Pain Management Practice Questions

Q: A 70-year-old man with advanced pancreatic cancer on sustained-release morphine 60 mg BD develops breakthrough pain 3-4 times daily. His pain is otherwise well controlled. What should be the dose of immediate-release morphine for breakthrough pain?

12 mg. ***12 mg*** - The standard dose for **breakthrough pain** is calculated as **one-sixth (approx 16%) or 10%** of the **total daily dose** (TDD) of the regular opioid. - Since the patient takes 60 mg twice daily, the **TDD is 120 mg**; 10% of 120 mg is **12 mg**, providing a safe and effective immediate-release dose [1]. *6 mg* - This dose represents only **5%** of the TDD, which is typically insufficient to manage moderate-to-severe **breakthrough pain**. - Using a dose this low may lead to **inadequate analgesia** and multiple repeat doses, which is not clinically optimal [1]. *20 mg* - This dose exceeds the standard **10-16% recommendation** for breakthrough medication in a patient whose pain is otherwise and normally **well controlled**. - High breakthrough doses relative to the TDD increase the risk of **opioid toxicity**, such as excessive sedation or **respiratory depression**. *30 mg* - This is **25%** of the daily dose, which is significantly higher than the recommended safety margin for **palliative care** breakthrough protocols [1]. - Such a high dose would typically only be considered if the **background pain** was also poorly controlled and the oral dose was being titrated upward.

Q: According to WHO analgesic ladder for cancer pain management, which medication should be added at Step 2?

Weak opioids. ***Weak opioids*** - Step 2 of the **WHO analgesic ladder** is indicated for **mild to moderate pain** and involves the addition of **weak opioids** such as **codeine** or **tramadol** to non-opioid medications [1]. - These are often administered in combination with **paracetamol** or **NSAIDs** to enhance analgesic efficacy through different mechanisms of action [1]. *Ketamine* - **Ketamine** is an **NMDA receptor antagonist** used as an **adjuvant** for complex or refractory pain, but it is not a standard component of the three basic steps. - It is typically reserved for specialized pain management rather than being a routine step 2 medication. *Strong opioids* - **Strong opioids**, such as **morphine**, **fentanyl**, or **oxycodone**, are the hallmark of **Step 3** of the ladder [1]. - Step 3 is reserved for **moderate to severe pain** or when pain is not controlled by weak opioids [1]. *NSAIDs alone* - Using **NSAIDs alone** constitutes **Step 1** of the WHO ladder, which is intended for **mild pain** [1]. - In Step 2, non-opioids like NSAIDs are continued as **background therapy**, but the defining addition is the opioid component.

Q: Which of the following is true about allodynia?

Perception of a non-painful stimulus as pain. **Explanation:** **Allodynia** is defined by the International Association for the Study of Pain (IASP) as **pain due to a stimulus that does not normally provoke pain**. It is a hallmark of neuropathic pain and central sensitization. In this condition, the threshold for pain is lowered such that innocuous stimuli (like a light touch, the brush of clothing, or a breeze) are perceived as painful. **Analysis of Options:** * **Option C (Correct):** This directly matches the definition. It involves a change in the *quality* of sensation, where a non-noxious stimulus triggers a pain response. * **Option A (Incorrect):** **Hyperalgesia** is an *increased* response to a stimulus that is *normally* painful (e.g., a pinprick feeling like a stab). While both involve sensitization, allodynia involves a non-painful trigger, whereas hyperalgesia involves a painful one. * **Option B (Incorrect):** Loss of sensory sensation is termed **anesthesia** or **hypesthesia**. Allodynia is a positive sensory phenomenon (gain of function), not a loss. * **Option D (Incorrect):** **Hyperesthesia** is a broad term referring to increased sensitivity to any stimulus (touch, thermal, etc.), not specifically the conversion of a non-painful stimulus into pain. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism:** Allodynia is primarily mediated by **A-beta fibers** (normally responsible for light touch) "shunting" signals into the pain pathways due to central sensitization in the spinal cord dorsal horn. * **Dynamic vs. Static:** Allodynia can be **mechanical** (moving a cotton wisp) or **thermal** (mild warmth feeling like a burn). * **Common Clinical Scenarios:** Post-herpetic neuralgia, Migraine (scalp tenderness), and Complex Regional Pain Syndrome (CRPS).

Q: Which of the following is true about the WHO analgesic ladder for chronic pain in adults?

Morphine is used for severe pain. The WHO Analgesic Ladder is a cornerstone of pain management, originally designed for cancer pain but now widely applied to chronic pain. It follows a stepwise approach based on pain intensity. ### **Explanation of the Correct Option** **B. Morphine is used for severe pain:** Morphine is the "gold standard" strong opioid. According to the WHO ladder, **Step 3** (Severe pain, VAS 7–10) involves the use of strong opioids like Morphine, Fentanyl, or Hydromorphone, with or without non-opioids and adjuvants. ### **Analysis of Incorrect Options** * **A. Analgesics are given 'as needed':** This is incorrect. The WHO principle is **"By the Clock."** Medications should be administered at fixed intervals to maintain a constant plasma concentration and prevent pain recurrence, rather than waiting for the pain to return (PRN). * **C. Adjuvants are indicated only for mild pain:** Incorrect. Adjuvants (e.g., anticonvulsants like Gabapentin or antidepressants like Amitriptyline) can be used at **any step** of the ladder to manage neuropathic components or enhance the efficacy of primary analgesics. * **D. Non-opioid analgesics are given for moderate pain:** While non-opioids (NSAIDs/Acetaminophen) are used in moderate pain, they are the primary treatment for **Step 1 (Mild pain)**. Moderate pain (**Step 2**) specifically requires the addition of **weak opioids** (e.g., Codeine, Tramadol). ### **High-Yield NEET-PG Pearls** * **The Five Principles:** 1. By the mouth (oral preferred), 2. By the clock (fixed intervals), 3. By the ladder (stepwise), 4. For the individual (tailored dosing), 5. Attention to detail. * **Step 1:** Non-opioids (NSAIDs, Paracetamol). * **Step 2:** Weak opioids (Tramadol, Codeine). * **Step 3:** Strong opioids (Morphine, Fentanyl). * **Step 4 (Recent addition):** Interventional techniques (e.g., Epidural, Neurolytic blocks, PCA pumps).

Question 1

A 62-year-old woman with advanced ovarian cancer has been on oral morphine 90 mg BD for 3 months. She now reports reduced pain relief despite increasing doses, but experiences severe pain at specific sites of bone metastases. What is the best management strategy?

Accepted Answer

Add gabapentin and consider palliative radiotherapy to metastatic sites

Answer

Add ketamine infusion for opioid resistance

Answer

Switch to fentanyl patch and continue dose escalation

Answer

Rotate to hydromorphone at equianalgesic dose

Question 2

A 70-year-old man with advanced pancreatic cancer on sustained-release morphine 60 mg BD develops breakthrough pain 3-4 times daily. His pain is otherwise well controlled. What should be the dose of immediate-release morphine for breakthrough pain?

Accepted Answer

12 mg

Answer

6 mg

Answer

20 mg

Answer

30 mg

Question 3

According to WHO analgesic ladder for cancer pain management, which medication should be added at Step 2?

Accepted Answer

Weak opioids

Answer

Ketamine

Answer

Strong opioids

Answer

NSAIDs alone

Question 4

Which of the following is true about allodynia?

Accepted Answer

Perception of a non-painful stimulus as pain

Answer

Hyperalgesia

Answer

Loss of sensory sensations

Answer

Hyperesthesia

Question 5

Which of the following drugs can be administered intravenously, epidurally, or via the transdermal route?

Accepted Answer

Fentanyl

Answer

Thiopentone

Answer

Succinylcholine

Answer

Vecuronium

Question 6

Which of the following statements regarding Complex Regional Pain Syndrome (CRPS) is false?

Accepted Answer

Type 1 CRPS occurs following a nerve injury.

Answer

Type 1 CRPS is also called as Reflex Sympathetic Dystrophy.

Answer

It occurs due to adrenergic sensitivity of afferent nociceptors.

Answer

CRPS Type 1 resolves with symptomatic treatment.

Question 7

Which of the following is true about the WHO analgesic ladder for chronic pain in adults?

Accepted Answer

Morphine is used for severe pain

Answer

Analgesics are given 'as needed'

Answer

Adjuvants are indicated only for mild pain

Answer

Non-opioid analgesics are given for moderate pain

Question 8

What is the most potent analgesic?

Accepted Answer

Sufentanil

Answer

COX-2 inhibitor

Answer

Remifentanil

Answer

Morphine

Question 9

A patient reports pain rated as 8 on a scale of 1 to 10. Which intervention should the nurse implement?

Accepted Answer

Attempt to rule out complications before administering pain medication.

Answer

Administer the client's ordered pain medication immediately.

Answer

Use guided imagery instead of administering pain medication.

Answer

Use therapeutic conversation to try to discourage pain medication.

Question 10

Which of the following is not considered an ideal method for postoperative analgesia?

Accepted Answer

Cryoanalgesia

Answer

Patient-controlled analgesia

Answer

Continuous epidural infusion with local anesthetics

Answer

Intercostal nerve block

Pain Management — MCQs

Pain Management — MCQs

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