Table 1 SP cases

Missing appointments

Patient frequently misses appointments. Recent refill request led to the scheduling of a telemedicine appointment today after missing an earlier in-person visit due to transportation issues. Patient is now out of medication and expresses urgency for a refill. History of intermittent attendance despite past reminders.

Taking opioids for symptoms other than pain

Patient is using oxycodone for symptoms beyond pain management. Seeking a refill during a visit to establish with a new primary care physician. High-stress job overseeing multiple restaurant chains, managing a team, and dealing with calendar issues. Balancing responsibilities as a parent of four boys adds to the stress. Unrecognized anxiety, difficulty falling asleep, and reliance on oxycodone for sleep aid over the past 2 weeks (approximately 10 nights).

Using more opioid medication than prescribed

Patient requests an early refill of pain meds, indicating potential opioid use disorder by the third visit. More active at home, engaging in renovations, leading to increased oxycodone usage (2–4 times daily instead of the prescribed twice). Patient experiencing heightened stress due to job loss a month ago. Pain typically at 2–3/10, managed without medication, but escalates to 10/10, prompting oxycodone use. Lack of awareness of opioid agreement details and increased frequency of use hint at emerging opioid use disorder.

Asking for an increase in opioid dose

Patient seeks an increase in opioid dose due to decreasing effectiveness over time. History of gradual dose adjustments with Dr. Williams, starting with short-acting oral morphine and transitioning to long-acting MS Contin. Current dose maintained for 8 months, with previous increases providing relief for 10–12 months each time. Patient familiar with the concept of tolerance and expresses nervousness about a new doctor’s understanding. Patient’s approach the visit is hopeful but tempered by some trepidation.

Alcohol use

Patient combines alcohol with prescribed opioid medication. Seeking a refill during the first visit to establish with a new primary care physician. Almost out of pills, with about 5 remaining. Pain meds are effective as prescribed, but a positive score on an alcohol use screening questionnaire raises concerns. Patient acknowledges alcohol use as the only "red flag" during the visit.

Other substance use

Patient uses heroin in addition to prescribed opioid medication. Seeking a refill during the first visit to establish with a new primary care physician. Out of prescribed pills, with the last one taken this morning. Expresses concern that the medication’s effectiveness has decreased and inquires about a higher dose or additional pills. Patient avoids disclosing heroin use and mentions financial challenges in obtaining the medication. Patient may be hesitant about a urine drug screen test but plans to delay it to ensure a clear result. Mild withdrawal symptoms occur if without medication for too long.