EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What additional history would you take to assess James’ prescription request?

• Prompt: How would you assess for opioid dependence or misuse?
• Prompt: What red flags would you look for in a patient on long-term opioids?

Q2. What are the potential risks of continuing oxycodone, and how would you address them?

• Prompt: What are the long-term effects of opioid use?
• Prompt: How would you discuss deprescribing with the patient?

Q3. Outline an appropriate management plan, including non-opioid pain management options.

• Prompt: What multimodal pain strategies could be introduced?
• Prompt: How would you manage patient resistance to change?

Q4. How would you approach this consultation to ensure safe prescribing and professional boundaries?

• Prompt: How would you manage a patient requesting opioids inappropriately?
• Prompt: What legal and ethical considerations apply to opioid prescribing?

Q5. James refuses alternative treatments and insists on oxycodone. What would you do next?

• Prompt: How would you maintain professional rapport while declining a prescription?
• Prompt: When would referral to pain specialists or addiction services be warranted?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What additional history would you take to assess James’ prescription request?

A comprehensive history is required to assess the appropriateness of James’ opioid prescription request.

1. Pain History:

• Onset, duration, and progression of back pain.
• Character and severity: Neuropathic vs nociceptive pain.
• Aggravating and relieving factors.
• Impact on daily function and work.

2. Current and Past Pain Management:

• Effectiveness of oxycodone and any previous dose escalations.
• Use of other pain relief methods (physiotherapy, exercise, heat therapy).
• Previous specialist input (pain management, orthopaedics).

3. Opioid Dependence and Risk Assessment:

• Signs of tolerance or withdrawal symptoms.
• Patterns of medication use (taking more than prescribed, running out early).
• History of doctor shopping or lost prescriptions.
• Use of other substances (alcohol, benzodiazepines, illicit drugs).

4. Psychosocial and Mental Health History:

• Mood symptoms, anxiety, depression, PTSD.
• Social supports, employment stressors.

5. Functional Impact and Goals:

• What does James hope to achieve with continued opioid use?
• Open discussion about opioid risks and non-opioid strategies.

Thorough history-taking identifies risk factors for opioid misuse and guides safer pain management.

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Q2: What are the potential risks of continuing oxycodone, and how would you address them?

Long-term opioid use has significant risks that should be discussed openly.

1. Physical Risks:

• Tolerance and dependence – requiring increasing doses for effect.
• Opioid-induced hyperalgesia – worsening pain with prolonged use.
• Constipation, sedation, respiratory depression (especially with alcohol use).

2. Psychological and Social Risks:

• Increased risk of depression and anxiety.
• Reduced quality of life and reliance on medication.
• Potential for opioid misuse or addiction.

3. Addressing Deprescribing:

• Explain benefits of reducing opioids (improved function, reduced side effects).
• Discuss tapering strategies (slow dose reduction to avoid withdrawal).
• Offer multimodal pain management options as alternatives.

4. Monitoring and Support:

• Regular GP reviews to assess withdrawal symptoms.
• Referral to a pain specialist or addiction service if high-risk.

A structured deprescribing plan ensures safe opioid withdrawal while supporting effective pain relief.

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Q3: Outline an appropriate management plan, including non-opioid pain management options.

James requires a comprehensive pain management plan that minimises opioid use.

1. Non-Pharmacological Strategies:

• Physiotherapy: Strengthening and mobility exercises.
• Heat therapy, acupuncture, cognitive behavioural therapy (CBT).
• Encourage regular physical activity (e.g., walking, swimming).

2. Non-Opioid Pharmacological Options:

• Paracetamol (regular, not PRN) and NSAIDs (if no contraindications).
• Neuropathic agents (e.g., pregabalin, amitriptyline) if neuropathic pain suspected.
• Consider duloxetine if coexisting depression or anxiety.

3. Opioid Reduction Strategy:

• Gradual tapering of oxycodone (e.g., 10-25% reduction every 1-2 weeks).
• Monitor for withdrawal symptoms and provide support.
• Avoid abrupt cessation to minimise withdrawal effects.

4. Mental Health and Psychosocial Support:

• Assess and manage underlying anxiety/depression.
• Encourage social support networks.
• Referral to addiction services if opioid dependency suspected.

A multidisciplinary approach provides holistic pain relief while minimising opioid reliance.

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Q4: How would you approach this consultation to ensure safe prescribing and professional boundaries?

Managing opioid requests requires a balance between empathy and professional responsibility.

1. Use Open and Non-Judgmental Communication:

• Acknowledge James’ pain and concerns while discussing risks of opioids.
• Use shared decision-making to explore safer options.

2. Explain Safe Prescribing Principles:

• Opioids are not first-line for chronic pain (RACGP opioid prescribing guidelines).
• Prescriptions must be evidence-based and in the patient’s best interest.

3. Set Clear Boundaries and Expectations:

• If opioids are prescribed, implement an opioid contract (single prescriber, regular review).
• Refuse opioid requests if not clinically appropriate, while offering alternative management.

4. Documentation and Monitoring:

• Check prescription monitoring programs (e.g., SafeScript in Australia).
• Record the discussion and rationale for prescribing or declining.
• Follow-up closely to reassess pain and medication use.

A firm but supportive approach ensures safe prescribing while maintaining rapport.

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Q5: James refuses alternative treatments and insists on oxycodone. What would you do next?

Managing opioid-seeking behaviour requires a structured and professional approach.

1. Reassess Risk and Justification:

• Is there a legitimate clinical indication for ongoing oxycodone?
• Has the patient demonstrated opioid misuse?

2. Decline the Prescription If Not Clinically Indicated:

• Explain that opioids are not appropriate for chronic pain.
• Offer alternative options but set clear prescribing boundaries.

3. Provide Referral Pathways:

• Pain management clinic for specialist review.
• Addiction medicine referral if dependence suspected.
• Mental health support for underlying psychological distress.

4. Maintain Professionalism and Safety:

• Avoid confrontation but be firm.
• Ensure James understands that safe prescribing is a duty of care.
• Document the discussion, including refusal and offered alternatives.

Safe prescribing prioritises patient safety while preserving the doctor-patient relationship.

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SUMMARY OF A COMPETENT ANSWER

• Comprehensive history-taking assessing pain severity, opioid dependence risk, and psychosocial factors.
• Understanding of opioid risks including tolerance, dependence, and long-term harms.
• Implementation of multimodal pain management, incorporating non-pharmacological and non-opioid strategies.
• Professional and structured approach to opioid prescribing, including deprescribing strategies.
• Clear communication of prescribing boundaries, while maintaining patient rapport.

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PITFALLS

• Failing to assess opioid dependence and the potential for misuse.
• Automatically prescribing opioids without exploring alternative pain management options.
• Not addressing psychosocial factors, including mental health and functional impairment.
• Poor documentation of the prescribing discussion, including refusal and alternatives offered.
• Not using prescription monitoring programs to assess for doctor-shopping or high-dose opioid use.

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REFERENCES

• RACGP – RACGP Guidelines on Prescribing Drugs of Dependence
• GP Exams – Prescription

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MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD