Station 32
Jason Stubbs
Age: 28 years old female
Full Case
Patient’s Data
Patient’s name: Jason Stubbs
Age: 28 years old male
Past medical history
- Asthma
- Recently released from prison (incarcerated for 2 years; released 1 week ago)
- Recently re-registered at the practice
Drug and Allergy History
- Salbutamol inhaler (PRN use)
Recent Notes/ Consultation
- Nil
Patient was advised by the pharmacist to contact the GP for medication reconciliation
Patient's Story (Role player’s brief)
Patient’s Story
You are Jason Stubbs, a 28-year-old male, and you have booked a telephone appointment with the GP following your release from prison one week ago, to request a repeat prescription for medications you were previously taking during your time in prison.
While in prison, you were prescribed pregabalin, tramadol, and zopiclone to manage chronic lower back pain and sleep difficulties. You no longer have access to these medications, and you would love them to be prescribed
ONLY DISCLOSE BELOW IF ASKED:
While you were in prison, you developed ongoing lower back pain and began experiencing persistent sleep difficulties. The prison doctor prescribed pregabalin, tramadol, and zopiclone, which you have been taking regularly since then. You believe these medications have been essential, without them, your back pain becomes severe, and you struggle to sleep. Youn have been on them for about one year now
You now have only one tablet left of each medication and have been trying to get a GP appointment since your release. A pharmacist recently advised you that only a GP can review and prescribe these medications in the community.
You do not feel low in mood and deny any symptoms of depression.
You were taking pregabalin 50mg, three times a day, tramadol 100mg, four times a day and zopiclone 7.5mg at night
Social History: You are currently homeless and staying with a friend in a caravan. No current employment as no one wants to employ an ex-convict. You are not in contact with your family, who have distanced themselves following your incarceration
You were imprisoned for assaulting your ex-girlfriend
You do not smoke, do not drink alcohol, and do not use illicit drugs
Idea: You believe you need these medications to manage your pain and sleep
Concern: You are worried about withdrawal symptoms, as you get jittery, shaky, and sweaty when you do not take them.
Expectation: You are hoping the doctor will restart your previous prescriptions
Say NO to any other questions asked outside of the details already provided in the scenario. Accept anything offered to you by the doctor.
Marking Scheme
Data Gathering and Diagnosis
- Ask how long he has been on pregabalin, tramadol, and zopiclone (to determine potential dependence and whether a gradual wean is needed rather than abrupt discontinuation)
- Ask about the original reason each medication was started
- Ask what happens when he doesn’t take the medications (to identify possible withdrawal symptoms such as sweating, agitation, aggression, confusion, pain – suggestive of drug dependence)
- Ask if he is taking any over-the-counter medications or supplements (to identify potential drug interactions or undisclosed usage)
- Ask about his lower back pain: Has it changed or worsened? any numbness around the back passage (saddle anaesthesia)? Any weakness in the legs? Any issues with bladder or bowel control? (to screen for red flag symptoms suggestive of cauda equina syndrome)
- Ask if he has ever tried physiotherapy or any non-pharmacological management for back pain (to assess previous interventions and suitability for referral)
- Ask about sleep difficulties – whether he struggles with falling asleep or staying asleep, and whether issues such as nightmares or past trauma may be contributing. Also ask about his night-time routine and sleep habits.
- Ask if he has tried any sleep hygiene measures, such as maintaining a regular bedtime routine, avoiding screens before bed, or creating a calm sleep environment
- Ask about symptoms associated with opioid misuse, such as chronic constipation, unexplained weight loss, nausea, or vomiting
- Ask about illicit drug use (if yes, ask whether he has ever injected drugs — this guides screening for blood-borne viruses such as HIV, hepatitis B and C)
- Ask about alcohol and smoking history
- Ask if he has purchased any of the medications online or obtained them through other non-medical sources (to assess for unsafe access or misuse)
- Take other important social history including his home and living situation, employment status and current financial support
- Ask about his mood and whether he feels low; If low mood is reported, ask about self-harm or suicidal thoughts
- Ask if the patient is currently driving, as the DVLA has strict regulations regarding the use of controlled medications such as opioids and benzodiazepines
Example of explanation to patient
Thank you for calling in today, Jason, I really appreciate you reaching out and sharing what’s been going on.”
Tramadol and pregabalin are both strong painkillers, and while they can help in the short term, using them for a long time can be risky. They can affect the way your brain works, making you feel like you need them to function or feel okay. Over time, your body can get used to them, meaning you may need higher doses to get the same effect — this is called tolerance. Eventually, that can lead to dependence or addiction, which can impact not just your health, but also your relationships and quality of life.
Because of this, we need to make a plan to gradually reduce and eventually stop these medications, not suddenly, but in a safe and supported way. I’m happy to prescribe a short supply now, but we’ll need to work together to reduce your dose week by week or every two weeks. We can arrange regular follow-ups, and I’ll coordinate with the pharmacist to do 1- to 2-week prescriptions so we can monitor things closely and keep you safe.
In terms of your back pain, I’d like to see you face to face so I can examine you properly. I’d also recommend referring you to our physiotherapy team, who are experienced in managing long-term back pain. They can help guide you through exercises and techniques to reduce pain. We can also use simple pain relief like paracetamol or ibuprofen during flare-ups, where appropriate.
Another option that has helped many people with chronic pain is talking therapy. This doesn’t mean the pain is in your head — rather, it helps you develop coping strategies, manage pain-related anxiety, and shift beliefs around pain. Many people find it reduces how much pain affects their day-to-day life. Would you be open to exploring that?
As for your sleep, I understand it’s been really difficult. Rather than relying on sleeping tablets, which aren’t safe long term, I’d recommend trying some sleep hygiene techniques, like:
- Going to bed and waking up at the same time every day
- Avoiding screens and phones before bedtime
- Limiting daytime naps
Staying active during the day to help your body rest at night. We can also look at talking therapy for sleep, which has shown great results in people with long-standing insomnia (Sleeping difficulty).
You also mentioned your housing situation, and I really want to support you with that. We have a brilliant social prescriber called David — he’s very approachable and can help you connect with housing services through the council. There are also charities that specialise in supporting people who’ve recently left prison, including:
- Nacro
- The Prison Reform Trust
- The Hardman Directory
- Shelter
- Unlock
Some also help with finding work or training, if and when you’re ready. Would you like help getting in touch with them?”*
I’ll book you in for a face-to-face appointment this afternoon to examine your back and support you in person. Then, let’s check in again in two weeks to review how you’re getting on with the plan and make any changes if needed. In the meantime, if anything changes, like new symptoms, worsening pain, weakness in your legs, numbness around your back passage or inability to control your bladder or bowel or you have any other concern — please don’t hesitate to reach out sooner. How does that sound to you?
Management
Management
- Prescribe a short-term supply of pregabalin, tramadol, and zopiclone, with a clear plan to gradually wean off under supervision.
- Arrange 1–2 weekly prescriptions with regular reviews to monitor withdrawal symptoms, compliance, and safety. This can be coordinated in partnership with the pharmacist.
- Book a face-to-face appointment the same day to examine his lower back and assess for red flag symptoms.
- Refer to physiotherapy for chronic lower back pain management and exercise guidance.
- Recommend paracetamol or ibuprofen as simple pain relief during flare-ups (if no contraindications).
- Offer referral to talking therapy to support coping with pain, anxiety, sleep issues, and emotional wellbeing.
- Provide education on sleep hygiene, including regular bedtime routine, avoiding screens before bed, reducing daytime naps, and increasing daytime physical activity.
- Refer to the social prescriber to support housing applications and access to social services.
- Signpost to charities that support people recently released from prison, such as: Nacro (National Association for the Care and Resettlement of Offenders), Prison Reform Trust, The Hardman Directory, Shelter, Unlock etc. These charities can help with accommodation and employment
- Arrange a follow-up review in 2 weeks to assess progress with medication reduction, back pain, housing, and psychological wellbeing.
- Provide safety-netting: advise Jason to contact the practice urgently if he experiences worsening pain, withdrawal symptoms, suicidal thoughts, or housing crisis.
Learning point from this station:
Managing patients who have recently been released from prison requires a trauma-informed, structured, and collaborative approach. These individuals often present with complex medical, psychological, and social needs, including dependence on prescribed controlled drugs such as benzodiazepines, Z-drugs (e.g. zopiclone), gabapentinoids (e.g. pregabalin), and opioids (e.g. tramadol, codeine).
It is important to recognise that abrupt discontinuation of these medications can lead to significant withdrawal symptoms, which may be dangerous and distressing. Therefore, where there are no immediate medical contraindications, these medications should be tapered gradually in partnership with the patient and, where appropriate, with input from a pharmacist.
Do not stop these medications abruptly unless there are exceptional clinical circumstances, such as:
- Respiratory depression from opioids
- Severe ataxia from pregabalin
- Gastrointestinal bleeding from antidepressants
In such situations:
Consider short-term symptomatic treatment for withdrawal (e.g. loperamide for diarrhoea, paracetamol for pain, prochlorperazine for nausea).
Increase frequency of reviews to ensure safety and support.
If there is a history of illicit opioid use like heroin or other opioid dependence, refer promptly to local drug and alcohol services. These services provide opioid substitution therapy (OST) using methadone or buprenorphine, under specialist assessment and daily supervision.
Do not prescribe methadone or other opioid substitutes in primary care on an unplanned basis to manage withdrawal symptoms. OST must be based on a thorough specialist assessment to avoid inappropriate prescribing and overdose risk.
Methadone’s long half-life means it stays in the body long after its effects wear off, causing the drug to build up and increasing the risk of life-threatening overdose from respiratory depression.
Methadone is far more dangerous if re-prescribed unsupervised, due to loss of tolerance, long half-life, and lethal overdose potential
In patients presenting with methadone withdrawal who are seeking an unsupervised prescription, offer symptomatic treatment to help manage withdrawal symptoms safely while arranging urgent referral to a drug and alcohol service to get them their methadone prescription. Do not be pressured to prescribe Methadone
Supportive treatment may include:
- Loperamide for diarrhoea
- Mebeverine for abdominal cramps
- Paracetamol or NSAIDs for muscle aches and headaches
- Topical rubefacients for muscle pain
- Metoclopramide or prochlorperazine for nausea and vomiting
If withdrawal symptoms are severe, the patient may require hospital admission for supportive care and monitoring.
In selected cases, a medication called lofexidine (an alpha-2 adrenergic agonist) may be used to reduce withdrawal symptoms. However, this is typically initiated by specialist addiction teams or in hospital settings and is not routinely prescribed in general practice.
Warn the patient about the serious risk of overdose if they use street drugs to relieve withdrawal symptoms, particularly if injecting. Emphasise that, following a period of abstinence, their tolerance is reduced, which significantly increases the risk of unintentional overdose and death.