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Pain Medicine
Board Review
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 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
ELSEVIER
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PAIN MEDICINE BOARD REVIEW ISBN: 978—0—823—4481 1—6

Copyright © 2018 by Elsevier, Inc. All rights reserved.

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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
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 Contributors
Jose Avila-Calles, MD, PhD Daniel P. Loren, MD
Assistant Professor, Department of Anesthesiology (Pain Interventional Pain Management Specialist and
Medicine),Jackson Stephens Spine Center, University Anesthesiologist, Orlando, Florida
of Arkansas for Medical Sciences
Joshua Meyer, MD
Brian Bobzien, MD Interventional Pain Medicine, Dothan, Alabama
Assistant Professor, Department of Anesthesiology (Pain
Medicine), Emory University School of Medicine, Preeti Narayan, MBBS
Director of Pain Services, Grady Memorial Hospital, Regional Anesthesia and Acute Pain Fellow, Department
Atlanta, Georgia of Anesthesiology, Emory University, Atlanta, Georgia

Eashwar Balu Chandrasekaran, MD, MSc Trusharth Patel, MD

Clinical Assistant Professor, Department of Emergency Assistant Professor, Department of Anesthesiology (Pain
Medicine, IUH Methodist Palliative Care Services, Medicine), Emory University School of Medicine,
Indiana University School of Medicine, Indianapolis, Atlanta, Georgia
Indiana
Joshua Scott Powers, MD
Shivang Vinod Desai, MD Bain Complete Wellness, Tampa, Florida
Associate, Departments of Interventional Pain and
Anesthesiology, Geisinger Clinic Moises Adrian Sidransky, MD
Danville, Pennsylvania Interventional Pain Management, East Texas Medical
Center, Tyler, Texas
Lisa Guo Foster, MD
Associate Professor, Department of Orthopedics, Emory Vinita Singh, MD
Orthopaedics 8c Spine Center, Atlanta, Georgia Assistant Professor, Director of Cancer Pain Services,
Department of Anesthesiology (Pain Medicine), Emory
Lynn Marie Fraser, MD University School of Medicine, Atlanta, Georgia
Pain Medicine Fellow, Department of Anesthesiology,
University of North Carolina School of Medicine, Boris Spektor, MD
Chapel Hill, North Carolina Program Director, Emory Pain Fellowship, Assistant
Professor, Department of Anesthesiology (Pain Medicine),
Jerry Kalangara, MD Emory University School of Medicine, Atlanta, Georgia
Assistant Professor, Department of Anesthesiology (Pain
Medicine), Emory University School of Medicine, Liliana Viera—Ortiz, MD
Veterans Affairs Medical Center, Atlanta, Georgia Palliative Medicine, Trauma Hospital, University of
Puerto Rico, Medical Center, San Juan, Puerto Rico
Brian H. Keogh, Jr., MD
Banner Health Interventional Pain and Spine Anna Woodbury, MD, C.Ac
Management Clinic, Greeley, Colorado Assistant Program Director, Emory Pain Fellowship,
Assistant Professor, Department of Anesthesiology (Pain
Zachary Leuschner, MD Medicine), Emory University School of Medicine,
Pain Management Physician, Baylor Scott 8c White Health, Division Chief, Veteran’s Affairs Medical Center, Atlanta,
Marble Falls, Texas Georgia
Preface

The field of pain medicine is an ever-developing and expand- This question book is not intended as a stand-alone re-
ing field with an inherently multidisciplinary nature. The source, but as an aid to guide studying and highlight key
field continues to advance with research into newer, safer, points in pain management. It is a companion book to Prac—
and more comprehensive techniques for the management of tical Management of Pain, edited by Honorio Benzon et al.
pain. In the face of a widespread opioid epidemic, physicians Practical Management of Pain stands out as a comprehensive
from a variety of fields have become intensely interested in resource for those interested in the study of pain; it is ap—
nonnarcotic management of acute and chronic pain condi- propriate both for those seeking board certification as well
tions and learning how to appropriately assess opioid risk. As as for those who simply wish to gain a deeper understanding
those who study pain know, there are many varieties of pain of pain and its various treatments. Healthcare practitioners
and many ways to target these individual pain sources and from a variety of fields would benefit from information
interrupt their mechanisms of development. found in these books. In assessing currently available books
This question book highlights some key concepts in the regarding pain medicine for our fellows to use for self-study
pathophysiology and treatment of pain. It was compiled by and board review, we found that most books on the market
physicians from specialties and subspecialties including An— were inadequate and inherently flawed. We therefore en—
esthesiology, Emergency Medicine, Pain Medicine, Pallia- couraged them to read Practical Management of Pain and, as
tive Care, Physical Medicine and Rehabilitation, and Re- a group interested in furthering education and understand-
gional Anesthesia/Acute Pain, and it also includes editors ing regarding pain medicine, came together (fellows and
with expertise and special interests in Cancer Pain, Integra- faculty) to develop a question book based off of this com-
tive Medicine, and Pediatric Pain. Questions were written prehensive text. As such, this question book should be used
primarily by fellows during their subspecialty training at as an adjunct to specifically target areas in need of further
Emory University School of Medicine and reviewed/ edited study, whether for board preparation or simply as a “test
by their attendings. Editors represent four separate institu- your knowledge” guide to accompany Practical Management
tions associated with Emory University School of Medicine, ofPain.
bringing with them a wide range of backgrounds and exper-
tise with diverse patient populations.

vi
 Acknowledgments

The editors would like to acknowledge helpful discussions (Emergency Medicine 8: Palliative Care), Lynn O’Neill
and input from their colleagues in multiple departments at (Geriatrics, Internal Medicine & Palliative Care), Michael
Emory University School of Medicine. The multidisciplinary Silver (Neurology), Taylor Harrison (Neurology 8c Electrodi—
pain fellowship at Emory and the development of this book agnostics), Natalie Strickland (Pediatric Pain), Jennifer
could not exist without the willingness and enthusiasm to Steiner (Pain Psychology), Nadine Kaslow (Pain Psychology),
teach that has come from the cohesive groups of individuals Howard Levy (Physical Medicine 8c Rehabilitation), William
within these departments. These departments include Anes- Beckworth (Physical Medicine & Rehabilitation),]ose Garcia
thesiology, Emergency Medicine, Hematology 8c Oncology, (Physical Medicine 8c Rehabilitation), Randy Katz (Occupa—
Interventional Radiology, Neurology, Palliative Care, Physical tional Medicine & Physical Medicine 8c Rehabilitation), Scott
Medicine and Rehabilitation, Primary Care, Psychiatry, Psy- Firestone (Psychiatry), Walter Carpenter (Radiology). And of
chology, Radiology, and many others. Specific individuals de— course, the field would not advance without the aid of those
serving of thanks for their support and their commitment to who have dedicated themselves to advancing research in
medical education include Laureen Hill (Chair, Department pain and neural networks, including Paul Garcia, Wei Huang,
of Anesthesiology), Anne Marie McKenzie—Brown (Director, Vitaly Napadow, Bruce Crosson, Ling Wei, and Shan Ping Yu.
Center for Pain), Colette Curtis (Acute Pain), Tammie Quest
(Emergency Medicine & Palliative Care), Paul Desandre Anna Woodbury, MD

vii
 GENERAL CONSIDERATIONS

The History of Pain Medicine

QUESTIONS
1. Which of the following anesthetics was administered for 3. Which of the following organizations is multidisci-
labor pain to Queen Victoria in 1874 and subsequently plinary, with members including but not limited to
cited as legitimizing analgesia during labor? physicians, dentists, psychologists, nurses, and physical
A. Chloroform therapists?
B. Nitrous oxide A. The American Academy of Pain Medicine (AAPM)
C. Cocaine B. The International Association for the Study of Pain
D. Morphine (IASP)
E. Procaine C. The International Spine Intervention Society
(SIS, formally ISIS)
2. Which of the following theories combines both physical D. The American Society of Interventional Pain
and psychological aspects of pain perception and is Physicians (ASIPP)
credited with revolutionizing pain research? E. The American Society of Regional Anesthesia
A. Pattern Theory (ASRA)
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- techniques, are based on the Gate Control Theory.
son in 1847 for the delivery of her eighth child, at This theory is cited as ending the debate regarding
which point it became widely accepted that labor pain whether or not the cerebral cortex plays a role in pain.
should be medically managed. Prior to this, it was con— Development of imaging such as PET, fMRI, and
sidered against Christian beliefs to provide or accept SPECT later added credibility to this theory by demon—
analgesia during labor. strating the activation of the cerebral cortex in
response to pain.
2. C. The Gate Control Theory, developed by Melzack
and Wall in 1965, states that nonnociceptive signals 3. B. The International Association for the Study of Pain
can override nociceptive signals, and, as a result, the (IASP) is the largest multidisciplinary international as-
perception of pain is reduced or eliminated. Interven- sociation, with a goal of furthering pain research by in-
tions such as peripheral nerve stimulators, TENS units, tegrating professionals with different backgrounds and
and spinal cord stimulators, as well as biofeedback 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 3

ANSWERS

l. E. The LASP (International Association for the Study of based on a theoretical relationship to the sympathetic
Pain) focuses on the classification of chronic pain syn- nervous system.
drome, but includes some acute syndromes for compar-
ison (and because these acute conditions can often be- E. Pain that is due to known or inferred psychophysio-
come chronic). Acute herpes zoster, burns with spasm, logic mechanisms, such as muscle tension pain or mi—
pancreatitis, and prolapsed intervertebral disk are all graines, but is believed to have a psychogenic cause
examples of acute pain syndromes that are included. falls under the ICD-lO classification of Psychological or
Behavioral Factor Associated with Disorders or Disease
. E. The classifications are divided into five axes: (l) ana- Classified Elsewhere.
tomic, (2) system, (3) temporal characteristics and pat-
tern, (4) intensity, (5) etiology. The second axis systems D. The definition of pain by the IASP is “an unpleasant
include (a) central, peripheral, and autonomic nervous sensory and emotional experience associated with ac-
and special senses; (b) psychological and social function; tual or potential tissue damage or described in terms of
(c) respiratory and vascular; (d) musculoskeletal and such damage.” This addresses the situation of patients
connective tissue; (e) cutaneous and subcutaneous tissue who appear to have pain but do not have obvious tissue
and glands, gastrointestinal, genitourinary, and other damage and acknowledges that pain is always subjective
organs/viscera; and (g) unknown systems. and psychological, regardless of tissue damage.

. D. To be diagnosed with complex somatic symptom . C. Chronic pain is pain that persists beyond the normal
disorder by DSM-IV criteria, patients must report at healing process. Although the timeframe for this may
least one distressing somatic symptom as well as at least differ in practice and many types of pain become
one of “emotional/ cognitive/behavioral disturbances: chronic or persistent at 3 months, the 6—month division
high levels of health anxiety, disproportionate and was chosen for scientific purposes by the IASP as a
persistent concerns about the medical seriousness of good entry to the patient population treated by pain
the ‘symptoms’ and an excessive amount of time and physicians.
energy devoted to the symptoms and health concerns,”
for at least 6 months’ duration. . D. The words “disorder,” “syndrome,” and “disease”
are all in dispute regarding whether they reflect the
4. A. Persistent Somatoform Pain Disorder is persistent, true phenomena that physicians treat. However, the
severe, distressing pain that cannot be explained fully word “symptom” is not in dispute.
by physiologic mechanisms. Pain during schizophrenia
or depression is not included. 10. E. Relatively generalized syndromes include diffuse or
widespread pain that is poorly localized, such as rheu-
. B. The name of CRPS was changed from RSD based on matoid arthritis, fibromyalgia, polymyalgia rheumatica,
the advice of a special subcommittee. Steps taken have pain of psychological origin, syringomyelia, central
(1) defined CRPS type 1 by its clinical phenomena and pain, CRPS, phantom pain, stump pain, and periph-
(2) developed identifying diagnostic criteria for clinical eral neuropathy. Localized syndromes are divided by
agreement as well as for more stringent research pur- the area affected (head, neck, limbs, thorax, abdomen,
poses. The classification has also helped in understand- spinal/ radicular) .
ing relatively new syndromes. The old name, RSD, was
 Organizing an Inpatient Acute
Pain Service

QUESTIONS
1. Which of the following factors is likely to influence C. 50%—60%
postoperative opioid requirements? D. 60%—70%
A. Preoperative pain sensitivity E. 80%—90%
B. Presurgical opioid tolerance or a history of drug
abuse . All of the following are examples of multimodal
C. Psychological factors, including catastrophizing and analgesia EXCEPT:
anxiety A. Neuraxial block and music therapy
D. Age B. IV morphine and fentanyl patch
E. All of the above C. PCA morphine and thoracic epidural
D. Acupuncture and TENS
2. Which is the best intervention for inhibition of surgical E. Femoral nerve block and stress reduction
stress responses?
A. Neuraxial steroids . Which is an important first step in organizing an inpa-
B. Neuraxial local anesthetics tient acute pain service?
C. Perineural local anesthetics A. Enlisting the support of hospital administration and
D. Systemic steroids defining resources
E. None of the above B. Assessment of need
C. Definition of service
. Postoperative pain is identified as one of the major D. Financing and business plan
fears of patients undergoing surgery. What percentage E. Nursing education
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 4. B. A time-, energy—, and cost-effective acute pain pro-
challenging. It is often difficult to estimate a patient’s gram should optimally provide multimodal and multidis-
postoperative analgesic requirements. The following ciplinary interventions, including systemic and regional
factors may influence postoperative opioid require— pharmacologic treatments, stress reduction, transcuta—
ments: preoperative pain sensitivity, coexisting medical neous electrical nerve stimulation, music therapy, and
conditions and associated multiple drug administration, acupuncture. Extracting and integrating the relevant
presurgical opioid tolerance or a history of drug abuse, expertise from multiple health care disciplines often
psychological factors (including catastrophizing and allows individualized and optimized pain management.
anxiety), age, and type of surgery. Disciplines commonly involved include psychology,
pharmacy, physical therapy, and nutrition.
. B. Surgical stress responses are best inhibited by neur-
axial administration of local anesthetics; the adminis- 5. A. Enlisting the support of hospital administration and
tration of other agents—systemically, neuraxially, or defining resources are a Vital first step in organizing an
perineurally—appears to contribute little additional inpatient acute pain service. Once the challenge of or—
reduction of the endocrine (metabolic and catabolic) ganizing an acute pain service is accepted, assessment
stress response following operative procedures. of need is mandatory. Once the mission statement has
been formulated in response to the perceived institu-
. C. Inadequacy of pain relief has been highlighted as a tional and community needs, it is necessary to define
quality-of—care measure and a focus of patients’ con- the resources that will be required. The next step in the
cern. In a questionnaire survey, 57% of patients identi- process of organizing an inpatient acute pain service is
fied pain after surgery as their primary fear. 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 C. Behavioral health specialist

with the dose of opioid used. Which of the following D. Addiction medicine specialist
is NOT an additional risk factor for obstructive sleep E. Sleep medicine specialist
apnea based on STOP-BANG criteria?
. Hypertension 13. The concept of “adverse selection” in relation to
mvow>

. Snoring substance use disorders and chronic pain opioid

. BMI greater than 35 prescribing argues which of the following:
. Age less than 50 A. The patients at highest opioid risk are being
. Male gender prescribed the highest opioid doses.
B. The patients with highest socioeconomic status are
10. According to the model of measurement—based being prescribed the highest opioid doses.
stepped care, referral to a behavioral health specialist C. The patients with lowest opioid needs are being
is indicated when all of the following are present prescribed the lowest opioid doses.
EXCEPT: D. The patients at highest opioid risk are being
PHQ—Q 2 15 prescribed the lowest opioid doses.
FCC???

PHQ—4 2 5 E. The patients at lowest opioid risk are being

Suicidal ideation prescribed the highest opioid doses.
PTSD
Anxiety 14. What is the morphine equivalent dose (MED) that
prompts a referral to a pain specialist according to
11. A 28-year-old male with chronic pain presents to your the stepped care model?
clinic. Opioid risk screening reveals a personal and A. 0—19 mg MED
family history of cocaine use as well as a psychological B. 20—49 mg MED
history of anxiety. According to the stepped care C. 50—79 mg MED
model, he should be referred to see: D. 80—119 mg MED
A. Pain physician E. Greater than 120 mg MED
B. Physiatrist
C. Behavioral health specialist 15. Physical medicine and rehabilitation referral is
D. Addiction medicine specialist prompted by all of the following EXCEPT:
E. Sleep medicine specialist A. Disability greater than 4 weeks
B. On-the—job pain interference
12. A primary care physician is treating a 26-year-old C. Ineffective return—to—work plan
female with chronic diffuse pain of unclear etiology, D. Roland Morris > 12/ 24
unresponsive to 3 months of conservative management E. Obesity
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 6. B. Presence of substance use disorder in addition to
strictly on alleviating the intensity of pain and does not mental health disorders predisposed patients to higher
incorporate suffering of the cancer pain patient in its opioid use in the TROUP study.
analgesic strategy. Other answer choices listed are true
statements regarding the ladder. 7. E. The first four options are validated opioid risk
screening tools: Opioid Risk Tool (ORT), the Screener
2. E. All of the listed pain treatment domains should and Opioid Assessment for Patients with Pain—Revised
ideally be included in a stepped care pain treatment (SOAPP—R) ; the Current Opioid Misuse Measure
algorithm. (COMM); and the Diagnosis, Intractability, Risk, and
Efficacy (DIRE). The DOLOPLUS scale, though vali-
3. E. The question regarding suicidality comes from the dated, is used for behavioral pain assessment in elderly
PHQ—Q screening tool rather than the simpler PHQ—4 with verbal communication problems, not for opioid
questionnaire. risk screening.

4. A. Relative risk of mortality with chronic opioid therapy . B. There is currently a significant shortage of
increases in parallel with escalating morphine equiva- board-certified pain physicians in the United States
lent dose. relative to the number of patients with chronic pain.

5. D. Contacting the office to report worsening pain is . D. Age greater than 50 is a risk factor for OSA per the
considered appropriate behavior meriting reevaluation. 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, 13. A. The patients at highest opioid risk are being
its presence alone is not considered sufficient for psy- prescribed the highest opioid doses.
chiatrist referral according to the stepped care model
unless deemed poorly controlled despite conservative 14. E. Greater than 120 mg MED.
measures.
15. E. All are true except obesity, which is one of the risk
11. D. This patient has an opioid risk tool score 28 and factors for sleep medicine referral.
thus merits referral to an addiction medicine specialist.

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

specialist for further evaluation.
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