Cancer Pain Management — MCQs

10 questions

Isotopes used in the relief of metastatic bone pain include – a) Strontium–89 b) I–131 c) Gold–198 d) P–32 e) Rhenium–186

A patient after undergoing thoracotomy complains of severe pain. The BEST method of pain control in this patient would be:

Which of the following is a pure opioid antagonist?

Which of the following is not a prokinetic?

Which of the following is true about coeliac plexus block?

What is the primary mechanism of action of opioids in pain management?

Which of the following pain medications requires the MOST caution in a patient with a history of opioid addiction?

Celiac plexus block all the following is true Except

Q10

A two month old infant has undergone a major surgical procedure. Regarding postoperative pain relief which one of the following is recommended:

Cancer Pain Management Indian Medical PG Practice Questions and MCQs

Question 1: Isotopes used in the relief of metastatic bone pain include – a) Strontium–89 b) I–131 c) Gold–198 d) P–32 e) Rhenium–186

A. ade (Correct Answer)
B. acd
C. abd
D. ad

Explanation: ***Strontium-89, Phosphorus-32, and Rhenium-186 (ade)*** - **Strontium-89**, **Phosphorus-32**, and **Rhenium-186** are all **beta-emitting radioisotopes** with bone-seeking properties that selectively localize to areas of increased osteoblastic activity in bone metastases. - These isotopes are **FDA-approved** and widely used for **metastatic bone pain relief**, delivering targeted radiation therapy to reduce pain while minimizing systemic toxicity. *Strontium-89, Gold-198, and Phosphorus-32 (acd)* - While **Strontium-89** and **Phosphorus-32** are correct, **Gold-198** is primarily used for **localized brachytherapy** applications rather than systemic bone pain management. - **Gold-198** does not have the same bone-seeking properties and is not commonly indicated for widespread metastatic bone pain relief. *Strontium-89, Iodine-131, and Phosphorus-32 (abd)* - **Strontium-89** and **Phosphorus-32** are appropriate choices, but **Iodine-131** is primarily used for **thyroid cancer treatment** and **hyperthyroidism**. - **Iodine-131** lacks bone-seeking properties and is not indicated for metastatic bone pain management. *Strontium-89 and Phosphorus-32 (ad)* - This option correctly identifies **Strontium-89** and **Phosphorus-32** as effective radioisotopes for bone pain relief. - However, it omits **Rhenium-186**, which is another well-established and **FDA-approved** isotope for metastatic bone pain, making this option incomplete.

Question 2: A patient after undergoing thoracotomy complains of severe pain. The BEST method of pain control in this patient would be:

A. Oral morphine
B. Diazepam rectal suppository
C. Intercostal cryoanalgesia (Correct Answer)
D. IV fentanyl

Explanation: ***Intercostal cryoanalgesia*** - **Intercostal cryoanalgesia** involves applying extreme cold to the intercostal nerves, leading to temporary nerve denervation and prolonged pain relief. This technique is particularly effective for **post-thoracotomy pain** due to its targeted action and reduced systemic side effects compared to opioids. - The goal is to provide **long-lasting pain control** specifically at the surgical site, allowing for better respiratory mechanics and early mobilization. *Oral morphine* - Oral morphine can provide systemic pain relief, but its onset of action is slower, and it carries the risk of significant **sedation** and **respiratory depression**, which are major concerns in a patient who has just undergone thoracotomy. - While effective, it may not provide optimal local pain control for incisional pain and often requires higher doses to achieve adequate relief, increasing the risk of adverse effects. *Diazepam rectal suppository* - Diazepam is a **benzodiazepine** primarily used for anxiety, muscle spasms, and seizures, not for severe acute surgical pain. It has **no significant analgesic properties**. - Its sedative effects would be contraindicated after thoracotomy due to the risk of respiratory depression and masking potential neurological changes. *IV fentanyl* - IV fentanyl is a potent opioid with a rapid onset and short duration of action, making it useful for breakthrough pain or during immediate post-operative periods. However, it requires **continuous monitoring** and frequent re-dosing. - Like other opioids, it carries risks of **respiratory depression**, nausea, and sedation, making it less ideal for sustained primary pain control immediately after thoracotomy where lung function is critical.

Question 3: Which of the following is a pure opioid antagonist?

A. Naloxone (Correct Answer)
B. Buprenorphine
C. Pentazocine
D. Morphine

Explanation: ***Naloxone*** - **Naloxone** is a pure opioid antagonist that rapidly reverses the effects of opioid agonists by competing for opioid receptor binding sites [1,2]. - It has a high affinity for μ-opioid receptors and acts as a competitive antagonist [1], making it clinically useful for treating **opioid overdose**. *Buprenorphine* - **Buprenorphine** is a **partial opioid agonist** at the μ-opioid receptor and an antagonist at the κ-opioid receptor [4]. - It can precipitate withdrawal in opioid-dependent individuals if administered while full agonists are present due to its partial agonistic activity. *Pentazocine* - **Pentazocine** is a **mixed opioid agonist-antagonist**, acting as a partial agonist or antagonist at μ-opioid receptors and an agonist at κ-opioid receptors. - Its effects can vary, including analgesia (kappa agonism) and potential for withdrawal symptoms in opioid-dependent individuals (mu antagonism). *Morphine* - **Morphine** is a potent **full opioid agonist** that primarily acts on μ-opioid receptors, producing analgesia, sedation, and euphoria [3]. - It does not block opioid receptors; instead, it activates them, leading to its therapeutic and adverse effects.

Question 4: Which of the following is not a prokinetic?

A. Macrolides
B. D2 blocker
C. 5HT4 agonist
D. Loperamide derivative (Correct Answer)

Explanation: **Loperamide derivative** - **Loperamide** is an **opioid receptor agonist** that acts on the mu-opioid receptors in the gut, primarily to **decrease gastrointestinal motility** and treat diarrhea. - Its mechanism of action directly opposes that of prokinetic agents, which aim to increase GI motility. *Macrolides* - Certain macrolide antibiotics, particularly **erythromycin**, act as **motilin receptor agonists** at low doses. - This agonism leads to increased gastric motility and can be used as a prokinetic in conditions like gastroparesis. *D2 blocker* - **Dopamine D2 receptor antagonists** (e.g., **metoclopramide**, **domperidone**) block the inhibitory effect of dopamine on cholinergic smooth muscle. - This blockade enhances acetylcholine release, leading to increased gastrointestinal motility and prokinetic effects. *5HT4 agonist* - **Serotonin 5-HT4 receptor agonists** (e.g., **cisapride**, **prucalopride**) stimulate the release of acetylcholine and other excitatory neurotransmitters in the enteric nervous system. - This action promotes increased gastrointestinal motility, making them effective prokinetic agents.

Question 5: Match the following drugs in Column A with their contraindications in Column B. | Column A | Column B | | :-- | :-- | | 1. Morphine | 1. QT prolongation | | 2. Amiodarone | 2. Thromboembolism | | 3. Vigabatrin | 3. Pregnancy | | 4. Estrogen preparations | 4. Head injury |

A. A-1, B-3, C-2, D-4
B. A-4, B-1, C-3, D-2 (Correct Answer)
C. A-3, B-2, C-4, D-1
D. A-2, B-4, C-1, D-3

Explanation: ***A-4, B-1, C-3, D-2*** - **Morphine** is contraindicated in **head injury** as it can increase intracranial pressure and mask neurological symptoms. - **Amiodarone** is contraindicated in patients with **QT prolongation** due to its risk of inducing more severe arrhythmias like Torsades de Pointes. - **Vigabatrin** is contraindicated during **pregnancy** due to its potential for teratogenicity and adverse effects on fetal development. - **Estrogen preparations** are contraindicated in patients with a history of **thromboembolism** due to their increased risk of blood clot formation. *A-1, B-3, C-2, D-4* - This option incorrectly matches **Morphine** with QT prolongation and **Estrogen preparations** with head injury, which are not their primary contraindications. - It also incorrectly links **Vigabatrin** with thromboembolism and **Amiodarone** with pregnancy. *A-3, B-2, C-4, D-1* - This choice incorrectly associates **Morphine** with pregnancy and **Vigabatrin** with head injury, which are not the most critical or direct contraindications. - It also misaligns **Amiodarone** with thromboembolism and **Estrogen preparations** with QT prolongation. *A-2, B-4, C-1, D-3* - This option incorrectly matches **Morphine** with thromboembolism and **Amiodarone** with head injury, which are not their most significant contraindications. - It also incorrectly links **Vigabatrin** with QT prolongation and **Estrogen preparations** with pregnancy.

Question 6: Which of the following is true about coeliac plexus block?

A. Usually done unilaterally
B. Most common side effects include diarrhea and hypotension (Correct Answer)
C. Located retroperitoneally at the level of L3
D. Useful for painful conditions of the lower abdomen

Explanation: ***Most common side effects include diarrhea and hypotension*** - A coeliac plexus block interrupts **sympathetic innervation** to the upper abdominal organs, which can lead to parasympathetic dominance. - This imbalance often results in **increased gastrointestinal motility (diarrhea)** and **vasodilation (hypotension)** as common side effects. *Located retroperitoneally at the level of L3* - The coeliac plexus is typically located **retroperitoneally** at the level of the **T12-L1 vertebrae**, not L3. - Its position is generally superior to the renal arteries, which are closer to L1-L2. *Usually done unilaterally* - A coeliac plexus block is almost always performed **bilaterally** or with a single posterior approach aiming for bilateral spread to effectively block the plexus. - The coeliac plexus is an extensive network, and a unilateral block would likely provide inadequate pain relief. *Useful for painful conditions of the lower abdomen* - The coeliac plexus primarily innervates **upper abdominal organs** (e.g., pancreas, liver, stomach, small intestine, kidneys, adrenal glands). - It is therefore generally **ineffective for lower abdominal pain**, which is innervated by different sympathetic plexuses (e.g., superior and inferior hypogastric plexuses).

Question 7: What is the primary mechanism of action of opioids in pain management?

A. Inhibition of cyclooxygenase (COX) enzymes
B. Activation of opioid receptors in the spinal cord only
C. Activation of opioid receptors in the brain only
D. Activation of opioid receptors at both spinal and supraspinal levels (Correct Answer)

Explanation: ***Activation of opioid receptors at both spinal and supraspinal levels*** - Opioids primarily exert their analgesic effects by binding to and activating **mu (μ), delta (δ), and kappa (κ) opioid receptors** located throughout the central nervous system, including the brain and spinal cord. - Activation of these receptors modulates **pain perception**, emotional responses to pain, and descending pain inhibitory pathways. *Inhibition of cyclooxygenase (COX) enzymes* - This is the primary mechanism of action for **Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)**, not opioids. - NSAIDs reduce pain, inflammation, and fever by blocking the synthesis of **prostaglandins**. *Activation of opioid receptors in the spinal cord only* - While opioids do activate receptors in the spinal cord to inhibit **pain transmission**, their action is not confined to this area. - Significant **supraspinal analgesic effects** contribute to their overall pain-relieving properties, affecting higher brain centers involved in pain processing. *Activation of opioid receptors in the brain only* - Opioids act on opioid receptors in the brain to modulate pain perception and emotional aspects of pain, but they also have crucial effects at the **spinal cord level**. - Their action at the spinal cord level helps to prevent pain signals from reaching the brain, making **both levels crucial** for their comprehensive pain management.

Question 8: Which of the following pain medications requires the MOST caution in a patient with a history of opioid addiction?

A. Morphine (Correct Answer)
B. Oxycodone
C. Methadone
D. Buprenorphine

Explanation: ***Morphine*** - Morphine is a **full mu-opioid agonist** with the highest potential for **abuse, dependence, and relapse** in patients with a history of opioid addiction due to its strong **euphoric effects**. - It carries the greatest risk of triggering **addictive behaviors** and relapse in recovering patients, making it require the MOST caution in this population. - Use should be avoided if possible, or limited to short-term use under strict supervision with alternative analgesics preferred. *Oxycodone* - Oxycodone is another **potent full opioid agonist** with very high abuse potential, nearly equivalent to morphine. - While requiring extreme caution, morphine remains the prototypical high-risk opioid in addiction-prone patients. *Methadone* - Methadone is a **long-acting full opioid agonist** used in opioid maintenance therapy with significant abuse potential. - However, when used appropriately in supervised programs, it has a role in addiction treatment, though acute pain prescribing requires caution due to its **long half-life and QTc prolongation risk**. *Buprenorphine* - Buprenorphine is a **partial mu-opioid agonist** with a **ceiling effect** that limits respiratory depression and euphoria. - It is the **standard medication for opioid use disorder treatment** and has LOWER abuse potential than full agonists. - While it requires careful timing to avoid precipitated withdrawal in opioid-dependent patients, it is actually SAFER than full agonists in patients with addiction history due to reduced relapse risk.

Question 9: Celiac plexus block all the following is true Except

A. Cause hypotention
B. Can be used to provide anesthesia for intra abdominal surgery
C. Relieved pain from gastric malignancy
D. Can be given only by retrocrural (classic) approach (Correct Answer)

Explanation: ***Can be given only by retrocrural (classic) approach*** - The celiac plexus block can be performed using various approaches, including **retrocrural (classic)**, **transcrural**, **anterior**, and **endoscopic ultrasound (EUS)-guided** techniques. - The choice of approach depends on patient anatomy, desired outcome, and the physician's expertise, making the statement of "only" a specific approach incorrect. *Cause hypotension* - **Hypotension** is a common side effect of celiac plexus block due to the blockade of **sympathetic innervation** to the splanchnic circulation, leading to vasodilation. - This effect is often managed with intravenous fluids and vasopressors if necessary. *Can be used to provide anesthesia for intra abdominal surgery* - Celiac plexus blocks are primarily used for **analgesia** in patients with chronic abdominal pain, particularly from **visceral malignancies**, not as the sole anesthetic for major intra-abdominal surgery. - While it can provide significant pain relief, it does not induce the level of muscle relaxation or unconsciousness required for surgical anesthesia. *Relieved pain from gastric malignancy* - The celiac plexus innervates many abdominal organs, including the stomach, pancreas, and liver, making its blockade effective in relieving **visceral pain** originating from these structures. - It is a well-established intervention for managing severe **pain associated with gastric** and pancreatic malignancies.

Question 10: A two month old infant has undergone a major surgical procedure. Regarding postoperative pain relief which one of the following is recommended:

A. Spinal narcotics intrathecal route
B. Intravenous narcotic infusion in lower dosage (Correct Answer)
C. Only paracetamol suppository is adequate
D. No medication is needed as infant does not feel pain after surgery due to immaturity of nervous system

Explanation: ***Intravenous narcotic infusion in lower dosage*** - **Intravenous narcotic infusion** provides continuous pain relief and allows for careful titration of the dose, which is crucial in infants due to their developing metabolism and increased sensitivity to opioids. - Lower dosages are recommended because infants have a **reduced capacity for drug metabolism** and excretion, making them more susceptible to side effects like respiratory depression. *Spinal narcotics intrathecal route* - While effective, the **intrathecal route** carries risks such as neurotoxicity and spinal cord injury, which are particularly concerning in infants due to their small size and developing neural structures. - The **pharmacokinetics** of intrathecal narcotics can also be unpredictable in infants, leading to potential for delayed respiratory depression. *Only paracetamol suppository is adequate* - For **major surgical procedures**, a single agent like **paracetamol** is typically insufficient to manage severe postoperative pain effectively. - While paracetamol is a useful adjunct, it lacks the potent analgesic effects of opioids needed for comprehensive pain control after significant surgery. *No medication is needed as infant does not feel pain after surgery due to immaturity of nervous system* - This statement is **incorrect** and a dangerous misconception; infants, even neonates, have a **fully developed pain pathway**, perceive pain, and require appropriate analgesia. - The **pain response** in infants can be more exaggerated due to an immature inhibitory pain system, necessitating careful and effective pain management.

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