NAPLEX Practice Case Study – Pain Management

In this NAPLEX practice case study, we test your knowledge of pain management. I hope you find some benefit with this case study and if you are looking for more study materials, check out our massive all-access package!

NAPLEX Pain Management Case Study

TM is a 47-year-old man who presents to the ambulatory care clinic for a follow up on his pain management. Ever since a work accident a few years ago, he has experienced debilitating back pain. He presents today with increased pain, stating “my therapy just isn’t helping anymore”. He reports missing work on multiple occasions and avoiding social events lately because he just can’t get out of bed or off the couch. He states he tries to exercise, and he was doing better, but lately he is unable to do his normal exercises. He has started taking OTC Tylenol 1,000mg q6h (taking 3-4x/day) lately on top of his prescription medications but has had no additional relief.

PMH: Hypertension, chronic back pain (since 2021), anxiety, depression, former smoker (quit 6 years ago)

Allergies: NKDA


  • Lisinopril 20mg PO QD
  • Metoprolol Succinate 100mg PO QD
  • Clonazepam 0.5mg PO TID
  • Bupropion XL 150mg PO QD
  • Tramadol ER 50mg PO QD
  • Norco 10/325mg PO q4-6h PRN for moderate-severe pain
  • Ibuprofen 400mg PO q6-8h PRN for mild pain (max 3.2g/day)

Vital Signs: BP 134/83 mmHg, HR 62 bmp, RR 20 bmp, Ht 6’ 1”, Wt 98 kg, Pain score 8


  • Potassium 4.7 mEq/L
  • Chloride 97 mEq/L
  • Bicarbonate 25 mEq/L
  • Serum creatinine 0.8 mg/dL
  • Sodium 135 mEq/L


Chronic back pain: Chronic pain uncontrolled. Counsel the patient to stop taking OTC acetaminophen. Adjust pain management therapy accordingly.

#1 Why should TM avoid taking OTC acetaminophen?

  • a)    Acetaminophen will not help with his pain
  • b)    Acetaminophen is contraindicated for TM
  • c)     His other medications interact with acetaminophen
  • d)    He is already receiving acetaminophen with his Norco

#2 Which of the following recommendations would be most appropriate for TM?

  • a)    Increase Tramadol ER to 100 mg PO QD
  • b)    Switch Tramadol ER to Diclofenac 50 mg PO BID
  • c)     Increase Ibuprofen to 800 mg 
  • d)    Add Oxycodone 5 mg PO q4-6h for severe pain

#3 Which antidepressant also provides pain benefit?

  • a)    Fluoxetine
  • b)    Cymbalta
  • c)     Viibryd
  • d)    Lexapro

#4 Based on his current medication list, which medication should be added to TM’s current med list?

  • a)    Aspirin
  • b)    Lyrica
  • c)     Naloxone
  • d)    KlorCon

#5 Which medication combination would be most likely to increase the risk of acute renal failure?

  • a)    Ibuprofen, lisinopril
  • b)    Clonazepam, bupropion
  • c)     Tramadol, bupropion
  • d)    Metoprolol, tramadol

This case was written by Sara Hoag, PharmD in collaboration with Eric Christianson, PharmD, BCPS, BCGP

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Answers – NAPLEX Pain Management Case Study

#1 ANSWER D – TM is already receiving acetaminophen with his Norco, and taking additional OTC acetaminophen puts him at risk of using more than the maximum recommended daily dose.

#2 ANSWER A – Diclofenac and ibuprofen are both NSAIDs and should not be used together. Increasing ibuprofen will only provide benefit when taken for mild pain. Adding oxycodone to Hydrocodone increases the risk of respiratory depression. While we don’t enjoy adding more opioids, given the options listed, increasing the tramadol makes the most sense.

#3 ANSWER B – Cymbalta (duloxetine) is an SNRI that will have the best analgesic properties of the medications listed.

#4 ANSWER C – TM is on both a benzodiazepine and a narcotic, which increases the risk of respiratory depression. He should keep naloxone on hand in case of emergency. However, it’s important to educate him that naloxone will not reverse a benzodiazepine overdose, only an opioid overdose.

#5 ANSWER A – The combination of ibuprofen and lisinopril can combine to work negatively on both the efferent and afferent pathways into the kidney which could increase the risk for acute renal failure when used together.

We hope you enjoyed and benefitted from this NAPLEX practice case study.

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1 Comment

  1. Amdrea

    Thank you for this case review


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Written By Eric Christianson

May 29, 2024

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