CCFP priority topic 16 of 105
Chronic Pain on the CCFP exam
9 key features, the mistakes that cost marks, and a practice question.
Checked by a Canadian family physician, MD, CCFP. Updated October 20, 2026.
What the exam tests
Key features
The CFPC’s 9 key features for Chronic Pain. Each one below has how the exam asks it, the common mistakes and the approach.
Practice question
Try one before you read
A real case from the bank, in the new short-menu format. Answer it first. Then read the key features.
Key feature 1 of 9
Cause, then recheck
Find what drives the pain, revisit it over time, and screen for mood and substance problems.
CFPC skill Clinical reasoning, selectivityPhase Diagnosis, follow-up, hypothesis generationSources Choosing Wisely Canada
On the exam
Years of back pain, now low mood, poor sleep and more drinking. Expect a short menu (pick several from a list).
Pick what to recheck and screen for.
Common mistakes
Treating the first diagnosis as settled for life. Missing the depression, drinking or past abuse that keeps the pain going is the other common miss.
Approach
- Name the cause at the start: a full history, an exam, and only the tests the story points to.
- No imaging for low back pain without a red flag.
- Look again at follow-up. Pain that changes in place, pattern or timing needs a fresh work-up.
- Ask about past trauma or abuse more than once. Many patients tell only once they trust you.
- Screen for low mood, anxiety and thoughts of suicide. They are common with long-term pain and change the plan.
- Ask about alcohol, cannabis and sleeping pills, and how each prescribed pill is really taken.
Key feature 2 of 9
Pain that gets worse
When pain gets much worse, look for a new cause before blaming the old one.
CFPC skill Clinical reasoningPhase Hypothesis generation, diagnosisSources Choosing Wisely Canada
On the exam
A man of 61, past cancer, on oxycodone for a lumbar disc. New mid-back pain wakes him at night. Expect a short menu (pick several from a list).
Pick the causes to rule out, then the tests.
Common mistakes
Re-imaging the old lumbar disc, or blaming a strain from lifting. Raising the dose is wrong too: it feeds diversion or addiction and misses a new illness.
Approach
- Think of three new causes: a new illness such as cancer, an opioid use disorder, and diversion (pills passed or sold to others).
- Image for red flags: suspected cancer or infection, severe or worsening weakness or numbness, or a suspected compression fracture. Cauda equina syndrome counts: new bladder or bowel loss, or saddle-area numbness.
- Image the region that hurts now, not the site of the old diagnosis.
- Order a urine drug test. A quick office test gives an answer today, but it has limits.
- No prescribed drug in the urine, or a drug you did not prescribe, can point to diversion or other use. Talk it through with the patient before you act. A lab test is more accurate but takes days.
- Check the provincial prescription monitoring record for other prescribers.
- Hold the dose until you know why the pain changed.
| Possible cause | Clues | First step |
|---|---|---|
| Cancer spread or infection | Night pain, past cancer, fever, weight loss | Image the painful region now |
| Compression fracture | Sudden back pain, thin bones | Image the spine |
| Opioid use disorder | Craving, early refills, using the drug for mood | Assess for the disorder (key feature 9) |
| Diversion | Prescribed drug missing from the urine, other prescribers | Urine drug test and monitoring record check |
Key feature 3 of 9
A patient you inherit
When you take over another doctor's pain patient, build trust, confirm the diagnosis and agree on aims.
CFPC skill Clinical reasoning, patient-centred approachPhase Treatment, diagnosisSources Choosing Wisely Canada
On the exam
A new patient on long-term opioids, from a doctor who retired, asks for a refill. Expect a short menu (pick several from a list).
Pick what to do at the first visit.
Common mistakes
Signing the refill exactly as written, or stopping it because you did not start it. Both skip checking the diagnosis and agreeing on aims.
Approach
- Start with the person. Hear the story of the pain and what it stops them doing.
- Get the old records, imaging and prescriptions. Confirm the diagnosis yourself with a history and exam.
- Set aims for function, such as work, sleep or walking, not a pain score of zero.
- Physical activity is the base of care for chronic low back pain and osteoarthritis.
- Do not start long-term opioids for chronic pain. Review whether an inherited opioid still helps.
- Agree on a plan and a review date. Say what will change if the aims are not met.
Key feature 4 of 9
Plan it together
Make treatment choices with the patient, and bring in other health workers when they can help.
CFPC skill Clinical reasoning, patient-centred approach, professionalismPhase Treatment, referralSources Choosing Wisely Canada
On the exam
Back pain and knee arthritis, and the patient wants something stronger than acetaminophen. Expect one best answer.
Pick the plan you agree on.
Common mistakes
Starting a long-term opioid because the patient asks for something stronger. Of the usual pain medicines, opioids carry the highest risk of side effects; exercise gives real relief in back pain and arthritis.
Approach
- Lay out the options with their benefits and harms. Ask what matters most to the patient.
- Physical activity first for back pain and osteoarthritis. Exercise programs bring real relief.
- Do not start opioids long term for chronic pain. Of the options, they cause the most side effects.
- If you start an opioid for surgery or a new injury, stop it once the acute pain settles.
- Bring in others as needed: physiotherapy, psychology for pain coping, pharmacy, addiction medicine or a pain clinic.
- Treat depression, anxiety and poor sleep alongside the pain.
Key feature 5 of 9
Write it down, share it
Record the work-up, the aims and every prescription, and share the plan with those who need it.
CFPC skill Communication, professionalismPhase Follow-up
On the exam
Your patient on daily opioids turns up in the emergency department on a weekend. Expect a short menu (pick several from a list).
Pick what your notes and plan must hold.
Common mistakes
A chart that says only “refill as before”. Without dose, quantity, aims and plan, the doctor on call or the pharmacist cannot act safely.
Approach
- Record the diagnosis, the exam, the aims and how function is changing.
- For each prescription, record the drug, dose, quantity, dates and the one pharmacy that fills it.
- Note urine test results, monitoring record checks, and any early refill with the reason.
- Give the patient a copy of the plan.
- Share it with the pharmacy, your team and the doctors on call. Name the one prescriber.
- Say in the plan what a hospital should do if the patient comes in with pain.
Key feature 6 of 9
New patient, no records
When someone new asks for a drug that can be misused, prescribe with care, not by reflex.
CFPC skill Professionalism, selectivityPhase Diagnosis, treatmentSources Choosing Wisely Canada
On the exam
A walk-in visit: a new patient, no records, out of oxycodone. Expect one best answer.
Pick the safest choice today.
Common mistakes
Writing the usual month's supply on trust, or refusing outright. Refusal can push the patient into withdrawal and toward street drugs.
Approach
- Check the provincial prescription monitoring record for other prescribers and recent fills.
- Call the last prescriber or pharmacy to confirm the dose.
- If you prescribe, give a small supply to the next visit, at no more than the confirmed dose.
- Write down why you prescribed, what you checked and the plan.
- Ask about other opioids, sleeping pills and alcohol. Order a urine drug test when the story does not fit.
- Book a follow-up, and get the records before the next prescription.
Key feature 7 of 9
A written agreement
Before prescribing a drug that can be misused, agree on written terms with fair, workable consequences.
CFPC skill Communication, professionalismPhase Treatment, follow-up
On the exam
A new opioid plan for a patient with past early refills. Expect a short menu (pick several from a list).
Pick the terms to put in writing.
Common mistakes
Terms you will never enforce, such as ending care after one slip. Letting a broken term pass because things seem stable empties the agreement too.
Approach
- Write it with the patient, in plain words, and give a copy.
- One prescriber and one pharmacy, named in writing.
- Say when urine drug tests will be done and why.
- Say how early refills and lost or stolen supplies will be handled.
- Name the consequences ahead of time: smaller supplies, daily or weekly pharmacy dispensing, more frequent visits.
- Say what it will not do: it does not end care or stop the drug overnight.
Key feature 8 of 9
A broken agreement
After a broken agreement, check your own feelings, support your staff, and apply or adjust the terms wisely.
CFPC skill Professionalism, clinical reasoningPhase TreatmentSources CRISM / BCCSU 2023
On the exam
Another early refill and a shouting scene at reception. Your receptionist is scared. Expect a short menu (pick several from a list).
Pick your response to the patient and the team.
Common mistakes
Stopping the opioid on the spot, or ending care. Both cause withdrawal and push toward street fentanyl. Telling scared staff to put up with abuse fails them too.
Approach
- Notice your anger before you act. Decide after the heat has passed.
- Debrief with your staff. Thank them, hear what happened, and plan how to keep them safe.
- Tell the patient plainly that shouting at staff is not accepted.
- Apply the term you agreed on, such as daily or weekly dispensing.
- Do not stop the opioid abruptly. With an opioid use disorder, withdrawal alone raises relapse, illness and death.
- Ask why it happened. A broken term can be the first sign of an opioid use disorder.
| Response | Use? | Why |
|---|---|---|
| Stop the opioid today | No | Withdrawal, and a push toward the street supply |
| End care after a verbal outburst | No | Abandons care of a dangerous disorder |
| Let it pass | No | The agreement then means nothing |
| Apply the agreed step, such as shorter dispensing | Yes | Fair, expected, and keeps care going |
Key feature 9 of 9
Addiction and new behaviour
When someone with pain and an addiction starts to unravel, find out why and change the plan.
CFPC skill Clinical reasoning, patient-centred approachPhase Hypothesis generation, treatmentSources CRISM / BCCSU 2023, Choosing Wisely Canada
On the exam
A man of 46 on morphine for back pain, past heavy drinking, runs out early and takes extra to blunt everything. Expect one best answer.
Pick the diagnosis, then the treatment.
Common mistakes
Raising the dose for “worse back pain”, or a slow taper alone. With an opioid use disorder, removing the opioid without treatment raises relapse, overdose and death.
Approach
- Ask what changed: craving, using the drug for mood, failed attempts to cut down, drinking, sleeping pills, stress, a new illness.
- Craving and use for mood point to an opioid use disorder, not tolerance or worse pain.
- Offer opioid agonist therapy: buprenorphine and methadone are both first choices. Slow-release oral morphine is second line.
- Do not offer withdrawal management (a supervised detox or taper) alone. It raises relapse, illness and death.
- Offer a take-home naloxone kit (the overdose antidote) and overdose teaching now, before any overdose.
- Offer counselling as an add-on, but never make it a condition of opioid agonist therapy.
- No benzodiazepines for opioid withdrawal. With opioids, they raise the risk of stopped breathing.
| Pattern | What you see | Not a fit if |
|---|---|---|
| Tolerance alone | Needs more for the same relief | There is craving or loss of control (look for opioid use disorder) |
| Hyperalgesia (pain made worse by opioids) | Pain spreads and grows as the dose rises | Pain stays where it began, at a steady dose |
| Opioid use disorder | Craving, use for mood, failed attempts to cut back | Use stays as prescribed, with no harm |
| Diversion | Prescribed drug missing from the urine, other prescribers | The patient describes taking the extra doses |
Flashcards
Answer it first, then check.
KF 2On opioids for a lumbar disc, past cancer, new night pain mid-back. What first?
Image the painful region. Suspected cancer is a red flag; do not re-image the old disc. Source: Choosing Wisely Canada
KF 2On oxycodone, the urine shows fentanyl and no oxycodone. What two problems?
Possible diversion and fentanyl use. Ask without blame, check the monitoring record, and read the office test with care before you act.
KF 4Should you start a long-term opioid for chronic low back pain?
No. Start with physical activity and exercise. Of the usual pain medicines, opioids carry the most side effects. Source: Choosing Wisely Canada
KF 6A new walk-in patient, no records, out of opioids. Refuse, or refill a month?
Neither. Check the monitoring record, give a small supply, write down why, and book follow-up.
KF 8A shouting scene after a broken term. Do you stop the opioid today?
No. Abrupt stopping causes withdrawal and pushes toward street fentanyl. Apply the agreed step instead.
KF 9Opioid use disorder on prescribed morphine. What is first-line treatment?
Opioid agonist therapy with buprenorphine or methadone. Slow-release oral morphine is second line. Source: CRISM / BCCSU 2023
KF 9Why not a slow taper alone for someone with opioid use disorder?
Withdrawal management alone raises relapse, illness and death. Pair it with long-term addiction care. Source: CRISM / BCCSU 2023
KF 9Opioid use disorder and nightly drinking. What do you hand over today?
A take-home naloxone kit, with teaching on how to spot and treat an overdose. Source: CRISM / BCCSU 2023
FAQ
Is pseudoaddiction still a diagnosis?
No. The idea that drug-seeking means pain is under-treated is no longer accepted, and it led to higher doses. Look for an opioid use disorder or diversion instead.
When should I order a urine drug test for a patient on opioids?
At the start of a long-term plan, and when there is a clear reason, such as an early refill or a story that does not fit. A quick office test has limits, so talk through any unexpected result before acting.
Does a broken agreement let me stop prescribing?
Not overnight. The agreement sets fair steps, such as smaller supplies or daily dispensing. Stopping abruptly causes withdrawal and, with an opioid use disorder, raises the risk of overdose.
Which guideline covers opioid use disorder in Canada?
The 2024 national guideline from the Canadian Research Initiative in Substance Matters. Buprenorphine and methadone are both first-line. It covers adults, and not pain prescribing itself.
Sources
Written from the CFPC Assessment Objectives and Canadian guidelines first. Checked by a Canadian family physician, MD, CCFP.
Last reviewed October 20, 2026For exam study. Not advice for a patient in front of you.
- Assessment Objectives for Certification in Family Medicine, 2nd editionCollege of Family Physicians of Canada · 2020
- Choosing Wisely recommendationsChoosing Wisely Canada
- CRISM national clinical resourcesCRISM / BCCSU · 2023