ABPN Pain Medicine cheat sheet

Numeric Rating Scale: 0-10; Visual Analog Scale: 0-100 mm; Faces Pain Scale-Revised: 0-10, used in children.

DN4: 10 items (7 symptom, 3 examination); total score ≥4/10 suggests neuropathic pain.

LANSS: 7 items; maximum score 24; score ≥12 suggests a neuropathic pain component.

PainDETECT: 9 items; score range −1 to 38; ≥19 indicates likely neuropathic pain, ≤12 makes it unlikely.

Fibromyalgia 2016 criteria: WPI ≥7 and SSS ≥5, or WPI 4-6 and SSS ≥9; symptoms ≥3 months with no better explanation.

Red flags: new onset after age 50, cancer history, fever, weight loss, night pain, neurologic deficit, bowel/bladder dysfunction, trauma.

Screening tools: ORT for opioid risk, DAST for drug abuse, AUDIT-C for alcohol, PHQ-9 for depression.

Pain mechanisms: nociceptive (somatic/visceral), neuropathic, and nociplastic; mixed mechanisms are common.

Acetaminophen maximum 4,000 mg/day; lower to ≤3,000 mg/day with hepatic disease, chronic alcohol use, or malnutrition.

NSAIDs inhibit cyclooxygenase; avoid in CKD stage 4-5, active GI bleed, and with anticoagulants; cardiovascular risk rises with duration.

Equianalgesic doses: oral morphine 30 mg = parenteral morphine 10 mg = oral oxycodone 20 mg = parenteral hydromorphone 1.5 mg.

Tramadol is a mu agonist and serotonin-norepinephrine reuptake inhibitor; avoid with serotonergic drugs, seizure history, and severe renal/hepatic impairment.

Duloxetine 60 mg daily is used for neuropathic pain and fibromyalgia; avoid in uncontrolled narrow-angle glaucoma and with MAOIs.

Gabapentin and pregabalin are alpha-2-delta ligands; adjust for renal function; adverse effects include sedation, dizziness, and peripheral edema.

Buprenorphine is a partial mu agonist with high affinity and a ceiling effect on respiratory depression; it can precipitate withdrawal.

Methadone prolongs QT; obtain ECG risk assessment; half-life is long and variable.

Naloxone 0.4 mg IV/IM or 4 mg intranasal reverses opioid respiratory depression; repeat every 2-3 minutes because duration is shorter than many opioids.

Facet-mediated pain: medial branch blocks; ≥50% pain relief is commonly used as a positive diagnostic response before radiofrequency ablation.

Radiofrequency ablation creates a heat lesion at 80-90°C for 60-90 seconds, denaturing nerve tissue and reducing pain transmission.

Epidural steroid injection routes: transforaminal, interlaminar, caudal; risks include infection, bleeding, dural puncture, cord injury, and hyperglycemia.

Neuraxial procedures require anticoagulation management per ASRA guidelines; warfarin is typically held about 5 days with INR checked before injection.

Stellate ganglion block: C6 anterior tubercle target; risks include Horner syndrome, hoarseness, pneumothorax, and vertebral artery injection.

Lumbar sympathetic block: L2-L4 target; used for lower extremity complex regional pain syndrome; risks include hypotension and genitofemoral nerve irritation.

Celiac plexus block relieves pancreatic cancer pain; adverse effects include hypotension and diarrhea.

Spinal cord stimulation delivers electrical pulses to dorsal columns; complications include infection, lead migration, and hardware failure.

Intrathecal morphine can cause catheter-tip granuloma with high concentration or long duration; ziconotide is an alternative intrathecal analgesic.

Cognitive behavioral therapy targets catastrophizing, fear-avoidance, and maladaptive beliefs; it reduces pain-related disability.

Graded exposure reduces fear of movement; graded activity uses planned quotas rather than pain-contingent stopping.

Pacing alternates activity and rest before pain flares, avoiding boom-bust cycles.

Operant conditioning reinforces well behaviors and reduces attention to pain behaviors.

Mindfulness-based stress reduction and acceptance and commitment therapy increase pain acceptance and psychological flexibility.

Biofeedback and relaxation training reduce sympathetic arousal and improve coping.

Physical therapy for chronic low back pain emphasizes aerobic exercise, strengthening, and flexibility; bed rest is not recommended.

Measures include Pain Catastrophizing Scale, Tampa Scale for Kinesiophobia, Oswestry Disability Index, and PHQ-9.

Biopsychosocial model: pain and disability arise from interacting biological, psychological, and social factors.

Interdisciplinary teams share goals and communicate regularly; multidisciplinary teams may provide parallel services without integrated treatment planning.

Core team members: physician, psychologist, physical therapist, occupational therapist, nurse, social worker, and pharmacist.

Functional restoration is an intensive, work-focused interdisciplinary program that improves function and work capacity.

Shared decision making combines evidence-based options with patient values and preferences.

Stepped care starts with low-intensity, lower-risk interventions and escalates when response is inadequate.

Outcome domains: pain intensity, function, quality of life, work status, and opioid use.

Palliative care provides symptom relief at any disease stage; hospice requires a prognosis of ≤6 months and comfort-focused care.

Informed consent requires capacity, disclosure of diagnosis, procedure, material risks and benefits, alternatives, no guarantee, and voluntary authorization.

HIPAA minimum necessary rule limits protected health information disclosure except for treatment, payment, operations, and authorized requests.

DEA schedules: Schedule II has no refills; Schedule III-V allows up to 5 refills within 6 months.

PDMP query before prescribing controlled substances; specific mandates vary by state.

CDC 2022 opioid guideline: individualized care, caution with abrupt discontinuation, and naloxone offer for elevated overdose risk.

Malpractice negligence elements: duty, breach, causation, and damages.

Confidentiality exceptions: danger to self or others, suspected abuse, court order, and required public health reporting.

Decision-making capacity requires understanding, appreciation, reasoning, and expression of choice; it differs from legal competency.

Evaluation and management billing is supported by documentation of medical decision making or time.