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BACKGROUND CONCEPTS: ANATOMY, PHYSIOLOGY & PHARMACOLOGY (Q1–15)
1. Which ascending pathway is the primary route for transmission of nociceptive signals
from the spinal cord to the thalamus?
A. Corticospinal tract
B. Spinothalamic tract
C. Dorsal column–medial lemniscus
D. Spinocerebellar tract
Answer: B — The spinothalamic tract carries pain and temperature; second-order neurons
cross at the spinal level and ascend to the VPL of the thalamus .
2. C-fibers transmit which type of pain?
A. Fast, sharp, well-localized pain
B. Slow, dull, poorly localized pain
C. Proprioception
D. Light touch
Answer: B — Unmyelinated C-fibers carry slow, dull, poorly localized "second pain" at
conduction velocities of ~0.5–2 m/s .
3. Per the IASP definition, allodynia refers to:
A. Increased pain from a normally painful stimulus
B. Pain in the absence of any stimulus
C. Pain caused by a normally non-painful stimulus
D. Loss of all sensation in a region
Answer: C — Allodynia is pain from a normally non-painful stimulus (e.g., light touch) .
4. The wind-up phenomenon in chronic pain is mediated primarily by which receptor in
dorsal horn neurons?
A. GABA-A receptor
B. Mu-opioid receptor
C. NMDA receptor
D. Alpha-2 adrenergic receptor
Answer: C — Wind-up is a progressive increase in dorsal horn neuron response to repeated
C-fiber stimulation, mediated by NMDA receptor activation .
5. The descending pain modulation system originates primarily in which brainstem region?
A. Substantia nigra
B. Periaqueductal gray (PAG) and rostral ventromedial medulla (RVM)
C. Nucleus tractus solitarius
D. Locus coeruleus only
Answer: B — The PAG projects via the RVM to the dorsal horn, releasing serotonin and
norepinephrine .
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6. Which best characterizes nociplastic pain?
A. Pain due to direct tissue injury
B. Pain from a lesion of the somatosensory nervous system
C. Altered nociception without clear evidence of tissue damage or somatosensory lesion
D. Pain from psychiatric disease only
Answer: C — IASP added nociplastic pain in 2017 as a third descriptor; fibromyalgia and IBS
are prototypical examples .
7. One of the effects created by activation or increased release of substance P is:
A. Vasoconstriction
B. Membrane stabilization
C. Analgesia
D. Vasodilation
Answer: D — Substance P causes vasodilation and plasma extravasation in neurogenic
inflammation .
8. Which opioid receptor is primarily responsible for analgesia?
A. Delta
B. Kappa
C. Mu
D. Nociceptin
Answer: C — Mu-opioid receptor activation produces the primary analgesic effects of
opioids.
9. Which enzyme is primarily responsible for the metabolism of codeine to morphine?
A. CYP3A4
B. CYP2D6
C. CYP1A2
D. CYP2C9
Answer: B — Codeine is a prodrug converted to morphine via CYP2D6.
10. Which local anesthetic has the longest duration of action?
A. Lidocaine
B. Mepivacaine
C. Bupivacaine
D. Chloroprocaine
Answer: C — Bupivacaine has the longest duration among commonly used local anesthetics.
11. The maximum dose of lidocaine without epinephrine is:
A. 3 mg/kg
B. 4.5 mg/kg
C. 7 mg/kg
D. 10 mg/kg
, 3
Answer: B — Maximum lidocaine without epinephrine is 4.5 mg/kg (7 mg/kg with
epinephrine).
12. Which receptor is the target of gabapentin?
A. GABA-A
B. Alpha-2-delta subunit of voltage-gated calcium channels
C. NMDA
D. Mu-opioid
Answer: B — Gabapentin binds the alpha-2-delta subunit to reduce neurotransmitter
release .
13. Which is the primary mechanism of action of tricyclic antidepressants in pain?
A. Serotonin reuptake inhibition only
B. Norepinephrine reuptake inhibition only
C. Combined serotonin and norepinephrine reuptake inhibition
D. Dopamine antagonism
Answer: C — TCAs inhibit both serotonin and norepinephrine reuptake .
14. Which antiarrhythmic has been used as an adjuvant analgesic for neuropathic pain?
A. Amiodarone
B. Mexiletine
C. Adenosine
D. Digoxin
Answer: B — Mexiletine, an oral lidocaine analog, has been used for neuropathic pain .
15. Which medication is a neurolytic agent used for chemical sympatholysis?
A. Bupivacaine
B. Phenol
C. Ketamine
D. Clonidine
Answer: B — Phenol is a neurolytic agent used for chemical ablation .
ASSESSMENT & PSYCHOLOGY OF PAIN (Q16–25)
16. Which validated tool screens for opioid misuse risk prior to prescribing?
A. PHQ-9
B. Opioid Risk Tool (ORT) or SOAPP-R
C. CAGE-AID alone
D. Wong-Baker FACES
Answer: B — ORT and SOAPP-R are validated for pre-prescribing risk stratification .
17. The depression commonly seen in chronic pain of nonmalignant origin differs from
typical major depression in that it is more likely to include:
BACKGROUND CONCEPTS: ANATOMY, PHYSIOLOGY & PHARMACOLOGY (Q1–15)
1. Which ascending pathway is the primary route for transmission of nociceptive signals
from the spinal cord to the thalamus?
A. Corticospinal tract
B. Spinothalamic tract
C. Dorsal column–medial lemniscus
D. Spinocerebellar tract
Answer: B — The spinothalamic tract carries pain and temperature; second-order neurons
cross at the spinal level and ascend to the VPL of the thalamus .
2. C-fibers transmit which type of pain?
A. Fast, sharp, well-localized pain
B. Slow, dull, poorly localized pain
C. Proprioception
D. Light touch
Answer: B — Unmyelinated C-fibers carry slow, dull, poorly localized "second pain" at
conduction velocities of ~0.5–2 m/s .
3. Per the IASP definition, allodynia refers to:
A. Increased pain from a normally painful stimulus
B. Pain in the absence of any stimulus
C. Pain caused by a normally non-painful stimulus
D. Loss of all sensation in a region
Answer: C — Allodynia is pain from a normally non-painful stimulus (e.g., light touch) .
4. The wind-up phenomenon in chronic pain is mediated primarily by which receptor in
dorsal horn neurons?
A. GABA-A receptor
B. Mu-opioid receptor
C. NMDA receptor
D. Alpha-2 adrenergic receptor
Answer: C — Wind-up is a progressive increase in dorsal horn neuron response to repeated
C-fiber stimulation, mediated by NMDA receptor activation .
5. The descending pain modulation system originates primarily in which brainstem region?
A. Substantia nigra
B. Periaqueductal gray (PAG) and rostral ventromedial medulla (RVM)
C. Nucleus tractus solitarius
D. Locus coeruleus only
Answer: B — The PAG projects via the RVM to the dorsal horn, releasing serotonin and
norepinephrine .
, 2
6. Which best characterizes nociplastic pain?
A. Pain due to direct tissue injury
B. Pain from a lesion of the somatosensory nervous system
C. Altered nociception without clear evidence of tissue damage or somatosensory lesion
D. Pain from psychiatric disease only
Answer: C — IASP added nociplastic pain in 2017 as a third descriptor; fibromyalgia and IBS
are prototypical examples .
7. One of the effects created by activation or increased release of substance P is:
A. Vasoconstriction
B. Membrane stabilization
C. Analgesia
D. Vasodilation
Answer: D — Substance P causes vasodilation and plasma extravasation in neurogenic
inflammation .
8. Which opioid receptor is primarily responsible for analgesia?
A. Delta
B. Kappa
C. Mu
D. Nociceptin
Answer: C — Mu-opioid receptor activation produces the primary analgesic effects of
opioids.
9. Which enzyme is primarily responsible for the metabolism of codeine to morphine?
A. CYP3A4
B. CYP2D6
C. CYP1A2
D. CYP2C9
Answer: B — Codeine is a prodrug converted to morphine via CYP2D6.
10. Which local anesthetic has the longest duration of action?
A. Lidocaine
B. Mepivacaine
C. Bupivacaine
D. Chloroprocaine
Answer: C — Bupivacaine has the longest duration among commonly used local anesthetics.
11. The maximum dose of lidocaine without epinephrine is:
A. 3 mg/kg
B. 4.5 mg/kg
C. 7 mg/kg
D. 10 mg/kg
, 3
Answer: B — Maximum lidocaine without epinephrine is 4.5 mg/kg (7 mg/kg with
epinephrine).
12. Which receptor is the target of gabapentin?
A. GABA-A
B. Alpha-2-delta subunit of voltage-gated calcium channels
C. NMDA
D. Mu-opioid
Answer: B — Gabapentin binds the alpha-2-delta subunit to reduce neurotransmitter
release .
13. Which is the primary mechanism of action of tricyclic antidepressants in pain?
A. Serotonin reuptake inhibition only
B. Norepinephrine reuptake inhibition only
C. Combined serotonin and norepinephrine reuptake inhibition
D. Dopamine antagonism
Answer: C — TCAs inhibit both serotonin and norepinephrine reuptake .
14. Which antiarrhythmic has been used as an adjuvant analgesic for neuropathic pain?
A. Amiodarone
B. Mexiletine
C. Adenosine
D. Digoxin
Answer: B — Mexiletine, an oral lidocaine analog, has been used for neuropathic pain .
15. Which medication is a neurolytic agent used for chemical sympatholysis?
A. Bupivacaine
B. Phenol
C. Ketamine
D. Clonidine
Answer: B — Phenol is a neurolytic agent used for chemical ablation .
ASSESSMENT & PSYCHOLOGY OF PAIN (Q16–25)
16. Which validated tool screens for opioid misuse risk prior to prescribing?
A. PHQ-9
B. Opioid Risk Tool (ORT) or SOAPP-R
C. CAGE-AID alone
D. Wong-Baker FACES
Answer: B — ORT and SOAPP-R are validated for pre-prescribing risk stratification .
17. The depression commonly seen in chronic pain of nonmalignant origin differs from
typical major depression in that it is more likely to include:
