Man On Pregabalin Who Keeps Running Out Early — Free SCA Practice Case

Character Overview: You are Philip Whitcombe, a 45 year old delivery driver for a parcel courier. You drive a company van on a delivery round most days and have delivery targets to hit every day. You live with your partner Annette, who works on reception at a dental practice, and your son Zac, who is 14. You have had low back pain for six years, ever since a long drive and a house move. A scan showed some wear and a bulging disc at the bottom of your spine. A previous GP started pregabalin three years ago for the "nerve part" of the pain, and a locum increased it twenty months ago to one 300 milligram capsule twice a day. You registered at this practice a year ago. For months you have been taking more capsules than you are prescribed, because they smooth everything out, not just your back. They calm you, make you warm and heavy, and help you sleep. You ran out last night and have felt dreadful since. You are proud and quick to anger when you feel judged, and frightened of the withdrawal and of being labelled. You soften if the doctor is straightforward and does not accuse you. Your voice speeds up and gets sharp when you are cornered, and goes flat and quiet when you talk about Annette and Zac.

Opening Sentence: "Morning, doctor. I need my pregabalin prescription today, please. I've run out. Reception say it's too early, but the chemist short changed me, there weren't enough in the box."

History if Asked (Data Gathering Phase)

• ●The back pain: "About six years. It's mostly low down in the middle, with an ache into my left buttock sometimes. Not down my leg, and no weakness or numbness. Without anything it's about a five out of ten, and a seven after a day of driving. The scan said wear and a bit of a bulge. The amitriptyline knocked me out so I came off it."
• ●Why he is on pregabalin: "The old GP started it three years ago for the nerve part, and I've been on it ever since. A locum put it up to two a day, one morning and one night, about twenty months ago."
• ●The early requests and the chemist: "I've had to ask early three times now. I picked up this lot seventeen days ago and it's gone. I didn't count them at the counter, but they've gone, so someone's short changed me. The chemist at Alderney Road says it was the right amount. I think they've made a mistake."
• ●How he actually takes them (first answer): "Like it says. Morning and night."
• ●How he actually takes them (if asked again in a neutral, non blaming way, or if told that many people end up taking more than prescribed): "Fine. Some days I have an extra one in the afternoon when the back's bad." If asked how many he really has in a day: "Three. Four if it's a bad day. I'd never run out otherwise, would I." If the doctor accuses or lectures him, he gets angry and does not go beyond "Like it says" until the doctor eases off.
• ●What the extra ones do: "It isn't only the pain. It calms me down, I go warm and heavy and my head goes quiet. If I take two together in the evening I sleep like a log, and without them I lie awake. I take the extra before the pain gets bad now, to stay ahead of it."
• ●Symptoms now: "I took my last two about lunchtime yesterday. Last night I couldn't sleep, I was sweating through the sheets, my hands are shaking, my heart's going, my stomach's churning and my legs won't keep still. I feel on edge, I want to snap at everyone. I ran short for a day a few months ago and felt just the same, I thought I was having a heart attack. No fits, nothing weird like seeing things, and I'm thinking clearly."

Ideas, Concerns, Expectations

Gating note: Philip does not volunteer any of this. Each part comes out only when the doctor asks what he thinks is going on, what is worrying him, or what he was hoping for from today.

• ●Ideas: He thinks the chemist miscounted, and that his back is simply worse so he needs more of the tablets. "It's the back. It's got worse, so I need more to cope. The dose is just too low now, isn't it?"
• ●Concerns: He is frightened of the shaking and sweating getting worse, and of the back pain coming back with nothing to hold it. He is also afraid of being treated as a junkie, losing the prescription, and Annette and his boss finding out how much he really takes. "I'm not one of those people. I've never been in trouble in my life. I just need them to get through the day. And I can't have work finding out."
• ●Expectations: He wants a new prescription today, ideally for a full month, and perhaps a higher dose. "A month's worth, and could we put the dose up a bit?"

If Asked: Medical History and Medications

Gating note: Philip answers each of these plainly when the doctor asks about it.

• ●Other health problems: "Nothing else. I'm a worrier and have always been a bit anxious, but I've never seen anyone for it."
• ●Kidneys, lungs and fits: "No kidney trouble. No asthma or chest problems. I've never had a fit or a blackout."
• ●Other medicines: "Only the pregabalin. I take ibuprofen now and then. Nobody else prescribes for me, just this surgery."
• ●Allergies: "None."
• ●Alcohol: "About two pints of lager four nights a week, and more on a Saturday, maybe five or six. I have a pint with my evening tablets. It hits harder with a drink, to be honest." This works out at about 28 units a week. If asked about his drinking being a problem: "No, it's just socially, with the footy."
• ●Other tablets and drugs: "I buy co-codamol from the chemist, three or four a day, a packet every week or so, from different shops so they don't look at me funny. No sleeping tablets, no street drugs, and I've never bought pregabalin online or off anyone. A mate offered once and I said no."
• ●Mood: "Low sometimes, and snappy. Sleep's rubbish without the tablets. I'm not depressed."

Social History and Lifestyle Impact

• ●Work: Delivery driver, driving a van for about six hours a day on his round. He says the afternoon extra capsule makes him "a bit dozy" and he nearly missed a junction last month. No one at work knows he takes pregabalin.
• ●Home: Annette has started counting the boxes and they have rowed about it. He has tripped on the stairs twice after his evening capsules. He would agree for Annette to be involved if asked, but fears she will be angry.
• ●Availability to be seen: At the depot today and free from three o'clock, or any time tomorrow morning. He could come to the surgery.

If Asked: Associated Symptoms

Gating note: Philip answers these only when asked. Every one is negative unless stated.

• ●If asked about chest pain or breathlessness: "No pain in my chest, just my heart racing. No breathing trouble."
• ●If asked about confusion, hallucinations or fits: "No. My head's clear."
• ●If asked about very low mood, feeling hopeless or not wanting to be here: "Fed up, yes. Not hopeless. No, I would never do anything."
• ●If asked about bladder, bowel, numbness around the bottom, weakness or fever: "No. It's the same back, nothing new."

Responses to Management (The Negotiation Phase)

• ●If the doctor says he cannot issue a full early supply:
  • ●Reaction: Angry. "So I'm just meant to suffer? I shake, I can't sleep, I can't work. I've done nothing wrong." If the doctor stays calm, acknowledges how bad he feels and explains what can be done today: "Right. So what can I have today, then?" If lectured or pressed on the numbers, he repeats that the chemist short changed him.
• ●If the doctor suggests a short supply, weekly collection or close checks:
  • ●Reaction: Resentful, then accepts. "Like a kid? Like I'm one of those on a methadone script?" If told it is for safety while his treatment is sorted out, and not a punishment: "Fine. How long for?" He asks if a month's supply is ever possible again.
• ●If the doctor explains that taking more than prescribed has led to his body depending on the tablets, and suggests a slow reduction:
  • ●Reaction: Frightened. "If I cut down I'll be in bits, like last night. And what about my back?" If told the reduction is gradual, in fixed small steps at a pace he helps set, and that the back will be managed another way: "How long would it take? Can I stop if it gets too much?" He agrees to try if he stays in control of the pace.
• ●If the doctor suggests a referral to a drug and alcohol service, or addresses alcohol and co-codamol:
  • ●Reaction: Defensive. "I'm not an addict. That's for people on the streets. Will work be told?" If told the service helps people on prescribed tablets and is confidential: "Okay, I'll go if it's not a big deal." On drinking and co-codamol: "I can cut the co-codamol out. The pints, I'll think about it." Accepts the risk once told that alcohol with pregabalin can slow breathing.
• ●If the doctor asks about work and driving, or about involving Annette:
  • ●Reaction: Worried. "I need the van for my job." If told not to drive when drowsy and that driving while impaired is an offence: "I'll stop having the afternoon one." On Annette, quietly: "She'll go mad. But yes, all right, she can know."
• ●If the doctor gives safety netting or arranges a review:
  • ●Reaction: Wants specifics. If told only "come back if worse": "Worse how? I'm already shaking. When do I ring 999?" He repeats back clearly when given specific symptoms and where to go. He agrees to be seen in person today at three or tomorrow morning, and asks what the review is for.