CHAPTER 27

Pain Medicine

Clinical Case 1

Ms. Castro is a 42-year-old woman with axial back pain. She has been taking opioids for the past 5 years. While she was returning home from a trip to Italy, she lost her medications. She reports that shortly thereafter, she began to experience muscle aches, abdominal cramping, diarrhea, and rhinorrhea.

1. Which of the following best describes the patient’s current state?
   1. Physical dependence.
   2. Tolerance.
   3. Addiction.
   4. Abuse.
2. Further investigation reveals that this is not the first time that Ms. Castro has called in for lost medications. There is concern that the patient is obtaining opioids from other sources. What would be the most appropriate next step?
   1. Write a prescription for the opioids.
   2. Deny the patient further opioid therapy.
   3. Review the Prescription Drug Monitoring Program (PDMP) database.
   4. Discharge the patient from your practice.
3. At the end of the week, the patient returns to your clinic for evaluation. She is sweaty, has dilated pupils and slightly elevated blood pressure, and appears intoxicated. What is the most appropriate next step?
   1. Perform an electrocardiogram.
   2. Order a computed tomographic (CT) scan of the head.
   3. Check a urine drug screen.
   4. Check cardiac enzymes.
   5. Order a pulmonary angiogram.

Clinical Case 2

Ms. Wilson is a 42-year-old obese black woman with fibromyalgia who presents to your clinic for an initial evaluation. She has a past medical history of hypertension, type 2 diabetes, and hypercholesterolemia.

1. Which of the following of Ms. Wilson’s statements may be assessed using the AMPS approach to psychiatric illness?
   1. “When I sleep, my husband can hear me snore from the next room.”
   2. “I was an alcoholic for 12 years.”
   3. “On a scale from 1 to 10, I rate my pain 5 most days of the week.”
   4. “Most nights I only sleep 4 hours because I wake up gasping for air.”
   5. “I frequently run out of oxycodone before it is time for my refill.”
2. Ms. Wilson has been undergoing several months of physical therapy, stretching, and meditation exercises, which had provided significant relief from her shoulder pain until recently. Currently, her pain, which she rates 5 of 10 on the visual analog scale (VAS), is unrelieved with these actions. She has not taken any type of medications. What would be your next step according to the World Health Organization’s three-step analgesic ladder?
   1. Try treatment with a short-acting opioid and a nonsteroidal anti-inflammatory drug (NSAID).
   2. Try treatment with a long-acting opioid.
   3. Try treatment with an NSAID for 1 week and then add a short-acting opioid.
   4. Recommend further lifestyle modification.
   5. Try treatment with a topical anesthetic.
3. At Ms. Wilson’s next clinic visit, she reports no improvement in symptoms after a trial with a topical anesthetic. Prior to considering an additional medication, which of the following needs to be performed before you make your decision?
   1. Urine drug screen.
   2. 2- to 4-week minimal duration trials of medications.
   3. PDMP database search.
   4. Interventional pain procedures if indicated.
   5. Answers B and D.
   6. All of the above.
4. Ms. Wilson has a body mass index (BMI) greater than 35 and hypertension. The presence of which additional factor would put the patient at high risk for obstructive sleep apnea?
   1. Neck circumference of 36 cm.
   2. Age less than 50 years.
   3. Quiet snoring.
   4. Nighttime tiredness.

Clinical Case 3

Mr. Bateman is a 54-year-old HIV-positive man who has been undergoing antiretroviral therapy for the past 20 years. He presents to your clinic as a new consultation and complains about “pins and needles” pain in both hands and rhinorrhea. His pain medication has been titrated up to 400 mg/day of morphine equivalents over the past 4 years. He is a recovering alcoholic and last used methamphetamine 5 days ago.

1. What would be the most appropriate next step before deciding how to proceed with treatment?
   1. Check a CD4 count.
   2. Check the PDMP database.
   3. Check liver function tests.
   4. Check a urine drug screen.
   5. Answers B and D.
2. The “pins and needles” pain that the patient is experiencing is best described as which of the following?
   1. Somatic pain.
   2. Referred somatic pain.
   3. Visceral pain.
   4. Nociceptive pain.
   5. Neuropathic pain.
3. In addition to the 400 mg/day of morphine equivalents, the patient also takes gabapentin 900 mg/day, acetaminophen 2 g/day, and diazepam 5 mg hs for sleep. With the patient’s current medication regimen, which of the following is he most at risk for?
   1. Tolerance.
   2. Hyperalgesia.
   3. Loss of bone mineral density.
   4. Accidental death.
   5. All of the above.

Clinical Case 4

Ms. Aterman is a 32-year-old woman with obstructive sleep apnea, hypertension, uncontrolled type 2 diabetes, and fibromyalgia. The patient reports to you that she has good pain relief and increased daily activity while on opioids. She drinks one glass of wine nightly and smokes one cigarette daily. She does not use her continuous positive airway pressure (CPAP) machine regularly.

1. Which of the following is important for the assessment of opioid management in this patient?
   1. Tobacco and alcohol use.
   2. Poor CPAP compliance.
   3. Adequate pain relief and increased daily activity.
   4. Uncontrolled type 2 diabetes.
2. While using the AMPS tool to assess for comorbid psychiatric illness, you discover that Ms. Aterman was an avid painter but does not enjoy painting anymore. She also reports poor sleep and loss of energy. The patient exhibits symptoms of which of the following that can make her pain worse?
   1. Anxiety.
   2. Depression.
   3. Mania.
   4. Psychosis.
   5. Substance misuse.
3. Ms. Aterman returns for a follow-up visit in your clinic 6 months after you last saw her. She did not show up for her two previously scheduled visits and did not cancel her appointments. When you query the PDMP database, you discover that she has several opioid prescriptions from other providers as well as from the emergency department, and has contacted your office for early opioid refills several times over the past few months. Which of the following is a possible explanation for her behavior?
   1. Opioid abuse.
   2. Diversion.
   3. Lost medication.
   4. Answers A and B.
   5. All of the above.
4. Which of the following is most the appropriate monitoring for high-risk patients?
   1. Urine drug screen once a year.
   2. Urine drug screens monthly.
   3. Urine drug screens every 3–6 months.
   4. PDMP database review for new prescriptions only.
   5. PDMP database review three times a year.

Clinical Case 5

Ms. Davis is a 34-year-old woman with no significant past medical history who sustained a whiplash injury from a motor vehicle collision last year, which causes waxing and waning neck pain. Since the accident she experiences repeated vivid memories of the accident, sleeps poorly, and avoids using the same route where the accident occurred. Ms. Davis feels detached and frequently avoids social situations.

1. Which of the following can be a potential amplifier of the patient’s pain?
   1. Poor blood glucose control.
   2. Poor compliance with medical care.
   3. Untreated anxiety.
   4. Occasional alcohol use.
2. Ms. Davis has been taking an antidepressant and an NSAID for several months with no appreciable improvement in symptoms. You are considering a trial of a short-acting opioid for the patient. Which of the following needs to be done prior to initiating this therapy?
   1. No further actions.
   2. Trial a different NSAID.
   3. Start a long-acting opioid.
   4. Longer trial of current medications.
3. Ms. Davis has been taking a short-acting opioid for approximately 1 year. She initially received pain relief on a low dose of morphine but has been requiring higher doses to obtain the same therapeutic benefit. What is most likely happening?
   1. Dependence.
   2. Addiction.
   3. Tolerance.
   4. Abuse.
   5. Diversion.
4. Ms. Davis has been using an increased dose of sustained-release morphine product for baseline pain control for about 14 months. She also uses an immediate-release morphine formulation for breakthrough pain every 6 hours. The addition of a benzodiazepine for muscle spasms would put the patient at risk for which of the following?
   1. Hyperalgesia.
   2. Tolerance.
   3. Loss of bone mineral density.
   4. Accidental death.
   5. Suppression of sex steroids.

Clinical Case 6

Ms. Bradford is a morbidly obese 42-year-old woman who presents to your clinic with headaches, general body aches, weight gain, fatigue, and depression.

1. Which of the following tests would be most beneficial in determining the patient’s pathology?
   1. Blood glucose.
   2. Thyroid-stimulating hormone test.
   3. Head and neck CT scan.
   4. Complete blood count.
   5. Liver function tests.
2. Ms. Bradford snores loudly at night and frequently wakes up her housemate. She weighs 260 lbs, is 5 feet 4 inches tall, and has a neck circumference of 34 inches. There have been no witnessed apneic episodes when she falls asleep on the couch, and the patient is frequently tired in the daytime. Which of the above findings demonstrate(s) that the patient needs additional studies by a sleep specialist?
   1. Loud snoring.
   2. Calculated BMI.
   3. Daytime somnolence.
   4. Female sex.
   5. Answers A, B, and C.
3. When you perform a physical examination of Ms. Bradford, you find multiple tight ropelike muscle bands over the periscapular and trapezius muscles. Palpation of these bands causes her to feel pain in other locations. Which intervention would be most appropriate for this patient?
   1. Radiofrequency ablation of the medial branch nerves.
   2. Epidural steroid injections.
   3. Facet steroid injections.
   4. Trigger point injections.

Clinical Case 7

Mr. Sidel is a 53-year-old man with hypertension, grade II obesity (BMI > 35), and chronic paranoid schizophrenia being treated with olanzapine monotherapy, who presents to the clinic for psychiatric follow-up. He is stable from a psychiatric standpoint but complains of persistent lateral leg and foot pain from known lumbar radiculopathy. He tried gabapentin but discontinued it due to sedative side effects. He continues to feel fatigued during the day despite sleeping 8–10 hours per night, but he is most concerned about his pain. He has declined epidural steroid injections and is discussing a trial of short-acting opioids with his primary care physician.

1. Which potentially serious medical condition should be ruled out prior to starting an opiate medication?
   1. Coronary artery disease.
   2. Diabetes.
   3. Obstructive sleep apnea.
   4. Hyperlipidemia.
2. Which of the following acronyms represents a screening tool for the medical condition referred to in the previous question?
   1. A-SCAR.
   2. STOP-BANG.
   3. VITAMIN D.
   4. CREATE.
3. Following a thorough sleep and sleep apnea assessment, what would you recommend to Mr. Sidel’s primary care provider?
   1. A trial of an opiate medication.
   2. Retrial of gabapentin at a lower dose.
   3. Referral for a sleep study.
   4. A trial of tramadol.

Clinical Case 8

Mr. Vincent is an 82-year-old Russian-speaking man with coronary artery disease who is seen regularly in the internal medicine clinic for angina. You note that Mr. Vincent is a high resource utilizer and is seen almost monthly in the emergency department for chest pain. He is frequently admitted to the cardiac care unit for monitoring. His medical assessments for acute ischemia, pulmonary embolism, or any other cardiac etiology are negative. On interview, the patient focuses on his blood pressure control and notes that he measures his blood pressure at least four times daily. He describes constant concern that he will have a heart attack and has been limiting his activities to prevent provoking his chest pain.

1. Which area of psychiatric pathology evaluated using the AMPS psychiatric assessment is likely contributing to Mr. Vincent’s chest pain?
   1. Anxiety.
   2. Mood.
   3. Psychosis.
   4. Substance abuse.
2. Which of the following nonpharmacological therapies for the treatment of pain would be most appropriate for this patient?
   1. Physical therapy.
   2. Acupuncture.
   3. Meditation.
   4. Cognitive-behavioral therapy.
3. How can anxiety maintain pain and limit the effectiveness of pain interventions?
   1. By intensifying the sympathetic response.
   2. By adversely affecting sleep.
   3. By causing the patient to feign symptoms.
   4. By hurting the doctor-patient relationship.
   5. Answers A and B.

Clinical Case 9

Ms. Juglar is a 43-year-old woman who is overweight (BMI = 28) and who has an unspecified mood disorder. She presents to your clinic for psychiatric follow-up. Over the last few months, she has consistently described three “knots” in her back that are exquisitely tender to palpation, with radiating sharp pain to her gluteal area. The pain is making it difficult for her to work the long hours her desk job requires. She is concerned that she may have to find a new job. She refuses to see her primary care physician because “the only thing he will suggest is that I see a physical therapist.”

1. Which of the following is the most likely diagnosis?
   1. Disc herniation with radicular pain.
   2. Facet arthropathy.
   3. Fibromyalgia.
   4. Myofascial pain syndrome.
2. Besides physical therapy, massage, and ultrasound, which of the following interventional modalities is commonly used to treat myofascial pain syndrome?
   1. Radiofrequency ablation.
   2. Trigger point injection.
   3. Epidural steroid injection.
   4. Sympathetic block.
3. Many patients have myofascial tenderness to palpation, which is not classified as a trigger point. Which of the following is required for the diagnosis of a trigger point?
   1. Hyperirritable spot with referred symptoms.
   2. Multiple points of tenderness throughout the body.
   3. Radicular spine pain.
   4. Motor or autonomic dysfunction.

Clinical Case 10

Ms. Palmer, a 67-year-old woman with poorly controlled type 2 diabetes, hypertension, obesity (grade II), and recently diagnosed major depressive disorder, is presenting for her initial evaluation in the psychiatry clinic. She was referred by her primary care physician who started the patient on mirtazapine 30 mg qhs last month. In the course of your evaluation, you discover that her depressive symptoms have been exacerbated by a progressive loss of function caused by bilateral lower extremity pain. She describes the pain as burning with some numbness and tingling in a stocking distribution. She has been taking ibuprofen and acetaminophen with minimal benefit. Her primary care physician has not yet trialed a pain medication.

1. What is the most likely cause of Ms. Palmer’s lower extremity pain?
   1. Spondylolisthesis.
   2. Degenerative disc disease.
   3. Diabetic peripheral neuropathy.
   4. Fibromyalgia.
2. Which of the following medications would be a first-line recommendation for Ms. Palmer’s pain condition and depressive disorder?
   1. Duloxetine.
   2. Amitriptyline.
   3. Gabapentin.
   4. Sertraline.
3. How might treatment with mirtazapine worsen her medical conditions?
   1. By worsening her depression.
   2. By increasing sensitivity to neuropathic pain.
   3. By increasing appetite.
   4. By impairing sleep.

Clinical Case 11

Mr. Whitcomb is a 54-year-old man with bipolar I disorder, peptic ulcer disease (well controlled with a proton pump inhibitor), and chronic axial lower back pain who presents to your clinic for psychiatric follow-up. Mr. Whitcomb has not experienced a manic episode in more than 2 years; his mood is currently stable with lithium maintenance therapy. Today, he complains of chronic axial lower back pain that is not radiating. The pain has worsened over the past 4 months. He has not seen his primary care provider in over a year and is hesitant to see his provider because “they can’t do anything for lower back pain anyway.” The pain is most noticeable when he extends and/or rotates his back. He denies any lower extremity numbness, paresthesia, or weakness.

1. Based on the patient’s history, which of the following is the most likely diagnosis?
   1. Disc herniation.
   2. Lumbar facet arthropathy.
   3. Spinal stenosis.
   4. Diabetic neuropathy.
2. Which analgesic class is typically recommended first for the treatment of this patient’s pain?
   1. NSAID.
   2. Opiate.
   3. Anticonvulsant.
   4. SNRI.
3. Mr. Whitcomb has peptic ulcer disease and is unable to take NSAIDs. In this situation, which of the following interventional procedures is commonly used to treat his kind of back pain?
   1. Transcutaneous electrical nerve stimulation (TENS).
   2. Epidural steroid injection.
   3. Trigger point injection.
   4. Radiofrequency ablation.

Clinical Case 12

Ms. Schulte is a 52-year-old woman with type 2 diabetes (with peripheral neuropathy), hypertension, grade III obesity (BMI ≥ 40), bilateral osteoarthritis of the knees, and recurrent major depressive disorder who was referred by her primary care physician to the psychiatry clinic for evaluation of worsening depression. The patient is tearful about her inability to get out of the house and find work. She cites pain with ambulation and fatigue as the reasons for her immobility. Her pain is localized in her knees. She denies significant burning, numbness, or tingling in her feet. She feels “constantly exhausted” and naps throughout the day. Her medications include gabapentin 600 mg tid, OxyContin (controlled-release oxycodone) 15 mg q12h, oxycodone 5–10 mg q6h, insulin glargine 60 units qhs, insulin aspart 10 units tid with meals, metoprolol 25 mg bid, hydrochlorothiazide 25 mg qam, and paroxetine 20 mg qam.

1. Which of the patient’s medications represents the greatest risk for respiratory depression?
   1. Gabapentin.
   2. Oxycodone.
   3. Paroxetine.
   4. Insulin glargine.
2. The knee pain Ms. Schulte experiences with ambulation is most consistent with bilateral osteoarthritis. Which of the following nonpharmacological therapies should be part of her comprehensive pain treatment program?
   1. Weight loss guidance.
   2. TENS.
   3. Yoga.
   4. Acupuncture.
3. Which of the following choices contains the two most likely reasons for Ms. Schulte’s fatigue?
   1. Ruminating thoughts at night and sedentary lifestyle.
   2. Obstructive sleep apnea and worsened pain at night.
   3. Sedentary lifestyle and multiple sedating medications.
   4. Obstructive sleep apnea and multiple sedating medications.
   5. Worsened pain at night and ruminating thoughts at night.