Medical Licensing (MD/DO) · Independent exam preparation
FPM Fellowship Examination: Clinical Reasoning Guide Study Guide
Practise pain formulation, neurological triage, safe analgesia and shared decisions across the FPM curriculum, with 60 focused concepts and 20 original MCQ drills.
By CertMedbry · Updated 18 October 2026
Build defensible pain formulations, recognise emergencies, interpret sensory findings and explain treatment choices using a sociopsychobiomedical approach. This selective guide develops 60 clinical and professional concepts across every curriculum domain. Sections 1–3 of the official FPM curriculum define the full examination scope; these concepts do not exhaust its learning outcomes. No topic percentage weights are published, so coverage prioritises meaningful breadth and integration of professional roles with clinical topics.
Try 20 free practice questionsWhat is the exam format?
Check the question types, timing and outline before planning your revision.
Which qualification and pathway does this guide address?
This guide addresses the FPM Fellowship Examination within the FPM Pain Medicine Training Program in Australia and New Zealand. FFPMANZCA denotes the fellowship qualification and postnominals. The program is post-specialist medical training, rather than an entry-to-practice medical licensing examination. Fellowship requires completion of the wider training and assessment requirements, not simply this examination.
ANZCA — Pain Medicine Training Program · FPM Training Handbook v1.13 — December 2025
What are the current item styles, station count and duration?
The current fellowship examination is oral: four OSCE stations lasting 10 minutes each and four structured viva voce stations lasting 15 minutes each. That gives eight stations and 100 minutes of station time. This arithmetic does not establish the total attendance time, which may include other circuit arrangements. The handbook states that every station carries equal marks.
ANZCA — FPM fellowship exam · FPM Training Handbook v1.13 — December 2025
How many scored and pretest questions are there, and is delivery adaptive?
The fellowship sources describe an eight-station oral examination rather than a numbered MCQ paper. They do not specify a scored-versus-pretest question split or an adaptive delivery model. The listed 2026 sitting is in Melbourne on 14 November. A numerical passing score and examination fee amount are not established by the supplied evidence.
ANZCA — FPM fellowship exam · FPM Training Handbook v1.13 — December 2025
Which curriculum version applies, and are topic weights published?
The examination page links the curriculum labelled for 2026. The document was last updated in December 2025; its register records version 1.8 with September 2025 approval. The accompanying handbook is v1.13, December 2025. No separate day-specific effective date or topic percentage weights are stated. Equal station marks do not establish equal topic weights. Curriculum sections 1–3 guide the examination scope.
ANZCA — FPM fellowship exam · FPM Pain Medicine Training Program Curriculum — December 2025 · FPM Training Handbook v1.13 — December 2025
How does the Foundations MCQ Examination differ from the fellowship examination?
The Foundations MCQ Examination is a separate earlier assessment and an eligibility prerequisite for the fellowship examination. It lasts three hours and contains 150 single-best-answer questions, approximately 100 basic and 50 applied knowledge questions. Those figures do not describe the current fellowship examination. Trainees who passed the former fellowship written section before 2026 are exempt from the foundations assessment.
What happened to descriptions of a written-plus-oral fellowship examination?
Those descriptions refer to the former assessment arrangement. For 2026, the dedicated fellowship examination page and December 2025 handbook establish the oral format, while the separate Foundations MCQ Examination replaces the former written component. These are assessment changes within the fellowship pathway; FFPMANZCA remains the qualification designation.
ANZCA — FPM fellowship exam · ANZCA — Foundations MCQ exam · FPM Training Handbook v1.13 — December 2025
What eligibility requirements are confirmed?
By the published application closing date, candidates must have completed at least six months FTE in the core training stage, completed at least two in-training assessments with the most recent satisfactory and the required supporting workplace feedback, passed the Foundations MCQ Examination, and submitted the approved application with the examination fee. Any applicable historical exemption should be checked against the issuer's rules.
Do these exercises cover other pathways or simulate the oral examination?
The 20 four-option questions are independent learning drills, accompanied by 20 recall cards. They do not reproduce OSCE or viva performance or predict passing. This guide selects the standard FPM training-program fellowship examination pathway. The specialist international medical graduate pathway and optional Procedures Endorsement Program have separate requirements; their arrangements should not be inferred from this guide.
FPM Training Handbook v1.13 — December 2025 · ANZCA — FPM fellowship exam
Independent preparation for the FPM Fellowship Examination in the Australian and New Zealand post-specialist training pathway leading to FFPMANZCA. The qualification, the current oral fellowship examination and the separate Foundations MCQ Examination have different purposes.
Outline used: Current outline verified for 2026: Pain Medicine Training Program Curriculum, last updated December 2025, with version 1.8 recorded in its change register; FPM Training Handbook v1.13, December 2025. No separate day-specific effective date was stated. The workbook label FFPMANZCA names the fellowship qualification and is mapped here to the official FPM Fellowship Examination within that training pathway. The assigned slug is preserved. In 2026 the fellowship examination is oral; the separate Foundations MCQ Examination replaced its former written component.
60 key concepts: understand, apply and avoid the traps
Work through the questions by exam domain. Explain the answer in your own words, try the example, then check the common pitfall.
Conceptual basis of pain medicinenot stated
1.What distinguishes pain from nociception?
Pain is an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage. Nociception is the neural encoding of noxious stimuli. Their relationship is not one-to-one: nociceptive activity does not itself establish a conscious pain experience, and pain cannot be inferred solely from sensory neuron activity. Clinically, a person's report deserves respect even when tissue injury or a conventional investigation cannot explain its intensity.
Apply it
A patient reports severe pain after a wound has healed. Explain that healing and pain processing can follow different courses, then assess sensory findings, function, sleep and context rather than dismissing the report because the scar appears healthy.
Common pitfall: Treating a normal scan as proof that pain is absent confuses an investigation of tissue structure with an assessment of a personal experience.
2.How does a sociopsychobiomedical formulation change care?
A sociopsychobiomedical formulation explains how biological processes, psychological responses and social circumstances interact in this particular person's pain and disability. It connects findings rather than merely listing diagnoses. Relevant elements include nociceptive or neurological disease, sleep, mood, beliefs, work demands, relationships and access to care. The resulting plan should target modifiable contributors and meaningful participation. Psychological or social contributions do not make the pain less real or exclude concurrent disease.
Apply it
A warehouse worker with back pain fears reinjury, sleeps poorly and cannot obtain modified duties. Combine a clinical assessment with graded activity, sleep support and workplace negotiation, linking each intervention to an identified barrier to recovery.
Common pitfall: Adding a psychological referral after completing an exclusively structural explanation preserves a split model and may make the referral feel dismissive or punitive.
FPM Pain Medicine Training Program Curriculum — December 2025
3.How should chronic pain classification inform formulation?
Chronic pain persists or recurs for longer than three months. Chronic primary pain additionally requires significant pain-related emotional distress or functional disability, with no other diagnosis better explaining the presentation. Biological contributors may be present; primary pain does not mean psychologically caused pain. The six secondary categories are chronic cancer-related pain, chronic postsurgical or post-traumatic pain, chronic neuropathic pain, chronic secondary headache or orofacial pain, chronic secondary visceral pain, and chronic secondary musculoskeletal pain. Headache or orofacial, visceral and musculoskeletal presentations also have primary classifications; anatomical location alone does not establish secondary pain. These distinctions follow the [IASP classification definitions](https://www.iasp-pain.org/advocacy/definitions-of-chronic-pain-syndromes/).
Apply it
An adult has eight months of low back pain that substantially restricts work and social participation. Assessment identifies no condition that better accounts for it: chronic primary musculoskeletal pain is appropriate. If inflammatory spinal disease instead explains the pain, classify chronic secondary musculoskeletal pain. Distress and disability can accompany either category.
Common pitfall: Normal imaging alone does not establish chronic primary pain. Establish duration, significant distress or disability, and the absence of a better explanation through clinical assessment. Record mechanisms, function and context alongside classification.
FPM Pain Medicine Training Program Curriculum — December 2025 · IASP — Terminology
4.Why do expectations alter treatment experience?
Treatment context, prior learning and expectations can alter pain experience and reported adverse effects. Placebo effects concern changes attributable to that context; a placebo response includes other changes observed after placebo administration, such as natural history and regression to the mean. Nocebo effects involve adverse expectations and contextual influences. Explain uncertainty and risks accurately while avoiding alarming, deterministic language. Contextual effects can accompany active treatments and do not establish that the underlying pain is imaginary.
Apply it
Before an injection, replace the claim that it will be extremely painful with a balanced explanation of expected sensations, available comfort measures and the patient's ability to ask for a pause during the procedure.
Common pitfall: Improvement after placebo does not prove deception or exclude pathology; the observed response also contains natural fluctuation and effects unrelated to the treatment context.
FPM Pain Medicine Training Program Curriculum — December 2025
5.Which pain mechanism descriptors can coexist?
Nociceptive pain arises from actual or threatened damage to non-neural tissue with activation of nociceptors. Neuropathic pain is caused by a lesion or disease of the somatosensory nervous system. Nociplastic pain arises from altered nociception without clear evidence that tissue damage or somatosensory disease or lesion explains it. These descriptors can coexist within one patient or pain region. Use history and examination to justify each contribution rather than assigning a permanent exclusive label.
Apply it
A patient with knee osteoarthritis also has confirmed diabetic neuropathy and widespread pressure sensitivity. Identify the joint-related and neuropathic contributions, and assess whether broader altered nociception contributes to symptoms beyond either anatomical explanation.
Common pitfall: Calling every pain with burning quality neuropathic bypasses the required evidence of somatosensory disease or lesion and a plausible distribution of the symptoms.
IASP — Terminology · FPM Pain Medicine Training Program Curriculum — December 2025
Pain medicine roles in practicenot stated
6.How does a pain formulation guide measurable goals?
A clinical formulation integrates diagnosis, function and context into an explanation that can guide an individual management plan. Goals should reflect activities and roles the patient values, with a baseline and a review point. Pain intensity remains relevant, but treatment value also depends on participation, sleep, safety and adverse effects. A medication or procedure should have an explicit purpose within the plan, with reassessment of whether its benefits justify its burdens.
Apply it
A patient wants to attend a grandchild's school event. Establish current sitting and walking tolerance, agree achievable increases and review these alongside pain and medication effects, making the family activity the shared treatment target.
Common pitfall: Defining success only as a lower numerical pain score can reward sedation or inactivity while overlooking deterioration in participation and the patient's valued roles.
FPM Pain Medicine Training Program Curriculum — December 2025 · FPM PS01(PM) — Opioid analgesics in chronic non-cancer pain, 2025
7.What makes consent for a pain procedure meaningful?
Informed consent is a decision-making process involving the proposed procedure, expected benefits, material risks, uncertainty and reasonable alternatives, including proceeding without that procedure. Information must suit the patient's needs and allow questions and sufficient consideration. Consent requires capacity and voluntariness; a signature alone cannot demonstrate understanding. Expectations deserve particular attention when evidence is limited or benefit may be temporary. Financial interests and contextual pressures should not distort the discussion or recommendation.
Apply it
A patient arrives expecting a guaranteed cure from an elective injection. Clarify likely outcomes and uncertainty, discuss rehabilitation and other alternatives, check understanding and allow further consideration before asking the patient to decide whether to proceed.
Common pitfall: Obtaining a signed form immediately before sedation cannot compensate for an earlier failure to explain alternatives, material risks or uncertainty about likely benefit.
FPM PS11(PM) — Procedures in Pain Medicine Clinical Care Standard, 2020
8.How is cultural safety assessed in a consultation?
Cultural safety requires reflection on the clinician's assumptions, biases and power within the therapeutic relationship. The patient's experience helps determine whether care is culturally safe; clinician confidence in cultural knowledge is insufficient. Ask about the person's preferences, priorities, family or whānau involvement and barriers to engagement. Apply this individually rather than attributing fixed beliefs to an ethnic group. In pain care, respectful assessment must also recognise historical and structural influences on trust and access.
Apply it
A Māori patient has missed appointments and appears reluctant to discuss medication. Ask about prior care experiences, practical barriers and preferred whānau participation, then agree changes to the consultation rather than assuming that the patient lacks interest.
Common pitfall: Using a cultural checklist to predict an individual's beliefs can reproduce stereotyping, even when the clinician intends to demonstrate cultural awareness and respect.
Medical Council of New Zealand — Statement on cultural safety, October 2019 · FPM Pain Medicine Training Program Curriculum — December 2025
9.When should an interpreter and support person have separate roles?
A support person may provide reassurance or help the patient participate, while an interpreter enables accurate communication across languages. These roles should be clarified, with the patient's agreement to another person's presence and attention to confidentiality. For complex clinical discussions, a competent interpreter reduces dependence on relatives who may filter information or have conflicting interests. Address the patient directly, check understanding and offer an opportunity for private discussion when sensitive matters arise.
Apply it
An adult daughter offers to translate a discussion about pelvic pain and an invasive procedure. Arrange an appropriate interpreter, ask the patient whether the daughter should remain as support and provide time to discuss concerns privately.
Common pitfall: Assuming that a relative's fluent English guarantees accurate interpretation overlooks confidentiality, sensitive information and the possibility that the patient feels unable to disagree.
Medical Council of New Zealand — When another person is present during a consultation, June 2022 · Medical Council of New Zealand — Doctor patient relationship: when another person is present
10.How is number needed to treat calculated?
For a beneficial binary outcome, number needed to treat is the reciprocal of the absolute increase in response probability compared with the specified control. If 50% respond to treatment and 30% to control, the absolute benefit is 0.20 and NNT is five. State the outcome, comparator and follow-up period because NNT changes with these conditions and baseline risk. Interpret benefits alongside harms, precision and applicability rather than treating NNT as a universal property of a drug.
Apply it
In a hypothetical 12-week trial, meaningful functional improvement occurs in 60 of 100 treated patients and 40 of 100 controls. Calculate an absolute benefit of 20 percentage points and an NNT of five for that outcome.
Common pitfall: Using relative improvement in the denominator produces the wrong NNT; comparing values across different outcomes or follow-up periods can also create a misleading ranking.
Cochrane Handbook — Chapter 15: Interpreting results and drawing conclusions
11.How should confidence intervals change treatment interpretation?
A confidence interval describes uncertainty around an estimated treatment effect under the statistical model. Interpretation should consider its width and whether it includes effects that would change clinical decisions, including important benefit, trivial benefit or harm. A result that does not meet a significance threshold does not establish equivalence or absence of benefit. Conversely, statistical significance does not establish a worthwhile clinical effect. Assess precision together with bias, outcome relevance and the patient's circumstances.
Apply it
A small procedure trial estimates modest benefit, but its confidence interval spans worthwhile improvement and slight harm. Explain that the estimate is insufficiently precise to exclude either possibility, then weigh the procedure's burdens against better-established alternatives.
Common pitfall: Calling a nonsignificant result proof that treatments are identical confuses failure to demonstrate a difference with a study designed and powered to establish equivalence.
Cochrane Handbook — Chapter 15: Interpreting results and drawing conclusions
12.How does interdisciplinary care improve a shared plan?
Multidisciplinary care involves contributions from several disciplines; interdisciplinary care integrates those contributions through shared formulation, goals and coordinated decisions. The distinction matters when advice conflicts or responsibility is unclear. Specify who manages medication, rehabilitation, psychological treatment and follow-up, and how progress will be communicated. Patient priorities should connect these activities. A common plan can explain how symptom management supports participation while reducing contradictory messages about movement, damage, medication and expected recovery.
Apply it
A physiotherapist encourages activity while another clinician advises avoiding all painful movement. Convene a shared discussion, agree the clinical safety boundaries and establish consistent activity goals and messaging with the patient and relevant professionals.
Common pitfall: Several referrals do not automatically create interdisciplinary care; without coordination, patients may receive incompatible explanations and carry responsibility for resolving professional disagreements themselves.
FPM Pain Medicine Training Program Curriculum — December 2025
13.How should service governance address incentives and adverse events?
Clinical governance connects professional accountability with systems that support safe, effective and timely care. A service should learn from adverse events, examine processes and measure whether changes improve outcomes. Financial or industry interests that could influence recommendations require recognition, disclosure and management; disclosure alone does not make a biased recommendation acceptable. For pain services, review patient selection, consent, medication safety and follow-up rather than measuring quality solely through activity or procedure volume.
Apply it
After an oversedation event, the service reviews prescribing, handover and observation processes, introduces a targeted change and rechecks outcomes. A clinician with an industry relationship steps back from a related purchasing decision under the organisation's conflict policy.
Common pitfall: Blaming one individual without examining system contributors misses preventable patterns; declaring an industry payment does not remove the obligation to make independent, patient-centred recommendations.
FPM Pain Medicine Training Program Curriculum — December 2025 · Medical Council of New Zealand — Good Medical Practice
14.Which social barriers require active health advocacy?
Health advocacy identifies circumstances that prevent people from accessing or using appropriate care and uses professional influence to address them. Housing insecurity, transport, cost, work conditions, language access and digital exclusion can shape pain-related disability and treatment feasibility. A technically sound plan may fail when these conditions are ignored. Advocacy should respond to the patient's priorities through practical adjustments, coordination or service-level change, while maintaining equitable access and avoiding assumptions about motivation or adherence.
Apply it
A rural patient cannot attend weekly rehabilitation because transport costs exceed their budget. Explore accessible local or remote options, coordinate with community services and revise the plan around available resources while preserving the patient's agreed functional goals.
Common pitfall: Recording missed appointments as nonadherence without exploring access barriers can convert structural disadvantage into an individual blame narrative and perpetuate ineffective care arrangements.
FPM Pain Medicine Training Program Curriculum — December 2025
Mechanisms in the biomedical dimension of painnot stated
15.What separates allodynia from hyperalgesia?
Allodynia is pain caused by a stimulus that does not normally provoke pain, such as light brushing. Hyperalgesia is increased pain from a stimulus that normally provokes pain, such as pinprick. Both are clinical sensory descriptions rather than diagnoses or proof of a single mechanism. Specify the stimulus and compare with an appropriate unaffected area. Their distribution, associated sensory loss and clinical history help distinguish neuropathic, inflammatory and other pain presentations.
Apply it
A healed shingles area hurts when stroked with cotton, while pinprick is markedly more painful than on the opposite side. Document brush allodynia and pinprick hyperalgesia separately, then map the findings against the previous rash and sensory deficits.
Common pitfall: Calling all increased sensitivity allodynia loses the distinction between normally innocuous and normally painful stimuli and weakens the interpretation of the sensory examination.
IASP — Terminology · IASP — Allodynia and Hyperalgesia in Neuropathic Pain
16.How does peripheral sensitisation alter nociceptor responses?
Peripheral sensitisation is increased responsiveness and reduced threshold of nociceptive neurons in the periphery to stimulation of their receptive fields. In an injured or inflamed region, this helps explain heightened pain to mechanical or thermal stimuli. It is a physiological mechanism inferred from an appropriate context rather than a label established by tenderness alone. Distinguish local sensitisation from a broader distribution of altered sensitivity, while recognising that peripheral and central changes may operate together.
Apply it
Following a minor burn, heat and pressure over the injured skin provoke more pain than equivalent stimuli on intact skin. Relate the local change to sensitised peripheral nociceptive processing while checking the wound and monitoring recovery.
Common pitfall: Assuming that tenderness proves ongoing structural deterioration mistakes altered stimulus responsiveness for a direct measure of tissue damage or the severity of the injury.
17.How can central processing amplify pain?
Central sensitisation is increased responsiveness of central nociceptive neurons to normal or subthreshold afferent input. Strengthening of excitatory synapses means that the same incoming afferent activity produces greater postsynaptic depolarisation and neuronal firing. Reduced inhibitory control permits inputs normally suppressed within spinal circuits to recruit nociceptive output. Descending pathways can further amplify transmission through reduced inhibition or increased facilitation. Together, these changes can increase responses to noxious stimuli and allow ordinarily innocuous stimulation to evoke pain. Altered ion-channel function and chemicals released by activated microglia and astrocytes can also increase neuronal excitability. These physiological processes are distinguished from their indirect clinical inference.
Apply it
After a nerve injury, a patient reports pain from brushing and exaggerated pain from pinprick beyond the original injury. These findings demonstrate allodynia and hyperalgesia and are compatible with central amplification. Map sensory changes and assess the underlying lesion and ongoing peripheral input; bedside findings do not directly establish which synaptic or descending mechanisms are operating.
Common pitfall: Allodynia and hyperalgesia describe clinical phenomena rather than a unique mechanism. Neither a questionnaire nor widespread tenderness proves central sensitisation, excludes concurrent disease or independently establishes neuropathic pain.
IASP — Terminology · IASP — Central Mechanisms of Neuropathic Pain, 2 September 2026 · IASP — Allodynia and Hyperalgesia in Neuropathic Pain
18.Which findings support possible neuropathic pain?
Possible neuropathic pain requires a history suggesting a relevant lesion or disease of the somatosensory nervous system and a neuroanatomically plausible pain distribution. Sensory signs in that distribution and confirmatory testing can increase diagnostic certainty. Burning, tingling and electric sensations are useful clues but cannot independently establish neuropathic pain. The examination should assess both loss and gain of sensory function, compare sites and consider whether the proposed neurological process explains the presentation.
Apply it
After a documented nerve injury, a patient reports electric pain in that nerve's territory with reduced pinprick sensation. Map the symptoms and deficits, then identify whether further investigation would clarify the lesion or change management.
Common pitfall: A high neuropathic screening score cannot replace the neurological history and anatomical assessment; similar descriptors may occur without a demonstrable somatosensory lesion or disease.
19.Why can sensory loss and evoked pain coexist?
A somatosensory lesion can impair some sensory functions while also producing abnormal painful responses through altered activity and processing. Reduced detection of touch or pinprick therefore does not exclude allodynia, spontaneous pain or hyperalgesia in the same territory. Record each modality rather than describing the whole area simply as sensitive or numb. The combination of anatomically coherent sensory loss and gain may strengthen a neuropathic formulation, but requires interpretation alongside the history.
Apply it
A patient with post-traumatic nerve injury detects light touch poorly but finds gentle brushing painful in the same region. Document detection loss and brush-evoked pain separately, avoiding the assumption that the apparently conflicting reports are inconsistent.
Common pitfall: Rejecting neuropathic pain because the region is partly numb assumes that nerve injury must produce either complete sensory loss or pain, rather than both.
IASP — Identifying Neuropathic Pain in the Clinic · IASP — Allodynia and Hyperalgesia in Neuropathic Pain
20.How do pain threshold and tolerance differ?
Pain threshold is the minimum intensity of a stimulus perceived as painful. Pain tolerance concerns the maximum intensity of a pain-producing stimulus that a person is willing to accept in a given situation. Both depend on the testing context, and neither is a direct measure of moral strength, tissue damage or credibility. Specify the modality and conditions when interpreting sensory testing, and distinguish detection of a stimulus from its first perception as painful.
Apply it
Two patients identify heat as painful at a similar stimulus level, but one stops testing sooner because of fear after a previous burn. Describe comparable thresholds with different tolerance in that setting, rather than different honesty or resilience.
Common pitfall: Comparing tolerance across patients without considering fear, expectations and testing conditions turns a contextual observation into an unsupported judgment about character or pain validity.
Acute painnot stated
21.How should acute analgesia be assessed through function?
Acute pain assessment should connect pain intensity with the functions needed for recovery, such as breathing deeply, coughing, mobilising and sleeping. Effective analgesia permits these activities without unacceptable sedation or other harms. A comfortable patient at rest may still have disabling movement-evoked pain. Review pain during a relevant task, treatment response and adverse effects together, and reassess for complications when the pain pattern or functional limitation is unexpected.
Apply it
After abdominal surgery, a patient reports mild resting pain but cannot cough or stand. Assess task-related pain and the surgical context, then adjust the multimodal plan toward safe coughing and mobilisation rather than relying on the resting score.
Common pitfall: Escalating opioids until every pain score reaches zero can worsen sedation and delay recovery; accepting a low resting score can also miss inadequate functional analgesia.
Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard, 2022
22.Why combine different acute analgesic approaches?
Multimodal analgesia combines complementary treatments to improve function while limiting individual drug exposure. Paracetamol provides centrally acting analgesia, although its precise mechanism remains incompletely established; excessive exposure can cause hepatotoxicity. Ibuprofen inhibits COX-1 and COX-2, reducing prostaglandin synthesis, but carries gastrointestinal bleeding and renal risks. Morphine activates mu-opioid receptors, providing analgesia with risks including sedation, ventilatory impairment and constipation; renal impairment promotes accumulation of its metabolites. Select treatments according to the patient's comorbidities, procedure and functional needs rather than automatically prescribing every drug class.
Apply it
An older postoperative patient with stage 4 chronic kidney disease, obstructive sleep apnoea and preserved liver function develops increasing sleepiness after morphine. Withhold further opioids, assess consciousness and ventilation immediately, and escalate clinical care according to severity; consider naloxone for ventilatory impairment under the emergency protocol. Support the airway and ventilation when required. After stabilisation, use appropriately dosed regular paracetamol, avoid ibuprofen because of advanced renal disease, and reassess morphine because of metabolite accumulation. Consider suitable regional analgesia to support mobilisation. Adding pregabalin would increase sedation risk alongside opioids without an established indication in this scenario.
Common pitfall: Increasing sedation is a warning of opioid toxicity, even when pain remains substantial. Escalation means escalation of clinical care, not increasing the opioid dose. Check total paracetamol exposure across combination products and assess cumulative sedation, breathing and mobilisation alongside pain relief.
Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard, 2022 · NCI — Cancer Pain (PDQ), health professional version, updated 24 April 2025 · FPM Pain Medicine Training Program Curriculum — December 2025
23.When does opioid-related sedation require urgent action?
Increasing sedation during opioid treatment is a warning of possible opioid-induced ventilatory impairment and requires prompt clinical assessment. Assess consciousness, breathing and relevant observations, stop further opioid delivery as appropriate and escalate according to severity and local emergency arrangements. Review other sedatives and patient risk factors. A pain complaint does not protect against toxicity, and supplemental oxygen can make oxygen saturation an incomplete indicator of ventilation. Restore safety before reconsidering the analgesic regimen.
Apply it
A patient receiving postoperative opioids becomes difficult to rouse despite a satisfactory oxygen saturation on supplemental oxygen. Withhold further opioid administration, obtain urgent assistance and assess ventilation and consciousness before considering any additional analgesic dose.
Common pitfall: Treating a normal oxygen saturation as reassurance can miss ventilatory impairment, particularly during supplemental oxygen; escalating an opioid because pain persists may worsen toxicity.
Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard, 2022
24.How should patient-controlled analgesia safety be planned?
Patient-controlled analgesia requires a patient who can understand and operate the device, an appropriate prescription and equipment, and reliable monitoring of analgesia, sedation and breathing. Patient participation is part of the safety design; other people pressing the button can undermine it. Risk assessment should account for comorbidity and concurrent sedatives. Review whether PCA remains appropriate as cognition, pain and function change, and plan transition to a simpler regimen when feasible.
Apply it
A postoperative patient becomes confused and their relative starts pressing the PCA button while the patient sleeps. Stop this practice, assess the patient and arrange an alternative supervised analgesic plan if safe independent device use is no longer possible.
Common pitfall: Assuming that a lockout interval makes proxy activation safe ignores the patient's impaired ability to regulate dosing and the need to reassess cognition and sedation.
FPM Pain Medicine Training Program Curriculum — December 2025 · Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard, 2022
25.How should regional analgesia fit the recovery and safety plan?
Select regional analgesia through assessment of functional benefit, alternatives, complications and monitoring capacity. Document baseline neurology and the expected sensory distribution, motor effects and duration. Anticoagulant and antiplatelet treatment requires drug- and technique-specific assessment, including catheter-removal timing. Establish oral analgesia before block resolution and reassess function during transition.
Apply it
With a thoracic epidural, stable sensory reduction matching the intended block may be expected; new progressive bilateral leg weakness, saddle sensory loss or severe back pain requires immediate reassessment. Stop the epidural infusion, obtain urgent anaesthetic review and, if compression is suspected, arrange emergency spinal MRI and spinal surgical assessment without waiting for routine block resolution. ANZCA's [PG03, 2026 pilot, sections 5.4–5.7](https://www.anzca.edu.au/getattachment/159a8905-b558-480b-82d7-79a653ff83a0/PS03-Guideline-for-the-management-of-major-regional-analgesia) addresses unexpected deficits, imaging and transition. Separately, perioral numbness and tinnitus progressing to seizure after a bolus suggest systemic local anaesthetic toxicity, as described in [ASRA's clinical discussion](https://asra.com/news-publications/asra-updates/blog-landing/legacy-b-blog-posts/2021/02/01/local-anesthetic-systemic-toxicity-%28last%29-a-problem-based-learning-discussion). Stop local anaesthetic delivery, call resuscitation help, support oxygenation and ventilation, treat seizures with a benzodiazepine and administer 20% lipid emulsion according to the [ASRA LAST checklist](https://asra.com/docs/default-source/guidelines-articles/local-anesthetic-systemic-toxicity-rgb.pdf).
Common pitfall: Effective analgesia does not exclude compression. Do not attribute progressive weakness automatically to the block. Before discharge, confirm adequate ongoing analgesia and provide limb-protection advice, expected recovery information and clear emergency contact instructions.
FPM Pain Medicine Training Program Curriculum — December 2025 · Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard, 2022 · PS41-Guideline-on-acute-pain-management
26.What belongs in an acute pain discharge plan?
Discharge planning should specify the purpose and intended duration of each analgesic, how treatment will reduce as recovery proceeds, relevant adverse effects and who will review persistent needs. Reconcile pre-existing and newly prescribed medicines to avoid duplication. Opioid quantities should reflect individual requirements rather than an automatic standard supply. Provide clear written information about safe use, storage and disposal, and communicate the plan to the next clinician so that short-term prescribing does not become unreviewed continuation.
Apply it
A patient already taking an opioid for chronic pain receives another after surgery. Reconcile both regimens, distinguish baseline treatment from temporary postoperative treatment and document the planned reduction and responsible follow-up clinician before the patient leaves hospital.
Common pitfall: A discharge list without duration, reduction instructions or ownership of review can unintentionally convert temporary postoperative treatment into prolonged prescribing with no shared therapeutic goal.
Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard, 2022
Spinal painnot stated
27.Which spinal symptoms require emergency assessment?
Spinal pain accompanied by new bladder dysfunction, saddle sensory change or progressive neurological deficit requires urgent assessment for serious neurological compression. Infection, fracture and malignancy are other important serious causes when supported by the clinical context. Red flags should trigger reasoned action rather than function as a diagnosis by themselves. Clarify onset, progression and associated findings, perform an appropriate neurological examination and arrange emergency referral when the presentation suggests an evolving neurological emergency.
Apply it
A patient with back pain develops new urinary retention and reduced perineal sensation. Arrange immediate emergency assessment for possible cauda equina compression instead of booking routine physiotherapy or waiting for a standard outpatient imaging appointment.
Common pitfall: Reassurance based on previously uncomplicated back pain is unsafe when new neurological features emerge; an older normal scan cannot exclude a newly developing compressive process.
28.When does imaging add value in low back pain?
Imaging is most useful when clinical assessment suggests serious or specific pathology and the result is expected to influence management. Routine imaging for uncomplicated low back pain can identify incidental abnormalities without clarifying the cause of symptoms. Explain why immediate scanning may not help, while giving clear advice about reassessment if concerning features develop. The decision should follow the history, examination and clinical question rather than pain intensity alone or a request for anatomical certainty.
Apply it
An adult has five days of improving back pain after lifting, a normal neurological examination and no features suggesting serious disease. Explain the limited value of immediate imaging and agree activity advice, follow-up and specific reasons for urgent reassessment.
Common pitfall: Ordering a scan solely to reassure can introduce incidental findings that increase fear and unnecessary intervention without improving the explanation or management of uncomplicated pain.
29.How should degenerative scan findings be interpreted?
A structural abnormality becomes clinically meaningful through concordance with the history, examination and proposed mechanism. Degenerative findings may be incidental and do not independently establish a pain source, prognosis or treatment indication. Assess whether the location and type of abnormality plausibly explain the symptoms and any neurological deficit. Communicate findings in proportion to their significance, avoiding deterministic language that suggests a damaged spine inevitably requires protection, invasive treatment or progressive disability.
Apply it
A scan shows multilevel degeneration, but a patient has diffuse axial pain without focal neurological findings. Explain that the scan does not identify a single responsible level and base the initial plan on clinical assessment and functional needs.
Common pitfall: Choosing the most dramatic radiology phrase as the diagnosis can produce an anatomically precise label with poor clinical validity and an unjustified rationale for intervention.
Australian Commission on Safety and Quality in Health Care — Low Back Pain Clinical Care Standard, 2022 · FPM Pain Medicine Training Program Curriculum — December 2025
30.How do radicular pain and radiculopathy differ?
Radicular pain describes pain related to abnormal activity involving a spinal nerve root or its ganglion. Radiculopathy describes neurological dysfunction attributable to a root, supported by findings such as anatomically coherent weakness, sensory loss or reflex change. They can occur together or separately. Somatic referred pain may also extend into a limb without root dysfunction. Distinguish these possibilities using the symptom pattern and examination rather than treating every episode of radiating leg pain as equivalent.
Apply it
One patient has shooting leg pain without objective deficits; another has little pain but new root-pattern weakness and reflex loss. Describe the first as potentially radicular pain and the second as possible radiculopathy requiring assessment of progression and cause.
Common pitfall: Using sciatica as a complete diagnosis can obscure the presence or absence of neurological dysfunction and whether urgent evaluation of a progressive deficit is required.
FPM Pain Medicine Training Program Curriculum — December 2025 · IASP — Identifying Neuropathic Pain in the Clinic
31.How do psychosocial factors guide spinal rehabilitation?
Fear of movement, distress, low recovery expectations and difficult work circumstances can increase disability and complicate recovery from spinal pain. Assess these alongside biomedical findings rather than waiting until all physical treatments fail. Their presence guides explanation, activity planning and support; it does not prove that symptoms lack a biological contribution. A useful plan helps the patient test safe activity, address barriers and rebuild participation while preserving clear pathways for reassessment of new clinical concerns.
Apply it
A patient avoids walking because they believe every pain flare means disc damage. After assessing clinical safety, explain the distinction between symptoms and injury, agree a tolerable walking baseline and coordinate consistent advice with the rehabilitation team.
Common pitfall: Labelling fear as catastrophising without exploring the patient's understanding may damage trust and leave the belief driving avoidance unchanged despite repeated reassurance or exercise prescriptions.
32.How should spinal procedures be appraised?
Appraise a procedure for a defined clinical syndrome, expected benefit and duration, procedure-specific harms and alternatives. UK NICE NG59 recommends considering epidural local anaesthetic and steroid for acute severe sciatica, while recommending against spinal injections for low back pain. NICE defines acute as less than three months. An epidural targets nerve-root pain through local anaesthetic effects and suppression of inflammation; it does not repair disc degeneration. Benefit may be limited or temporary, and durable functional improvement or avoidance of surgery cannot be promised. These are UK clinical recommendations, not Australian or New Zealand regulatory rules.
Apply it
Compare two patients. One has three weeks of severe leg-dominant pain radiating below the knee in a nerve-root distribution, reproduced by straight-leg raising, without progressive weakness or cauda equina features. An epidural may be considered after assessment and shared decision-making, with goals such as improved walking and participation in rehabilitation. The other has six months of nonspecific axial back pain, no radicular symptoms and degenerative MRI findings. Those findings alone do not justify an epidural; NICE recommends against spinal injections for this presentation. Discuss epidural risks including dural puncture with headache, infection, bleeding or epidural haematoma, and rare neurological injury. Corticosteroid can transiently raise glucose, particularly relevant in diabetes.
Common pitfall: Correct needle placement establishes technical success, not clinical effectiveness. Explain the possibility of no benefit, compare pain and function against baseline, and avoid automatic repeat injections after an ineffective procedure. Review infection, anticoagulant use and diabetes before proceeding, and preserve active rehabilitation as part of the management plan.
FPM PS11(PM) — Procedures in Pain Medicine Clinical Care Standard, 2020 · FPM Pain Medicine Training Program Curriculum — December 2025 · Recommendations | Low back pain and sciatica in over 16s: assessment and management | Guidance | NICE
Problematic substance usenot stated
33.What distinguishes physical dependence from opioid use disorder?
Physical dependence is physiological adaptation that can produce withdrawal when opioid exposure is reduced or stopped. Tolerance is reduced effect with repeated exposure. Opioid use disorder involves a problematic pattern causing clinically significant impairment or distress, assessed using diagnostic criteria. Tolerance and withdrawal occurring solely during appropriate medical treatment do not count toward DSM-5 opioid use disorder criteria. Assess impaired control, consequences and behaviour rather than diagnosing a disorder from long-term prescribing or withdrawal alone.
Apply it
A patient taking a stable prescribed opioid develops sweating and diarrhoea after missed doses but reports no loss of control or related impairment. Recognise possible physical dependence and assess comprehensively rather than automatically diagnosing opioid use disorder.
Common pitfall: Equating withdrawal with addiction can stigmatise expected physiological adaptation; assuming all prescribed use is safe can also miss impaired control and harmful use patterns.
CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022
34.How should concerning opioid use be assessed?
DSM-5 opioid use disorder requires a problematic pattern causing clinically significant impairment or distress, with at least two of eleven criteria within twelve months. Assess systematically: (1) larger amounts or longer use than intended; (2) persistent desire or unsuccessful efforts to control use; (3) substantial time obtaining, using or recovering; (4) craving; (5) recurrent failure of major responsibilities; (6) continued use despite opioid-related interpersonal problems; (7) important activities reduced or abandoned; (8) recurrent physically hazardous use; (9) continued use despite known opioid-related physical or psychological harm; (10) tolerance, meaning markedly increased requirements or diminished effect; and (11) characteristic withdrawal or use to prevent it. Severity is mild with two to three criteria, moderate with four to five, and severe with six or more. Tolerance and withdrawal arising solely during appropriate medical supervision do not count.
Apply it
During the past year, a patient repeatedly used more than intended, unsuccessfully tried to reduce use, experienced craving and repeatedly missed work because of opioid use. These four established criteria support moderate opioid use disorder. Investigate other criteria and coordinate addiction treatment with continuing pain care.
Common pitfall: An early refill alone does not establish the diagnosis. Clarify chronology and consequences without assuming that physical dependence or inadequate analgesia establishes opioid use disorder.
CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022 · FPM Pain Medicine Training Program Curriculum — December 2025
35.Why is medication reconciliation central to opioid safety?
Medication reconciliation establishes what has been prescribed, dispensed and actually taken, including nonprescription substances and medicines obtained elsewhere. Differences may reflect misunderstanding, fragmented care or problematic use and need clarification. Opioids combined with benzodiazepines, alcohol or other central nervous system depressants can increase sedation and respiratory risk. Coordinate prescribers and dispensing points, assess the purpose of each medicine and use jurisdiction-appropriate monitoring systems without treating a database entry as a complete clinical assessment.
Apply it
A patient reports one opioid, but reconciliation identifies another opioid and a nightly benzodiazepine from separate prescribers. Clarify actual use, assess sedation and coordinate a single documented plan with all relevant clinicians and the dispensing pharmacy.
Common pitfall: Assuming a medicine is not being taken because it is absent from one clinic's list misses fragmented prescribing and potentially dangerous pharmacodynamic interactions between sedating agents.
FPM Pain Medicine Training Program Curriculum — December 2025 · CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022
36.How should an opioid reduction be supported?
When opioid harms outweigh benefits, a supported reduction should be individualised, collaborative and accompanied by ongoing pain care. Explore patient concerns, strengthen other treatments and review withdrawal, mood, function and safety during the process. Long-term therapy should not usually be stopped abruptly or reduced rapidly without a compelling immediate safety reason. Tapering is different from treatment for opioid use disorder: if a disorder is present, evidence-based addiction treatment must be offered or arranged.
Apply it
A patient on long-term opioids has poor function and troublesome sedation but fears withdrawal. Agree a gradual, reviewable plan with other pain supports, monitor distress and function, and reassess for opioid use disorder if impaired control becomes apparent.
Common pitfall: Applying a rigid reduction schedule regardless of duration of use, withdrawal or distress can cause avoidable harm and undermine engagement with both pain and addiction care.
CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022 · FPM PS01(PM) — Opioid analgesics in chronic non-cancer pain, 2025
37.When should naloxone and addiction treatment enter the plan?
FPM PS01(PM) advises considering take-home naloxone and accompanying education with all outpatient opioid prescriptions, and recommending them when the oral morphine equivalent daily dose exceeds 40 mg, adjusted for individual risk. These are clinical recommendations, not mandatory prescribing law. Risk assessment also considers previous overdose, concurrent sedatives, sleep-disordered breathing and loss of opioid tolerance; a lower dose does not establish safety. Teach patients and relevant supporters to recognise overdose, summon emergency assistance and administer naloxone. When opioid use disorder is diagnosed, offer or arrange evidence-based medication treatment, including buprenorphine or methadone, alongside continuing pain care. Withdrawal management alone leaves substantial relapse and overdose risk.
Apply it
A patient taking 50 mg oral morphine daily for persistent back pain should be recommended take-home naloxone with education even without a previous overdose. A patient taking a lower equivalent dose who also uses benzodiazepines warrants individual risk assessment and may likewise need naloxone. If assessment establishes opioid use disorder, coordinate medication treatment and pain rehabilitation.
Common pitfall: Treating 40 mg as a legal prescribing limit or a boundary below which overdose cannot occur misrepresents the recommendation. Naloxone provision complements safer prescribing and treatment of opioid use disorder; it does not replace either.
FPM PS01(PM) — Opioid analgesics in chronic non-cancer pain, 2025 · CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022
Visceral painnot stated
38.Why can visceral pain be felt at a distant site?
Visceral pain can be diffuse and referred to somatic regions because central processing receives convergent information from visceral and somatic structures. The perceived location therefore may not identify the organ of origin. Associated organ symptoms, timing, examination and relevant investigations help distinguish visceral nociception from musculoskeletal or neuropathic pain. Referral is a mechanism to consider rather than a reason to bypass assessment for acute pathology, particularly when the pattern is new or changing.
Apply it
A patient reports recurrent pelvic discomfort with pain extending into the back. Explore bowel, bladder and reproductive associations as well as musculoskeletal and neurological findings, rather than assuming the perceived back location establishes a spinal source.
Common pitfall: Localising the disease solely from the point of maximum reported pain overlooks referral and may lead to treatment of a somatic region while missing visceral pathology.
FPM Pain Medicine Training Program Curriculum — December 2025
39.How should persistent pelvic pain be formulated?
Persistent pelvic pain can involve organ pathology, pelvic floor and other musculoskeletal contributions, neuropathic processes and altered nociceptive processing, alongside psychological and social effects. Endometriosis may be important, but lesion-focused explanations alone can miss the mechanisms maintaining pain and disability. Assess menstrual, bowel, bladder and sexual symptoms, previous treatment effects, function and patient priorities. Build an individual plan that addresses identified contributors and coordinates relevant specialties rather than relying on one diagnostic label.
Apply it
A patient remains in pain after endometriosis treatment and reports painful intercourse, bowel symptoms and fear of movement. Reassess the whole presentation, including pelvic floor function and psychosocial consequences, while retaining appropriate review of the underlying disease.
Common pitfall: Persistent pain after lesion treatment does not automatically prove recurrent disease, failed surgery or a psychological cause; each possibility requires assessment within a broader formulation.
FPM PS15(PM) — Persistent pelvic pain including endometriosis-associated pain, 2025
40.How do visceral, abdominal-wall and neuropathic contributions change an abdominal-pain decision?
Visceral pain is often deep, poorly localised and referred; hollow-organ distension or inflammation can provoke it, while sensitisation can make normal organ activity painful. Abdominal-wall somatic pain is usually more focal and worsened by local pressure or movement. Burning or electric pain with sensory loss or allodynia in an anatomically plausible nerve distribution after surgery suggests a neuropathic contribution. These patterns can coexist, and pain quality alone cannot establish nerve injury.
Apply it
A patient with pancreatic cancer describes deep upper-abdominal pain and a separate, sharply localised painful surgical scar. Examine and map both components. New vomiting and abdominal distension warrant investigation for obstruction before attributing worsening pain to sensitisation. Once treatable complications are addressed, persistent upper-abdominal visceral pain despite tolerated systemic analgesia can justify assessment for a coeliac plexus intervention. NCI's Cancer Pain PDQ supports imaging for treatable visceral causes and coeliac plexus blockade for pancreatic-cancer pain. Scar-associated sensory abnormalities require a separate neuropathic assessment and treatment plan.
Common pitfall: A visceral procedure cannot be assumed to relieve abdominal-wall or neuropathic scar pain. Conversely, identifying scar tenderness does not exclude concurrent visceral disease or explain new obstructive symptoms.
FPM PS15(PM) — Persistent pelvic pain including endometriosis-associated pain, 2025 · FPM Pain Medicine Training Program Curriculum — December 2025 · NCI — Cancer Pain (PDQ), health professional version, updated 24 April 2025 · IASP — Identifying Neuropathic Pain in the Clinic
41.When is an invasive pelvic treatment justified?
An invasive treatment needs a defined indication and an individual assessment of expected benefit, harms, uncertainty and alternatives. In persistent pelvic pain, the presence of pain alone does not identify a lesion that surgery or a block will reliably resolve. Review previous responses, current disease evidence and other contributors before recommending further intervention. Explain what outcome is realistic and how the procedure fits with ongoing whole-person management, including rehabilitation and appropriate organ-specific care.
Apply it
A patient requests repeat surgery solely because pain persists after an earlier operation. Review current indications, prior benefit and risks, then discuss other identified contributors and alternatives before deciding whether further surgical assessment is likely to add value.
Common pitfall: Repeated intervention without a renewed indication can expose the patient to harm while reinforcing an incomplete lesion-only explanation and delaying treatment of other important contributors.
FPM PS15(PM) — Persistent pelvic pain including endometriosis-associated pain, 2025 · FPM PS11(PM) — Procedures in Pain Medicine Clinical Care Standard, 2020
Pain related to cancernot stated
42.Which cancer-related spinal symptoms are an emergency?
New or progressive spinal pain in a patient with cancer is particularly concerning when accompanied by weakness, gait change, sensory disturbance or bladder or bowel dysfunction. These features can indicate metastatic spinal cord compression, an oncological emergency requiring immediate assessment and urgent MRI through the appropriate pathway. Do not wait for profound neurological loss. Analgesia is necessary but does not address compression, and an apparently mechanical pain component does not exclude metastatic disease.
Apply it
A patient with metastatic cancer develops worsening thoracic pain, difficulty walking and new leg weakness. Arrange emergency assessment and urgent spinal imaging rather than merely increasing analgesia and reviewing the patient at the next routine oncology appointment.
Common pitfall: Waiting for incontinence or complete paralysis can allow further neurological deterioration; a history of ordinary back pain does not explain away new deficits in cancer.
Cancer Institute NSW eviQ Education — Metastatic Spinal Cord Compression, version 2, reviewed December 2024 · Cancer Institute NSW eviQ Education — Metastatic spinal cord compression (MSCC)
43.How do background and breakthrough cancer pain differ?
Breakthrough pain is a transient exacerbation occurring against otherwise adequately controlled background pain. Persistent pain throughout the day or predictable deterioration before each regular dose suggests an inadequately controlled baseline regimen rather than isolated breakthrough episodes. Characterise timing, duration, triggers and rescue use before changing treatment. The distinction guides whether to optimise background therapy, address a specific cause or plan episode-specific management. Reassess disease progression and adverse effects rather than responding only to the highest pain score.
Apply it
A patient has comfortable intervals but brief severe flares during transfers. Contrast this with another patient whose pain remains high between every rescue dose, and tailor the first plan to episodes while reassessing the second patient's baseline management.
Common pitfall: Calling every severe episode breakthrough pain can conceal continuously uncontrolled background pain and lead to repeated rescue dosing without correction of the underlying treatment problem.
NCI — Cancer Pain (PDQ), health professional version, updated 24 April 2025
44.How should predictable incident cancer pain be approached?
Incident pain is associated with an identifiable trigger, such as movement, coughing or a care procedure. When background pain is controlled, increasing continuous analgesia may cause unwanted sedation between episodes without adequately matching brief triggered pain. Identify the trigger and consider anticipatory episode-specific analgesia, practical adaptations and treatment of the underlying cause. Assess for instability or fracture when movement-related bone pain changes. The plan should support necessary activity while minimising burdens during comfortable periods.
Apply it
A patient with a painful bone metastasis is comfortable at rest but has severe pain during dressing and transfers. Review structural safety, organise care around an anticipatory analgesic plan and consider disease-directed treatment with the oncology team.
Common pitfall: Escalating continuous opioid treatment solely to abolish every short transfer-related flare may worsen alertness during the rest of the day and still leave the trigger untreated.
NCI — Cancer Pain (PDQ), health professional version, updated 24 April 2025
45.When can cancer-directed therapy provide analgesia?
Pain management can include treatment of the cancer itself when tumour burden or local effects contribute to pain. Palliative radiotherapy is an important option for painful bone metastases, alongside appropriate analgesia and assessment of fracture or neurological risk. Its role depends on clinical circumstances, goals and expected benefit. Symptom relief need not wait for a curative opportunity, and medication-only management may overlook a useful disease-directed intervention. Coordinate decisions with oncology and palliative care.
Apply it
A patient has persistent focal pain from a documented bone metastasis despite medication optimisation, with no new neurological deficit. Discuss palliative radiotherapy assessment while continuing analgesia and checking whether the lesion creates a fracture or stability concern.
Common pitfall: Assuming palliative care excludes anticancer treatment overlooks interventions used specifically for symptom relief; radiotherapy also does not replace urgent management of spinal compression or instability.
NCI — Cancer Pain (PDQ), health professional version, updated 24 April 2025
46.How should persistent pain after cancer treatment be assessed?
Cancer survivors may experience pain from treatment, recurrent disease or unrelated conditions, often with overlapping mechanisms. Surgery can leave persistent regional pain, and some systemic treatments can cause peripheral neuropathy. Reassess new or changing symptoms rather than attributing everything to a past treatment. For a stable treatment-related syndrome, formulate neurological findings, function, distress and medication effects and set longer-term goals. A history of cancer does not make every chronic pain problem require the same approach as advanced cancer pain.
Apply it
A survivor reports persistent distal burning after chemotherapy but now also has new focal vertebral pain. Assess the longstanding neuropathic pattern separately from the new focal symptom, which needs evaluation for a different cause and appropriate oncological review.
Common pitfall: Assigning all pain to previous chemotherapy risks missing recurrence or another disorder; treating stable survivorship pain solely with escalating opioids may overlook rehabilitation and long-term harms.
NCI — Cancer Pain (PDQ), health professional version, updated 24 April 2025 · FPM Pain Medicine Training Program Curriculum — December 2025
Headache and orofacial painnot stated
47.Which features establish adult migraine without aura?
ICHD-3 requires at least five attacks lasting 4–72 hours untreated or unsuccessfully treated in adults, with at least two features: unilateral location, pulsating quality, moderate or severe intensity, and aggravation by or avoidance of routine activity. During headache there must be nausea or vomiting, or both photophobia and phonophobia. Another diagnosis must not better explain the presentation. Migraine need not be unilateral in every attack, and an isolated feature cannot substitute for the full pattern.
Apply it
An adult has six 12-hour attacks with pulsating moderate pain, activity avoidance, nausea and light sensitivity, with no better explanation. Apply the complete criteria rather than rejecting migraine because some attacks involve both sides of the head.
Common pitfall: Requiring every typical feature, or diagnosing migraine from throbbing alone, misapplies a classification that uses specified combinations of attack characteristics and associated symptoms.
International Headache Society — ICHD-3: Migraine without aura
48.When does triptan use meet medication-overuse criteria?
Triptan-overuse headache requires headache on at least 15 days per month in a person with a pre-existing headache disorder, together with regular triptan use on at least 10 days per month for more than three months. Count treatment days rather than tablets or doses. The underlying headache disorder should also be identified. Increased headache frequency and medication use can reinforce each other, so a diary should capture both headache days and acute-treatment days.
Apply it
A patient with migraine reports headaches on 18 days monthly and triptan use on 12 days monthly for four months. Recognise that the frequency and duration meet triptan-overuse thresholds and assess the underlying migraine pattern as well.
Common pitfall: Counting the number of tablets instead of days of use can misclassify overuse; frequent triptan use alone does not satisfy the required headache-frequency criterion.
International Headache Society — ICHD-3: Triptan-overuse headache · International Headache Society — The International Classification of Headache Disorders, 3rd edition, 2018
49.Which headache features demand a secondary-cause assessment?
Headache classification begins with a clinical assessment for an alternative cause, particularly when onset is abrupt, the pattern changes substantially or neurological and systemic findings are present. A previous migraine diagnosis does not establish the cause of a new presentation. History, cranial nerve examination and other relevant assessment should guide targeted investigation. Consider vascular disease, intracranial pathology and eye or ear disease when supported by the presentation rather than assigning a primary headache label from pain quality alone.
Apply it
A patient with established migraine develops a sudden maximal-intensity headache that differs from previous attacks. Arrange emergency assessment for a secondary cause instead of assuming the familiar diagnosis justifies repeating the usual migraine treatment at home.
Common pitfall: Diagnostic anchoring on a known primary headache disorder can obscure a new secondary cause; resemblance to one migraine feature does not neutralise a major change in presentation.
International Headache Society — The International Classification of Headache Disorders, 3rd edition, 2018 · FPM Pain Medicine Training Program Curriculum — December 2025
50.How does trigeminal neuralgia differ from persistent facial pain?
Trigeminal neuralgia is characterised by recurrent brief unilateral facial pain paroxysms within trigeminal distributions, typically severe and electric shock-like, shooting, stabbing or sharp, and precipitated by innocuous stimuli. The characteristic attacks usually last from a fraction of a second to two minutes. Persistent poorly localised facial aching has a different pattern and needs its own assessment. A dental location does not prove dental disease, and neurological findings can change the investigation needed to identify an underlying cause.
Apply it
A patient has seconds-long electric facial attacks triggered by tooth brushing, with no dental lesion explaining them. Assess trigeminal distribution and neurological findings before recommending further dental procedures or treating the presentation as continuous nonspecific facial pain.
Common pitfall: Repeated irreversible dental treatment without corroborating dental pathology can harm a patient whose triggerable paroxysms indicate a neuralgic syndrome requiring a different diagnostic and treatment pathway.
51.How should acute and preventive migraine decisions be separated?
Acute treatment relieves an individual attack; prevention reduces future attack frequency, severity and disability. UK NICE CG150 recommends an oral triptan with an NSAID or paracetamol for acute migraine, selected according to preferences, comorbidities and adverse effects. It recommends considering propranolol, topiramate or amitriptyline for prevention after an individual benefit–risk discussion. These recommendations inform clinical appraisal but do not replace Australian or New Zealand product information, prescribing requirements or funding criteria. Use a diary to distinguish attack response, monthly headache burden and days of acute medication use.
Apply it
A 40-year-old adult has six disabling migraine days monthly and incomplete relief from oral sumatriptan. They also have hypertension, but no asthma, bradycardia, conduction disease, ischaemic cardiovascular disease, renal impairment or peptic ulcer history. For attacks, consider adding naproxen to sumatriptan after reviewing cardiovascular, gastrointestinal and renal risks; use paracetamol instead when an NSAID is unsuitable. Triptans require avoidance in relevant vascular disease or uncontrolled hypertension. For prevention, propranolol is a reasonable option that may also help hypertension. Monitor pulse, blood pressure, fatigue and exercise tolerance; bronchospasm and bradycardia are important potential harms. Compare diary-recorded migraine days, disability, acute medication days and tolerability with baseline, and review the need for continuing prevention three to six months after starting.
Common pitfall: Successful attack relief does not establish adequate overall control. Triptan-overuse headache requires headache on at least 15 days monthly and triptan use on at least 10 days monthly for more than three months. Assess these separately. Propranolol requires particular caution when overdose or self-harm risk is present. If topiramate is considered instead, NICE prohibits its use for migraine prevention in pregnancy and requires the UK Pregnancy Prevention Programme conditions for women of childbearing potential; apply relevant local prescribing safeguards.
FPM Pain Medicine Training Program Curriculum — December 2025 · International Headache Society — ICHD-3: Triptan-overuse headache · Recommendations | Headaches in over 12s: diagnosis and management | Guidance | NICE
Complex regional pain syndrome (CRPS)not stated
52.What are the Budapest clinical criteria for CRPS?
The Budapest clinical criteria require continuing pain disproportionate to the inciting event, at least one reported symptom in three of four categories, and at least one observed sign in two or more categories at assessment. The categories are sensory, vasomotor, sudomotor or oedema, and motor or trophic. No other diagnosis should better explain the findings. Distinguish what the patient reports from what is currently observed; several findings within one category do not count as several categories.
Apply it
After a wrist injury, a patient reports touch sensitivity, colour change and swelling. Examination shows allodynia and oedema. Check disproportionate continuing pain and alternative explanations, then count three symptom categories and two sign categories rather than individual features.
Common pitfall: Diagnosing CRPS from pain and swelling alone omits the required category distribution, observed signs and exclusion of a better explanation such as infection or vascular disease.
Royal College of Physicians — Complex regional pain syndrome in adults, second edition, 2018
53.How do CRPS types I and II differ?
CRPS type I occurs without an identified major nerve lesion; type II occurs with an identified major nerve lesion. The RCP guideline recognises that distal small-fibre injury can occur in type I, so small-fibre abnormalities alone do not establish type II. Both types require the regional CRPS syndrome. Budapest clinical criteria require continuing disproportionate pain, symptoms in at least three of four categories, signs on examination in at least two categories, and no better explanation. The categories are sensory, vasomotor, sudomotor/oedema and motor/trophic. Nerve injury alone establishes neither CRPS nor its regional pattern.
Apply it
Following a documented major median nerve injury, a patient develops disproportionate regional hand pain with reported allodynia, colour change and swelling, plus demonstrable allodynia and oedema. If no alternative better explains the presentation, the criteria support CRPS type II. An isolated small-fibre biopsy abnormality in otherwise established CRPS would not justify that type assignment.
Common pitfall: Pain and sensory loss confined to an injured nerve may represent neuropathic pain without CRPS. Establish the regional syndrome before assigning a type; both types still require individual rehabilitation planning.
Royal College of Physicians — Complex regional pain syndrome in adults, second edition, 2018
54.Which alternative diagnoses can mimic CRPS?
A painful swollen or discoloured limb may reflect infection, vascular disease, an unrecognised injury, inflammatory disease or a focal neurological disorder. CRPS requires that no other diagnosis better explains the presentation. Assess timing, systemic symptoms, vascular status, neurological distribution and local structural findings, choosing investigations to answer specific clinical concerns. A prior CRPS label should not prevent reassessment when the pattern changes. Warmth, colour change or oedema are meaningful findings but are not individually diagnostic.
Apply it
A patient labelled with CRPS develops new fever and rapidly increasing local redness. Reassess urgently for infection rather than attributing every change in temperature and swelling to the existing pain diagnosis or continuing routine rehabilitation unchanged.
Common pitfall: A diagnostic label can create anchoring; new systemic illness, vascular compromise or focal structural findings require fresh assessment even when some CRPS features are already present.
Royal College of Physicians — Complex regional pain syndrome in adults, second edition, 2018
55.How should rehabilitation techniques and surgery be appraised in CRPS?
Functional rehabilitation integrates education, physiotherapy or occupational therapy, pain management and psychological support. Desensitisation uses graded, tolerable exposure to touch and textures to reduce tactile intolerance and support everyday limb use. Graded motor imagery progresses through limb laterality recognition, imagined movement and mirror visual feedback. Its rationale is to engage sensorimotor processing while initially limiting painful movement; this proposed rationale does not establish a proven mechanism of benefit. Small studies suggest possible improvements in pain and disability, but evidence is limited and responses vary. The RCP guideline recommends rehabilitation despite uncertainty about the effectiveness of individual techniques. In CRPS type II, surgery may be considered for an identifiable remediable nerve lesion, such as compression. Its potential benefit is correction of that lesion, weighed against nerve injury, ordinary surgical complications and exacerbation of CRPS. Surgery requires a specific indication and coordinated specialist planning.
Apply it
For a patient avoiding hand use because light contact hurts, agree tolerable texture exposure and graded functional tasks, measuring dressing, grip and participation. Consider graded motor imagery and modify it if symptoms worsen. If CRPS type II coexists with a demonstrable surgically remediable nerve compression, compare the expected neurological and functional benefits of surgery with exacerbation risk through joint surgical and pain-team assessment.
Common pitfall: A guideline recommendation does not imply high-certainty trial evidence or guarantee that desensitisation or graded motor imagery will help every patient. Avoid forceful progression through sustained deterioration. Conversely, the risk of exacerbation should inform appraisal of a remediable nerve lesion rather than become an absolute prohibition on surgery.
Royal College of Physicians — Complex regional pain syndrome in adults, second edition, 2018 · FPM Pain Medicine Training Program Curriculum — December 2025
Chronic widespread painnot stated
56.How do fibromyalgia, nociplastic pain and sensitisation differ?
Fibromyalgia is a clinical syndrome; chronic primary pain is a taxonomic category; nociplastic pain is a mechanistic descriptor; and central sensitisation is a physiological process. These concepts can illuminate the same presentation but are not interchangeable diagnoses. A syndrome does not prove a particular mechanism in every patient. Explain the distinctions while assessing the person's symptoms, function and context, and consider coexisting nociceptive or neuropathic disease instead of assuming one label accounts for every complaint.
Apply it
A patient asks whether fibromyalgia means that central sensitisation has been measured. Explain that the clinical syndrome and proposed processing mechanisms are different levels of description, then relate the formulation to their sleep, fatigue, activity and other clinical findings.
Common pitfall: Using the terms as synonyms turns a useful explanatory model into an unsupported claim of a single proven mechanism and can obscure important coexisting conditions.
FPM Pain Medicine Training Program Curriculum — December 2025 · IASP — Terminology
57.Which features make widespread pain assessment individual?
Chronic widespread pain is heterogeneous: pain distribution, fatigue, sleep problems, cognitive symptoms, distress and functional limitation vary between people. A useful assessment identifies the dominant problems and relevant alternative or coexisting conditions rather than treating the syndrome label as a complete formulation. Review the time course, examination, current medicines and social demands, then select investigations according to specific findings. New focal deficits or systemic features should not be absorbed automatically into the established widespread pain diagnosis.
Apply it
Two patients report similar widespread pain, but one is limited mainly by unrefreshing sleep and the other by fear of activity and caregiving demands. Build different priorities while evaluating any findings that suggest additional disease.
Common pitfall: Assuming every patient with the same syndrome needs the same treatment sequence overlooks heterogeneous symptoms, different risks and the practical circumstances determining whether a plan is feasible.
FPM Pain Medicine Training Program Curriculum — December 2025 · EULAR — Fibromyalgia recommendations summary
58.Why is exercise central to fibromyalgia management?
EULAR's revised recommendations give exercise the strongest treatment recommendation for fibromyalgia and place initial emphasis on education and nonpharmacological management. Exercise should be adapted to current capacity, preferences and barriers, with progression that supports sustainable participation. Aerobic and strengthening approaches can be considered rather than presenting one universally necessary exercise form. Discuss expected fluctuations and functional goals. A strong recommendation supports offering the intervention; it does not guarantee immediate relief or justify an inflexible prescription.
Apply it
A sedentary patient wants to resume community activities but fears exercise flares. Agree a manageable starting activity and progression, explain how to adjust during symptom fluctuation and review participation and tolerability rather than demanding a fixed high-intensity programme.
Common pitfall: Interpreting the recommendation as an instruction to push through every symptom can undermine adherence; a brief flare alone also does not establish that all exercise is harmful.
EULAR — Fibromyalgia recommendations summary · EULAR — Management recommendations
59.When can psychological treatment help widespread pain?
Psychological approaches can address distress, unhelpful coping patterns, fear and barriers to activity within a broader fibromyalgia plan. EULAR supports tailoring additional interventions to individual needs rather than treating psychological therapy as a universal explanation for the syndrome. Explain its purpose in terms of function and coping with a real pain condition. Integrate it with education, activity and management of relevant sleep or mood problems, using shared goals and reviewing the person's response.
Apply it
A patient repeatedly stops valued activities because they predict intolerable pain and harm. Offer a psychological approach alongside graded rehabilitation, explaining how it can help test predictions and support participation rather than suggesting that the pain is imagined.
Common pitfall: Presenting psychological therapy as evidence that symptoms are unreal damages trust; excluding it because pain is real equally misunderstands how coping, distress and activity influence disability.
EULAR — Fibromyalgia recommendations summary · FPM Pain Medicine Training Program Curriculum — December 2025
60.How should medicines be weighed in fibromyalgia?
Education and nonpharmacological management form the initial approach. The original EULAR guideline gives exercise a strong recommendation for use and strong opioids and corticosteroids strong recommendations against use for fibromyalgia. Duloxetine and pregabalin have weak recommendations for selected patients with severe pain; pregabalin may also address sleep disturbance. Attribute these recommendation strengths to [Macfarlane and colleagues, EULAR revised recommendations, Annals of the Rheumatic Diseases 2017;76:318–328](https://ard.bmj.com/content/76/2/318). The patient summary's evidence stars are a separate presentation and should not be treated as equivalent to recommendation strength.
Apply it
A patient taking pregabalin reports slightly less pain but disabling daytime sleepiness and unchanged daily participation. Agree on a functional target and review whether the benefit justifies continued treatment. If severe pain persists, discuss a selective alternative such as duloxetine in light of comorbidity and adverse effects while maintaining an achievable exercise plan.
Common pitfall: A weak recommendation permits an individual treatment trial; it does not justify automatic prescribing or indefinite continuation. Severe pain alone does not establish a favourable benefit–harm balance for strong opioids or corticosteroids used specifically for fibromyalgia.
EULAR — Fibromyalgia recommendations summary · EULAR — Management recommendations
What to focus on during revision
The following are CertMedbry study suggestions. Use the official outline to check the full scope of your examination.
- Connect every clinical topic to a sociopsychobiomedical formulation, meaningful functional goals and a reviewable management plan.
- Practise emergency discrimination: evolving neurological compression, cancer-related spinal symptoms and opioid-induced ventilatory impairment.
- Describe sensory findings precisely and justify neuropathic or nociplastic contributions without claiming that one symptom proves a mechanism.
- Rehearse consent, cultural safety, interpreter use, interdisciplinary coordination and evidence appraisal alongside clinical decisions.
- Use the full official curriculum to identify remaining learning outcomes, including pharmacology, regional techniques, jurisdiction-specific regulation and broader professional responsibilities.
A practical preparation plan
1. Map the complete curriculum
Review sections 1–3 and distinguish outcomes assessed by the Fellowship Examination from those also assigned to the Foundations MCQ assessment. Mark gaps beyond this selective guide and connect each essential topic area to relevant roles in practice.
2. Build a repeatable clinical formulation
For each case, state the presenting problem, urgent exclusions, supported mechanisms, functional consequences and contextual contributors. Link each proposed treatment to a goal, an expected benefit, a risk and a review decision.
3. Practise observed clinical tasks
Rehearse focused history taking, cranial nerve examination, cervical assessment and pain-oriented sensory testing with feedback. Explain findings in plain language and practise consent, shared decisions and difficult conversations.
4. Defend decisions aloud
Use timed 10-minute clinical exercises and 15-minute viva discussions to practise synthesis. State the decisive evidence, acknowledge uncertainty and explain why plausible alternatives are less suitable for the particular patient.
5. Use the drills to expose reasoning gaps
Complete the 20 MCQs, explain every option and revisit weak distinctions with the flashcards. Convert errors into oral follow-up tasks; performance on these exercises does not estimate a fellowship examination result.
6. Integrate evidence and local practice
Review current FPM professional documents and the rules applying in your Australian or New Zealand jurisdiction. Compare treatment evidence by indication, outcome, follow-up and harms, then incorporate supervisor feedback into further case practice.
Use your sample score as a starting point
The free set contains 20 original practice questions. It is a small learning sample, not an official examination or a validated pass prediction. Review each explanation and its source before moving to another topic.
Start the free sampleOfficial sources and updates
- ANZCA — FPM fellowship exam
- FPM Pain Medicine Training Program Curriculum — December 2025
- FPM Training Handbook v1.13 — December 2025
- ANZCA — Pain Medicine Training Program
- ANZCA — Foundations MCQ exam
- IASP — Terminology
- IASP — Allodynia and Hyperalgesia in Neuropathic Pain
- IASP — Central Mechanisms of Neuropathic Pain, 2 September 2026
- IASP — Identifying Neuropathic Pain in the Clinic
- Cochrane Handbook — Chapter 15: Interpreting results and drawing conclusions
- FPM PS11(PM) — Procedures in Pain Medicine Clinical Care Standard, 2020
- FPM PS01(PM) — Opioid analgesics in chronic non-cancer pain, 2025
- FPM PS15(PM) — Persistent pelvic pain including endometriosis-associated pain, 2025
- Australian Commission on Safety and Quality in Health Care — Low Back Pain Clinical Care Standard, 2022
- Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard, 2022
- CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022
- Cancer Institute NSW eviQ Education — Metastatic Spinal Cord Compression, version 2, reviewed December 2024
- NCI — Cancer Pain (PDQ), health professional version, updated 24 April 2025
- Royal College of Physicians — Complex regional pain syndrome in adults, second edition, 2018
- EULAR — Management recommendations
- EULAR — Fibromyalgia recommendations summary
- Medical Council of New Zealand — Statement on cultural safety, October 2019
- Medical Council of New Zealand — When another person is present during a consultation, June 2022
- Medical Council of New Zealand — Good Medical Practice
- International Headache Society — ICHD-3: Triptan-overuse headache
- International Headache Society — ICHD-3: Migraine without aura
- International Headache Society — The International Classification of Headache Disorders, 3rd edition, 2018
- Medical Council of New Zealand — Doctor patient relationship: when another person is present
- Cancer Institute NSW eviQ Education — Metastatic spinal cord compression (MSCC)
- 1.1 Migraine without aura - ICHD-3
- 13.1 Pain attributed to a lesion or disease of the trigeminal nerve - ICHD-3
- ANZCA%20Bulletin%20-%202009%20-%20December%20-%20ads%20removed.pdf
- Recommendations | Low back pain and sciatica in over 16s: assessment and management | Guidance | NICE
- Recommendations | Headaches in over 12s: diagnosis and management | Guidance | NICE
- PS41-Guideline-on-acute-pain-management
- 296-Spinal cord compression palliative EBRT | eviQ
- When-another-person-is-present-during-a-consultation.pdf
- 2.2 Frequent episodic tension-type headache - ICHD-3
- IpcaPropranololtab.pdf
- sumagrantab.pdf
- PART_I-C.pdf
- PS03-Guideline-for-the-management-of-major-regional-analgesia
- local-anesthetic-systemic-toxicity-rgb.pdf
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