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148 DOI: 10.1201/9781003533337-33
This 47-year-old man presented to the emergency department (ED) earlier this morning with a
are of his long-standing low back pain. The pain has always been localised to the lumbar region,
with no radiation down his legs, neurological symptoms in the legs, or sphincter disturbance.
There have been no features suggestive of an underlying medical condition, like cancer, infection,
or spondylarthritis. Over the years, he has consulted a number of healthcare practitioners, includ-
ing general practitioners, an orthopaedic surgeon, a chiropractor, and a physiotherapist. He had a
magnetic resonance imaging (MRI) scan 18 months ago, which showed degenerative changes in the
lumbar spine, with no evidence of nerve root compression.
His background medical problems include diabetes and hyperlipidaemia. He takes codeine,
tramadol, and pregabalin for his back pain, having previously tried paracetamol, naproxen, muscle
relaxants, amitriptyline, gabapentin, transcutaneous nerve stimulation, acupuncture, and massage.
Naproxen caused an allergic skin rash, while none of the other measures were greatly helpful. He
smokes about 20 cigarettes a day and drinks a few beers every week. He used to be a train driver
but stopped working about two years ago because of his back pain. He lives with his wife.
The ED doctor has asked for your help as he is asking for morphine and she is ‘unable to handle
his demands’. She feels that his presentation is in keeping with non-specic chronic low back pain.
You are the medical registrar in the acute medical unit.
Case 29
The 47-Year-Old Man Who Is
Demanding Strong Opioids for His
Chronic Back Pain
• After the initial introduction, ask how you can help.
He says he has had the back pain for a long time but the problem is gradually getting worse.
He is fed up because no one is interested in helping him. He hasn’t been able to work for
nearly two years because of his back pain. He thinks he will end up in a wheelchair one day.
He wants you to prescribe something stronger, like morphine, because the pain has been
really bad for the last two to three days. He takes codeine, tramadol, and pregabalin, but they
do not afford much relief.
There are several key differences between acute and chronic pain. Acute pain serves a pro-
tective function and resolves once the underlying problem is treated (‘biomedical approach’).
Demanding Strong Opioids 149
Chronic pain, by comparison, does not serve a protective function (except in a small pro-
portion of patients in whom it is caused by an ongoing medical problem) and persists past
the point of tissue healing due to psychosocial factors. The pain is usually accompanied by
non-restorative sleep, physical deconditioning, and psychological distress. Management of
these patients should also focus on improving physical function and reducing psychological
distress (‘biopsychosocial approach’).
‘Yellow ags’ (factors that maintain the problem) in chronic back pain include wrong beliefs,
passive dependence on practitioners, failure to accept medical reassurance, prolonged absence
from work, and unhelpful thoughts, emotions, and behaviours (‘There must be something
wrong with my spine’, ‘I am fed up’, ‘No one is helping me’, ‘I will end up in a wheelchair one
day’). Chronic back pain is indeed a very difcult problem to manage, and it may not be pos-
sible for a single healthcare practitioner to address all the issues, certainly not in ten minutes.
Those with secondary gains because of chronic pain are more challenging because they may not
be receptive to your suggestions.
It appears that the main reason for his ED visit was to ask for a stronger analgesic, like
morphine. It is important to be mindful of patients with chronic pain whose main problem
may be drug dependence or drug-seeking behaviour rather than pain. It should be suspected
if the patient (1) sees multiple doctors or visits multiple pharmacies, (2) shows unwillingness
to accept other forms of treatment (legitimate sufferers will usually accept your suggestions),
(3) grades the pain as 10/10, (4) asks for a specic drug by brand name, or (5) atters you
(‘You are my favourite doctor’).
• After you say a few reassuring words (‘We are keen to help you’, ‘We want you to get
better’), check his understanding of his back pain (‘What do you think might be caus-
ing your back pain?’).
• Ask if there is a specic reason for requesting morphine.
He says he thought his back pain was caused by wear-and-tear changes in his backbone. He
asked for morphine as he thought it might be stronger than tramadol or codeine. He is not
keen to carry on taking the pills long-term. He is happy to accept any treatment that will
take his pain away.
• Tell him that the degenerative changes seen on the MRI scan will not entirely explain
his symptoms.
‘The MRI scan done last year indeed showed some wear and tear in your backbone, but
these changes will not entirely explain your pain. Wear-and-tear changes are quite com-
mon as we grow older. If we scan a hundred people with back pain and another hundred
without back pain, we can expect to see such changes in nearly the same proportion of
people in both groups.
‘I also do not feel that your pain is caused by some medical condition or disease. The
idea that all symptoms are caused by disease is incorrect. Symptoms like headache, back-
ache, tingling, constipation, heartburn, and ringing in the ears are quite common but often
not caused by a disease. Out of ten people who complain of headache, one or two may be
found to have an infection, tumour, or bleeding in the brain. In the rest, the headache is
not caused by a disease. They just have a headache. The same is true for back pain as well.’
150 Clinical Communication Skills in Medicine
Having established that his request for morphine is not due to drug-seeking behaviour:
• Provide some advice on managing his ares, which should include pharmacological as
well as non-pharmacological measures.
‘I’m not very comfortable writing a prescription for morphine. You could become
addicted to it and develop side effects, like drowsiness and constipation. Iam concerned
that we may be doing more harm than good with morphine. If tramadol and codeine are
helpful to an extent, Iwould suggest that you stick with them but without exceeding the
recommended dosages.
‘In addition to taking painkillers, you can try ice packs or a warm bath. You should start
moving as soon as the pain starts to ease, because resting too much will make the muscles
stiffer and prolong the are. You’ll feel worse if there is nothing on your mind except the
pain, so you should distract yourself as much as possible by doing something that you
enjoy, like watching a comedy show, movie, or your favourite sport; listening to music; or
reading a book. Flare-ups are quite common in people with long-standing pain. You should
think if you did something different during the days preceding the are and try to avoid
them next time.’
• Briey ask about his daily routine, sleep, and mood.
He admits that he has become sedentary ever since he stopped working. He sits on his sofa
all day, watching TV or playing games on his phone. His sleep is not good. He wakes up feel-
ing unrefreshed most mornings. He feels a bit low all the time and worries a lot about what
might happen to him in the future. His frustration mainly stems from the thought that he
must live with this pain for the rest of his life and nothing seems to be working.
Tell him that:
• Chronic pain will not respond to painkillers alone and needs a different approach.
‘When pain becomes long-standing, it impairs your ability to work, disturbs your sleep,
and affects your emotions. Pain, poor sleep, and low mood can aggravate each other and
set up a vicious cycle, so pain alone is not the problem anymore. This is the reason you
don’t nd the painkillers helpful.
‘We should address each of these elements to make you feel better overall. In addition
to reducing the pain, we should look at ways of improving your tness, sleep, and mood.’
• It is important to address his unhelpful thoughts, emotions, and behaviours.
‘If you remain convinced that your pain is caused by a medical problem, it’ll only increase
your distress and make the pain worse. Our thoughts and beliefs can affect our emotions
and behaviours in a positive or negative way. In many people, back pain starts as a physi-
cal problem, but it becomes persistent and long-standing because of the way they react
to the pain, not because the original problem got worse.’
• He should gradually increase his physical activity.
‘Our backbone is meant to move a lot, so resting too much will make the muscles
stiffer and worsen the pain. You should therefore try to gradually increase your physi-
cal activity. Start with some gentle walking, and then slowly increase your pace and
Demanding Strong Opioids 151
distance. It’ll make you tter and reduce the deconditioning – it is one way of breaking
the vicious cycle that Italked about just now. It may hurt more when you start moving,
but that doesn’t mean that you are damaging your backbone.’
He says he understands but is not sure where to start. He asks if there are any medications
to improve his sleep and emotions.
• You will refer him to the multi-disciplinary pain team.
‘I’ll prescribe a medication to improve the quality of your sleep and make you feel fresh
in the mornings. If that is not helpful on its own, we’ll add an antidepressant medication
to improve your mood.
‘I’ll also refer you to our pain team. In addition to doctors who are interested in man-
aging people with long-standing pain, the team includes a psychologist and physiothera-
pists. The psychologist can address some of your unhelpful thoughts and beliefs, which
will help alter the emotions and behaviours in a positive manner. The physiotherapist can
help with an exercise program that suits you.’
• His active involvement is more important than the passive treatments that we offer.
‘Rather than relying on doctors to do everything, it is important for you to take charge
and play an active part in self-managing your pain. Gradually increasing your activity,
improving your sleep, and changing the way you think or feel about your pain will all
help. It may not cure the problem, but even a 50% reduction in pain will make you feel
200% better. As the problem has been there for a long time, it’ll take time. I’m afraid
there are no quick-x solutions.’
End the conversation by summarising the main points. Reiterate that (1) his back pain is not
caused by an underlying medical condition, (2) it is best to avoid morphine because the ben-
ets do not outweigh its risks, (3) non-pharmacological measures are helpful in managing his
ares, and (4) you will prescribe a small dose of amitriptyline and refer him to the pain team.
SUMMARY
This scenario tests your skills in talking to a patient who is demanding strong opioids
for his chronic pain problem. You will be expected to:
• Identify his main concerns.
• Make sure he is not requesting morphine because of a drug-seeking behaviour.
• Provide advice on pharmacological and non-pharmacological measures that can help
manage his flares.
• Explain that his back pain is not caused by an underlying medical condition.
• Explain that chronic pain needs a multi-disciplinary approach that aims not only to
reduce his pain but also to improve his function, sleep, and low mood.
• Tell him that a cure is unrealistic. The overall aim of management is to improve his
symptoms and quality of life.
152 DOI: 10.1201/9781003533337-34
• Introduce yourself, and conrm the identity of the husband. Tell him that you have
come to update him about his wife’s progress.
He says he is frustrated that you still haven’t told them what the problem is ‘even after doing
hundreds of blood tests, urine tests, X-rays, and scans’. He asks in an angry tone if you all
know what you are doing.
This 43-year-old Asian woman was admitted one week ago with a four-week history of fever asso-
ciated with tiredness and weight loss of about 3–4 kg. Her past medical history is blameless, and
she is not taking any regular medication. She denies travelling anywhere recently or keeping any
pets at home. She has never knowingly been in contact with anyone with tuberculosis. She does an
ofce-based job. Her family history is unremarkable. She has never smoked or used recreational
drugs and drinks alcohol only socially. Her menses are regular. She is in a monogamous relation-
ship with her husband and has two healthy children.
Physical examination over the last week has been unremarkable, except for fever and propor-
tional tachycardia. Investigations done so far have revealed normocytic anaemia, elevated eryth-
rocyte sedimentation rate and C-reactive protein, low serum albumin, low serum iron, and mildly
elevated ferritin. Her white cell and platelet counts; peripheral blood lm; liver, renal, and thyroid
function; serum calcium and phosphate; creatine kinase; lactate dehydrogenase; lipid panel; HbA
1
c;
urinalysis; serum autoantibodies (anti-nuclear antibody, double-stranded antibody, antibodies to
extractable antigens, rheumatoid factor, anti-neutrophil cytoplasmic antibody); complement levels;
angiotensin-converting enzyme; and myeloma screens are all normal. Three sets of blood cultures
have been sterile. Tests for human immunodeciency virus, hepatitis B and C, COVID-19, Epstein–
Barr virus, cytomegalovirus, toxoplasma, brucella, rickettsia, and respiratory virus panel are nega-
tive. Chest X-ray; computed tomography scan of the thorax, abdomen, and pelvis; transthoracic
echocardiogram; and mammogram are also unremarkable.
She was discussed with the haematologist, rheumatologist, and consultant in infectious diseases
yesterday. Their consensus opinion was to ask for a uorodeoxyglucose positron emission tomog-
raphy–computed tomography (FDG PET-CT) scan. You are the registrar in the ward. The patient
asks you to update her husband, whom you have not met. She says he is quite vexed that you have
done numerous tests and still not given them a clear answer.
Case 30
The 43-Year-Old Woman with
No Diagnosis Despite Extensive
Evaluation
No Diagnosis Despite Extensive Evaluation 153
• Acknowledge his frustration, and ask what he has been told already.
‘We are sorry that we haven’t been able to nd out the cause of her fever yet. Ican under-
stand your frustration. It’s frustrating for us too. May Irst nd out what you have been
told so far?’
He says his wife has been going for one test after another ever since she got admitted a week ago.
The doctors have been updating him and his wife on a daily basis about the results of the tests.
They have so far told them that her inammation reading is up and she is anaemic. They also told
them that the other blood tests, urine tests, CT scan, heart scan, and mammogram are all normal.
Tell him that:
• The underlying causes of prolonged fever include infection, cancer, and autoimmune
disease.
‘In most people with fever, we nd a viral or bacterial infection. The fever usually sub-
sides quickly either on its own or with appropriate treatment. In some people, the fever
does not subside even after several days or weeks, and we then start thinking of unusual
infections, cancers, and autoimmune problems – autoimmune means the immune system
makes a mistake and attacks our own body.’
• The investigations done so far have not revealed any of these causes.
‘We had to do multiple tests because her medical history, our examination ndings, and
the initial tests did not point to the cause of her fever. Regrettably, the second-line tests
also did not give us an answer. Although this is disappointing, the important thing is that
we haven’t found anything serious. There is indeed a small chance that there is something
serious, which the tests done so far haven’t picked up.’
• An underlying cause of her fever may never be found.
‘From time to time, we do see people in whom we struggle to make a diagnosis. Some-
times the problem evolves slowly and the diagnosis may only become evident later. In
about one in three people with prolonged fever, an underlying cause is never found, and
the illness eventually resolves without any treatment.’
He says he is not convinced with your explanation and asks if he could get a second opinion.
• Tell him that you have discussed with consultants from various specialties.
‘We have discussed her case in detail with various specialists, including a blood specialist;
a rheumatologist, who is a specialist on autoimmune problems; and a specialist in infec-
tious diseases. They are experts in dealing with people with prolonged fever.
‘You are, of course, free to seek another opinion, but please allow me to share their
thoughts with you. [Pause.] All three of them feel that it is best to do a special kind of
scan called PET-CT.’
154 Clinical Communication Skills in Medicine
He asks how this scan is better than the ones that you have done already.
• Tell him that a PET scan can pick up inammation or cancer much earlier than a CT
scan could.
‘What we did earlier was a CT scan. On a CT scan, we see cancer or inammation as an
abnormal shadow. However, it can take a while before cancer or inammation shows up
on the CT scan. Therefore, we sometimes miss them in the early stages. The advantage
of a PET scan is that it can show the cancer or inammation at a much earlier stage
compared to a CT scan.’
• Briey explain how the PET-CT scan works.
‘The PET-CT scan is two different scans combined into one. They’ll rst inject a special
sugar substance into the vein. The sugar will get into all the cells and emit a small amount
of radiation. If there are cancer cells or inammatory cells, they’ll take up more sugar
than the other cells and give out more radiation. We can see the parts of the body that
are emitting more radiation as bright spots on the scan.
‘We then have the option of taking a sample of cells from the part of the body that is
emitting more radiation and sending it to the lab so that it can be examined under the
microscope. We call this biopsy. APET scan is also better than the other types of scans
to detect some unusual causes of prolonged fever, like inammation of the muscles or the
lining of the blood vessels.’
He asks if this scan will denitely give an answer and why it was not done earlier.
• Tell him that there is no guarantee that the PET-CT scan will give us an answer. It was
not considered earlier as it is not a rst-line investigation.
‘We did not ask for this scan earlier because it is not a rst-line test. We ask for this scan
only if the other tests do not give us an answer. Iam afraid this scan may or may not give
us an answer. However, if it is completely normal, there is a very high chance that her
illness will resolve in due course.’
He says he is concerned that you are injecting a substance that emits radiation into her body.
• Discuss the risks of a PET-CT scan.
‘There is no radiation risk from the sugar substance. The sugar should be ushed out of
the body by the end of the day. She should just avoid being very close to pregnant women
or young children for a few hours after having the scan.
‘There is, however, some radiation risk from the CT, which is the second part of the
scan. In a small number of people, the dye used with the CT scan can cause an allergic
reaction or harm the kidneys. Harm to the kidneys is more common in people with pre-
existing kidney problems. It is unlikely that she’ll have these reactions, as her kidneys are
working well and we have already used that dye when she had the earlier scans.’
No Diagnosis Despite Extensive Evaluation 155
He says his uncle is a retired GP. He suggested that steroids should be tried to control the
fever. He asks if you would consider that.
Tell him that:
• PET-CT is a better option than empirical steroid therapy.
‘We used to blindly give steroids after ruling out infections, but it was before the days
when PET-CT scans were available. Steroids are probably still tried in parts of the world
where these scans are not widely available. If we start steroids, we might have to deal
with the side effects of steroids, like a rise in blood pressure and blood sugar, weight gain,
and thinning of bones. Moreover, we wouldn’t know what we are treating, so the initial
dose of steroid, how long to treat, and how to lower the dose will all be based on guess-
work. We would therefore not recommend giving her steroids, at least for now.’
• If the PET-CT is normal, you would prefer to continue to observe her.
‘People with prolonged fever are sometimes subjected to invasive procedures, like biop-
sies from the bone marrow, which is the inner part of the bone, or an operation to open
the tummy to check for any infection. In countries where tuberculosis is common, doc-
tors start medications for tuberculosis even if the test results are normal.
‘In her case, if the PET-CT is normal, and as long as fever is the only issue, Ithink we
should sit on the fence and continue to observe.’
End the discussion by reassuring him that you will make sure she is not subjected to any
unnecessary tests. Tell him that you will continue to liaise with the specialists and regularly
update them. He and his wife can discuss and let them know their decision regarding getting
the PET-CT scan, but they are free to seek a second opinion if they wish to do so.
SUMMARY
This scenario tests your skills in talking to a frustrated husband about the inability to
reach a diagnosis in his wife, who continues to spike a fever. You will be expected to:
• Acknowledge the husband’s frustration.
• Explain why so many tests had to be done.
• Tell him that an underlying cause of PUO is sometimes never found.
• Tell him that he is free to seek a second opinion.
• Share with him the opinions of the different specialists with whom her case was
discussed.
• Explain why the team wishes to do a PET-CT and how this is different from the scans
that she has already had.
• Explain why you wouldn’t recommend empirical steroid therapy yet.
156 DOI: 10.1201/9781003533337-35
This 66-year-old man with a background history of diabetes mellitus and hyperlipidaemia pre-
sented to the emergency department (ED) yesterday (it was a Saturday) with a four-week history
of pain around his shoulders and hips associated with early morning stiffness lasting a few hours.
His younger sister, who works abroad as a urology nurse practitioner, came to visit him a couple of
days ago. She chided him for not seeking medical advice earlier and decided to bring him to the ED.
He denied headache, visual symptoms, jaw claudication, loss of weight, night sweats, or swelling
in his joints. Systems enquiry was entirely unremarkable. His vital signs were normal, and physical
examination was unremarkable. His erythrocyte sedimentation rate (ESR) was 92 mm/hour, and
C-reactive protein (CRP) 64 mg/L. His blood counts; glucose, liver, and renal function; HbA
1
c; uri-
nalysis; and chest X-ray were normal. Although the ED physician was keen on arranging an urgent
outpatient appointment, the sister demanded admission.
You saw him earlier today in the ward with your consultant, who diagnosed polymyalgia rheu-
matica (PMR). She explained the diagnosis to him and suggested oral prednisolone. The patient,
however, asked the consultant to discuss the diagnosis and treatment plan with his sister later. It is
now 4:00 p.m. on a Sunday, and his sister has just arrived. The consultant has left the site, and you
are the registrar on call. The ward nurse has informed you that she wishes to speak to the medical
team about her brother. She warns you that “she is a bit difcult”.
Case 31
The 66-Year-Old Man Whose Sister
Does Not Agree with Your Diagnosis
• Introduce yourself. Conrm her identity and her relationship to the patient.
In real life, always take a chaperone when you go see such ‘difcult’ relatives.
She conrms that she is his sister, but in response to your questions on whether she is a nurse
practitioner and where she works, she replies curtly, ‘Why does it matter to you what job Ido
or where Iwork? It’s not about me. We are here to talk about my brother. Let’s stick to that.
Where’s your consultant by the way?’
Disagreement with Diagnosis 157
• Remain calm and conduct yourself professionally. Tell her that you would be happy to
answer any questions that she may have.
‘I saw your brother with my consultant this morning. She’ll be back tomorrow morning.
Iam happy to update you about your brother and answer as many of your questions as
possible. Before Istart, may Iask what exactly your concerns are?’
She continues to talk in an angry tone and says she does not agree with your diagnosis. She
is worried about infection, as his ESR and CRP are so high. She feels that the team should
do blood cultures and start him on antibiotics. She says she is appalled that a 66-year-old
diabetic man with such a high ESR and CRP has been sent to the general ward and not the
high-dependency unit.
This woman comes across as hostile, confrontational, and unpleasant, with some mis-
conceptions and unreasonable demands. Indeed, we all regularly come across such unrea-
sonable patients or relatives, whose requests may range from asking for extended medical
certicates and unnecessary specialist referrals for trivial issues to non-indicated diagnostic
tests or treatments. Dealing with such individuals requires patience, skill, and experience.
The challenge here is that PMR is a clinical diagnosis that is made on the basis of symptoms
and elevated inammatory markers. However, elevated ESR and CRP are not specic to
PMR, and there are no conrmatory laboratory, radiological, or histological studies. Arapid
response to corticosteroid is the best way to conrm the diagnosis. All this should be clearly
explained to her. She should also be told that his elevated inammatory markers are unlikely
to be due to infection.
• Explain why you feel that his presentation is in keeping with PMR.
‘I can see that you are upset. Please allow me to explain. Polymyalgia is essentially an
inammatory condition that affects people over the age of 50. It causes pain and stiff-
ness of the muscles around the shoulders and hips. Symptoms are worse rst thing in
the morning, and they gradually ease as the day progresses. These are the exact symp-
toms that your brother has been experiencing for the last month or so, which is why we
thought of it.’
• Tell her that the elevated ESR and CRP would support a diagnosis of PMR in the con-
text of his clinical presentation.
‘We often see a high ESR or CRP in people with polymyalgia, so that ts in as well.
Iappreciate your concern, but a high ESR or CRP is not specic to infection – they also
go up in people with any form of inammation. We always consider the overall clinical
presentation when we interpret the ESR or CRP. We never look at the test results in
isolation.’
She asks if you have done any tests to conrm that his pain is due to polymyalgia and how
you can be so sure that his elevated ESR and CRP are due to polymyalgia before ruling out
an infection.
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