41. Which of the following drug is categorized as Agonist-Antagonist and should "Not" be used in opioid tolerant patients.
(A) Morphine
(B) Tramadol
(C) Nalbuphine
(D) Hydromorphone
(E) Methadone

37. Which of the followings clinical indicators with its suspected pathology for spinal pain is suggested to receive X-ray for first line test? (A) fracture due to severe trauma (B) aortic aneurysm with cardiovascular risk factors (C) weight loss due to tumor (D) susecpted infection with fever, sweating (E) x-ray is not a first line test for the above causes of spinal pain

38. 關於｢The principles of pharmacotherapy endorsed by WHO｣，下列敘述何者不適當? (A)五大原則: by the mouth, by the clock, by the ladder, for the individual, and with attention to detail。 (B) Cancer pain 病患盡可能以口服止痛藥物為主，但如果病患有 dysphagia, uncontrolled vomiting, or GI obstruction 可以考慮改用其他途徑給予止痛藥物。 (C) By the clock 的用意在於止痛藥物是”around-the-clock”的方式給予，讓大多數癌症病患 不再使用快速作用(immediate or rapid-onset)的嗎啡類止痛藥物。 (D) 沒有標準的嗎啡藥物使用劑量，理想的正確劑量是可以緩解病人疼痛，又能有最少的 副作用。 (E)癌症疼痛病患的處方，是需要定期追蹤服藥順從性、藥物止痛效果、身體功能、副作用、 或是有無服藥後異常行為。

39. Which one of the following statement about the pathophysiology of herpes zoster is wrong? (A) Herpes zoster most commonly manifests in the distribution of a single dorsal sensory or cranial nerve ganglion. (B) Why the reactivation of virus occurs in one ganglion when latent virus is present throughout the patient’s sensory ganglia is clear. (C) Declining cellular immunity is a major risk factor for reactivation of the virus, which is thought to occur when cell-mediated immunity falls below a critical level. (D) This impression is supported by evidence that even individuals with adequate levels of serum antibodies to varicella-zoster virus (VZV) antigen can, over time, exhibit T cells with reduced ability to proliferate and defend against VZV infections. (E) Cell-mediated immunity appears to play a crucial role in preventing reactivation of latent VZV.

40. Which of the following is the acceptable statement about neurodestructive RF lesions? (A) These temperatures are resulted from friction heat. (B) The size of RF lesion with 22 gauge RF needle is around with a radius of 5 mm (C) The heat is generated on the tip of RF needle. The RF needle then heat up the tissues. (D) The RF pe 口 nanent neurodestructive lesion is formed when neural temperatures exceed 42 C (E) All of the above

42. 關於 breakthrough pain (BTP)，下列敘述何者不適當 (A) BTP 的原因與發生的部位就是 baseline persistent pain 相同。 (B) BTP 可以是可預期，或是特定動作或生理反應而產生。 (C)在給予定時止痛藥物之後發生的 BTP，有可能是給予藥物的間距時間過長，通常這樣的 BTP 是可以預期，而且會在固定的期間發生。 (D) 發生 BTP 的時間可能是無法預期，跟特定動作或時間無關。 (E)典型的 BTP 通常在 3-5 分鐘發生，持續約 30 分鐘，每次發生的強度不一定相同。

43. Which of following description about opioid receptors is "Incorrect" ? (A) Opioid receptors belong to the superfamily of G protein–coupled receptors (GPCR) (B) Opioid receptors are coupled to Gs protein to trigger downstream signaling. (C) Overall opioid receptor activation leads to inhibit neuronal activity (D) In spinal cord level, opioid receptors are located mostly in the superficial dorsal horn (E) Endogenous opiates maybe released by immune cells and work on both central and peripheral opioid receptors.

44. Which of following description about non-steroidal anti-inflammatory drugs (NSAIDs) pharmacology is "Correct"? (A) NSAIDs work by inhibiting the inflammation associated enzyme cyclooxygenase and lipoxygenase (B) Perioperative use of NSAIDs will not increase the risk of surgical site bleeding (C) NSAIDs will not have drug-drug interaction with anticoagulant (such as warfarin) (D) Cyclooxygenase-2 (Cox-2) is the inducible isoform of cyclooxygenase but is constitutively expressed in certain tissues such as brain and kidney (E) Compared with non-selective NSAIDs, long term use of Cox-2 inhibitors will significantly reduce the risk of serious cardiovascular events, renal failure or congestive heart failure.

45. Which of following description about using anticonvulsants (used as Analgesic Drugs is "Correct"? (A) Most commonly used anticonvulsants as analgesics appear to work through potentiation of voltage-gated sodium and calcium channels (B) Sodium channel subtype 1.4 &1.5 are highly expressed in neuronal cell and could be the drug target for anticonvulsant medication (C) Gabapentinoid (Gabapentin & Pregabalin) works on GABA receptor (D) Topiramate works only on voltage-gated sodium channel (E) Lamotrigine and Phenytoin work on voltage-gated sodium channels

46. Which of the folllowing medication has a greater and long term effect for palliation of pain than placebo in treating chronic low back pain? (A) bezodiazepaine (B) antidepressants (C) pregabalin (D) opioids (E) none of the above medications can offter a greater and lon-term analgesic effect

47. Which of following description about "antidepressant analgesic" is "Correct"? (A) In terms of treatment efficacy (smaller number needed to treat NNT), pregabalin is much better than tricyclic antidepressant and listed as first line therapy for neuropathic pain (B) In terms of treatment efficacy (smaller number needed to treat NNT), SSRI is better than SNRI for common neuropathic pain such as postherpetic neuralgia or painful diabetic polyneuropathy (C) Venlafaxine is effective for treatment of neuropathic pain associated with beast cancer. (D) For painful diabetic neuropathy, comparison of amitriptyline and pregabalin showed no difference in pain relief but fewer adverse effects with pregabalin. (E) All of above