Man Requesting His Methadone Prescription After Missing Collections — Free SCA Practice Case

Character Overview: You are Wayne, 41, established on methadone through the drug and alcohol service for about four months and doing reasonably well. You have missed your last four days of pharmacy collections. The reason is that your partner was admitted to hospital unexpectedly and you have been managing your 8-year-old son and hospital visits, and you simply could not get to the pharmacy during opening hours. You have not used heroin or anything else — you have been determined not to. You are starting to feel unwell: aching, sweating, restless, and anxious. You went to the pharmacy today and they told you the prescription had lapsed and you needed to see a doctor. You have tried ringing your keyworker but could not get through. You want a prescription today at your usual dose, and you will be frustrated and frightened if told you cannot simply have it. You are honest and not aggressive.

Opening Sentence: "Hello Doctor. I'm on methadone through the drug team — sixty mils a day, supervised at the chemist. I've missed the last four days' collections because my partner's been in hospital and I've had our lad to sort out. The chemist says my script's lapsed and I need to see a doctor. I'm starting to feel rough. Can you sort me a prescription today?"

History if Asked (Data Gathering Phase)

• ●How many doses missed: "Four days. My last dose was four days ago — Monday."
• ●Why: "My partner was taken into hospital suddenly. I've been running around with our son and visiting her. I couldn't get to the chemist in opening hours. That's the honest truth."
• ●Whether he has used anything: "No. I haven't touched heroin or anything else. I've been determined not to — I've worked too hard."
• ●How he feels now: "Aching all over, sweaty, restless, can't settle, a bit anxious. Not awful yet, but I know how it goes."
• ●Contact with the service: "I've tried ringing my keyworker twice today and couldn't get through."
• ●What he wants: "My prescription. Same as usual, sixty mils, so I don't get ill."

ICE — Ideas, Concerns, Expectations

The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores his perspective.

• ●Ideas: Wayne assumes he can simply restart at his usual dose — he does not know that missing doses changes anything. "I just need my usual sixty mils. It's the same script I've been on for months."
• ●Concerns: His dominant concerns are going into withdrawal and — underneath — relapsing after months of progress, and coping with his son while his partner is in hospital. "I'm frightened of getting properly ill, and of ending up using again after all this. And I've got my lad to look after."
• ●Expectations: He expects a same-day prescription at his usual dose. "I want the script today, my normal dose."

If Asked — Tolerance, Substance, Safety, and Safeguarding Screen

The patient answers these only when directly asked.

• ●If asked precisely when the last dose was taken and how many consecutive days missed: "Four consecutive days. Last dose Monday morning." (Critical — three or more missed days means tolerance is lost.)
• ●If asked about withdrawal severity (sweating, aches, restlessness, gooseflesh, diarrhoea, vomiting, insomnia): "Aching, sweating, restless, not sleeping. No vomiting or diarrhoea yet."
• ●If asked about any use of heroin or other opioids during the gap: "No, nothing. I haven't used."
• ●If asked about other substances — benzodiazepines, pregabalin/gabapentin, alcohol, crack/cocaine: "No benzos, no pregabalin, no alcohol, nothing else."
• ●If asked about whether he has obtained methadone from anyone else: "No, I haven't."
• ●If asked about previous overdose: "Years ago, before I got into treatment. Not since."
• ●If asked about whether he has take-home naloxone: "I was given one of those kits when I started, but I'm not sure where it is now."
• ●If asked about whether this has happened before: "No, never. I've not missed a collection before this."
• ●If asked about his son and childcare — safeguarding: "He's eight. My mum's been helping while my partner's in hospital. He's fine and he's being looked after."
• ●If asked about safe storage of medication: "It's supervised at the chemist, so there's nothing at home."
• ●If asked about his mood and coping: "Stressed and worried about my partner, but I'm holding it together."
• ●If asked about his keyworker and engagement: "I see her regularly and I've been doing well. I just couldn't reach her today."

Responses to Management (The Negotiation Phase)

• ●If the Doctor explains that tolerance is lost after missed doses — the key point: "Hang on — you're saying that because I've missed four days, going back on my normal dose could actually be dangerous? Nobody's ever explained that to me." (The tested point is recognising and explaining lost tolerance and the risk of fatal overdose on resuming the previous dose.)
• ●If the Doctor explains they cannot simply re-issue the prescription: "So you can't just print me my usual script? What am I supposed to do — I'm going to be really ill." (The tested point is declining to re-issue while still taking responsibility for a safe outcome.)
• ●If the Doctor arranges urgent liaison with the drug service: "You'll get hold of the drug team today and get me reassessed? That's what I need, then." (The tested point is urgent liaison with the specialist service, which holds the prescribing responsibility.)
• ●If the Doctor discusses symptomatic relief in the interim: "Is there anything that'll take the edge off while this gets sorted?"
• ●If the Doctor raises naloxone — key harm reduction: "The naloxone kit — I should find that, or get another one? I hadn't thought about it."
• ●If the Doctor safety-nets about not topping up: "You're saying don't try to sort it myself with anything off the street, because that's when people come unstuck? Yeah. I understand that."