Is pain management high yield on the PEBC exam?

Yes. Pain is universal in practice and opioids are a major safety topic, so analgesic selection, opioid safety, neuropathic pain, and palliative care come up often. The exact mix is randomized from one sitting to the next, but pain management is consistently worth strong preparation.

What pain management topics should I focus on for the PEBC?

Focus on analgesic selection by pain type, safe opioid prescribing and equianalgesic conversions, neuropathic pain agents, palliative symptom management, and the basics of opioid use disorder and naloxone. Safety and monitoring are frequent question targets.

Which guidelines should I use for pain management on the PEBC?

The Canadian standard references are the Canadian Guideline for Opioids for Chronic Non-Cancer Pain, and the CRISM guidance for opioid use disorder. The PEBC expects the Canadian approach to safe opioid prescribing and monitoring.

How should I study pain management for the PEBC?

Learn to match the analgesic to the pain type, get comfortable with opioid conversions and monitoring, and know the naloxone and safety counselling.

PEBC Pain Management Practice Questions

Pain management is high yield on the PEBC exam and heavy on safety. Acute and chronic pain, opioids, neuropathic pain, palliative care, and opioid use disorder all show up, and most questions test matching the analgesic to the pain type and prescribing opioids safely.

The questions below are a sample across those areas. Answer one and the breakdown shows where all four options stand, including the safety detail or the pain type that decided it.

Written and reviewed against current Canadian guidelines and references.

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All 4

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How to approach a PEBC pain management question

1Match the analgesic to the pain type: non-opioids and adjuvants for mild or neuropathic pain, with opioids reserved and monitored for the cases that warrant them.
2For opioids, know safe starting doses, equianalgesic conversions, and the monitoring for sedation, respiratory risk, and constipation prophylaxis.
3For neuropathic pain, know the first-line agents such as the gabapentinoids and certain antidepressants.
4Anchor opioid prescribing on the Canadian Guideline for Opioids for Chronic Non-Cancer Pain, and opioid use disorder on the CRISM guidance.
5Watch for the safety flags: interacting CNS depressants, the patient at risk of misuse, and naloxone counselling.

Practice questions

Tap an answer to see why each option is right or wrong.

Question 1Pain Mgmt & Palliative Care

GF is a 48-year-old male with chronic pain receiving opioid therapy. He develops opioid-induced respiratory depression with a respiratory rate of 6 breaths per minute. Which intervention is most appropriate as the immediate next step?

Incorrect · Answer: A

PEBC Yield: Highurgency-referralADR-recognition

A) (Correct)

Correct -- naloxone is an opioid antagonist that can quickly reverse opioid-induced respiratory depression. The opioid should be held and naloxone administered as the immediate intervention for life-threatening respiratory depression.

Supplemental oxygen may provide supportive care but does not address the underlying cause of respiratory depression. Naloxone is the specific antidote for opioid-induced respiratory depression.

Switching opioids is a long-term management strategy. In acute respiratory depression, the priority is immediate reversal with naloxone, not agent substitution.

Dose reduction is appropriate for mild opioid-related sedation but is insufficient for acute respiratory depression with significantly depressed respiratory rate. Immediate reversal is needed.

Question 2Opioid Use Disorder

Which of the following is FALSE regarding naltrexone for alcohol use disorder?

Incorrect · Answer: C

PEBC Yield: Highdrug-selectioncontraindication-check

True — naltrexone is contraindicated in patients currently using opioids or in opioid withdrawal. As an opioid antagonist, it would precipitate severe opioid withdrawal in dependent patients.

True — naltrexone is unique among AUD agents in that it can be used for both abstinence and harm-reduction (reduced consumption) goals. Acamprosate is for abstinence only.

C) (Correct)

FALSE — naltrexone can be started in patients who are still actively drinking, though it is more effective after withdrawal management. It does not require complete abstinence before initiation, unlike disulfiram which requires 48 hours of abstinence.

True — naltrexone is an opioid antagonist that blocks mu-opioid receptors, reducing the rewarding/euphoric effects of alcohol and decreasing cravings.

Question 3Pain Mgmt & Palliative Care

SV is a 52-year-old female on morphine SR 30 mg PO Q12H for chronic cancer pain. She is using morphine IR 10 mg PO Q4H PRN and requires approximately 5 breakthrough doses daily. What is the most appropriate next step in her opioid management?

Incorrect · Answer: B

PEBC Yield: Highdose-adjustmentmonitoring

Using 5 breakthrough doses daily indicates the maintenance dose is inadequate. Continuing without adjustment will result in ongoing poor pain control and is not appropriate.

B) (Correct)

Correct -- when a patient requires breakthrough medication 4-6 times daily, the scheduled maintenance dose should be increased. Her total daily morphine is 60 mg (SR) + 50 mg (5 breakthrough doses) = 110 mg. The SR dose should be recalculated to cover this total daily requirement.

Adding gabapentin may be helpful if a neuropathic component is suspected, but the primary issue is that her opioid maintenance dose is inadequate as evidenced by frequent breakthrough use. The opioid dose should be optimized first.

Switching formulations is premature when the current agent has not been dose-optimized. The morphine SR dose should be increased based on total daily breakthrough requirements before considering a switch.

Question 4Pain Mgmt & Palliative Care

NR is a 40-year-old male taking tramadol 100 mg PO Q6H for chronic pain. He was recently started on sertraline 50 mg daily for depression. Which adverse drug reaction is most likely with this combination?

Incorrect · Answer: D

PEBC Yield: Highdrug-interactionADR-recognition

Opioid withdrawal is associated with abrupt discontinuation or use of mixed agonist-antagonists with pure agonists, not with SSRI co-administration.

QT prolongation is more commonly associated with methadone and buprenorphine among opioids, not tramadol. While SSRIs can prolong QT, this is not the most likely interaction with tramadol specifically.

Hepatotoxicity is not a recognized interaction between tramadol and SSRIs. This adverse effect is more commonly associated with acetaminophen overdose or certain hepatotoxic drugs.

D) (Correct)

Correct -- tramadol has serotonin and norepinephrine reuptake inhibitor activity in addition to its weak mu-opioid agonism. Combining tramadol with an SSRI like sertraline significantly increases the risk of serotonin syndrome. This risk is further elevated in patients over 65 and in CYP2D6 poor metabolizers.

Question 5Opioid Use Disorder

VN is a 55-year-old male with a 20-year history of heavy alcohol use who presents to the ED 12 hours after his last drink. He is tremulous and reports seeing ants crawling on his arms. His PAWSS score is high. Which of the following alcohol withdrawal complications is most likely developing at this time point?

Incorrect · Answer: C

PEBC Yield: Highdiagnosis-classification

Autonomic instability (hypertension, tachycardia, hyperthermia) is a feature of severe withdrawal but typically accompanies delirium tremens at 48+ hours. Early tremor and diaphoresis (0-6 hours) are initial autonomic signs.

Alcohol withdrawal seizures typically occur between 12-48 hours after the last drink. While he is at the early edge of this window, the presenting symptom (tactile hallucinations of insects) is more characteristic of the hallucination phase.

C) (Correct)

Correct — alcohol withdrawal hallucinations (tactile, auditory, and visual) typically occur during the 6-24 hour window after the last drink. Tactile hallucinations of insects (formication) are a classic presentation. At 12 hours post-last drink, this fits the expected timeline.

Delirium tremens typically occurs later in the withdrawal course (48-72+ hours). It is characterized by agitation, confusion, fever, and autonomic instability, not isolated hallucinations at 12 hours.

Question 6Opioid Use Disorder

Which of the following assessment tools is used to PREDICT the severity of alcohol withdrawal before symptoms develop?

Incorrect · Answer: C

PEBC Yield: Highscreeningdiagnosis-classification

CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol, Revised) is used to MONITOR and quantify ongoing withdrawal symptoms (tremor, diaphoresis, anxiety, hallucinations, etc.). It guides benzodiazepine dosing during active withdrawal, not prediction.

PHQ-9 is a depression screening tool and has no role in alcohol withdrawal assessment.

C) (Correct)

Correct — PAWSS (Prediction of Alcohol Withdrawal Severity Scale) is used to stratify risk BEFORE withdrawal develops, determining whether a patient requires outpatient (low risk) or inpatient (high risk) management. It is a predictive tool, unlike CIWA-Ar which monitors active symptoms.

COWS (Clinical Opioid Withdrawal Scale) is used for opioid withdrawal assessment, not alcohol withdrawal. It guides buprenorphine induction timing (typically COWS ≥ 5-8).

Question 7Opioid Use Disorder

LP is a 30-year-old male on sublingual buprenorphine/naloxone 16 mg daily for OUD. He reports dental discolouration that has developed over the past 4 months. Which of the following is the most appropriate counselling to minimize further dental damage?

Incorrect · Answer: C

PEBC Yield: HighcounsellingADR-recognition

Brushing immediately after the sublingual dose can worsen enamel erosion. The acidic sublingual environment temporarily softens enamel, and immediate brushing abrades the weakened surface.

Dental trays during sublingual administration would interfere with drug absorption. The medication needs direct mucosal contact for sublingual bioavailability.

C) (Correct)

Correct — the recommended dental hygiene protocol for sublingual buprenorphine is: rinse mouth with water after dissolving the dose, swish around teeth and gums, and wait at least 1 hour before brushing. This allows saliva to remineralize enamel before mechanical abrasion from brushing.

Switching to methadone solely for dental concerns is disproportionate. Methadone carries its own significant risks (QTc prolongation, no ceiling effect, stricter supervision). Dental management with proper hygiene protocols is the appropriate first step.

Question 8Pain Mgmt & Palliative Care

Which of the following statements about codeine is NOT accurate?

Incorrect · Answer: A

PEBC Yield: Highcontraindication-checkdrug-selection

A) (Correct)

Correct -- this statement is NOT accurate. Codeine should be avoided in advanced CKD because its active metabolites can accumulate, leading to unpredictable and potentially dangerous effects.

This is accurate. Codeine is the least potent commonly used opioid, with 200 mg of codeine being equianalgesic to only 30 mg of oral morphine.

This is accurate. Codeine is a prodrug that requires CYP2D6 metabolism to convert it to its active metabolite morphine. Genetic polymorphisms in CYP2D6 significantly impact the therapeutic effect.

This is accurate. Codeine should be avoided in breastfeeding women due to the risk of morphine accumulation in the infant from maternal CYP2D6 ultra-rapid metabolism.

Question 9Pain Mgmt & Palliative Care

TH is a 55-year-old female with diabetic peripheral neuropathy reporting burning and tingling in both feet. She also has difficulty sleeping due to pain and reports generalized anxiety. Her medical history includes type 2 diabetes and mild renal impairment. Which first-line agent is most appropriate?

Incorrect · Answer: D

PEBC Yield: Highdrug-selectionintraclass-differentiation

Opioids are second-to-third line for neuropathic pain. Starting morphine before trying first-line agents like pregabalin, gabapentin, or duloxetine is not guideline-concordant.

TCAs are first-line for neuropathic pain but carry many limiting anticholinergic side effects and require caution in the elderly. Amitriptyline is a tertiary amine with more side effects than secondary amines.

Duloxetine is first-line for diabetic peripheral neuropathy, but it does not address co-existing anxiety and sleep disturbance as effectively as pregabalin. Additionally, duloxetine should be used with caution in severe renal impairment.

D) (Correct)

Correct -- pregabalin is first-line for diabetic peripheral neuropathy and is particularly useful when co-existing sleep disturbance and anxiety are present. It has linear kinetics, better bioavailability, and faster onset than gabapentin. It is renally cleared so dose adjustment may be needed, but it remains appropriate at adjusted doses.

Question 10Opioid Use Disorder

RS is a 28-year-old female found unresponsive by her roommate. She has shallow breathing, constricted pupils, and cyanotic lips. An empty fentanyl patch is found nearby. Naloxone is administered intranasally. After 5 minutes, she regains consciousness but is drowsy. Which of the following is the most important next step?

Incorrect · Answer: A

PEBC Yield: Highurgency-referralcounselling

A) (Correct)

Correct — naloxone's duration of action (30-90 minutes) is shorter than most opioids, especially fentanyl from a transdermal patch. Hospital observation is mandatory because the patient can re-sedate and develop respiratory depression after naloxone wears off. This is the most critical safety concern.

Discharging a patient after naloxone reversal is dangerous. Naloxone has a duration of only 30-90 minutes, while most opioids (especially fentanyl from transdermal patches) have much longer durations. The patient may re-sedate after naloxone wears off.

She has already responded to the first dose (regained consciousness). A second dose should be given if there is no response after 2-3 minutes, but she is already conscious. The priority is ongoing monitoring, not additional doses.

Buprenorphine induction cannot begin immediately after an overdose. The patient must be medically stable and in mild-moderate opioid withdrawal (COWS ≥ 5-8) before induction. Premature induction risks precipitated withdrawal.

Want the full bank?

These are a sample. The full bank adds full-length cases and timed mock exams.

Sample full case

One patient with several linked questions, the format the real exam uses for case clusters.

JR is a 62-year-old man who comes to the pharmacy complaining of persistent headaches and worsening knee pain. He has hypertension, dyslipidemia, and was treated 2 weeks ago for cellulitis of the right lower leg. His active prescriptions and refill records over the past 90 days show:

Medication	Indication	Last filled	Days supply
Nifedipine XL 60 mg po daily	HTN	62 days ago	30
Atorvastatin 40 mg po at bedtime	Dyslipidemia	28 days ago	30
Acetaminophen 500 mg, 2 tabs po qid prn	Pain	4 days ago	7
Amoxicillin-clavulanate 875/125 mg po bid x 7 days	Cellulitis	14 days ago	7

His BP today is 168/96 mmHg. He says, "I take everything when I remember, and I refill when I run out." There is no record of him picking up nifedipine refills since the last fill, which was for 30 days. He has not been seen by his family physician in 4 months.

Question 1Pain Mgmt & Palliative Care

Reviewing JR's refill history, which assessment is most accurate?

Incorrect · Answer: B

PEBC Yield: Highmonitoringdrug-selectiondeprescribing

Tempting because his pain is described as worsening and acetaminophen alone may be insufficient for chronic OA pain. Wrong as the most accurate statement because escalating to an opioid before addressing the BP and adherence problem skips an essential step. Pain management can be revisited after primary issues are corrected.

B) (Correct)

Correct. The nifedipine fill was 62 days ago for a 30-day supply, meaning he has had no antihypertensive on hand for at least 32 days. His BP today is 168/96 mmHg and he openly states he refills only when reminded. This is a clear primary-non-adherence and refill-non-adherence pattern, which is the most accurate single statement about his current presentation.

Tempting because LDL targets in secondary or high-risk primary prevention may favour higher-intensity statins. Wrong as the most accurate statement here because there are no lipid panels or ASCVD-event details given to support a dose change; the dominant signal is missed antihypertensive doses, not statin titration.

Wrong. Amoxicillin-clavulanate was prescribed as a 7-day course for cellulitis. Long-term continuation would be inappropriate antibiotic stewardship and is not indicated outside of specific suppressive scenarios.

Question 2Pain Mgmt & Palliative Care

JR agrees adherence has been inconsistent. Which initial intervention is most appropriate before escalating any therapy?

Incorrect · Answer: C

PEBC Yield: Highcounsellingdrug-selectionmonitoring

Tempting because his BP is uncontrolled and add-on therapy is a guideline option for true uncontrolled HTN on monotherapy. Wrong as the first step here because the BP is uncontrolled in the setting of demonstrated non-adherence, not refractory disease. Adding a thiazide before fixing adherence will produce hypotension if he resumes both drugs together.

Wrong as the first step. A higher-dose combination has the same problem as adding a thiazide - it treats apparent uncontrolled HTN without addressing the actual cause (missed doses) and risks orthostatic hypotension once adherence improves.

C) (Correct)

Correct. Once non-adherence is identified as the primary driver, the first-line intervention is adherence support - blister-packing or pill-organizer, simplified regimen review, and a short-interval BP follow-up to confirm whether the BP normalizes once he is actually taking the prescribed therapy. Therapy escalation before adherence support risks over-treating once he resumes regular dosing.

Wrong. BP 168/96 mmHg in an asymptomatic patient is uncontrolled hypertension, not hypertensive urgency or emergency. Hypertensive emergency requires evidence of acute end-organ damage. ED referral is over-triage for this presentation.

Question 3Pain Mgmt & Palliative Care

JR also asks if he can take ibuprofen 400 mg po tid daily for his knee pain since acetaminophen is not enough. Which response best reflects appropriate analgesic selection in this patient?

Incorrect · Answer: D

PEBC Yield: Highdrug-interactiondrug-selectioncontraindication-check

Wrong. Daily oral ibuprofen will worsen his already uncontrolled BP, blunt the nifedipine, and add cardiovascular and renal risk. Recommending it as requested without addressing the BP context is inappropriate.

Wrong. Naproxen has the most favourable cardiovascular profile within the oral NSAID class but still raises BP and impairs renal function. In uncontrolled hypertension it is not the most appropriate first step over a topical option.

Wrong. Topical capsaicin can provide modest analgesia for OA but has slow onset (2-4 weeks), causes burning that limits adherence, and lacks the head-to-head efficacy of topical diclofenac for knee OA in OARSI guidelines. It is a reasonable adjunct, not the most appropriate primary recommendation.

D) (Correct)

Correct. In a patient with poorly controlled hypertension, scheduled oral NSAIDs raise BP, blunt antihypertensive effect (especially with calcium channel blockers and ACE inhibitors), and risk renal injury. Topical diclofenac delivers analgesia at the joint with minimal systemic absorption and is guideline-preferred per OARSI for localized knee OA pain in patients with cardiovascular or renal risk.

Full-length cases like this, across every PEBC domain, live in the question bank.

Frequently asked questions

Is pain management high yield on the PEBC exam?: Yes. Pain is universal in practice and opioids are a major safety topic, so analgesic selection, opioid safety, neuropathic pain, and palliative care come up often. The exact mix is randomized from one sitting to the next, but pain management is consistently worth strong preparation.
What pain management topics should I focus on for the PEBC?: Focus on analgesic selection by pain type, safe opioid prescribing and equianalgesic conversions, neuropathic pain agents, palliative symptom management, and the basics of opioid use disorder and naloxone. Safety and monitoring are frequent question targets.
Which guidelines should I use for pain management on the PEBC?: The Canadian standard references are the Canadian Guideline for Opioids for Chronic Non-Cancer Pain, and the CRISM guidance for opioid use disorder. The PEBC expects the Canadian approach to safe opioid prescribing and monitoring.
How should I study pain management for the PEBC?: Learn to match the analgesic to the pain type, get comfortable with opioid conversions and monitoring, and know the naloxone and safety counselling.