusion, or both.
There was no increased risk of ischemic
cardiovascular events among patients who also
received celecoxib, or among patients with
diabetes who received glucosamine.In the United
States, glucosamine and chondroitin sulfate are
regulated as dietary supplements and are not held
to the more stringent standards for
pharmaceuticals. Substantial variation exists
between the content listed on the labels of these
products and the actual product. Because the GAIT
trial was conducted under pharmaceutical rather
than dietary supplement regulations, agents
identical to the ones used in the study may not
be commercially available (Evidence level
III).In making therapeutic decisions,
physicians and patients alike should be aware of
data suggesting that celecoxib has a much faster
time to response than glucosamine, chondroitin
sulfate, or the two in combination. Continuing
research is needed to establish the potential
efficacy and increase our understanding of the
biology, pharmacology, and pharmacokinetics of
these agents.
78
A 68-year-old female completed surgery,
radiation, and chemotherapy for breast cancer 6
years ago. She has recently developed recurrent
breast cancer metastatic to bone. She does not
want further radiation or chemotherapy, and her
oncologist thinks she has less than 6 months to
live. She asks you to continue to be her primary
physician as she enters hospice care. True
statements regarding the treatment of pain in
this situation include which of the following?
(Mark all that are true.)The management of
cancer pain requires specialty consultationNSAIDs
are contraindicated in cancer patientsAcute or
escalating pain requires prompt medical
attentionFor constant pain with exacerbation,
the analgesic regimen should include a routine
baseline dose and breakthrough dosingAddiction
is rarely an issue in patients with terminal
illness
79
Answer

• Acute or escalating pain requires prompt medical
  attention
• For constant pain with exacerbation, the
  analgesic regimen should include a routine
  baseline dose and breakthrough dosing
• Addiction is rarely an issue in patients with
  terminal illness

80
Cancer pain varies greatly between individuals
and during different stages of the illness. The
physician must therefore assess the intensity and
quality and type of pain and choose appropriate
interventions. NSAIDs are quite useful in cancer
pain syndromes, particularly bone pain.
Escalating pain that is not promptly addressed
will require more drastic and more intense
therapy than pain that is treated promptly (C
level recommendation). Many patients at the end
of life have constant pain with exacerbations,
requiring both a routine baseline dose and
patient-controlled dosing for breakthrough pain.
A long-acting formulation is typically used for
baseline dosing and a shorter, quicker-acting
formulation for acute exacerbations. Breakthrough
doses are usually 10-30 of the patient's usual
daily dose (C level recommendation).Addiction
behaviors at the end of life are usually seen in
active substance abusers whose addiction predates
their terminal illness. Drugs also may be
diverted by family members with active addiction.
Terminal patients who do not have active
substance abuse problems will experience
tolerance, but almost never display addictive
behaviors.
81
True statements regarding physical dependence on
opioids include which of the following? (Mark all
that are true.)Physical dependence develops in
most patients taking opioids on a regular basis
for more than a few weeksPhysical dependence is
a marker of addictionWithdrawal symptoms develop
after abrupt cessation of the opioidPhysical
dependence explains why patients take higher
doses than prescribedPhysical dependence
explains the symptoms produced by administration
of an opioid antagonist, such as naloxone (Narcan)
82
Answer

• Physical dependence develops in most patients
  taking opioids on a regular basis for more than a
  few weeksWithdrawal symptoms develop after
  abrupt cessation of the opioidPhysical
  dependence explains the symptoms produced by
  administration of an opioid antagonist, such as
  naloxone (Narcan)

83
The American Pain Society, the American Academy
for Pain Management, and the American Society of
Addiction Medicine have jointly created
definitions for both physical dependence and
addiction. Physical dependence is defined as "a
state of adaptation that is manifested by a drug
class-specific withdrawal syndrome that can be
produced by abrupt cessation, rapid dose
reduction, decreasing blood level of the drug,
and/or administration of an antagonist." It is an
expected consequence of chronic opioid use and is
distinct from addiction, which is defined as "a
primary, chronic, neurobiologic disease, with
genetic, psychosocial, and environmental factors
influencing its development and manifestations.
It is characterized by behaviors that include one
or more of the following impaired control o