1 . The reported prevalence of pain at the end of life is greatest among adults with
| A) | | cancer. |
| B) | | COPD. |
| C) | | diabetes. |
| D) | | heart failure. |
The prevalence of pain at the end of life has been reported to
range from 8% to 96%, occurring at higher rates among people with cancer than among adults
with other life-limiting diseases [19,20]. Pain can be caused by a multitude of factors
and is usually multidimensional, with pain frequently being exacerbated by other physical
symptoms and by psychosocial factors, such as anxiety or depression [8].
2 . Which of the following is the most reliable indicator of pain?
| A) | | Patients' self-report |
| B) | | Results of physical examination |
| C) | | Results of functional assessment |
| D) | | Results of multidimensional assessment |
Pain should be assessed routinely, and frequent assessment
has become the standard of care [8]. Pain is a
subjective experience, and as such, the patient's self-report of pain is the most reliable
indicator. Research has shown that pain is underestimated by healthcare professionals and
overestimated by family members [8,21]. Therefore, it is essential to obtain a pain
history directly from the patient, when possible, as a first step toward determining the cause
of the pain and selecting appropriate treatment strategies. When the patient is unable to
communicate verbally, other strategies must be used to determine the characteristics of the
pain, as will be discussed.
3 . Research has shown that pain is
| A) | | overestimated by patients. |
| B) | | overestimated by healthcare professionals. |
| C) | | underestimated by healthcare professionals. |
| D) | | underestimated by patients' family members. |
Pain should be assessed routinely, and frequent assessment
has become the standard of care [8]. Pain is a
subjective experience, and as such, the patient's self-report of pain is the most reliable
indicator. Research has shown that pain is underestimated by healthcare professionals and
overestimated by family members [8,21]. Therefore, it is essential to obtain a pain
history directly from the patient, when possible, as a first step toward determining the cause
of the pain and selecting appropriate treatment strategies. When the patient is unable to
communicate verbally, other strategies must be used to determine the characteristics of the
pain, as will be discussed.
4 . Generalized pain is usually indicative of
| A) | | tissue lesions. |
| B) | | underlying tissue injury. |
| C) | | central nervous system damage. |
| D) | | All of the above |
Questions should be asked to elicit descriptions of the pain
characteristics, including its location, distribution, quality, temporal aspect, and
intensity. In addition, the patient should be asked about aggravating or alleviating factors.
Pain is often felt in more than one area, and physicians should attempt to discern if the pain
is focal, multifocal, or generalized. Focal or multifocal pain usually indicates an underlying
tissue injury or lesion, whereas generalized pain could be associated with damage to the
central nervous system. Pain can also be referred, usually an indicator of visceral
pain.
5 . According to the World Health Organization (WHO) ladder, pain should be managed
| A) | | with only nonopioids for steps 1 and 2. |
| B) | | in a stepwise progression from step 1 to step 3. |
| C) | | in a manner according to the severity of the pain. |
| D) | | with opioids given around the clock and nonopioids given on an as-needed basis. |
The WHO analgesic ladder, introduced in 1986 and disseminated
worldwide, remains recognized as a useful educational tool but not as a strict protocol for
the treatment of pain. It is intended to be used only as a general guide to pain management
[31]. The three-step analgesic ladder
designates the type of analgesic agent based on the severity of pain (Figure
1) [31].
Step 1 of the WHO ladder involves the use of nonopioid analgesics, with or without an
adjuvant (co-analgesic) agent, for mild pain (pain that is rated 1 to 3 on a 10-point
scale). Step 2 treatment, recommended for moderate pain (score of 4 to 6), calls for a weak
opioid, which may be used in combination with a step 1 nonopioid analgesic for unrelieved
pain. Step 3 treatment is reserved for severe pain (score of 7 to 10) or pain that persists
after Step 2 treatment. Strong opioids are the optimum choice of drug at Step 3. At any
step, nonopioids and/or adjuvant drugs may be helpful. Some consider this model to be
outdated and/or simplistic, but most agree that it remains foundational. It can be modified
or revised, as needed, to apply more accurately to different patient populations.
6 . The maximum recommended dose of acetaminophen is
| A) | | 1–1.5 g per day. |
| B) | | 3–4 g per day. |
| C) | | 5–7 g per day. |
| D) | | 8–10 g per day. |
Nonopioid analgesics, such as aspirin, acetaminophen
(Tylenol), and nonsteroidal anti-inflammatory drugs (NSAIDs), are primarily used for mild
pain (Step 1 of the WHO ladder) and may also be helpful as coanalgesics at Steps 2 and 3.
Acetaminophen is among the safest of analgesic agents, but it has essentially no
anti-inflammatory effect. Toxicity is a concern at high doses, and the maximum recommended
dose is 3–4 g per day [8]. Acetaminophen
should be avoided or given at lower doses in people with a history of alcohol abuse or renal
or hepatic insufficiency [8].
7 . The onset of action of fentanyl transdermal patch is
| A) | | 5 to 10 minutes. |
| B) | | 30 to 60 minutes. |
| C) | | 8 to 12 hours. |
| D) | | 12 to 18 hours. |
OPIOIDS FOR THE MANAGEMENT OF PAIN IN ADULTSa
| Drug | Typical Starting Doseb | Onset of Action | Duration of Action |
|---|
| Codeine | 15–60 mg | 30 to 60 minutes | 4 to 6 hours |
| Hydrocodone | 2.5–10 mg | 10 to 20 minutes | 4 to 8 hours |
| Morphine, immediate release | 15–30 mg |
| 15 to 30 minutes (oral) | | 5 to 10 minutes (IV) |
| 3 to 6 hours |
| Oxycodone, immediate release | 5–10 mg | 10 to 30 minutes | 3 to 4 hours |
| Oxymorphone, sustained release | 10 mg | 5 to 10 minutes | 8 to 12 hours |
| Hydromorphone | 2–4 mg | 15 to 30 minutes | 4 to 5 hours |
| Methadone | 5–10 mg | 30 to 60 minutes | 4 to 6 hours |
| Tapentadol | 50–100 mg | <60 minutes | 4 to 6 hours |
| Tapentadol, extended release | 50–100 mg | — | — |
| Fentanyl (buccal tablet) | 100–200 mcg | 5 to 15 minutes | 2 to 4 hours |
| Fentanyl (transdermal patch) | 25 mcg/hour (worn for 3 days) | 12 to 18 hours | 48 to 72 hours |
| Buprenorphine (transdermal patch) | 5–10 mcg/hour (worn for 7 days) | — | — |
| aAll information is given for oral formulations
unless otherwise specified. | | bDoses given are guidelines for opioid-naïve
patients; actual doses should be determined on an individual basis. |
|
8 . According to the WHO ladder, which of the following is the opioid considered to be the first-line treatment for Step 3 pain management?
| A) | | Fentanyl |
| B) | | Morphine |
| C) | | Methadone |
| D) | | Oxycodone |
Morphine is considered to be the first-line treatment for a
Step 3 opioid [34]. Morphine is available in
both immediate-release and sustained-release forms, and the latter form can enhance patient
compliance. The sustained-release tablets should not be cut, crushed, or chewed, as this
counteracts the sustained-release properties. Morphine should be avoided in patients with
severe renal failure [28].
9 . What is the most common side effect of opioid use?
| A) | | Allergy |
| B) | | Nausea |
| C) | | Sedation |
| D) | | Constipation |
Opioids are associated with many side effects, the most
notable of which is constipation, occurring in nearly 100% of patients. The universality of
this side effect mandates that once extended treatment with an opioid begins, prophylactic
treatment with laxatives must also be initiated. Tolerance to other side effects, such as
nausea and sedation, usually develops within three to seven days. Some patients may state
that they are "allergic" to an opioid. It is important for the physician to explore what the
patient experienced when the drug was taken in the past, as many patients misinterpret side
effects as an allergy. True allergy to an opioid is rare [8]. Opioid rotation may also be done to reduce adverse events.
10 . Which of the following is NOT a barrier to the use of palliative radiotherapy?
| A) | | Transportation issues |
| B) | | Patient inconvenience |
| C) | | Longer life expectancy |
| D) | | Lack of knowledge in the primary care community |
However, palliative radiotherapy has become a controversial
issue. Although the benefits of palliative radiotherapy are well documented and most hospice
and oncology professionals believe that palliative radiotherapy is important, this treatment
approach is offered at approximately 24% of Medicare-certified freestanding hospices, with
less than 3% of hospice patients being treated [56,57,58]. As previously noted, reimbursement issues
present a primary barrier to the use of palliative radiotherapy [56,57,58]. Among other
barriers are short life expectancy, transportation issues, patient inconvenience, and lack
of knowledge about the benefits of palliative radiotherapy in the primary care community
[55,56,57,59].
