ABFM KSA Pain Management Actual Exam
Questions and Answers with Rationales 2026/2027 |
Family Medicine Board Exam | Pass Guarantee
1. A patient with chronic low back pain and no prior opioid use presents requesting
pain relief. The patient has a history of untreated depression and uses alcohol daily.
According to the CDC 2022 Clinical Practice Guideline for Prescribing Opioids,
which of the following is the most appropriate initial approach?
A. Initiate low-dose oxycodone with a 7-day supply and schedule follow-up in 2 weeks.
B. Prescribe naproxen 500 mg twice daily and refer for cognitive behavioral therapy.
C. Start tramadol 50 mg every 6 hours as needed and recommend physical therapy.
D. Order an MRI of the lumbar spine before any pharmacological intervention.
Answer: B
Rationale: For chronic pain, nonopioid therapies are preferred first-line. The patient's
depression and alcohol use increase risks of opioid misuse. Naproxen plus CBT is
guideline-concordant. Opioids (A, C) are not first-line; MRI (D) is not indicated without
red flags.
2. A patient on chronic morphine therapy for cancer pain develops refractory
constipation despite aggressive bowel regimens. Which of the following mechanisms
best explains the persistence of constipation?
A. Morphine-6-glucuronide accumulation causing direct colonic smooth muscle paralysis.
B. Activation of peripheral mu-opioid receptors in the enteric nervous system reducing
peristalsis.
C. Central mu-opioid receptor stimulation leading to decreased vagal outflow to the gut.
D. Morphine-induced histamine release causing intestinal edema and obstruction.
Answer: B
Rationale: Opioid-induced constipation is primarily due to peripheral mu-receptor
activation in the gut, reducing motility and secretion. M6G (A) contributes to analgesia
but not constipation; central effects (C) are less direct; histamine (D) is not the main
mechanism.
Page 1
,3. A patient with diabetic peripheral neuropathy has inadequate pain relief from
gabapentin 900 mg/day. Which of the following medication adjustments is most
supported by current evidence?
A. Increase gabapentin to 3600 mg/day in divided doses.
B. Switch to pregabalin 150 mg twice daily.
C. Add amitriptyline 25 mg at bedtime.
D. Discontinue gabapentin and start duloxetine 60 mg daily.
Answer: D
Rationale: Duloxetine is a first-line agent for diabetic neuropathy with strong evidence.
Gabapentin at 900 mg is subtherapeutic; increasing (A) may help but switching to a
proven first-line agent (D) is more appropriate. Pregabalin (B) is an alternative, but
duloxetine has better evidence. Adding amitriptyline (C) increases side effects without
clear benefit.
4. A patient with chronic non-cancer pain on fentanyl patch 25 mcg/h reports
inadequate relief. The patch is changed every 72 hours. After increasing to 37.5
mcg/h, the patient develops respiratory depression. Which pharmacokinetic
property of fentanyl most likely contributed to this adverse event?
A. Short elimination half-life leading to rapid accumulation of active metabolites.
B. High lipid solubility causing delayed release from adipose tissue stores.
C. Extensive first-pass hepatic metabolism reducing bioavailability.
D. Protein binding displacement by albumin leading to increased free fraction.
Answer: B
Rationale: Fentanyl is highly lipophilic, accumulating in adipose tissue. After dose
increases, slow redistribution from fat can cause delayed respiratory depression.
Fentanyl has no active metabolites (A), minimal first-pass (C) due to transdermal route,
and low protein binding (D) is not a major factor.
5. A patient with fibromyalgia reports persistent widespread pain, fatigue, and sleep
disturbance. Which of the following medication regimens is most consistent with the
2020 EULAR recommendations?
A. Pregabalin 150 mg twice daily plus cyclobenzaprine 10 mg at bedtime.
B. Duloxetine 60 mg daily plus tramadol 50 mg every 6 hours as needed.
C. Amitriptyline 25 mg at bedtime plus aerobic exercise and cognitive behavioral therapy.
D. Gabapentin 1200 mg three times daily plus ibuprofen 800 mg three times daily.
Answer: C
Rationale: EULAR recommends nonpharmacological therapy (exercise, CBT) as first-line,
with amitriptyline or duloxetine as pharmacological options. Amitriptyline plus exercise
and CBT is guideline-concordant. Pregabalin (A) is second-line; tramadol (B) is not
Page 2
,recommended; gabapentin (D) lacks strong evidence, and NSAIDs are ineffective.
6. A patient with severe osteoarthritis of the hip is not a surgical candidate. Despite
maximum doses of acetaminophen and topical diclofenac, the patient has moderate
pain. Which of the following is the most appropriate next step?
A. Initiate oral celecoxib 200 mg daily with a proton pump inhibitor.
B. Refer for intra-articular hyaluronic acid injection.
C. Start tramadol extended-release 100 mg daily.
D. Prescribe a transdermal lidocaine patch 5% applied to the hip.
Answer: A
Rationale: According to ACR guidelines, oral NSAIDs (including COX-2 inhibitors) are
recommended for patients with inadequate response to topical NSAIDs and
acetaminophen. Celecoxib with PPI reduces GI risk. Hyaluronic acid (B) is conditionally
against; tramadol (C) is not first-line; lidocaine (D) is for localized pain but less evidence
in OA.
7. A patient with chronic low back pain and radicular symptoms has been on
oxycodone 15 mg every 6 hours for 3 months. Urine drug screen shows no oxycodone
but presence of morphine. Which of the following is the most likely explanation?
A. The patient is diverting oxycodone and using heroin.
B. The urine sample was contaminated with a morphine-containing product.
C. Oxycodone is metabolized to morphine via CYP2D6.
D. The patient has a genetic variant causing ultra-rapid metabolism of oxycodone to
oxymorphone.
Answer: A
Rationale: Oxycodone is not metabolized to morphine; its metabolites include
oxymorphone and noroxycodone. Absence of oxycodone with presence of morphine
suggests use of a different opioid (heroin or morphine). Option C is false; option D does
not explain morphine; option B is less likely.
8. A patient with advanced cancer and bone metastases has severe pain despite
high-dose morphine. Which of the following additional interventions is most likely to
provide the greatest analgesic benefit?
A. Add pregabalin 75 mg twice daily.
B. Initiate a single-fraction radiation therapy to the most painful site.
C. Switch from morphine to methadone using a 5:1 conversion ratio.
D. Start intravenous bisphosphonate therapy with zoledronic acid.
Answer: B
Page 3
, Rationale: Radiation therapy is highly effective for painful bone metastases, providing rapid pain relief in many patients.
Pregabalin (A) is for neuropathic pain; methadone conversion (C) is complex and not first-line; bisphosphonates (D) prevent
skeletal events but provide slower, less robust analgesia.
9. A patient with chronic pancreatitis has constant epigastric pain radiating to the
back. Which of the following pain mechanisms is most dominant in this condition?
A. Nociceptive pain from inflammation of the pancreatic parenchyma.
B. Neuropathic pain due to damage to pancreatic nerves.
C. Central sensitization with allodynia and hyperalgesia.
D. Visceral pain mediated by splanchnic afferents with referred pain patterns.
Answer: D
Rationale: Chronic pancreatitis pain is primarily visceral, mediated by splanchnic
afferents, with referred pain to the back. While inflammation (A) and nerve damage (B)
occur, the dominant mechanism is visceral. Central sensitization (C) is a secondary
phenomenon. The classic radiation to the back supports visceral referral.
10. A patient with chronic migraine is being started on a preventive medication. The
patient has a history of hypertension and is currently on lisinopril. Which of the
following preventive agents is contraindicated due to a significant drug interaction?
A. Propranolol 80 mg daily.
B. Topiramate 50 mg daily.
C. Amitriptyline 25 mg at bedtime.
D. OnabotulinumtoxinA injections.
Answer: A
Rationale: Propranolol is a beta-blocker that can cause additive bradycardia and
hypotension when combined with lisinopril, an ACE inhibitor. While not absolutely
contraindicated, it requires caution and is less preferred. Topiramate (B), amitriptyline
(C), and botulinum toxin (D) do not have significant interactions with lisinopril.
11. A patient with chronic low back pain is currently on oxycodone 10 mg every 4
hours as needed for breakthrough pain, and a fentanyl transdermal patch 75 mcg/h
every 72 hours. The patient reports inadequate pain control and requests a dose
increase. Which pharmacologic principle best explains why simply increasing the
fentanyl patch dose may not provide additional benefit and could increase risk?
A. Fentanyl has a ceiling effect for analgesia beyond which only side effects increase.
B. The patch delivers drug at a constant rate, and dose escalation does not change the time to
steady state.
C. Tolerance to the analgesic effect of fentanyl develops more rapidly than tolerance to
respiratory depression.
Page 4
Questions and Answers with Rationales 2026/2027 |
Family Medicine Board Exam | Pass Guarantee
1. A patient with chronic low back pain and no prior opioid use presents requesting
pain relief. The patient has a history of untreated depression and uses alcohol daily.
According to the CDC 2022 Clinical Practice Guideline for Prescribing Opioids,
which of the following is the most appropriate initial approach?
A. Initiate low-dose oxycodone with a 7-day supply and schedule follow-up in 2 weeks.
B. Prescribe naproxen 500 mg twice daily and refer for cognitive behavioral therapy.
C. Start tramadol 50 mg every 6 hours as needed and recommend physical therapy.
D. Order an MRI of the lumbar spine before any pharmacological intervention.
Answer: B
Rationale: For chronic pain, nonopioid therapies are preferred first-line. The patient's
depression and alcohol use increase risks of opioid misuse. Naproxen plus CBT is
guideline-concordant. Opioids (A, C) are not first-line; MRI (D) is not indicated without
red flags.
2. A patient on chronic morphine therapy for cancer pain develops refractory
constipation despite aggressive bowel regimens. Which of the following mechanisms
best explains the persistence of constipation?
A. Morphine-6-glucuronide accumulation causing direct colonic smooth muscle paralysis.
B. Activation of peripheral mu-opioid receptors in the enteric nervous system reducing
peristalsis.
C. Central mu-opioid receptor stimulation leading to decreased vagal outflow to the gut.
D. Morphine-induced histamine release causing intestinal edema and obstruction.
Answer: B
Rationale: Opioid-induced constipation is primarily due to peripheral mu-receptor
activation in the gut, reducing motility and secretion. M6G (A) contributes to analgesia
but not constipation; central effects (C) are less direct; histamine (D) is not the main
mechanism.
Page 1
,3. A patient with diabetic peripheral neuropathy has inadequate pain relief from
gabapentin 900 mg/day. Which of the following medication adjustments is most
supported by current evidence?
A. Increase gabapentin to 3600 mg/day in divided doses.
B. Switch to pregabalin 150 mg twice daily.
C. Add amitriptyline 25 mg at bedtime.
D. Discontinue gabapentin and start duloxetine 60 mg daily.
Answer: D
Rationale: Duloxetine is a first-line agent for diabetic neuropathy with strong evidence.
Gabapentin at 900 mg is subtherapeutic; increasing (A) may help but switching to a
proven first-line agent (D) is more appropriate. Pregabalin (B) is an alternative, but
duloxetine has better evidence. Adding amitriptyline (C) increases side effects without
clear benefit.
4. A patient with chronic non-cancer pain on fentanyl patch 25 mcg/h reports
inadequate relief. The patch is changed every 72 hours. After increasing to 37.5
mcg/h, the patient develops respiratory depression. Which pharmacokinetic
property of fentanyl most likely contributed to this adverse event?
A. Short elimination half-life leading to rapid accumulation of active metabolites.
B. High lipid solubility causing delayed release from adipose tissue stores.
C. Extensive first-pass hepatic metabolism reducing bioavailability.
D. Protein binding displacement by albumin leading to increased free fraction.
Answer: B
Rationale: Fentanyl is highly lipophilic, accumulating in adipose tissue. After dose
increases, slow redistribution from fat can cause delayed respiratory depression.
Fentanyl has no active metabolites (A), minimal first-pass (C) due to transdermal route,
and low protein binding (D) is not a major factor.
5. A patient with fibromyalgia reports persistent widespread pain, fatigue, and sleep
disturbance. Which of the following medication regimens is most consistent with the
2020 EULAR recommendations?
A. Pregabalin 150 mg twice daily plus cyclobenzaprine 10 mg at bedtime.
B. Duloxetine 60 mg daily plus tramadol 50 mg every 6 hours as needed.
C. Amitriptyline 25 mg at bedtime plus aerobic exercise and cognitive behavioral therapy.
D. Gabapentin 1200 mg three times daily plus ibuprofen 800 mg three times daily.
Answer: C
Rationale: EULAR recommends nonpharmacological therapy (exercise, CBT) as first-line,
with amitriptyline or duloxetine as pharmacological options. Amitriptyline plus exercise
and CBT is guideline-concordant. Pregabalin (A) is second-line; tramadol (B) is not
Page 2
,recommended; gabapentin (D) lacks strong evidence, and NSAIDs are ineffective.
6. A patient with severe osteoarthritis of the hip is not a surgical candidate. Despite
maximum doses of acetaminophen and topical diclofenac, the patient has moderate
pain. Which of the following is the most appropriate next step?
A. Initiate oral celecoxib 200 mg daily with a proton pump inhibitor.
B. Refer for intra-articular hyaluronic acid injection.
C. Start tramadol extended-release 100 mg daily.
D. Prescribe a transdermal lidocaine patch 5% applied to the hip.
Answer: A
Rationale: According to ACR guidelines, oral NSAIDs (including COX-2 inhibitors) are
recommended for patients with inadequate response to topical NSAIDs and
acetaminophen. Celecoxib with PPI reduces GI risk. Hyaluronic acid (B) is conditionally
against; tramadol (C) is not first-line; lidocaine (D) is for localized pain but less evidence
in OA.
7. A patient with chronic low back pain and radicular symptoms has been on
oxycodone 15 mg every 6 hours for 3 months. Urine drug screen shows no oxycodone
but presence of morphine. Which of the following is the most likely explanation?
A. The patient is diverting oxycodone and using heroin.
B. The urine sample was contaminated with a morphine-containing product.
C. Oxycodone is metabolized to morphine via CYP2D6.
D. The patient has a genetic variant causing ultra-rapid metabolism of oxycodone to
oxymorphone.
Answer: A
Rationale: Oxycodone is not metabolized to morphine; its metabolites include
oxymorphone and noroxycodone. Absence of oxycodone with presence of morphine
suggests use of a different opioid (heroin or morphine). Option C is false; option D does
not explain morphine; option B is less likely.
8. A patient with advanced cancer and bone metastases has severe pain despite
high-dose morphine. Which of the following additional interventions is most likely to
provide the greatest analgesic benefit?
A. Add pregabalin 75 mg twice daily.
B. Initiate a single-fraction radiation therapy to the most painful site.
C. Switch from morphine to methadone using a 5:1 conversion ratio.
D. Start intravenous bisphosphonate therapy with zoledronic acid.
Answer: B
Page 3
, Rationale: Radiation therapy is highly effective for painful bone metastases, providing rapid pain relief in many patients.
Pregabalin (A) is for neuropathic pain; methadone conversion (C) is complex and not first-line; bisphosphonates (D) prevent
skeletal events but provide slower, less robust analgesia.
9. A patient with chronic pancreatitis has constant epigastric pain radiating to the
back. Which of the following pain mechanisms is most dominant in this condition?
A. Nociceptive pain from inflammation of the pancreatic parenchyma.
B. Neuropathic pain due to damage to pancreatic nerves.
C. Central sensitization with allodynia and hyperalgesia.
D. Visceral pain mediated by splanchnic afferents with referred pain patterns.
Answer: D
Rationale: Chronic pancreatitis pain is primarily visceral, mediated by splanchnic
afferents, with referred pain to the back. While inflammation (A) and nerve damage (B)
occur, the dominant mechanism is visceral. Central sensitization (C) is a secondary
phenomenon. The classic radiation to the back supports visceral referral.
10. A patient with chronic migraine is being started on a preventive medication. The
patient has a history of hypertension and is currently on lisinopril. Which of the
following preventive agents is contraindicated due to a significant drug interaction?
A. Propranolol 80 mg daily.
B. Topiramate 50 mg daily.
C. Amitriptyline 25 mg at bedtime.
D. OnabotulinumtoxinA injections.
Answer: A
Rationale: Propranolol is a beta-blocker that can cause additive bradycardia and
hypotension when combined with lisinopril, an ACE inhibitor. While not absolutely
contraindicated, it requires caution and is less preferred. Topiramate (B), amitriptyline
(C), and botulinum toxin (D) do not have significant interactions with lisinopril.
11. A patient with chronic low back pain is currently on oxycodone 10 mg every 4
hours as needed for breakthrough pain, and a fentanyl transdermal patch 75 mcg/h
every 72 hours. The patient reports inadequate pain control and requests a dose
increase. Which pharmacologic principle best explains why simply increasing the
fentanyl patch dose may not provide additional benefit and could increase risk?
A. Fentanyl has a ceiling effect for analgesia beyond which only side effects increase.
B. The patch delivers drug at a constant rate, and dose escalation does not change the time to
steady state.
C. Tolerance to the analgesic effect of fentanyl develops more rapidly than tolerance to
respiratory depression.
Page 4
