OPIOID DEPENDENCY

JAMES WILLOW

47 YEARS, MALE

Role-play cases simulate real clinical practice to guide how candidates respond to clinical scenarios and real life practice.

Presenting Complaint:

"I need my medications, doctor. These were my regular meds in prison: tramadol, codeine, zopiclone, and gabapentin."

Open History:
James was recently released from prison after serving a 9-year sentence for severe assault and drunk driving. He reports that while in prison, he was prescribed tramadol, codeine, zopiclone, and gabapentin for back pain and anxiety. However, the prison discharge letter only mentions that he was on codeine 15mg as needed for mild back pain.

Detailed History (Only if asked):

Back Pain: James explains that he developed back pain following an altercation in the local bar and fighting with the police during his arrest, he then drove his car when drunk and was involved in a traffic accident where his broke his left leg and hurt his back. The leg has since healed, and he has not experienced back pain for the past three years.
Medication Use in Prison: James states that attempts to stop his medications in prison led to withdrawal symptoms such as shaking, sweating, dizziness, andvomiting. He was weaned off his medication after a lot of difficulties, he no longer gets these symptoms, but he continues to crave the medications for their calming effect when he is stressed.
Current Symptoms: He admits he does not have back pain currently but likes the feeling of calmness and reduced anxiety the medications provided.
Life After Prison: Since his release, James has been under significant stress and anxiety. His family (mother and sister) has not welcomed him back, leaving him to live in a shelter or occasionally stay on his friend's couch. He is trying to rebuild his life and has found a potential job as a taxi driver, pending his driving license application.

Social History:

Living Situation: James is currently living in a shelter and occasionally sleeps on his friend's couch. His family has not welcomed him back.
Employment: A friend named Matt is helping him find a taxi job, and James is in the process of applying for his driving license.
Support System: James lacks a strong support system and is worried about his future stability.

Past Medical History:

Back Pain: Resulted from an altercation during his arrest but resolved three years ago.
Withdrawal Symptoms: Experienced during attempts to discontinue medications in prison, now resolved.
Substance Use History: History of alcohol abuse leading to drunk driving incident, no current mention of ongoing substance abuse other than medication dependence.

Ideas:
James believes that the medications will keep him calm, reduce his anxiety, and prevent him from getting angry and potentially ruining his chance at securing a job and rebuilding his life.

Concerns:

Reintegration into Society: James is worried about life outside prison and the lack of support from his family.
Stability: He is very concerned about his financial stability and finding a permanent place to live.
Relapse: Fearful of not having medications to keep him calm, which he believes may lead him to relapse into behaviors that could send him back to prison. He has been thinking of buying it off the streets.

Expectations:
James expects the GP to prescribe the medications he was on in prison, believing they are essential for managing his anxiety and helping him remain calm during this challenging period.

How to React:
James will be pushy about getting his medications and will insist on a prescription being sent today. He will pleaad for a small dose, and then threaten to buy them illegal off street drug vendors.

You are a doctor in your routine clinic, ready to begin your day of consultations. A patient has been booked to see you,

Name: Mr James Willow

Age: 47 years
Gender: Male

Past Medical History:

•Age 16years: Negative childhood experience, domestic abuse by minor, moved to foster care age 15 years.

•Age 25 years: Red Flag Alert! Drug seeking behaviour, verbally aggressive with staff, always book chaperone.

•Age 30 years : Drug and alcohol abuse. Referred to local drug and alcohol services.

•Age 35 years: Relapse in substance misuse/abuse, not willing to disclose how much. Has lost his job as factory worker.

•Age 38 years: Letter from HMRC, has been incarcerated for 9years, complex police case, had sustained MSKL injuries following RTA also.

•Age 47 years; ADMIN TASK.
HMRC Letter - May 15, 2024, recent release from prison. Letter states that patient advised to contact GP. Unable to contact patient as do not have any recent number. Letter to be sent to patient address on records.

HMRC PRISON DISCHARGE LETTER

To Whom It May Concern,

Re: Discharge Summary for James Willow
DOB: 47 years

Prison Admission:

James Willow was incarcerated following his conviction for severe assault and drunk driving. He served a 9-year sentence, during which he received various medical and psychological assessments and treatments.

Medical Care During Incarceration:

Mr. Willow has left leg fracture and back pain resulting from injuries sustained during his arrest and RTA. He required lots of pain medication which led to more dependency and withdrawal symptoms. He has since being weaned off opoids During his incarceration, Mr. Willow reported additional symptoms of anxiety and insomnia. HIs current medication:

Codeine: 15mg one tablet four times daily when needed for mild back pain.

Psychological Care:

Mr. Willow participated in counseling sessions aimed at managing his anxiety and stress and medication overuse.

Discharge Summary:

At the time of discharge, he was no longer experiencing back pain, and his medications were reviewed and adjusted accordingly. The prison medical team has determined that ongoing prescriptions for tramadol, zopiclone, and gabapentin are not necessary based on his current clinical status. No other medications were deemed necessary upon discharge. He was advised to contact his GP if he needs medication for back pain.

Contact Information:

Prison Medical Officer

Marking Scheme for Opioid Dependency Case
1. Data Gathering
Good Indicators:

Comprehensive history of opioid use, including types, dosages, and duration.
Detailed account of withdrawal symptoms experienced.
Exploration of physical symptoms related to past injuries and current health status.
Inquiry into past and current mental health issues, including anxiety and stress.
Assessment of the patient’s social history, including living situation, family support, and employment status.
Clarification of the patient's ideas, concerns, and expectations regarding opioid use and management.
Verification of prison medical records and comparison with the patient’s account.

Negative Indicators:

Incomplete or superficial history of opioid use.
Failure to explore withdrawal symptoms or their management.
Neglecting to assess mental health status or history.
Lack of inquiry into social circumstances and support systems.
Ignoring discrepancies between patient’s account and prison records.
Inadequate attention to the patient’s ideas, concerns, and expectations.

2. Interpersonal Skills
Good Indicators:

Displaying empathy and understanding towards the patient's situation and struggles.
Building rapport and trust through active listening and non-judgmental communication.
Providing reassurance and support while discussing sensitive topics.
Encouraging the patient to express their thoughts, feelings, and concerns openly.
Using clear and simple language to explain medical terms and treatment options.
Maintaining a calm and professional demeanor, especially when the patient is pushy or insistent.

Negative Indicators:

Showing impatience or frustration with the patient’s requests or behavior.
Using judgmental or stigmatizing language about opioid use or the patient's history.
Failing to establish a supportive and trusting relationship.
Poor listening skills or interrupting the patient frequently.
Providing unclear explanations or using overly technical language.
Reacting defensively or dismissively to the patient’s concerns or insistence.

3. Clinical Management
Good Indicators:

Developing a safe and appropriate plan for managing opioid dependence.
Considering non-opioid alternatives for pain management.
Implementing medication-assisted treatment (MAT) if indicated.
Providing information on withdrawal management and offering supportive care.
Referring the patient to counseling or psychological support services.
Coordinating care with other healthcare providers and community resources.
Scheduling regular follow-up appointments to monitor progress and adjust treatment plans.
Educating the patient about the risks and benefits of various treatment options.
Ensuring the patient understands the importance of adhering to the treatment plan.

Negative Indicators:

Prescribing opioids without a thorough assessment or consideration of alternatives.
Ignoring the patient’s mental health needs or failing to refer to appropriate services.
Inadequate follow-up or monitoring of the patient’s progress.
Failing to coordinate care with other healthcare providers or support systems.
Providing insufficient information about treatment options and their risks/benefits.
Neglecting to address the patient’s social and environmental factors that contribute to opioid use.
Overlooking the importance of a comprehensive, multidisciplinary approach to treatment.

These are the key issues in this clinical scenario.

Key Issues in Managing the Case of Opioid Dependency for James Willow
1. Assessment of Substance Use History

Detailed History: Obtaining a thorough history of James' substance use, including the types of opioids used, duration of use, and any previous attempts at cessation.
Verification of Medication Use: Cross-referencing prison records with James' account to accurately understand his medication history and any discrepancies.

2. Assessment of Current Health Status

Physical Health: Evaluating James for any ongoing or past health conditions related to opioid use, such as chronic pain, infections, or other comorbidities.
Mental Health: Screening for mental health conditions such as anxiety, depression, or PTSD, which may be contributing to his substance use.

3. Management of Withdrawal Symptoms

Monitoring Withdrawal: If discontinuing opioids, managing withdrawal symptoms through supportive care or medication-assisted treatment (MAT) to ensure James’ safety and comfort.
Medication Tapering: Developing a plan for tapering off opioids if appropriate, to minimize withdrawal symptoms and reduce dependency.

4. Addressing Psychological Dependence

Counseling and Therapy: Providing access to psychological support, including counseling or therapy, to address underlying issues such as stress, anxiety, and trauma that contribute to his opioid use.
Behavioral Therapies: Utilizing cognitive-behavioral therapy (CBT) or other evidence-based behavioral therapies to help James develop coping strategies and manage triggers.

5. Social Support and Reintegration

Social Support Networks: Assisting James in rebuilding relationships and social support networks, including reconnecting with family and integrating into community support groups.
Housing and Employment: Addressing James' immediate needs for stable housing and employment, as these are critical factors in preventing relapse.

6. Safe Prescribing Practices

Alternative Pain Management: Exploring non-opioid options for managing any pain James may have, including physical therapy, NSAIDs, or other modalities.
Medication Review: Careful consideration before prescribing any controlled substances, with regular reviews to assess the necessity and effectiveness of the treatment.

7. Ongoing Monitoring and Follow-Up

Regular Appointments: Scheduling regular follow-up appointments to monitor James' progress, adjust treatment plans as necessary, and provide ongoing support.
Urine Drug Screening: Periodic drug screening to ensure compliance with the treatment plan and to detect any unauthorized substance use.

8. Legal and Ethical Considerations

Informed Consent: Ensuring that James is fully informed about the risks and benefits of any treatment plans and that he consents to the proposed interventions.
Confidentiality: Maintaining confidentiality and privacy of James' health information in compliance with legal and ethical standards.

9. Coordination of Care

Interdisciplinary Approach: Collaborating with other healthcare providers, social workers, and community resources to provide comprehensive care for James.
Communication: Ensuring clear and consistent communication between all parties involved in James' care to provide coordinated and effective treatment.

Prescribing opioids without a thorough assessment or consideration of alternatives.
Ignoring the patient’s mental health needs or failing to refer to appropriate services.
Inadequate follow-up or monitoring of the patient’s progress.
Failing to coordinate care with other healthcare providers or support systems.
Providing insufficient information about treatment options and their risks/benefits.
Neglecting to address the patient’s social and environmental factors that contribute to opioid use.
Overlooking the importance of a comprehensive, multidisciplinary approach to treatment.

Tips for Effective Consultation in Opioid Dependency Case

Build Rapport and Trust: Start by listening actively and empathetically. Show understanding and respect for the patient's experiences and concerns.
Comprehensive History Taking: Gather detailed information about the patient's opioid use, medical history, and social circumstances. Understand their ideas, concerns, and expectations.
Non-Judgmental Approach: Avoid stigmatizing language. Treat the patient with dignity and respect, recognizing the complexity of opioid dependency.
Clear Communication: Explain medical terms and treatment options in simple, understandable language. Ensure the patient feels informed and involved in their care plan.
Collaborative Planning: Work with the patient to develop a safe and appropriate management plan, considering non-opioid alternatives and support services. Involve the patient in decision-making to enhance adherence to the treatment plan.