ABFM Pain Medicine common mistakes
ABFM Pain Medicine · Understand the traps and how to avoid them.
Treating the 0–10 numeric rating scale as the entire pain assessment, documenting a score and then moving straight to a prescription without characterizing quality, timing, radiation, neuropathic features, or functional impact.
The NRS is quick, is embedded in every workflow, and feels objective; under time pressure candidates anchor on the number and skip the history that actually determines mechanism and drug class.
What to do instead
Use a fixed multidimensional template on every new pain visit: nociceptive vs neuropathic vs nociplastic screeners (DN4, painDETECT, LANSS), functional measures (walking distance, sleep hours, work status), and a body diagram. Document how the phenotype changes the plan.
Reading degenerative disc disease, facet arthropathy, or a labral tear on MRI as the cause of the pain and building the treatment plan around the imaging report alone.
Imaging findings are highly prevalent in asymptomatic adults, and candidates want a concrete structural explanation; the report's authoritative language encourages diagnostic closure.
What to do instead
Correlate every imaging finding with a matching examination maneuver and dermatomal/myotomal pattern before assigning causality. When imaging and exam disagree, treat the exam and state explicitly in the note that the imaging finding is of uncertain clinical significance.
Converting between opioids using published equianalgesic tables and prescribing the full calculated dose of the new agent, with no reduction for incomplete cross-tolerance.
The tables appear to give an exact arithmetic answer, and the cross-tolerance caveat is a one-line footnote that is easily forgotten under testing pressure.
What to do instead
After calculating the equianalgesic dose, reduce it by roughly 25–50% (larger reductions with higher prior doses, older age, renal/hepatic impairment, or sleep-disordered breathing), then titrate. Write the calculation and the reduction rationale in the note.
Managing neuropathic pain by escalating the opioid first, and only adding a gabapentinoid, tricyclic, or SNRI after opioid doses have already climbed.
Opioids produce rapid relief and are familiar, while adjuvants take weeks and require titration; candidates default to the drug class they use most.
What to do instead
For confirmed neuropathic pain, make an adjuvant the backbone and reserve opioids for refractory or malignant cases. Memorize the caveats that drive drug choice: avoid tricyclics in elderly, cardiac, glaucoma, and urinary retention; adjust gabapentinoids in renal impairment.
Proceeding with a neuraxial steroid injection or a deep joint injection without documenting the anticoagulant/antiplatelet regimen, last dose, renal function, and an individualized hold decision.
The procedure is scheduled in advance, the medication list is long, and candidates assume someone else has already cleared the patient; bleeding risk in a closed space is invisible until it is catastrophic.
What to do instead
Before every deep or neuraxial injection, explicitly reconcile anticoagulants against current ASRA interval guidance, document last dose and planned hold, check platelets/INR when indicated, and note the shared decision for patients on antiplatelets for coronary stents.
Performing a diagnostic medial branch block, obtaining partial or equivocal relief, and then proceeding directly to radiofrequency ablation without repeat or comparative blockade.
Patients want definitive treatment and a second procedure feels like delay; candidates also treat any numeric improvement as a positive response rather than applying a validated threshold.
What to do instead
Apply the accepted criterion of substantial relief (commonly at least 80%) with concordant functional improvement, and confirm with a second, preferably comparative or placebo-controlled, block using a consistent local anesthetic volume before denervation.
Labeling persistent pain as psychogenic and discharging the patient from further medical workup as soon as catastrophizing, depression, or a high fear-avoidance score is identified.
Discovering a psychological contributor creates a tempting shortcut to closure, and candidates worry about reinforcing illness behavior by continuing to investigate.
What to do instead
Frame psychological findings as modulators, not causes: continue appropriate medical evaluation while initiating CBT, pain reprocessing, or graded exposure. Document both tracks in the plan so the referral does not replace the diagnostic workup.
Writing a prescription for a chronic pain patient without addressing sleep, deconditioning, and activity, and without an explicit functional goal or rehabilitation referral.
The medication visit is short, and function is not prompted by the electronic record; without a reminder, the visit collapses into refill processing.
What to do instead
Attach a measurable functional target to every chronic pain plan (minutes walked, stairs, return-to-work step) and pair medication changes with a rehabilitation, sleep, and self-management component. Reassess the functional target, not just the pain score, at follow-up.
Managing complex or high-dose opioid patients in a solo silo without a written multimodal plan, defined follow-up interval, or documented referral triggers to behavioral health, physical therapy, or a pain specialist.
Continuity feels easier alone, referral access is often poor, and candidates do not want to appear to be abandoning the patient.
What to do instead
Write an explicit comprehensive plan with named team members, a follow-up interval matched to risk, and pre-specified triggers for escalation (dose threshold, aberrant behavior, new functional decline). Frame referral as augmentation of care, not discharge.
Tapering or discontinuing long-term opioids abruptly, or refusing further prescribing, when risk signals appear, without a taper schedule, withdrawal management, or documented exit strategy.
Risk-avoidance and regulatory anxiety push toward rapid termination, and candidates underestimate how dangerous abrupt cessation and untreated withdrawal are.
What to do instead
Use gradual, individualized tapering with patient agreement, plan for withdrawal and mental health support, offer naloxone, and document the rationale and alternatives discussed. Know that abrupt discontinuation is not an acceptable default even when risk is high.