Managing Pain
Demonstration Scenarios:
Jack encounters three doctors.
Purpose:
Relief of suffering is a foundational obligation of medical practice, but so too is
preventing harm to patients.
Every physician is familiar with the dilemma when patients attempt to direct them to
prescribe medications that the doctor believes are inappropriate. Humans are neurochemically hardwired to overvalue opioids, benzodiazepines, and cannabinoids.
Observational studies show that compassion frequently drives physicians to prescribe
unsafely. Patients in tragic circumstances are more likely to receive these
medications—high risk individuals end up receiving high risk prescriptions.
These encounters regularly degenerate into conflict. Doctors and patients alike
naturally come to dread them. Decisions about medications, which have very limited
potential to benefit people living with chronic pain, come to dominate the interaction
between doctor and patient. The dynamic is counterproductive.
This brief skit (in three parts) engages attendees because it authentically reflects their
everyday struggles with these issues. The goal is to reassure them that a simple,
structured approach aimed at defusing the situation is workable.
Structure:
The patient in these scenarios, Jack, is not living with chronic pain. This is deliberate. It
is natural for practitioners to transfer the discomfort and frustration that people like Jack
trigger to the very different realm of chronic pain. A reluctance to readily accept people
with chronic pain as patients has its roots, in part, in a desire to minimize the number of
these encounters.
Jack does not have chronic pain. But the clinical vigilance competencies required to
keep Jack safe are transferable.
The demonstration scenarios require a total of about five minutes and are followed by
about 15 minutes of content to set out the basic principles of safe and effective opioid
prescribing.
1
Scenario 1 - The Easy Mark
Name of Patient: Jack Wilson
Setting: Walk-in clinic, Friday evening
Casting: Male, construction worker clothing
The person portraying the doctor may hold the script in the “chart”.
____________________________________________________
(Smiling, good humor)
JACK
Hi Doc, I’m glad you guys are open. My doctor’s office is closed and I’m going out
of town first thing tomorrow. I’m working in Fort McMurray and I’ll be there for a
month. I have a stone in my right kidney. I’ll be getting it zapped in six weeks in
Vancouver. I’m having two to three attacks of pain a week.
Yesterday, my doctor gave me 30 Dilaudid to tide me over. They work really well
for me. You wouldn’t believe what happened. I was down at the bus depot buying
a ticket and my backpack was stolen, with all the pills inside.
Anyway, if you can give me a refill...my doctor gave me 30 tablets. That should be
enough to last me until I get back. Your nurse took a urine sample when I told her
I had a kidney stone; it probably will show blood in it. I’ve just had an attack.
DOCTOR
Who’s your regular doctor?
JACK
Doc Smith - just down the road. He’s been my doctor for years.
DOCTOR
Okay, when did you say you’re getting the stone
blasted?
JACK
Six weeks.
DOCTOR
So, you’re having two to three attacks of pain per
week?
Yeah.
JACK
Managing Pain
DOCTOR
You take Dilaudid for the pain…
JACK
Yeah - eight milligram tablets.
DOCTOR
(While writing a prescription…)
Thirty tablets will do you until you get back.
JACK
Yeah, should be enough.
DOCTOR
Okay, no problem. Just be more careful with these.
You can’t just leave them lying around anywhere,
you know.
(Hands prescription to Jack)
JACK
(Reads prescription)
I know, Doc, I’ll be more careful with this one.
(While speaking, he holds prescription up in the air, and gives it a little shake.
Getting up to leave, he comments:)
Thanks a lot Doc.
(Jack exits.)
~ End of Scenario 1 ~
3
Scenario 2 – The Confrontation
Name of Patient: Jack Wilson
Setting: Walk-in clinic, Friday evening
Casting: Same Jack; same doctor—different attitude.
____________________________________________________
(Smiling, good humor)
JACK
Hi Doc, I’m glad you guys are open. My doctor’s office is closed and I’m going out
of town first thing tomorrow. I’m working in Fort McMurray and I’ll be there for a
month. I have a stone in my right kidney. I’ll be getting it zapped in six weeks in
Vancouver. I’m having two to three attacks of pain a week.
Yesterday, my doctor gave me 30 Dilaudid to tide me over. They work really well
for me. But you’ll never guess what happened. I was taking a shower. The pills
were on the bathroom counter with some other stuff I was getting ready to pack.
My girlfriend’s cat came in and jumped up on the counter - the pills ended up in
the toilet. I didn’t notice until I got out of the shower.
Anyway, if you can give me a refill...my doctor gave me 30 tablets. That should be
enough to last me until I get back. Your nurse took a urine sample when I told her
I had a kidney stone; it probably will show blood in it. I’ve just had an attack.
DOCTOR
I have to tell you up front that I don’t refill narcotics
for patients I don’t know.
JACK
I understand doc, but I’m really stuck. I wouldn’t have come in if I didn’t need the
prescription. You guys are the only clinic open.
DOCTOR
(Arrogant tone)
That’s not my problem. You should have been
careful with your pills.
(Getting anxious)
JACK
I know, I know...if you give me a refill, I promise I’ll be more careful.
(Sees doctor writing a prescription and relaxes a bit)
This will be a big help, Doc. Thank you.
Managing Pain
(Short silence while doctor finishes writing prescription. Doctor then hands it to
Jack.)
JACK
(Reads prescription, gets upset)
What’s this? I don’t recognize the name!
DOCTOR
(Cool, detached)
Indocid suppositories. An anti-inflammatory. They
work really well for kidney stone pain.
JACK
But Dilaudid is the only thing that works! Besides, I can’t take anti-inflammatories.
They kill my gut.
(Hands prescription back to doctor)
DOCTOR
(Takes prescription and tears it up)
I guess you’re out of luck.
(Anxious again)
JACK
I know you don’t know me, but I don’t abuse them. How about ten or twenty? I’ll
only take one or two if I’m desperate. You’re a doctor - you’re supposed to help
people who are in pain. Didn’t you take an oath or something?
DOCTOR
(Becoming sarcastic)
I didn’t take an oath to give narcotics to a drug
addict!
5
JACK
(Getting angry now)
Are you calling me a drug addict?
DOCTOR
(Also becoming angry)
Let’s just say that I don’t think you have a kidney
stone and your story about the cat is bullshit!
JACK
(Angrier)
Are you calling me a liar?
(Angrily)
DOCTOR
I don’t have time for this crap. It’s time for you to
leave.
(Stands up and motions for Jack to get out…)
(Stands up)
JACK
I’m going to make a complaint about you. You can’t refuse to treat me. I just read
about it in the paper!
(Walks away)
(Loudly)
DOCTOR
Don’t come back to this clinic again!
JACK
(Stomps out, swearing loudly—doctor may swear back at him)
Note to actors - Choose your own expletives.
~ End of Scenario 2 ~
Managing Pain
Scenario 3 - In Control
Name of Patient: Jack Wilson
Setting: Walk-in clinic, Friday evening
Casting: Same Jack; same doctor—different attitude.
____________________________________________________
(Smiling, good humor)
JACK
Hi Doc, I’m glad you guys are open. My doctor’s office is closed and I’m going out
of town first thing tomorrow. I’m working in Fort McMurray and I’ll be there for a
month. I have a stone in my right kidney. I’ll be getting it zapped in six weeks in
Vancouver. I’m having two to three attacks of pain a week.
Yesterday, my doctor gave me 30 Dilaudid to tide me over. They work really well
for me. But you’ll never guess what happened. [Again, the actor portraying Jack is
encouraged to improvise a different scenario here—for variety. Experienced
doctors have heard many such stories.]
Anyway, if you can give me a refill...my doctor gave me 30 tablets. That should be
enough to last me until I get back. Your nurse took a urine sample when I told her
I had a kidney stone; it probably will show blood in it. I’ve just had an attack.
DOCTOR
I have to tell you up front that I don’t usually like to
refill narcotics for patients I don’t know.
JACK
I understand doc, but I’m really stuck. I wouldn’t have come in if I didn’t need the
prescription. You guys are the only clinic open.
DOCTOR
Well, before I make up my mind, I need to ask you a
few questions.
JACK
Okay…. (Doubtfully)
DOCTOR
7
Who else have you obtained Dilaudid prescriptions
from?
JACK
Just my family doctor, Doctor Smith.
DOCTOR
Do you drink alcohol?
JACK
Why are you asking that? What’s that got to do with kidney stones?
DOCTOR
It’s just part of my usual routine before I prescribe
anything that might be addictive.
JACK
Just a few six-packs most weekends; but I won’t drink when I take the Dilaudid.
DOCTOR
Have you ever felt you should cut down on your
drinking?
No.
JACK
DOCTOR
Have people annoyed you by criticizing your
drinking?
JACK
Yeah, sometimes--but not my friends.
DOCTOR
Have you ever felt bad or guilty about your
drinking?
Managing Pain
JACK
No way.
DOCTOR
Have you ever had a drink first thing in the morning
to steady your nerves or get rid of a hangover (eyeopener)?
JACK
(Laughing)
Only if I’ve really tied one on!
DOCTOR
Do you use any other recreational drugs?
JACK
No.
DOCTOR
So, you’ve never smoked pot or used cocaine?
JACK
Well, some pot in high school—but that’s a long time ago.
DOCTOR
None since?
JACK
Well, sometimes...nothing lately, though.
DOCTOR
So you won’t have any objection to giving me a
urine sample for drug screening?
9
JACK
Why do you need that?
DOCTOR
It’s just my routine policy for all patients for whom
I prescribe narcotics. All doctors should be doing it.
JACK
Are you going to give me a prescription?
DOCTOR
Oh, sorry. Excuse me. That’s the assistant, from
the front desk. She’ll have that PharmaNet profile
you consented to when you clerked in. It is alright
with you if I check to see what medications have
been prescribed for you by other doctors?
JACK
Well. Yeah. I guess so.
DOCTOR
(…makes like he is reviewing a PharmaNet profile)
Well, it’s just as you said. You picked up 30 Dilaudid
from Dr. Smith at London Drugs yesterday. That’s
the only narcotic prescription showing here this
year. Unless you’ve had prescriptions in Alberta?
Hmmm.
I’ll tell you what. I’ll give you some Dilaudid. But
not thirty. After all, you have to accept
responsibility for what happened to those pills.
I’ll need a urine sample and I also want you to sign
a consent form so I can get your records about the
kidney stone.
Managing Pain
I’m giving you the benefit of the doubt for now, but
you won’t get anything anything without a urine
sample and the consent form.
The most I’m willing to give you is ten tablets.
JACK
Can I get more than ten?
DOCTOR
No, take it or leave it.
JACK
Okay, I’ll take ten.
DOCTOR
I’ll meet you at the front desk after you’ve signed
the consent form and provided the urine. Then I’ll
give you the prescription.
~ End of Scenario 3 ~
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