BCPS pain management and palliative care: opioids, conversions and comfort

Study cases written by our editors, not BPS items. The real BCPS exam is computer-based multiple choice, answered in order with no going back.

1. Case 01

   A 68-year-old woman with type 2 diabetes reports 6 months of burning pain in both feet that disrupts her sleep and is diagnosed with painful diabetic peripheral neuropathy. She also has major depressive disorder that is currently untreated (PHQ-9 score 14). CrCl is 72 mL/min. She takes metformin and lisinopril. Which medication is most appropriate to start?

   1. AOption A: Tramadol 50 mg every 6 hours as needed
   2. BOption B: Amitriptyline 50 mg at bedtime
   3. COption C: Pregabalin 75 mg twice daily
   4. DOption D: Duloxetine 30 mg daily, then 60 mg

   Pick an option: the verdict and a note on every option open here.

   Best answer: D.

   Duloxetine is a first-line agent for painful diabetic neuropathy (ADA) and also treats her untreated major depression, so one drug addresses both problems; starting at 30 mg improves GI tolerance before titration to 60 mg. Pregabalin is also first-line for neuropathic pain but leaves the depression untreated. Amitriptyline is strongly anticholinergic and on the Beers list for adults 65 years and older, and tramadol is not first-line for neuropathic pain and adds opioid and serotonergic risks.

   A

   Tramadol is not first-line for neuropathic pain and adds opioid and serotonergic risks.

   B

   Amitriptyline is strongly anticholinergic and on the Beers list at 68, especially at 50 mg.

   C

   Pregabalin treats the neuropathic pain but leaves her untreated depression unaddressed.

   D

   Correct: duloxetine treats both painful neuropathy and depression, and starting at 30 mg eases GI effects before the 60 mg target.

2. Case 02

   An 84-year-old woman with stage D HFrEF (LVEF 15%) is enrolling in home hospice. Her goals are to stay comfortable at home and avoid rehospitalization. BP is 112/68 mm Hg, K 4.3 mEq/L, SCr 1.3 mg/dL. Medications: sacubitril/valsartan 24/26 mg twice daily, metoprolol succinate 50 mg daily, furosemide 40 mg twice daily, and atorvastatin 80 mg daily. Which medication is most appropriate to discontinue first?

   1. AOption A: Sacubitril/valsartan
   2. BOption B: Atorvastatin
   3. COption C: Furosemide
   4. DOption D: Metoprolol succinate

   Pick an option: the verdict and a note on every option open here.

   Best answer: B.

   Aligning therapy with comfort-focused goals means removing drugs whose time to benefit exceeds her life expectancy and that do not relieve symptoms; a statin fits that description. Furosemide controls congestion and dyspnea and is central to keeping her comfortable at home. Abrupt beta-blocker withdrawal can provoke tachycardia and worsening symptoms, and the ARNI, tolerated at her current BP, still reduces symptoms and HF admissions.

   A

   The ARNI is tolerated at her BP and still reduces symptoms and admissions, so it is not the first to go.

   B

   Correct: a statin’s benefit takes longer than her life expectancy and relieves no symptoms, so it is stopped first.

   C

   Furosemide controls congestion and dyspnea, which is central to keeping her comfortable at home.

   D

   Abrupt beta-blocker withdrawal can provoke tachycardia and worsen symptoms, so it is not stopped first.

3. Case 03

   A hospice patient with metastatic lung cancer has had good pain control on morphine ER 30 mg orally every 12 hours with no breakthrough doses. He can no longer swallow, and the team will start a continuous subcutaneous morphine infusion at home. Using an oral-to-parenteral morphine ratio of 3:1, which infusion rate is most appropriate?

   1. AOption A: Morphine 5 mg/hr SC
   2. BOption B: Morphine 2.5 mg/hr SC
   3. COption C: Morphine 0.8 mg/hr SC
   4. DOption D: Morphine 0.4 mg/hr SC

   Pick an option: the verdict and a note on every option open here.

   Best answer: C.

   His oral morphine is 60 mg/day; dividing by 3 gives 20 mg/day parenterally, or about 0.8 mg/hr, with breakthrough doses per the hospice protocol. A rate of 2.5 mg/hr (60 mg/day) ignores oral bioavailability and triples his exposure. A 0.4 mg/hr rate applies an unnecessary cross-tolerance reduction—that reduction is for switching to a different opioid, not changing routes of the same drug—and 5 mg/hr divides the oral daily dose by 12 instead of converting it.

   A

   Five mg/hr results from dividing the oral daily dose by 12 instead of converting it, a large overdose.

   B

   A rate of 2.5 mg/hr equals 60 mg/day parenterally and ignores oral bioavailability, tripling his exposure.

   C

   Correct: 60 mg of oral morphine a day divided by 3 is 20 mg parenterally, about 0.8 mg per hour.

   D

   Cutting again for cross-tolerance applies when changing to a different opioid, not when changing the route of morphine.

4. Case 04

   A 46-year-old man with a traumatic brain injury and a small cerebral contusion is intubated and needs hourly neurologic examinations. Pain from rib fractures is partly controlled with a fentanyl infusion, and the team wants a multimodal adjunct to reduce opioid needs. Platelets are 150,000 cells/mm³ and SCr is 0.8 mg/dL. Which adjunct is most appropriate?

   1. AOption A: Gabapentin 300 mg via tube three times daily
   2. BOption B: Meperidine 25 mg IV every 3 hours as needed
   3. COption C: Ketorolac 15 mg IV every 6 hours
   4. DOption D: Acetaminophen 650 mg via tube every 6 hours

   Pick an option: the verdict and a note on every option open here.

   Best answer: D.

   Scheduled acetaminophen is an opioid-sparing analgesic without antiplatelet, sedative or ICP effects, so it suits a patient with an intracranial contusion who needs frequent neurologic examinations. Ketorolac is the tempting potent non-opioid, but NSAIDs impair platelet function and are generally avoided with intracranial hemorrhage. Meperidine’s metabolite normeperidine lowers the seizure threshold, and gabapentin adds sedation that clouds neurologic examination.

   A

   Gabapentin adds sedation that clouds the hourly neurologic examinations he needs.

   B

   Meperidine’s metabolite normeperidine lowers the seizure threshold, a real hazard after brain injury.

   C

   Ketorolac impairs platelet function and is generally avoided with an intracranial contusion.

   D

   Correct: scheduled acetaminophen spares opioids without antiplatelet or sedative effects that would complicate the brain injury.

5. Case 05

   A 70-year-old hospice patient with ovarian cancer has complete malignant bowel obstruction confirmed on CT. Surgery is not an option. She has colicky abdominal pain and vomits several times a day. She has a subcutaneous line and cannot keep oral medications down. Which antiemetic is most appropriate?

   1. AOption A: Prochlorperazine 10 mg orally every 6 hours
   2. BOption B: Dronabinol 2.5 mg orally twice daily
   3. COption C: Haloperidol 1 mg SC every 8 hours
   4. DOption D: Metoclopramide 10 mg SC every 6 hours

   Pick an option: the verdict and a note on every option open here.

   Best answer: C.

   In complete malignant bowel obstruction, haloperidol is the preferred antiemetic because it acts centrally without increasing gut motility and can be given SC; it is often combined with octreotide to reduce secretions. Metoclopramide is the usual first choice for chronic nausea from gastric stasis, but as a prokinetic it worsens colic and is contraindicated in complete obstruction. Dronabinol and oral prochlorperazine cannot be relied on when she vomits everything she swallows.

   A

   Oral prochlorperazine cannot be relied on when she vomits several times a day and keeps nothing down.

   B

   Dronabinol is oral and weak against obstructive vomiting, so it does not fit here.

   C

   Correct: haloperidol acts centrally without increasing gut motility and can be given SC in complete obstruction.

   D

   Metoclopramide is a prokinetic that worsens colic and is contraindicated in complete obstruction.

6. Case 06

   A 50-year-old man with chronic low back pain has taken oxycodone IR 10 mg every 6 hours for 2 years under a pain treatment agreement. His routine urine immunoassay is negative for opiates, and he states he took his last dose 4 hours ago. Which is the most appropriate next step?

   1. AOption A: Request confirmatory LC-MS/MS testing for oxycodone
   2. BOption B: Repeat the same opiate immunoassay in 1 week
   3. COption C: Taper oxycodone by 50% over the next 2 weeks
   4. DOption D: Discontinue oxycodone because of suspected diversion

   Pick an option: the verdict and a note on every option open here.

   Best answer: A.

   Standard opiate immunoassays target morphine and codeine and frequently miss semisynthetic opioids such as oxycodone, so a negative screen does not prove he is not taking it; definitive LC-MS/MS testing is needed before any conclusion. Stopping or tapering on an unconfirmed result risks withdrawal, uncontrolled pain, and loss of trust. Repeating the same immunoassay simply repeats the same blind spot.

   A

   Correct: opiate immunoassays often miss oxycodone, so confirmatory LC-MS/MS is needed before drawing any conclusion.

   B

   Repeating the same immunoassay simply repeats the same blind spot for semisynthetic opioids.

   C

   Tapering on an unconfirmed result risks withdrawal, uncontrolled pain and loss of trust.

   D

   Discontinuing for suspected diversion acts on a screen that was never designed to detect oxycodone.

7. Case 07

   A 66-year-old woman with knee osteoarthritis has pain of 5/10 despite acetaminophen 1 g three times daily. Two years ago she had a bleeding gastric ulcer while taking naproxen. She has no cardiovascular disease, and CrCl is 70 mL/min. Which analgesic is most appropriate to add?

   1. AOption A: Celecoxib 200 mg daily without a PPI
   2. BOption B: Ibuprofen 400 mg three times daily plus famotidine
   3. COption C: Tramadol 50 mg every 6 hours as needed
   4. DOption D: Diclofenac 1% gel 4 g four times daily

   Pick an option: the verdict and a note on every option open here.

   Best answer: D.

   Topical NSAIDs are strongly recommended for knee osteoarthritis (ACR 2019) and give local pain relief with systemic exposure low enough to suit a patient with a prior ulcer bleed. Celecoxib is tempting because it is COX-2 selective, but after a bleeding ulcer it still needs PPI co-therapy. Standard-dose famotidine does not prevent NSAID-induced gastric ulcers, and tramadol carries falls, seizure and serotonergic risks with weaker benefit.

   A

   Celecoxib after a bleeding ulcer still needs PPI co-therapy, so using it without one is unsafe.

   B

   Standard-dose famotidine does not prevent NSAID gastric ulcers, so ibuprofen stays risky after her bleed.

   C

   Tramadol brings falls, seizure and serotonergic risks with weaker benefit in knee OA.

   D

   Correct: topical diclofenac is strongly recommended for knee OA and keeps systemic exposure low after an ulcer bleed.

8. Case 08

   A 70-year-old hospice patient with metastatic bladder cancer and CrCl 12 mL/min takes morphine IR 10 mg orally every 4 hours. Over 3 days she has developed multifocal myoclonus, new confusion and visual hallucinations; there is no infection or hypercalcemia. Pain was previously well controlled. Which opioid change is most appropriate?

   1. AOption A: Switch to oxycodone
   2. BOption B: Increase morphine to control pain
   3. COption C: Switch to codeine
   4. DOption D: Switch to fentanyl

   Pick an option: the verdict and a note on every option open here.

   Best answer: D.

   Morphine’s active glucuronide metabolites (especially morphine-3-glucuronide) accumulate in renal failure and cause myoclonus, delirium and hallucinations, so rotating to fentanyl, which has no active metabolites and is hepatically cleared, is preferred at CrCl below 30 mL/min. Oxycodone is the tempting alternative, but its metabolites and the parent drug also accumulate and it requires caution in severe kidney disease. Codeine is metabolized to morphine and should be avoided in renal failure, and increasing morphine would worsen the neurotoxicity.

   A

   Oxycodone and its metabolites also accumulate in severe kidney disease, so it is a weaker escape route.

   B

   More morphine adds more neurotoxic glucuronide metabolites and worsens the myoclonus and delirium.

   C

   Codeine is converted to morphine and should be avoided in renal failure.

   D

   Correct: fentanyl has no active metabolites and is cleared by the liver, which suits a CrCl of 12 mL/min.

9. Case 09

   A 40-year-old man with chronic low back pain for 7 months has opioid use disorder in remission and receives methadone 80 mg daily from an opioid treatment program. Ibuprofen 400 mg three times daily gives partial relief, and his pain (6/10) limits work. Imaging shows no red-flag findings. Which addition to his plan is most appropriate?

   1. AOption A: Carisoprodol 350 mg three times daily for spasm
   2. BOption B: Referral for CBT and supervised exercise therapy
   3. COption C: Tramadol 50 mg every 6 hours as needed for pain
   4. DOption D: Oxycodone 5 mg every 6 hours as needed for flares

   Pick an option: the verdict and a note on every option open here.

   Best answer: B.

   For chronic low back pain the ACP and CDC 2022 guidelines make non-drug therapies—exercise, CBT, mindfulness, multidisciplinary rehabilitation—first-line, and they carry no relapse risk for a patient in OUD remission. Adding oxycodone layers a full agonist onto methadone and threatens his recovery. Carisoprodol is metabolized to meprobamate and is widely misused, and tramadol adds opioid and serotonergic effects (with QT and seizure concerns alongside methadone) without addressing the behavioral components of chronic pain.

   A

   Carisoprodol is metabolized to meprobamate and widely misused, a poor addition for someone in OUD remission.

   B

   Correct: exercise therapy and CBT are first-line for chronic low back pain and carry no relapse risk for his OUD.

   C

   Tramadol adds opioid and serotonergic effects, with QT and seizure concerns alongside methadone.

   D

   Adding a full agonist such as oxycodone on top of methadone threatens his recovery.

10. Case 10

    A 55-year-old man with chronic low back pain has taken oxycodone ER for 3 years, increased over the past 6 months from 20 mg to 40 mg twice daily. His pain has become diffuse, now involves areas beyond the back, and is triggered by light touch. There is no new injury and imaging is unchanged. He wants to keep working with the clinic. Which approach is most appropriate?

    1. AOption A: Switch to hydromorphone at the full equianalgesic dose
    2. BOption B: Increase oxycodone ER to 60 mg twice daily
    3. COption C: Stop oxycodone today and start naltrexone 50 mg daily
    4. DOption D: Taper oxycodone slowly and add non-opioid therapy

    Pick an option: the verdict and a note on every option open here.

    Best answer: D.

    Diffuse pain and allodynia that worsen as the opioid dose rises suggest opioid-induced hyperalgesia, which improves with dose reduction; CDC 2022 advises a gradual taper (about 10% per month after long-term use) combined with non-opioid and non-drug therapies. Increasing the dose is the instinctive response but worsens hyperalgesia. Abrupt discontinuation risks withdrawal and overdose on relapse, and rotation at the full calculated dose ignores incomplete cross-tolerance (a 25–50% reduction is needed).

    A

    Rotation at the full calculated dose ignores incomplete cross-tolerance and does not treat hyperalgesia.

    B

    Raising the dose is the instinctive response but worsens opioid-induced hyperalgesia.

    C

    Abrupt discontinuation risks withdrawal, and overdose on relapse, after 3 years of therapy.

    D

    Correct: diffuse allodynia as doses climb suggests hyperalgesia, which improves with a slow taper plus non-opioid therapy.

11. Case 11

    A 52-year-old man with painful diabetic neuropathy has had an adequate 8-week trial of gabapentin titrated to 1,200 mg three times daily with little relief and persistent insomnia from pain. He has alcohol-related cirrhosis (Child-Pugh class B). ECG is normal, he has no glaucoma or urinary retention, and CrCl is 90 mL/min. Which medication is most appropriate?

    1. AOption A: Amitriptyline 10 mg at bedtime
    2. BOption B: Pregabalin 150 mg twice daily
    3. COption C: Topiramate 25 mg orally twice daily
    4. DOption D: Duloxetine 30 mg daily

    Pick an option: the verdict and a note on every option open here.

    Best answer: A.

    Amitriptyline is an effective neuropathic pain agent whose sedation helps pain-related insomnia, and starting at 10 mg at bedtime limits anticholinergic effects in a younger patient with a normal ECG. Duloxetine would otherwise be a first-line choice, but it should be avoided in chronic liver disease and heavy alcohol use because of hepatotoxicity. Pregabalin shares gabapentin’s mechanism, so adequate gabapentin failure predicts little gain, and topiramate lacks good evidence in diabetic neuropathy.

    A

    Correct: low-dose bedtime amitriptyline relieves neuropathic pain and helps pain-related insomnia, with a normal ECG and no glaucoma.

    B

    Pregabalin shares gabapentin’s mechanism, so an adequate gabapentin failure predicts little further gain.

    C

    Topiramate lacks good evidence in diabetic neuropathy.

    D

    Duloxetine would otherwise be first-line, but it should be avoided with chronic liver disease and heavy alcohol use.

12. Case 12

    A 79-year-old man with stage D HFrEF on maximally tolerated GDMT and furosemide 80 mg twice daily has distressing dyspnea at rest. He is euvolemic on exam, SpO2 is 96% on room air, and SCr is 1.2 mg/dL. His goal is comfort at home, and he has declined inotropes and further hospitalization. Which is most appropriate for his dyspnea?

    1. AOption A: Lorazepam 1 mg orally every 6 hours as needed
    2. BOption B: Oral morphine 2.5 mg every 4 hours as needed
    3. COption C: Increase furosemide to 160 mg twice daily
    4. DOption D: Supplemental oxygen at 2 L/min around the clock

    Pick an option: the verdict and a note on every option open here.

    Best answer: B.

    Low-dose oral opioids reduce the sensation of breathlessness in advanced heart failure and fit a comfort-focused plan alongside the GDMT he tolerates. Benzodiazepines are not first-line for dyspnea and add sedation and fall risk. Doubling the loop diuretic in a euvolemic patient causes hypotension and AKI without relieving dyspnea, and oxygen gives no benefit when he is not hypoxemic.

    A

    Benzodiazepines are not first-line for dyspnea and add sedation and fall risk.

    B

    Correct: low-dose oral morphine eases the sensation of breathlessness and fits a comfort-focused plan.

    C

    A higher loop dose in a euvolemic patient brings hypotension and AKI without relieving dyspnea.

    D

    Oxygen gives no benefit for dyspnea when SpO2 is 96% on room air.

13. Case 13

    A 52-year-old patient with chronic low back pain presents prescriptions for oxycodone ER 20 mg every 12 hours (60 MME/day) and continues alprazolam 0.5 mg at bedtime. The prescription is valid and the PDMP shows no other prescribers. Which pharmacist action is most appropriate?

    1. AOption A: Dispense and offer naloxone with overdose counseling
    2. BOption B: Dispense and counsel only on constipation and drowsiness
    3. COption C: Require a taper below 50 MME before dispensing the fill
    4. DOption D: Refuse to dispense because the daily dose exceeds 50 MME

    Pick an option: the verdict and a note on every option open here.

    Best answer: A.

    The CDC 2022 guideline recommends offering naloxone when overdose risk is elevated, such as doses of 50 MME/day or more or concurrent benzodiazepine use, both of which apply here. The 2022 guideline removed hard MME ceilings, so refusing or forcing a taper because of a 50 MME threshold misapplies it and risks harm from abrupt changes. Counseling on adverse effects without naloxone misses the main overdose-prevention step.

    A

    Correct: an opioid plus a benzodiazepine raises overdose risk, so naloxone and overdose counseling come with the fill.

    B

    Counseling on constipation and drowsiness alone misses the main overdose-prevention step.

    C

    CDC 2022 removed hard MME ceilings, and forcing a taper before dispensing risks harm from an abrupt change.

    D

    Refusing a valid prescription over a 50 MME threshold misapplies the 2022 guideline.

14. Case 14

    A 74-year-old woman with knee osteoarthritis, hypertension, and stage 3b CKD (eGFR 38 mL/min/1.73 m²) takes lisinopril 20 mg daily and acetaminophen 1,000 mg three times daily. Knee pain (6/10) now limits her walking, and she has fallen once this year. Which addition to her plan is most appropriate?

    1. AOption A: Tramadol 50 mg every 6 hours as needed
    2. BOption B: Topical diclofenac gel and a physical therapy referral
    3. COption C: Naproxen 500 mg twice daily with a proton pump inhibitor
    4. DOption D: Glucosamine–chondroitin 1,500/1,200 mg daily

    Pick an option: the verdict and a note on every option open here.

    Best answer: B.

    Topical NSAIDs give knee OA relief with minimal systemic exposure, and a physical therapy referral adds strengthening and gait training that also address her fall risk—an interprofessional, multimodal plan. Oral naproxen threatens her renal function and BP control with an ACE inhibitor, and a PPI does not offset that. Tramadol adds falls, hyponatremia, and seizure risk in an older adult, and ACR strongly recommends against glucosamine–chondroitin.

    A

    Tramadol adds falls, hyponatremia and seizure risk in an older adult who has already fallen.

    B

    Correct: topical diclofenac plus physical therapy relieves knee pain with minimal systemic exposure and addresses her fall risk.

    C

    Oral naproxen threatens her kidney function and BP control alongside lisinopril, and a PPI does not offset that.

    D

    ACR strongly recommends against glucosamine–chondroitin for knee osteoarthritis.

15. Case 15

    A 45-year-old patient with chronic low back pain has a substance use disorder in remission for 5 years. Current medications: oxycodone 10 mg as needed (about 30 MME/day), duloxetine 60 mg daily, and occasional ibuprofen. The patient reports moderate pain that limits work, wants better function, and wants to avoid relapse. Which plan is most appropriate?

    1. AOption A: Add PT and CBT, offer naloxone, and plan a shared taper review
    2. BOption B: Add gabapentin 300 mg three times daily and change nothing else
    3. COption C: Increase oxycodone to about 60 MME/day for better function
    4. DOption D: Stop oxycodone today and rely on PT and CBT alone

    Pick an option: the verdict and a note on every option open here.

    Best answer: A.

    A multimodal plan—structured physical therapy and CBT, naloxone, PDMP checks, and periodic shared review of a gradual taper—improves function while lowering relapse and overdose risk, as the CDC 2022 guideline advises. Escalating oxycodone raises overdose and relapse risk without proven functional gain. Abrupt discontinuation risks withdrawal and return to use, and adding gabapentin increases respiratory depression and misuse potential without the behavioral therapies that drive improvement.

    A

    Correct: PT and CBT, naloxone and a shared taper review improve function while lowering relapse and overdose risk.

    B

    Gabapentin adds respiratory depression and misuse potential and leaves out the behavioral therapies that drive improvement.

    C

    Escalating to 60 MME/day raises overdose and relapse risk without proven functional gain.

    D

    Stopping oxycodone abruptly risks withdrawal and a return to use.