Pain Management and Opioids: Balancing Risks and Benefits-Updated 2019-20

1. Which comorbid condition may predict the development of chronic pain following
acute pain? // Komorbid apa yang dapat menentukan perkembangan nyeri kronis yang
diikuti oleh nyeri akut?
a. Asthma
b. Depression
c. Diabetes mellitus
d. Hypertension
Depression and anxiety have been shown to be predictors of persistent pain
following surgery or acute injury.
2. Pain secondary to post-herpetic neuralgia is what type of pain? // Tipe nyeri apakah
yang terjadi pada PHN?
a. Mixed type
b. Neuropatik
c. Nosiseptif
d. Nociplastik
Post-herpetic neuralgia (PHN) is listed in the CO*RE materials as an example of
neuropathic pain. Neuropathic pain develops when the nervous system is
damaged. In PHN, an activation of the herpes zoster virus causes inflammation
in a peripheral sensory nerve which can cause damage to the nerve, causing
chronic dysfunction of the nerve, which manifests in pain.
3. Which of the following is an anticipated outcome of a patient taking a prescribed
opioid medication as recommended? // Manakah dibawah ini yang merupakan hasil
yang diharapkan oleh pasien yang menggunakan terapi opioid sesuai anjuran?
a. Diversion
b. Misuse
c. Tolerance
d. Withdrawal
Tolerance is the anticipated biological phenomenon in which increased dosage
of opioids is needed to produce the specific analgesic effect.
4. What is the first step in assessment of a patient’s pain who complains of burning and
tingling in his lower extremities? // Apa langkah pertama pada pemeriksaan nyeri pada
pasien yang mengeluhkan sensasi terbakar dan geli pada ekstremitas bawah?

a. Complete history and physical exam to determine the cause of his pain

b. Perform social history to establish cultural background

c. Send patient for an EMG to determine possible neuropathic pain

 d. Validate the patient’s provided treatment history with your state’s PDMP

The first step in evaluating and managing a patient’s pain is to perform a

complete history and physical exam. History and physical is important in
determining the cause of the pain, location, duration and characteristic features.

5. Which of the following is the most important thing to consider in creating a pain
treatment plan? // Manakah di bawah ini yang menjadi hal terpenting untuk
dipertimbangkan dalam merencanakan terapi nyeri?
a. Quality of life is not significant factor in pain management
b. Reduction of the pain score by 25% will be the primary endpoint
c. The goal is to completely resolve pain
d. The goal is to improve functional outcomes
Improving functional outcomes and quality of life are the main treatment goals.
6. According to expert guidelines, which of the following is the best sequence for
establishing a pain treatment plan of care? // Berdasarkan para ahli, manakah di bawah
ini yang merupakan urutan terbaik untuk melaksanakan terapi nyeri?
a. Establish the cause & type of the pain, initiate pharmacological and/or non-
opioid therapies, regularly reassess
b. Identify the pain generator through a complete history and physical examination,
initiate opioid therapy, regularly reassess
c. Obtain imaging, intiate non-pharmacological and/or non-opioid therapies, refer to
pain management
d. Validate the patient’s pain complaint, obtain imaging, initiate opioid therapy,
follow up regularly

Always establish the cause/type of pain and then develop a multimodal treatment
plan that considers all pain management options, including non-pharmacologic
and pharmacologic options. Opioids should be prescribed only when non-opioid
options are inadequate and when the benefits of using an opioid are expected to
outweigh the risks.
7. Which side effect of opioid therapy should always prompt proactive treatment? // Efek
samping manakah pada terapi opioid yang segera/ biasa terjadi saat proactive
treatment?
a. Constipation
b. Dizziness
c. Itching
d. Nausea

Constipation does not improve over time and requires proactive treatment with
stimulating laxatives prescribed at the initiation of the opioids.
8. In which of the following circumstances is the patient at greatest risk of life-
threathening respiratory depression from opioid treatment? // Manakah di bawah ini
yang merupakan kondisi mengancam nyawa pasien dengan gejala respiratory
depression/ distress (hipoventilasi) akibat terapi opioid?
a. During dosage taper
b. Upon treatment initiation
c. When converting dosage from opioid to another
d. When co-prescribed with a benzodiazepine

There is a significant body of evidence that shows that co-administration of a

benzodiazepine with an opioid results in extreme sedation and reduced
respiratory drive.
9. Select the correct statement regarding counseling a woman, currently on chronic
opioid therapy, who is contemplanting a possible pregnancy // Pilih pernyataan yang
tepat mengenai konseling seorang wanita, yang saat ini berada pada terapi opioid
kronik, yang mempertimbangkan kemungkinan kehamilan
a. Chronic opioid therapy causes congenital skeletal abnormalities as well as bone
demineralization in women
b. For pregnant women with opioid dependence, switching to methadone is
safer and more successful than detoxification
c. Neonatal abstinence syndrome (NAS) is a rare adverse outcome in babies born
to mothers using opioids
d. Since chronic opioid use impairs fertility, women taking opioids cannot become
pregnant

Opioid agonist pharmacotherapy (methadone or buprenorphine) are

recommended for pregnant women with an opioid use disorder or on chronic
opioid therapy; evidence shows these medications yield better postnatal
outcomes than detoxification.
10. After determining that non-opioid therapies are inadequate for a patient’s pain,
which of the following are the three most important things to have in place at the
beginning of a trial of opioids? // Setelah menentukan bahwa terapi non-opioid kurang
adekuat untuk nyeri pasien, manakah 3 hal penting yang harus dilakukan pada awal
percobaan terapi opioid?
a. Baseline urine drug test (UDT), psychological testing, and patient’s medication
preference identified
b. Informed consent, family history, current medication reconciliation
c. Patient provider agreement (PPA), baseline urine drug test (UDT), informed
consent
d. Patient provider agreement (PPA), lab work-up and social worker referral

The patient provider agreement (PPA), results from a baseline UDT, and
informed consent are all essential to have in place at the start of a trial of opioids.
11. While all of the following behaviors might merit investigation in a patient receiving
long term opioid therapy, which would most strongly prompt your concern for a possible
opioid use disorder? // Walaupun semua dari perilaku berikut mungkin berguna untuk
investigasi pada pasien dengan terapi opioid jangka panjang, manakah yang langsung
menjadi perhatian anda terhadap kemungkinan penyalahgunaan opioid?
a. Negative urine drug test (UDT) results for the medication prescribed
b. Patient reports recent family problems and being fired from job
c. Request for a dosage increase due to lack of pain control
d. Request for an early refill

While all four of these options could potentially be problematic, the recent family
problems and job loss are most indicative of a possible OUD. Role failure (at
work, home, or school) and social/interpersonal problems are on the DSM-5 list
of criteria for a substance use disorder, while the other three answers are not.
12. In transitioning an 80 y/o patient from morphine 180 mg/day to oxycodone, and
accounting for incomplete cross-tolerance, which one of the following would be an
appropriate initial dose? Recall that thirty (30) mg of PO morphine is approximately
equianalgesic to 20 mg long-acting oxycodone; that is, the equianalgesic ratio for
morphine:oxycodone is 3:2 (although some tables indicate, oxycodone is roughly twice
as potent as morphine).
a. Oxycodone ER 30 mg PO Q 12 hours
b. Oxycodone ER 80 mg Q 8 hours
c. Oxycodone ER 5 mg PO Q 4 hours
d. Oxycodone ER 10 mg PO Q 6 hours

Because the patient is taking 180 mg of morphine in 24 hours, a dose of

approximately 120 mg of oxycodone in a 24-hour period is appropriate and
taking into account the patient’s age and the high MME, a 50% reduction in the
full 24-hour equianalgesic dose is warranted. Refer to the Equianalgesic Dosing
Table on slide 66 in the CO*RE PPT deck.
13. Of the following, which is an appropriate reason for tapering and discontinuing
opioid medication and not a situation that calls for further investigation and increased
monitoring? // Manakah dari berikut, yang merupakan alasan tepat untuk menurunkan dan
menghentikan terapi opioid dan tidak dalam situasi yang membutuhkan investigasi lebih lanjut
dan meningkatkan monitoring?

a. Negative urine drug screen

b. Ongoing pain with aberrant use
c. Pain is resolving
d. Scheduled for a future surgical procedure

The goal of opioid therapy is to reduce pain and improve functionality; if the
patient’s pain has decreased and function improved, the benefit of the opioids
may no longer outweigh the risks.
14. What is the most important piece of information when educating patients and their
families about naloxone use? // Apakah hal paling penting yang harus disampaikan pada
pasien dan keluarganya terkait penggunaan naloxone?

a. Be prepared to give the patient an IR dose for pain upon awakening

b. Discourage naloxone access because it promotes drug misuse
c. Secure naloxone in a home drug safe
d. Seek medical attention as soon as possible when naloxone is used
While naloxone reverses opioid-induced respiratory depression, it could also
reverse analgesia, precipitate acute withdrawal, or wear off before the opioid that
caused the overdose, so prompt medical attention is required.
Vulvodynia: A Common and Under-Recognized Pain Disorder in Women and Female
Adolescents -- Integrating Current Knowledge Into Clinical Practice
1. Vulvodynia is.. // Vulvodynia adalah..
Chronic vulvar pain without a clear identifiable cause
2. The most commonly reported symptom of vulvodynia is..// Gejala yang paling sering
dilaporkan pada vulvodynia..
Burning
3. Which statement most accurately describe the prevalence of vulvodynia? //
Pernyataan manakah yang tepat untuk menggambarkan prevalensi vulvodynia?
Vulvodynia is a prevalent disorder affecting women of all ages and ethnic
groups
4. Vulvodynia often limits.. // Vulvodynia sering membatasi aktivitas..
Sitting and sexual intercourse
5. The vulvar vestibule differs from other external vulvar tissue in that it is derived from
which embryological germ layer? // Vestibular vulvar memiliki jaringan yang
berbeda dibandingkan dengan jaringan vulva eksterna yang lain, dimana
jaringan tersebut berasal dari lapisan embriologi…
Endoderm
6. Which of the following disorders must be ruled out prior to making a diagnosis of
vulvodynia? // Manakah di bawah ini yang merupakan penyakit yang harus di
eksklusi untuk menegakkan diagnosis vulvodynia?
All of the above  vulvodynia is an idiopathic pain disorder and a diagnosis of
exclusion. All infectious, inflammatory, dermatologic, neurologic, traumatic,
iatrogenic, hormonal and neoplastic cause of vulvar pain must be ruled out prior
to making a diagnosis of vulvodynia.
7. Epidemiologic studies have found that _______ is a risk factor for vulvodynia
Vulvovaginal candidiasis
8. How is vulvodynia classified?
Vulvodynia is first classified by location and then by provocation
9. Which of the following is not necessarily a symptom of vestibulodynia?
Vestibular erythema
10. The vulva is innervated by the… // Vulva diinervasi oleh..
All of the above  multiple nerves, including illioinguinal, genitofemoral, and
pudendal nerves.
11. Vulvodynia assessment includes a visual examination of the vulva, cotton swab test
of the vulva, neurosensory examination, and what other component?
Pelvic floor muscle evaluation
12. In addition to the differences in location of pain, generalized vulvodynia is
differentiated from vestibulodynia by… // Untuk membedakan lokasi nyeri,
vulvodynia general dibedakan dengan vestibulodynia dengan melihat…
Consistency of the pain
13. Researchers have found ____ in vulvar tissue biopsies from women who have
vestibulodynia // Peneliti telah menemukan _______ pada jaringan biopsy vulva
pada wanita yang menderita vestibulodynia
Neuroproliferation
14. Which of the following is among the current treatments used for women with
generalized vulvodynia? // Manakah terapi terkini yang digunakan untuk wanita
dengan vulvodynia general?
Tricyclic antidepressants
15. Which of the following statements is true?
Pelvic floor muscle therapy lessons pain in some patients with vulvodynia