Vancouver 2011 Precourse Questions with answers

Complex Chronic Pain Precourse Self-Assessment Questions Vancouver, B.C. 2011

DISCLOSURE STATEMENT Pain & Suffering Symposium March 11-12, 2011
Faculty disclosure of relevant financial relationships in the past 12 months:
Barry Egener, M.D. Chris Stewart-Patterson, M.D.
Andrea Furlan, M.D., Ph.D. Mark Sullivan, M.D.
Daniel O’Connell, Ph.D. Paul Farnan, M.D.
Mick Oreskovich, M.D. Patrick McGowan
Launette Rieb, MSc, M.D., FCFP Galt Wilson, M.D., MSc, FCFP
Planning Committee: Ray Baker, M.D., Barry Egener, M.D.,
Edward Keenan, Ph.D., Mick Oreskovich, M.D., and Galt Wilson, M.D.
All of our faculty as well as the Planning Committee members have
disclosed they have no financial relationships with entities producing
health-care products and/or services.
Dr. Furlan’s plenary presentation includes discussion of commercial products and services.

Sullivan, Friday 8:25 AM
Which of the following is true?
1) Randomized clinical trials have clearly shown long-term opioid therapy (>3 mos.) to be effective for the treatment of chronic pain
2) Longer acting opioid formulations have been demonstrated to lessen opioid abuse
3) Rates of chronic opioid use and daily doses are higher among patients with major depression or substance abuse
Patients with possible or probable opioid misuse are more likely to discontinue chronic opioid therapy

Rieb, Friday 9:10 AM
60 y.o. janitor presents with persistent low back and left leg pain 6 months post L5-S1 discectomy. He is 1 year sober from alcohol dependence. Which approach is best?
Opioids, benzodiazepines and cannabinoids should not be used since relapse risk too high
Opioids can be given first line since severe pain can trigger a relapse to drinking
Opioids may be used cautiously if other medications and modalities have failed and an increase in function can be documented
Refer for a second surgical opinion

Furlan, Friday 10:05 AM
According to the Canadian Opioid Guideline, it is recommended that physicians and pharmacists collaborate to improve outcomes of patients receiving opioids for chronic non-cancer pain. Which is FALSE regarding physician-pharmacist collaboration?
When initiating opioid therapy, physicians may consider a three-day “tolerance check” for patients at risk of overdose: the pharmacist calls the patient three days after starting the prescription to check for any signs of sedation.
A complete prescription history in one location can support physician-pharmacist collaboration. Physicians can enable this by encouraging patients to select a single pharmacy to have prescriptions filled.
Pharmacists, through their multiple interactions with the patient, can reinforce patient education about safe, appropriate use of opioids.
Pharmacists may observe adverse effects (e.g. constipation) that should be communicated to the physician
Pharmacists cannot alert physicians of concerns about opioid misuse (e.g. taking opioid belonging to someone else) because of client confidentiality.

McGowan, Friday 11:10 AM
What is the most effective type of strategy that can be used with patients in the context of a 15-minute office encounter?
Provide information about their type of pain
Review their medications
Teach them how to do specific types of exercise
Teach them how to make an action plan
Show them how to use a problem-solving process
Refer them to a pain program
Teach them how to communicate their pain experience

Furlan and Wilson, Fri. 11:10 AM
According to the National Opioid Guidelines Group (NOUGG), which of the following is TRUE:
Randomized controlled trials following subjects for an average of one year found opioids effective for chronic low back pain.
Opioids may be used safely to treat patients with addiction, provided only controlled release preparations are employed.
Patients taking opioids long term report somnolence and drowsiness no more frequently those given a placebo.
The NOUGG Guideline sets the equivalent of 200 mg of oral morphine daily as a “watchful dose”, prompting reassessment of therapy.
Young people are treated as adults, provided they have reached skeletal maturity.

Rieb, Friday, 11:10 AM
42 y.o. millwright with left shoulder pain, U/S = rotator cuff tendonopathy, GERD, tobacco 2 ppd, coffee 30 cups/d, marijuana 5 gm/d (20 joints) up from 1 gm/d since age 15. You suggest…
An NSAID, like ibuprofen
An opioid, like codeine
Application for exemption to prescribe marijuana for the patient from Health Canada
Non-medication, non-substance coping strategies and a taper of current substances

Sullivan, Friday 11:10 AM
How should you determine the therapeutic goal when starting a patient on chronic opioid therapy?
1. Ask patients what they want. That is the core of patient centered care. 2. Focus on providing pain relief. This is the quality indicator tracked by health systems and accreditation organizations
3. Ask the patient how their life would be different if his/her pain were significantly reduced. Use these changes in life activities and role functions as goals of care.
4. Improved physical function is the most important and enduring benefit. This should be the goal regardless of what the patient wants.

Egener, Friday 11:10
Your 35 yo patient is on MS Contin 30 mg. BID for chronic LBP from a non-operable vertebral crush injury. A random urine drug screen reveals cocaine and marijuana. You should:
Stop prescribing any further opioid now
Warn him that another dirty urine will result in terminating your relationship
Taper him off opioids over 1 week
Refer him to a pain clinic

Stewart-Patterson, Friday 1:30
Which medications are recommended in the treatment of fibromyalgia?
a) NSAIDS
b) Corticosteroids
c) Anti-depressants
d) Pregabalin
e) Calcitonin
Answer:
a and b
a and c
c and d
All the above

Oreskovich Friday 2:15PM
Because of the transference issues of the patient with
chronic pain disorder, the patient may bring which of the
following attitudes and expectations to the relationship with
his or her treating physician:
a) Realistic basic trust
b) Over idealization
c) Eroticized fantasy
d) Basic distrust
e) Expectation of contempt and abuse
Answer:
a and d
a, b, and d
b, c, and e
b and e
all of the above

Egener, Friday 3:15
Marijuana is approximately as efficacious in relieving pain as:
Acetaminophen, 1 gram po
Codeine, 30 mg. po
Morphine, immediate release, 30 mg. po
Oxycodone, 10 mg. po
Fentanyl patch, 25 mcg., topical

Farnan 3:15 Fri; 10:15 Sat.
In general, physicians enjoy better health than the population as a whole and have lower rates of all-cause mortality
Stress associated with distressing feelings of sadness, anger, and helplessness in a physician are indicative of a loss of control of the clinician-patient relationship.
Research has suggested that physicians at any stage in their career may experience ‘Burnout’
Alcohol use, abuse, and dependence are more prevalent among health care professionals than other professionals
Physician self-awareness & resilience are typically inherited traits and cannot be learned
Answer:
a
a and c
b and d
c, d, and e

O’Connell, Saturday 8:30
Acceptance and Commitment Therapy differs from traditional Cognitive Behavioral Therapy in that it:
Is unconcerned with patient's beliefs
Looks to early childhood as a source of distress
Does not encourage disputing maladaptive thoughts but instead focuses on their workability in terms of patient's valued directions
Does not encourage the therapist to explore patient's emotions.

Oreskovich, Saturday 9:15 AM
Offspring from dysfunctional families often have problems with boundaries
When it comes to addictive disorders, enabling is not therapeutic
People who somatize their emotional discomfort often show alexithymia
Codependence refers to being addicted to a combination of drugs and activities
Which are correct?
all of the above
none of the above
1 and 3.
1,2, and 3.

Oreskovich, Sat. 10:15 AM
The likelihood of a patient developing
Chronic Pain Disorder has the highest
correlation with:
a) Intensity of the underlying pain
b) Presence of co-occuring depression
c) Degree of somatic focus
d) Self-perceived disability
a
a and c
b and d
b, c, and d
all of the above

O’Connell, Fri. 3:15; Sat. 10:15
Thinking a thing must be more true because I feel it more intensely is a distortion known as
All or nothing thinking
Emotional Reasoning
Postponement
Entitlement

Rieb, Saturday, 10:15 AM
32 y.o. hairdresser with mild right extensor tendonopathy at the elbow, sleep disturbance, fatigue and irritability currently taking full strength ibuprofen and acetaminophen, and practicing yoga and relaxation. What type of medication would you add next?
Opioid, like codeine
SNRI, like duloxetine
Cannabinoid, like nabilone
Neuromodulator, like pregabalin

Vancouver 2011 Precourse Questions with answers

by The Foundation for Medical Excellence on Apr 11, 2011

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