Newly Registered Man Requesting Codeine for Chronic Back Pain — Free SCA Practice Case

Character Overview: You are Tomasz, a 34-year-old man who recently moved to the UK from Poland and has just registered with the practice. You have had low back pain for over a year, since a road traffic accident. You take 7–10 tablets of 30 mg codeine a day and have only two left; you last got them three months ago in Poland. You are worried that without codeine the pain will be unbearable and you won't cope. You have no red-flag symptoms and the pain has been unchanged for a year. Physiotherapy in Poland did not help. You work at a car wash and live with a friend; you don't smoke and drink occasionally. You want codeine prescribed today, and if the doctor refuses outright you become persistent and frustrated.

Opening Sentence: "Hello Doctor. I've just registered here. I need a prescription for codeine — for my back. I've only got two tablets left and I really can't manage the pain without them."

History if Asked (Data Gathering Phase)

• ●The pain: "Lower back pain, for over a year, since a car accident. It's been about the same the whole time."
• ●The codeine: "I take seven to ten of the 30 mg tablets a day. I've got two left. I last got them three months ago, back in Poland."
• ●What he fears: "If I run out, the pain will be unbearable and I won't be able to work or cope."
• ●Previous treatment: "I had physiotherapy in Poland — it didn't help."
• ●What he wants: "I just need you to prescribe the codeine."

ICE — Ideas, Concerns, Expectations

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

• ●Ideas: Tomasz believes codeine is what he needs to control his back pain and that nothing else works. "Codeine is the only thing that helps — I need it."
• ●Concerns: His dominant concern is that the pain will become unbearable without it and he won't cope or be able to work. "I'm scared of the pain without it, and of not being able to work."
• ●Expectations: He expects a codeine prescription today. "I want the codeine prescribed."

If Asked — Pain, Red-Flag, Dependence, and Social Screen

The patient answers these only when directly asked.

• ●If asked about the pain (site, radiation, character): "Lower back, doesn't really shoot down my legs, a constant ache. Unchanged for a year."
• ●If asked about cauda equina red flags (saddle numbness, bladder/bowel control, leg weakness): "No numbness down below, no problems with my waterworks or bowels, no leg weakness."
• ●If asked about malignancy/infection red flags (weight loss, fever, night sweats): "No weight loss, no fevers or night sweats."
• ●If asked about trauma: "Just the car accident over a year ago."
• ●If asked about impact on work/sleep/mood: "It affects my sleep and my mood a bit, and it's hard at work."
• ●If asked about what happens if he misses a dose of codeine: "I feel rotten — achy, restless, sweaty, on edge." (Suggests physical dependence/withdrawal.)
• ●If asked about previous investigations: "I had some physio in Poland, no scans that I know of."
• ●If asked, sensitively, about alcohol and recreational drugs: "I drink occasionally, no drugs."
• ●If asked about occupation/living/mood: "I work at a car wash, live with a friend. Settling in has been stressful."

Responses to Management (The Negotiation Phase)

• ●If the Doctor explains it can't simply be continued without assessment: "But I've been on it for a year — why can't you just prescribe it?" (The tested point is not prescribing on demand without assessment, given no verifiable records — explained clearly.)
• ●If the Doctor explains the risks of long-term high-dose codeine: "You're saying it can be harmful and stop working? I didn't realise." (The tested point is explaining dependence, tolerance, and the harms/limited benefit of opioids in chronic pain.)
• ●If the Doctor offers a limited supply with a reduction plan (not abrupt stop): "So you'll give me a small amount and we make a plan to cut down slowly, not stop suddenly?" (The tested point is a safe, limited prescription with a gradual reduction plan to avoid withdrawal.)
• ●If the Doctor offers non-drug alternatives: "Physio didn't help before — but a different approach here, and other options? I suppose I'd consider it." (The tested point is offering non-drug alternatives and other analgesia.)
• ●If the Doctor stays firm but supportive under pressure: "I'm not happy, but… if there's a proper plan and you're not just cutting me off, okay." (The tested point is handling the pressure professionally — neither caving nor abandoning him.)