Initial assessment You walk in to find Bill in a crumpled and ill- fitting suit, sitting at the edge of the bed clutching his side. Sweaty and apparently in considerable pain, he tells you it’s exactly the same pain he had 10 years ago when he first developed kidney stones and again 2 years ago. He describes passing the stone on both occasions and experiencing the worst pain imaginable. Bill describes his pain as ‘coming in waves’, which is consistent with the colicky pain that occurs with renal stones. Bill reports good health apart from an appen- dicectomy years ago. He asks if he can have something for the pain, to which you respond that you first need to examine him. Bill’s mucous membranes look dry, his pulse is 92 and regular, and his blood pres- sure is 156/90. He is tender in the left iliac fossa and left flank. A urine sample con- firms the presence of microscopic haematuria. After checking his drug history and allergies you administer 100 mg of pethidine intramuscularly. When you inform Bill of your wish to investigate further, he replies, ‘That’s what they wanted to do last time but I passed the stone before I got there’. Bill agrees to have a plain abdominal X-ray today and to return immediately after. His pain appears to settle and he looks considerably better, at which point he uses his mobile phone to call his wife to pick him up. The story unfolds Later that day you notice that he hasn’t returned and your receptionist contacts the radi- ology clinic, only to discover that he never attended. As the reception staff had expected Bill to return later that day they had agreed to let him settle the account that afternoon. The practice tries to contact Bill but his telephone Moira G Sim, MBBS, FRACGP, FAChAM, is Associate Professor, Edith Cowan University, Adjunct Senior Clinical Lecturer, School of Psychiatry and Clinical Neurosciences, the University of Western Australia, Senior Medical Officer, the Drug and Alcohol Office of Western Australia, and a general practitioner, Yokine, Western Australia. Gary K Hulse, BBSc, PhD, is Professor and Head, Unit for Research and Education in Drugs and Alcohol, School of Psychiatry and Clinical Neurosciences, University of Western Australia. Eric Khong, MBBS, GradDipPHC, FRACGP, is Medical Officer, Drug and Alcohol Office, adjunct Senior Lecturer, Edith Cowan University, Adjunct Clinical Lecturer, School of Psychiatry and Clinical Neurosciences, the University of Western Australia, and a general practitioner, Edgewater and Duncraig, Western Australia. Acute pain and opioid seeking behaviour Reprinted from Australian Family Physician Vol. 33, No. 12, December 2004  1009 Case files  CLINICAL PRACTICE BACKGROUND Acute pain is a common presentation associated with opioid seeking behaviour. OBJECTIVE This case study provides a practical approach for general practitioners seeing patients with acute pain whom they suspect of seeking opioids because of dependence. DISCUSSION Acute pain commonly presents as an emergency appointment ‘squeezed in’ between booked appointments. General practitioners have to make a rapid assessment of the possible underlying causes, relieve pain, and establish a plan for further investigation and management. Furthermore, some opioid dependent people can and do effectively feign acute pain in order to obtain opioid medication. Case history – Bill Bill, 49 years of age, presents to the prac- tice for the first time one Monday morning, clearly in discomfort and com- plaining of pain from kidney stones. Your receptionist arranges for him to lie down in a spare room and ‘squeezes’ this con- sultation in between appointments. This is the ninth and final article in a series of case files from general practice that explore treatment issues around substance use and commonly encountered general practice presenta- tions.