MRCGP SCA Consultation Skills Course
Station 11 · Painkillers
Video consultation · Long-term conditions · Mental health · Prescribing · Professional dilemma · Circuit 2 · 11:20–12:45 · 14-minute station
A 45-year-old wants his co-codamol 30/500 doubled and a sick note extended; he is angry, in pain, and — if you ask — no longer sure he wants to be here.
Candidate brief
Read this as you would in the exam. One to two minutes' reading, then ten minutes. You may ask the patient for examination findings; there is no reference material.
| Patient | Darren Coyle, 45, warehouse team leader (currently off sick 8 weeks) |
| Reason for appointment | "Painkillers + sick note" (booked by patient) |
| PMH | Chronic low back pain (MRI 2023: degenerative disc disease, no nerve compression). Depression 2016 (citalopram, stopped 2018) |
| Medication | Co-codamol 30/500, 2 tablets qds — issued monthly for 14 months; naproxen 500 mg bd; omeprazole 20 mg. Allergies: none |
| Recent entries | Fit notes: 8 weeks continuous ('back pain'). 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. Alcohol: 'social' |
Role-player script — tutors only
Delegates: please do not open this section until you have consulted at this station.
Open the role-player script (660 words)
Persona and manner
- Tense, jaw set, arms folded; speaks fast and loud at first; feels judged and expects to be refused. Under the anger he is exhausted and ashamed.
- If the doctor is calm and asks about him rather than the tablets, he deflates and becomes very honest.
Opening line — say this 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."
Volunteer freely if given the space
- Back pain 'every day, all day' — 7/10; worse sitting; can't do the warehouse shifts; 'they're going to get rid of me'.
- Takes 'eight, sometimes ten' co-codamol a day — 'so I run out early, and then I'm climbing the walls'.
- Sleeps three or four hours.
Only if asked
- No red flags: no leg weakness, no bladder or bowel symptoms, no saddle numbness, no weight loss, no fever, no night pain distinct from usual, no trauma.
- Withdrawal when he runs out: sweats, restless legs, diarrhoea, 'can't sit still' — he has bought codeine from a mate twice.
- Mood: 'what do you think?' Then: low every day for months, no pleasure, poor appetite, 'useless', 'a burden'. Sleep broken. Irritable with his teenage sons. Has thought 'they'd be better off with the insurance money'; no plan; 'I wouldn't do it — the boys'. No previous attempts. Drinks 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; he thinks the note is the only thing protecting him. Would like to go back 'if I could do the office job they offered, but I'd lose the shift pay'.
- Partner Kelly works nights; 'we don't talk'. Money tight; car finance in arrears.
- Previous depression 'lifted when I got the team leader job'. Citalopram 'worked, I think'.
- Pain management programme: declined because 'it's for people who just have to live with it' — he thought that meant they'd given up on him.
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: co-codamol increased (or 'something stronger') and a four-week note.
Cues to deliver, timed
- Minute 1: 'I don't want a lecture about addiction.'
- Minute 4: 'climbing the walls' — only if asked what happens when he runs out.
- Minute 6: 'they'd be better off with the insurance money' — only if the doctor asks about mood properly and then asks directly about thoughts of not being here.
How to respond to the doctor's plan
- If the doctor absorbs the anger, takes the pain seriously, screens red flags, identifies opioid dependence and withdrawal without using the word 'addict', screens mood and asks directly about suicidal thoughts and makes a safety plan (protective factors, crisis numbers, agreed contact), proposes treating the depression (restart an SSRI he has tolerated; talking therapy), proposes a supported opioid plan (no increase; a slow, agreed taper — 10% every 1–2 weeks — with regular review; consider a pain-team re-referral for the programme, reframed), addresses alcohol, and handles the fit note honestly ('may be fit' with adjustments to the office role, and a letter for HR about the capability meeting), with follow-up in one week: he is silent, then wipes his eyes — 'nobody's asked me that before' — and agrees, asking 'will you write to HR?'
- If the doctor increases the co-codamol and issues a four-week note: 'cheers' — he leaves; the examiner will not.
- If the doctor refuses flatly ('I'm not giving you more opioids'): he stands up — 'knew it' — and only sits again if the doctor recovers by asking about him.
Examination findings if requested
- Guarded lumbar movements; no neurological deficit; straight-leg raise negative; gait normal; pupils normal; no signs of intoxication.
Do not
- Volunteer the withdrawal, the bought codeine or the suicidal thoughts without direct, well-asked questions.
- Stay angry if the doctor is calm and interested in him; de-escalate within two minutes of being heard.
Mark scheme
Delegates: open after your consultation. Examiner-observers: open during it.
Generic mark scheme — identical at every station
Domain grades
| Domain | CF (0) | F (1) | P (2) | CP (3) | Points |
|---|---|---|---|---|---|
| Data Gathering and Diagnosis | ☐ | ☐ | ☐ | ☐ | /3 |
| Clinical Management and Medical Complexity (×1.5) | ☐ | ☐ | ☐ | ☐ | /4.5 |
| Relating to Others | ☐ | ☐ | ☐ | ☐ | /3 |
| Total | /10.5 |
Global rating: ☐ Fail ☐ Bare Fail ☐ Bare Pass ☐ Pass (CF Clear Fail · F Fail · P Pass · CP Clear Pass)
Feedback statement(s) — tick the one (at most two) you would attach
| Domain 1 | Domain 2 | Domain 3 |
|---|---|---|
| ☐ 1.1 Insufficient data | ☐ 2.1 Referral | ☐ 3.1 Cues / listening / formulaic |
| ☐ 1.2 Notes not used | ☐ 2.2 Prescribing | ☐ 3.2 Agenda / beliefs |
| ☐ 1.3 Psychosocial | ☐ 2.3 Investigations | ☐ 3.3 Circumstances / culture |
| ☐ 1.4 Unsystematic | ☐ 2.4 Prevention | ☐ 3.4 Explanations |
| ☐ 1.5 Prioritisation | ☐ 2.5 Risk management | ☐ 3.5 Judgemental |
| ☐ 1.6 Implications of findings | ☐ 2.6 Co-morbidity | ☐ 3.6 Respect / sensitivity |
| ☐ 1.7 Differentials | ☐ 2.7 Uncertainty | ☐ 3.7 Ownership |
| ☐ 1.8 Diagnosis / decision | ☐ 2.8 Follow-up / safety-net | ☐ 3.8 Teamwork |
| ☐ 2.9 Time management | ☐ 3.9 Safeguarding |
Timing checkpoints (Observer)
| Checkpoint (10-minute frame) | Done | Minute |
|---|---|---|
| Patient allowed to open without interruption (≈1 min) | ☐ | |
| ICE and psychosocial context elicited by 3:30 | ☐ | |
| Red flags covered; examination findings requested by 5:00 | ☐ | |
| Working diagnosis verbalised; gear change by 5:00–5:30 | ☐ | |
| Options shared; patient's preference used | ☐ | |
| Specific safety-net and follow-up by 9:30 | ☐ | |
| Understanding checked; finished inside 10:00 | ☐ |
Key points for this station — customised standard
Key points for this station
| Domain | Pass requires | Clear Pass adds | Fail if |
|---|---|---|---|
| Data Gathering & Diagnosis |
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| Clinical Management & Medical Complexity |
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| Relating to Others |
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Global rating guide: Pass = red flags excluded, opioid dependence and depression recognised, suicidal ideation asked about with a safety plan, taper plus antidepressant, fit note handled honestly, one-week review.
Teaching points
- NICE NG193 chronic pain and NG59 low back pain: do not start or continue opioids for chronic primary pain; where already dependent, taper gradually (reductions of about 10% every 1–2 weeks) with support — never abrupt withdrawal. Antidepressants may help pain and mood.
- Any patient with chronic pain, opioid dependence and alcohol use needs an explicit suicide-risk question; passive ideation with protective factors still needs a documented safety plan and early review.
- A hostile opening is a cue, not an obstacle (3.1): the examiner marks whether you lower the temperature and then ask the hard question.
Guidelines for this station
- NICE NG193 — Chronic pain (primary and secondary) in over 16s: assessment and management
- NICE NG59 — Low back pain and sciatica in over 16s
- NICE NG215 — Medicines associated with dependence or withdrawal symptoms: safe prescribing and withdrawal management
- NICE NG222 — Depression in adults: treatment and management
- Faculty of Pain Medicine — Opioids Aware
Your reflection
Record your grades, the statement attached, what you will keep and change, and your own reflection. Your entry is emailed to you as a record of this station; this page stays live so you can revisit the full case during revision.
Write my reflection for Station 11
Revision link for this case: mdacumen.com/sca-station11-painkillers
Editorial stamp · MRCGP SCA Consultation Skills Course · Station pages v1.0 · 11 September 2026 · Prof Rajesh Varma, Course Director · MD Acumen. Formative training material; not a prediction of exam performance. Not for onward distribution.