History Taking · Intermediate · Psychiatry

Substance Misuse and Harm Reduction

Practise this PLAB 2 history taking station on Opioid Dependence. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in a GP surgery. Mr Craig Neal, a 29-year-old man, has come to the surgery at the insistence of his partner because of drug use concerns. Please take a focused substance misuse history, assess risk, and discuss harm reduction strategies and treatment options.

Background notes: PMH: Nil significant, Anxiety in university (undiagnosed), Overdose 18 months ago

What this station tests

  • Non-judgmental engagement with a resistant patient: building trust before assessing
  • Harm reduction even if not ready to stop: needle exchange, BBV testing, take-home naloxone
  • Take-home naloxone: nasal or IM kit for overdose reversal, should be offered to all opioid users
  • Opioid substitution therapy: methadone or buprenorphine as evidence-based treatment reducing harm
  • Never injecting alone: the highest risk factor for fatal overdose

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

Substance misuse stations test non-judgmental engagement with a patient who does not believe he has a problem. Mr Neal is 29, attending at his girlfriend's insistence because of opioid use that has escalated from recreational to dependent. He is defensive. Open with: 'Craig, I know coming here was not your idea. But you are here, so let me understand what has been happening. No judgement.'

Core approach

Build trust before assessing. He uses heroin (initially smoked, now injecting) and crack cocaine. He does not think he has a problem ('I can stop whenever I want'). Explore without confronting: 'Tell me about a typical day. When do you first use? What happens if you cannot get hold of it?'

Assess dependence. Injecting frequency (daily suggests dependence). Withdrawal symptoms when he cannot use (sweating, diarrhoea, agitation, muscle aches). Tolerance (using more to get the same effect). Spending significant money. Neglecting work (lost his job). Impact on relationship (girlfriend threatening to leave).

Harm reduction assessment. Injecting practices: does he share needles? (Hepatitis B, C, HIV risk.) Does he use clean equipment? Does he know about needle exchange? Has he ever overdosed? Does he have naloxone? Has he ever injected alone (highest overdose death risk)?

Closing and safety netting

Harm reduction first (even if he is not ready to stop). Needle exchange programme. Hepatitis B vaccination. BBV testing (HIV, hepatitis B and C). Take-home naloxone kit (nasal or IM, for overdose reversal). Never inject alone. Do not mix with alcohol or benzodiazepines.

If he is open to treatment: referral to local drug and alcohol services for opioid substitution therapy (methadone or buprenorphine). This reduces injecting, overdose risk, and criminal activity. If not ready: 'The door is always open. When you are ready, we are here.' Do not force.

Address his girlfriend's concern: she is also at risk and may benefit from support (Al-Anon equivalent). Safety net: 'If you feel unwell, develop chest pain, or notice any injection site infections (redness, swelling, abscess), come in urgently.' Follow-up: open appointment.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for opioid dependence. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1 (Primary focus)

Scores well: Dependence assessed without confrontation. Injecting practices documented. BBV risk assessed. Overdose history. Psychosocial impact explored.

Costs marks: Confrontational assessment. Not checking injecting practices. Not assessing overdose risk.

Domain 2 (Primary focus)

Scores well: Harm reduction: needle exchange, BBV testing, naloxone. OST referral offered. Not forcing abstinence. Injection site infection safety netting.

Costs marks: No harm reduction. No naloxone. Insisting on abstinence. No BBV testing.

Domain 3 (Primary focus)

Scores well: Non-judgmental throughout. Meeting him where he is. Not confronting denial. Leaving the door open. Supporting girlfriend too.

Costs marks: Judgmental. Confrontational. Forcing change. Not acknowledging girlfriend's needs.

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Being judgmental or confrontational: he is already defensive, judgment will end the consultation
  2. Insisting he must stop using: harm reduction is the priority if he is not ready for abstinence
  3. Not offering naloxone: take-home naloxone saves lives and should be offered to every opioid user

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

How should I structure the opioid dependence history in this PLAB 2 station?

Substance misuse stations test non-judgmental engagement with a patient who does not believe he has a problem. Mr Neal is 29, attending at his girlfriend's insistence because of opioid use that has escalated from recreational to dependent. He is defensive.

What are examiners marking in this opioid dependence station?

Marks are won for: Dependence assessed without confrontation. Injecting practices documented. BBV risk assessed. Overdose history. Psychosocial impact explored. Marks are lost for: Confrontational assessment. Not checking injecting practices. Not assessing overdose risk.

What is the most common mistake candidates make in this opioid dependence station?

Being judgmental or confrontational: he is already defensive, judgment will end the consultation. Another frequent error: Insisting he must stop using: harm reduction is the priority if he is not ready for abstinence.

How do I prepare for this station if I have not managed opioid dependence in clinical practice?

Structure beats experience here. Focus on harm reduction even if not ready to stop: needle exchange, BBV testing, take-home naloxone. Work through the consultation approach above, then rehearse it aloud under the 8-minute time pressure so the structure holds up in the exam.

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