MD Acumen · MRCGP SCA course · free practice resources
MRCGP SCA course · Station 11
Station 11 · Painkillers
A 45-year-old wants his co-codamol doubled and a sick note extended; he is angry, in pain, and, if you ask, no longer sure he wants to be here.
Reviewed and kept current
Video consultation · Mental health · Prescribing · Long-term condition · 12-minute case · 3 min reading · Last editorial review: 11 October 2026 · Next scheduled refresh: 11 April 2027 · Clinical content signed by Course Director, 11 October 2026.
Candidate instructions
Read this as you would outside the room
Read the brief as you would in the examination (RCGP: twelve consultations with simulated patients, each lasting twelve minutes, with 3 minutes' reading at the start of each). There is no reference material. Everything below the brief is folded until the consultation is over.
| Information | |
|---|---|
| Frame | You have 3 minutes to read, then 12 minutes. Video consultation. Everything below this brief is folded away until the consultation is over. |
| Your role | Salaried GP at an urban practice, holding the afternoon's video list. |
| Patient | Darren Coyle, 45. |
| Reason for consultation | “Painkillers and sick note.” Booked by the patient. The locum four weeks ago advised him to book a review. |
| Format | Video. He is at home at the kitchen table; you can see his face and arms. You cannot examine him; you may ask what he can do. |
Information available
The records extract, printed as it appears.
| Problem list | Chronic low back pain. MRI 2023: degenerative disc disease, no nerve-root compression. Depression 2016, treated with citalopram, stopped 2018. Alcohol recorded as “social”. |
| Medication | Co-codamol 30/500, two tablets four times a day: issued monthly for 14 months. Naproxen 500 mg twice daily. Omeprazole 20 mg daily. Allergies: none recorded. |
| Fit notes | Eight weeks continuous, “back pain”. Employer: warehouse team leader. |
| Pain clinic | Discharged 2024: “declined pain management programme”. |
| Last contact, 4 weeks ago | Telephone, locum: “requests increase in co-codamol; advised to book review”. PHQ-9: none recorded since 2016. |
Your task
•
Assess his pain, his painkiller use and how he is.
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Reach a working diagnosis of each problem, with the alternatives you have considered.
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Agree a plan with him, including his painkillers and the fit note.
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Address his concerns.
Folded away
For the role player and the observer
Open these after the consultation, or during it if you are observing. The role-player script and every marking section are public (D-76): this is practice material, not an examination.
1 · Role-player script — opening line, story, ICE, hidden facts and triggers (examination findings last)
Candidates: do not open until you have consulted.
Persona and manner
- Darren Coyle, 45, a warehouse team leader off sick for eight weeks; tense, jaw set, arms folded; you speak fast and loud at first; you feel judged and expect to be refused. Under the anger you are exhausted and ashamed.
- If the doctor is calm and asks about you rather than the tablets, you deflate within two minutes and become honest.
Opening line (verbatim)
- “Right. I've been told to 'book a review' three times now. I need the co-codamol doubled because it's not touching it, and I need my sick note doing — and I don't want a lecture about addiction, I've had that from the locum.”
The story
- “The back's every day, all day. Seven out of ten. Worse sitting. I can't do the warehouse shifts. They're going to get rid of me.”
- “I take eight, sometimes ten, a day. So I run out early, and then I'm climbing the walls.”
- “I sleep three or four hours.”
- If asked about red flags: no leg weakness, no bladder or bowel trouble, no numbness between the legs, no weight loss, no fever, no new night pain, no injury.
- If asked what happens when you run out: sweats, restless legs, diarrhoea, you cannot sit still; you have bought codeine from a mate twice.
- If asked about mood properly: “What do you think?” Then: low every day for months, no pleasure in anything, poor appetite, “useless”, “a burden”; broken sleep; irritable with your teenage sons.
- If asked directly and well about thoughts of not being here: you have thought “they'd be better off with the insurance money”; no plan; “I wouldn't do it — the boys.” No previous attempts.
- Four or five cans most nights “to sleep”. No drugs other than the codeine.
- Work: HR have started a capability process; a meeting next week; you think the note is the only thing protecting you. You would go back “if I could do the office job they offered, but I'd lose the shift pay”.
- Your partner Kelly works nights; “we don't talk”. Money is tight; the car finance is in arrears. The previous depression lifted when you got the team leader job; the citalopram “worked, I think”. You declined the pain programme because you thought it meant they had given up on you.
Ideas, concerns and expectations
- Idea: “The disc's crumbling. I need stronger tablets until they fix it.”
- Concern: Losing the job; being called an addict; “ending up on the sick for life”.
- Expectation: The co-codamol increased, or something stronger, and a four-week note.
Impact
- Work: the capability meeting next week; the office job offered at lower pay.
- Home: Kelly on nights; the boys; the car finance in arrears.
- Sleep: three or four hours; the cans to get off.
Red flags
- Present: Opioid dependence with withdrawal and a second source of codeine; a depressive episode with passive thoughts of death; alcohol at 30 to 40 units a week; a capability process at work.
- Absent: No cauda equina or cord features; no weight loss, fever, night pain or trauma; no history of cancer.
- Absent: No plan or intent to end his life; no previous attempt; protective factors present (the boys).
Hidden facts and their triggers
- The withdrawal symptoms and the codeine bought from a mate — released only if asked what happens when he runs out, without judgement
- The low mood, the anhedonia and the guilt — released only if the doctor asks about him and his mood properly, not as a tick-box
- The thought that they would be better off with the insurance money — released only only if mood has been explored properly and the doctor then asks directly about thoughts of not being here
- The office job offered and the shift pay — released only if asked what work could look like
- Why he declined the pain programme — released only if asked what the programme meant to him
Behaviour
- Minute 1: “I don't want a lecture about addiction.”
- Minute 4, only if asked what happens when you run out: “climbing the walls”.
- Minute 6, only if mood has been explored properly and the doctor asks directly: “they'd be better off with the insurance money”.
- If the doctor absorbs the anger, takes the pain seriously, screens the red flags, recognises the dependence and the withdrawal without using the word addict, asks about your mood and then directly about thoughts of not being here, makes a safety plan with you, proposes treating the depression and a supported slow reduction rather than an increase, deals with the drink, handles the note honestly with a letter for HR, and books a review in a week: silence; wipe your eyes. “Nobody's asked me that before.” Agree. Ask, “Will you write to HR?”
- If the doctor increases the co-codamol and issues a four-week note: “Cheers.” Leave.
- If the doctor refuses flatly: stand up. “Knew it.” Sit again only if the doctor recovers by asking about you.
- If the word addict is used: “There it is.” Fold your arms.
Examination findings, if the candidate states what they would examine and why
- Video: if the candidate asks you to stand, turn and bend: guarded movements, you can walk across the room normally; no obvious weakness.
- If the candidate states what they would examine in person and why: no neurological deficit, straight-leg raise negative, pupils normal, no signs of intoxication. Nothing is examined today.
2 · Examiner mark sheet — generic SCA scheme plus the key facts for this case
Domain grades — with the key facts that earn a clear pass at this station
| Domain (RCGP wording) · key facts for this case | CF (0) | F (1) | P (2) | CP (3) | Score |
|---|---|---|---|---|---|
1 · Data gathering and diagnosis
| ☐ | ☐ | ☐ | ☐ | /3 |
2 · Clinical management and medical complexity (×1.5)
| ☐ (0) | ☐ (1.5) | ☐ (3) | ☐ (4.5) | /4.5 |
3 · Relating to others
| ☐ | ☐ | ☐ | ☐ | /3 |
| Case total | /10.5 |
Global rating (recorded, not added to the total): ☐ Fail ☐ Bare Fail ☐ Bare Pass ☐ Pass
The domain grades (RCGP descriptors): CP clear pass — above the standard of a newly qualified, independent GP · P pass — sufficiently demonstrated at the standard · F fail — insufficiently demonstrated at the standard · CF clear fail — clearly demonstrated below the standard.
The RCGP grades each domain CF, F, P or CP and weights clinical management and medical complexity against the other two domains; the examination's maximum is 126 over twelve cases, which is 10.5 per case. The RCGP does not publish the mark each grade carries. MD Acumen's training sheet uses CF 0 · F 1 · P 2 · CP 3, with clinical management weighted ×1.5 (0 · 1.5 · 3 · 4.5), so that a case is marked out of 10.5 and a twelve-case circuit out of 126. A P in all three domains is 7.0; MD Acumen treats that line as the training standard for a case. The examination's pass mark is set by borderline regression for each diet and is published in the RCGP's diet summary reports; it is not a fixed fraction of 126.
Weighting rationale, in the RCGP's words: “To reflect the capability coverage within the clinical management and medical complexity domain this is weighted in comparison to the other two domains.”
3 · Expanded station standard — what earns a clear pass, pass, fail and clear fail here
Written to the standard of a newly qualified independent GP; the clear-pass row describes practice above that standard. It is a debriefing aid, not a checklist: the grade is a judgement that the essentials, the italic key facts on the mark sheet, were done well, at the patient's pace and in plain language. MD Acumen training standard; the RCGP does not publish case mark sheets.
| Grade | Data gathering and diagnosis | Clinical management and medical complexity | Relating to others |
|---|---|---|---|
| CP | Lowers the temperature in the first minute by asking about him, not the tablets, and takes the pain seriously before anything else. Quantifies the opioid use and finds the withdrawal and the second source without a flicker of judgement. Explores mood properly and then asks directly about thoughts of not being here, with plan, intent and protective factors. Reasons aloud that the pain, the tolerance, the depression and the alcohol are one problem. | Says plainly that the opioid will not be increased and why, and offers in its place a supported reduction with a date, a rate and weekly scripts if needed, the withdrawal explained and managed. Treats the depression with an SSRI he has tolerated and talking therapy. Writes the safety plan with him and documents it. Addresses the alcohol as sleep and mood. Re-refers to the pain programme reframed as rehabilitation. Handles the note as may-be-fit and writes to HR. | Absorbs “I don't want a lecture about addiction” without defensiveness and never uses the word. Names the shame and the fear of the job and answers them. Asks the hard question without euphemism and stays with the answer. Responds to “Nobody's asked me that before” with something true. Frames the taper as his decision with support and the note as protection rather than refusal. Offers to be the named doctor. Checks what he has understood and agreed. |
| P | Screens the red flags for back pain. Quantifies the opioid use; identifies withdrawal symptoms and the extra-source codeine. Assesses depression (sleep, appetite, concentration, guilt, anhedonia) and asks directly about suicidal thoughts: ideation, plan, intent, protective factors, alcohol. Understands the work situation and the capability process. Uses the record: 14 months of monthly issues, the pain clinic discharge, the previous depression on an SSRI. | No dose increase; explains that opioids are not effective for long-term back pain and offers a supported taper with a date and review, with the withdrawal explained. Treats the depression: restarts an SSRI, refers to talking therapies. Makes a safety plan: crisis line, 111 option 2, an agreed contact person, review within one week, documented. Brief alcohol intervention. Fit note as may-be-fit with adjustments; a letter to HR with consent. Re-referral to the pain programme reframed as rehabilitation. | De-escalates: acknowledges the anger and the previous consultations without defensiveness. Avoids the word addict; uses dependence and explains tolerance. Asks about him before the tablets; asks the direct question about suicidal thoughts without euphemism. Honest about what will and will not be prescribed; a shared plan; checks he has understood and agreed the taper and the note. |
| F | Handles the consultation as a prescription negotiation. Does not quantify the opioid use or ask what happens when he runs out. Screens mood with a single question or not at all because he is hostile. Asks about suicidal thoughts with a euphemism he can deflect, or not at all. Does not ask about work beyond the note. Does not use the record. | The co-codamol increased, or a stronger opioid started. Or a blanket refusal with no alternative. No safety plan after the disclosure. No antidepressant or therapy. The alcohol unaddressed. A four-week note with no plan, or the note refused. No review date. | Matches the anger; lectures; uses the word addict. Avoids the mood question because he is hostile. Colludes to end the conflict. Dismissive of the job or the money. Does not respond to “Nobody's asked me that before”. Ends without checking what he has agreed. |
| CF | No assessment of mood or risk in a man with chronic pain, opioid dependence and alcohol use who says “what do you think?” when asked how he is; the red flags not screened; the opioid use never quantified. Or the consultation ends at “Knew it” because the doctor refused before asking anything. | Unsafe: the opioid doubled or a stronger opioid started; or the opioid stopped abruptly with no plan for withdrawal; or a disclosure of thoughts of death met with no safety plan, no follow-up and no treatment. He leaves more dependent, more hopeless, or both. | Hostile, moralising or frightened into silence; the word addict used as a verdict; the patient's standing up met with a shrug; no attempt to find out what the pain, the job or the tablets mean to him. No partnership and a patient who will not come back. |
Where candidates lose this station
- Taking the hostile opening as an obstacle rather than a cue, so that the consultation stays a negotiation about tablets and mood is never asked about (statement R1)
- Asking about suicidal thoughts with a euphemism he can deflect, or not at all because he is angry (statement D1)
- Increasing the co-codamol and issuing a four-week note to end the conflict (statement C2)
What the examiner is listening for in the last four minutes
By 8:00 the working diagnoses should have been stated: chronic back pain with opioid dependence, a depressive episode with passive thoughts of death, and alcohol above the low-risk level. The examiner is listening for: no increase, and the taper offered as a plan with a date and support; the antidepressant and the therapy; the safety plan in his words (who he will ring, the crisis numbers, the agreed person); the alcohol named as part of the sleep and the mood; the note as may-be-fit with adjustments and the letter to HR; the review in one week; and his own words on what he has agreed.
4 · RCGP feedback statements — where underperformance was identified — with case-specific examples
The ten statements below are postulated: the feedback an examiner would most likely attach at this station, chosen from the RCGP's standardised list of 26 feedback statements that applies to every SCA case and spans the three marking domains (Data Gathering and Diagnosis; Clinical Management and Medical Complexity; Relating to Others). They are a prediction from the case content, its complexity and the marks that matter, not an examiner's record: any statement on the full list can be attached to any case, and feedback plays no part in the mark. Record the statements that applied in the practice log.
| RCGP feedback statement (postulated top ten) | Underperformance it signals (generic) | Station-specific example |
|---|---|---|
| D1 · Data gathering was insufficient to enable safe assessment of the condition/situation Data gathering and diagnosis · Data gathering and interpretation | History too thin to decide safely: the presenting problem not characterised, the essential negatives not asked. |
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| D5 · Ineffective approach or prioritisation in data gathering, when presented with multiple or complex problems Data gathering and diagnosis · Managing medical complexity | With several problems on the table, none is prioritised; time spent on the least important. |
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| D6 · The implications of relevant findings identified during the data gathering were insufficiently recognised or understood Data gathering and diagnosis · Data gathering and interpretation | A finding or result is elicited but its meaning is not recognised or not followed up. |
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| D7 · Differential diagnoses or hypotheses were inadequately generated or tested Data gathering and diagnosis · Making diagnosis/decisions | One diagnosis assumed; alternatives not generated, or generated but not tested with a question. |
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| C2 · The management plan relating to prescribing of medication was inappropriate or not reflective of current practice Clinical management and medical complexity · Clinical management | A drug started, continued or stopped against current guidance, or without the checks it needs. |
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| C5 · The plan relating to the medical management of risk was inadequate or inappropriate Clinical management and medical complexity · Clinical management; Organisation, management and leadership | Clinical risk left unmanaged: no plan for the thing that could go wrong, or the risk not weighed. |
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| C8 · Inappropriate or inadequate arrangements for follow-up, continuity and/or safety netting Clinical management and medical complexity · Clinical management | No follow-up, continuity or safety-net, or one too vague to act on. |
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| R1 · Communication skills, including the non-verbal, responding to cues and/or active listening were insufficiently demonstrated Relating to others · Communication and consultation skills | Cues missed; the patient interrupted; non-verbal signals ignored; questions read like a form. |
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| R5 · A judgemental approach was shown to the person Relating to others · Communication and consultation skills; Maintaining an ethical approach | Disapproval, moralising or blame shown in words or manner. |
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| R6 · Respect and/or sensitivity shown to the person was inadequate or inappropriate Relating to others · Fitness to practise; Maintaining an ethical approach | Discourtesy, insensitivity to distress or to privacy; the person's dignity not protected. |
|
The full list of 26 statements, with the generic meaning of each, is on the exam and the mark scheme.
5 · Examiner points of fact and guidelines
Points of fact the examiner should have to hand
Each statement is drawn from the named guideline, in its current version, with the date it was checked. The examiner marks against these facts; the candidate is not expected to quote them.
- Do not initiate opioids to manage chronic primary pain; for people already taking them, explain the risks and lack of evidence of benefit and agree a plan to reduce and stop, with support, where the person agrees. Antidepressants may be considered for chronic primary pain even without depression. NICE — NG193 Chronic pain (primary and secondary) in over 16s: assessment and management, section 1.2, managing chronic primary pain: pharmacological management, April 2021, checked 10 Oct 2026
- Do not offer opioids for managing chronic low back pain; consider oral NSAIDs with gastroprotection at the lowest effective dose for the shortest time; offer a group exercise programme and consider a combined physical and psychological programme for people with significant psychosocial obstacles to recovery. NICE — NG59 Low back pain and sciatica in over 16s: assessment and management, section 1.2, non-invasive treatments, 2016, last updated December 2020, checked 10 Oct 2026
- When withdrawing an opioid after long-term use, agree a plan with the person, reduce in steps, start with a reduction of about 10% of the dose every one to two weeks or more slowly, adjust the rate to withdrawal symptoms, and do not stop abruptly; review regularly and treat withdrawal symptoms. NICE — NG215 Medicines associated with dependence or withdrawal symptoms: safe prescribing and withdrawal management for adults, section 1.5, withdrawing a medicine, April 2022, checked 10 Oct 2026
- Opioid withdrawal symptoms include sweating, restlessness, diarrhoea, abdominal cramps, anxiety, insomnia and craving; they appear within hours of a missed dose of a short-acting opioid and are a marker of physical dependence, which is distinct from the pattern of use that defines addiction. Faculty of Pain Medicine — Opioids Aware: a resource for patients and healthcare professionals, opioid dependence and withdrawal, 2015, updated 2021, checked 10 Oct 2026
- Ask anyone with depression directly about suicidal ideation and intent; assess risk including previous attempts, alcohol and drug use, and protective factors; for a person with passive ideation and protective factors, agree a safety plan and arrange follow-up within a short interval, and give crisis contacts. NICE — NG222 Depression in adults: treatment and management, section 1.3, assessment and risk; section 1.4, safety planning, June 2022, checked 10 Oct 2026
- For a new episode of more severe depression offer a combination of individual CBT and an antidepressant, or either alone according to the person's preference; where a person has previously responded to a particular antidepressant, consider restarting it; review within two weeks of starting. NICE — NG222 Depression in adults: treatment and management, section 1.6, treatment for a new episode of more severe depression, June 2022, checked 10 Oct 2026
- A fit note can state that the person may be fit for work with adjustments (altered hours, amended duties, a phased return or workplace adaptations); the doctor describes the functional effects of the condition, and the employer decides whether the adjustments can be made. GOV.UK (DWP) — Getting the most out of the fit note: guidance for healthcare professionals, may be fit for work; adjustments, 2022, updated 2024, checked 10 Oct 2026
- The UK Chief Medical Officers' low-risk drinking guideline is not more than 14 units a week spread over three or more days; four or five cans of 4% lager a night is about 60 to 75 units a week, a level at which brief advice and an offer of support are indicated. NICE CKS (citing the UK Chief Medical Officers' 2016 guideline) — Alcohol, problem drinking, background: the low-risk drinking guideline and unit calculation, current online version, checked 10 Oct 2026
- Co-codamol 30/500 is taken as one or two tablets every four to six hours when needed, maximum eight tablets in 24 hours, which is 4 g of paracetamol, the adult daily ceiling. Eight to ten tablets a day, plus codeine from another source, exceeds the paracetamol limit on some days and gives 240 to 300 mg of codeine; the entry carries the MHRA warning that long-term opioid use can lead to tolerance, dependence and addiction, and that a treatment plan with an end point is agreed before prescribing. BNF (NICE) — Co-codamol, indications and dose; important safety information, current BNF online, checked 10 Oct 2026
- Before starting or continuing an opioid for non-cancer pain, the prescriber discusses the risk of tolerance, dependence and addiction, which rises with dose and duration, agrees a treatment strategy and a plan for the end of treatment, and reviews the patient regularly. When an opioid is withdrawn after long-term use the dose is tapered, because abrupt withdrawal brings withdrawal symptoms; the warnings now appear in the product information for every opioid. MHRA — Drug Safety Update: Opioids: risk of dependence and addiction, advice for healthcare professionals, September 2020, checked 10 Oct 2026
- Risk assessment tools and scales are not used to predict future suicide or to decide who is offered treatment, and people are not sorted into low, medium or high risk to determine their care. The assessment is psychosocial: current and past suicidal thoughts and intent, previous self-harm, alcohol and drug use, mental state, work and financial pressures, relationships, and protective factors. A safety plan written with the person names warning signs, coping strategies, people to contact and the crisis services available, and makes the environment safer. NICE — NG225 Self-harm: assessment, management and preventing recurrence, section 1.5, assessment and care by healthcare professionals; safety plans, September 2022, checked 10 Oct 2026
- AUDIT is the identification tool: a score of 8 or more indicates hazardous or harmful drinking and a brief intervention is offered; a score of 20 or more, or drinking more than 15 units a day, calls for assessment for assisted withdrawal rather than advice to stop. Four or five cans a night to get to sleep, with low mood and an opioid, is harmful use in which dependence is checked for, and alcohol is named as a cause of the broken sleep and the low mood. NICE — CG115 Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence, section 1.2, identification and assessment; section 1.3, assisted withdrawal, February 2011, checked 10 Oct 2026
- The Smoking, alcohol and substance misuse Topic Guide expects the GP to recognise and manage misuse of prescribed and over-the-counter medicines, including analgesics, with risk-minimisation strategies and safe prescribing; to assess alcohol use and offer brief intervention; to recognise combined misuse of drugs and alcohol; to assess mental health alongside; and to work with pain and addiction services. The Mental health Topic Guide expects suicide risk to be asked about directly and suicide prevention strategies to be understood. RCGP — GP curriculum: Smoking, alcohol and substance misuse, Topic Guide: knowledge and skills, Being a GP, 2025 curriculum, checked 10 Oct 2026
Working references for this station
13 statements, 783 words. Every statement is signed by the Course Director before it is published; a station whose facts have changed since signature carries no signature line until it is signed again.
This case's topic and its signed Golden Triangle, for review after the station.
Golden Triangle
Depression in adults
Knowledge Green · Evidence Green · Real-world Red
Not yet at the Equinox · UK (NHS England) · as of 8 October 2026 · How the triangle works
6 · RCGP curriculum tags for this case
| RCGP curriculum (2025) | This case |
|---|---|
| Topic Guide(s) | Mental health · Smoking, alcohol and substance misuse · Continuity and quality of care, safety and prescribing |
| Core capabilities | Communicating and consulting · Data gathering and interpretation · Clinical management · Medical complexity |
| SCA Clinical Experience Group(s) | Mental health, including addiction, smoking, alcohol, substance misuse · Prescribing · Long-term condition, including cancer, multi-morbidity, and disability |
| AKT blueprint clinical area | Psychiatry (broader representation) |
| Case type | prescribing |
| Modality | video |
7 · My marks and reflection — practice log form
Record your three domain grades, your case total out of 10.5, your global rating, the RCGP feedback statements that applied, and what you will keep and change. The form is already labelled with this case and its web address; a copy of your entry is emailed to you, so your practice log builds up in your inbox and can be downloaded.
Record my marks and reflection for SCA-11
Revision link for this case: mdacumen.com/sca-station11-painkillers
Independence & scope. Formative training material from MD Acumen Ltd; not a prediction of exam performance. Not affiliated with, endorsed by, or delivered on behalf of the Royal College of General Practitioners; the marking domains and feedback statements are the RCGP's published ones, and every descriptor on this page is an Acumen training tool calibrated to them. Clinical content reflects UK guidance at the date of editorial review — always check the current guideline. All patients are fictional.
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