ABFM Pain Medicine cheat sheet

Pain has sensory-discriminative, affective-motivational, and cognitive-evaluative dimensions; assessment therefore records intensity, quality, temporal pattern, functional impact, and psychosocial modifiers.

A 0–10 numeric rating scale reduction of about 2 points, or a 30% reduction, is commonly used as the minimal clinically important difference for chronic pain.

The DN4 neuropathic pain screen has 7 symptom and 3 examination items; a score of 4 or more out of 10 suggests a neuropathic component.

The PainDETECT questionnaire is scored 0–38; 19 or higher suggests a likely neuropathic component, 13–18 is uncertain, and 12 or lower is unlikely.

The 2010 fibromyalgia criteria combine a 0–19 widespread pain index with a 0–12 symptom severity score; diagnosis requires symptoms for at least 3 months and no other explanation.

The Pain Catastrophizing Scale has 13 items scored 0–52; a score of 30 or higher indicates clinically relevant catastrophizing.

New headache with fever, neurologic deficit, cancer history, age over 50, sudden maximal onset, or papilledema is a red flag requiring urgent evaluation for secondary causes.

The McGill Pain Questionnaire assesses sensory, affective, and evaluative pain dimensions; the short form uses 15 descriptors and is not a substitute for functional assessment.

Acetaminophen is usually limited to 3 g/day in adults; 4 g/day is reserved for supervised short-term use, and chronic alcohol use or liver disease lowers the threshold for hepatotoxicity.

NSAIDs inhibit cyclooxygenase, reducing prostaglandin synthesis; risks include gastrointestinal ulceration, acute kidney injury, hypertension, and cardiovascular events, with risk varying by agent and duration.

Duloxetine is an SNRI approved for diabetic peripheral neuropathic pain, fibromyalgia, and chronic musculoskeletal pain; usual initiation is 30 mg daily, with 60 mg daily as a common target.

Gabapentin and pregabalin bind alpha-2-delta calcium channel subunits; both require renal dose adjustment and can cause sedation, dizziness, peripheral edema, and weight gain.

Amitriptyline and nortriptyline are used for neuropathic pain; anticholinergic effects, orthostatic hypotension, and cardiac conduction delay limit use, especially in older adults.

Tramadol is a weak mu agonist and serotonin-norepinephrine reuptake inhibitor; it lowers seizure threshold, can cause serotonin syndrome, and analgesia depends on CYP2D6 metabolism.

Buprenorphine is a partial mu agonist with high receptor affinity; it can precipitate withdrawal in opioid-dependent patients and has a ceiling effect on respiratory depression.

The 2022 CDC opioid guideline recommends individualized risk-benefit assessment, PDMP review, urine drug testing when indicated, naloxone offer for elevated risk, and gradual tapering rather than abrupt discontinuation.

Naloxone reverses opioid-induced respiratory depression; intranasal 4 mg or intramuscular/intravenous 0.4 mg may be repeated every 2–3 minutes while ventilation is supported.

Medial branch blocks anesthetize the dorsal ramus innervating facet joints; concordant temporary relief supports radiofrequency ablation for facet-mediated pain.

Stellate ganglion block is performed at the C6 level; a successful block produces Horner syndrome (ptosis, miosis, anhidrosis) and may be used for upper-extremity complex regional pain syndrome.

Celiac plexus block targets visceral afferents for upper abdominal pain, especially pancreatic cancer; image guidance helps avoid the aorta, inferior vena cava, and diaphragmatic crura.

Spinal cord stimulation is used for failed back surgery syndrome and complex regional pain syndrome; a trial precedes permanent implantation, and lead migration or infection are common complications.

Epidural steroid injection can cause infection, bleeding, dural puncture, nerve injury, and transient adrenal suppression; particulate steroid near the spinal cord carries rare embolic risk.

Sacroiliac joint injection is more accurate with image guidance; intra-articular local anesthetic and steroid may provide diagnostic and therapeutic benefit for sacroiliac-mediated pain.

Trigger point injection into a taut band with local anesthetic, with or without steroid, can relieve myofascial pain; evidence is limited and landmark guidance is typical.

Intrathecal drug delivery uses implanted pumps for refractory pain; catheter-tip granuloma is a rare complication presenting with progressive neurologic deficit and requires urgent imaging.

Lumbar sympathetic block targets the sympathetic chain for lower-extremity complex regional pain syndrome; fluoroscopic or ultrasound guidance improves accuracy and avoids vascular puncture.

Cognitive behavioral therapy for chronic pain targets catastrophizing, fear-avoidance, and maladaptive beliefs; it produces modest improvements in pain coping, mood, and function.

Graded exposure gradually reintroduces feared movements or activities; it is used when pain-related fear and avoidance drive disability, and it is distinct from simply resting until pain resolves.

Acceptance and commitment therapy increases psychological flexibility through acceptance, mindfulness, and values-based action; it is an evidence-supported psychological approach for chronic pain.

Pain neuroscience education explains pain as a protective output modulated by biological and psychosocial factors; it is most effective when paired with active rehabilitation rather than used alone.

Cognitive behavioral therapy for insomnia is first-line for chronic insomnia, including in patients with chronic pain; it improves sleep onset, maintenance, and daytime function without hypnotic medication.

The Tampa Scale of Kinesiophobia is a 17-item measure of fear of movement and reinjury; higher scores indicate greater kinesiophobia and can predict pain-related disability.

Pacing breaks activity into manageable intervals with planned rest, aiming to reduce boom-bust cycles and sustain function; it is a rehabilitation self-management strategy, not enforced inactivity.

Aerobic exercise and strengthening are recommended for chronic low back pain; prolonged bed rest is discouraged because it worsens deconditioning and disability.

Fear-Avoidance Beliefs Questionnaire measures beliefs about how physical activity and work affect pain; the work subscale predicts work disability in musculoskeletal pain.

The biopsychosocial model integrates biological, psychological, and social contributors to pain; interdisciplinary care addresses these domains with coordinated goals rather than parallel unimodal treatments.

Morphine milligram equivalents standardize opioid exposure: morphine 30 mg = 30 MME, oxycodone 20 mg = 30 MME, hydromorphone 7.5 mg = 30 MME, and fentanyl 25 mcg/hour = 60 MME.

The 2022 CDC guideline recommends checking the prescription drug monitoring program before opioid initiation and periodically thereafter, and offering naloxone when overdose risk is elevated.

Naloxone should be offered to patients taking 50 MME or more daily, those using concurrent benzodiazepines, and those with substance use disorder or prior overdose.

Urine drug testing can confirm adherence to prescribed opioids and detect nonprescribed substances; unexpected results require clinical reassessment, not automatic discharge.

Schedule II controlled substances include oxycodone, hydrocodone, morphine, and fentanyl; Schedule IV includes tramadol and benzodiazepines, with different refill and prescribing rules.

An interdisciplinary pain program typically includes medicine, psychology, physical therapy, occupational therapy, pharmacy, nursing, and social work, with shared functional goals.

Aberrant medication behaviors include early refills, multiple prescribers, lost prescriptions, and unauthorized dose escalation; these trigger reassessment, PDMP review, and possible urine drug testing.

Informed consent for opioid therapy covers benefits, risks, alternatives, storage, disposal, driving impairment, and the possibility of dependence or withdrawal; documentation supports safe practice.