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Abstract Background Chronic non-cancer pain is a common problem that is often accompanied by psychiatric comorbidity and disability. The effectiveness of a multi-disciplinary pain management program was tested in a 3 month before and after trial. Methods Providers in an academic general medicine clinic referred patients with chronic non-cancer pain for participation in a program that combined the skills of internists, clinical pharmacists, and a psychiatrist. Patients were either receiving opioids or being considered for opioid therapy. The intervention consisted of structured clinical assessments, monthly follow-up, pain contracts, medication titration, and psychiatric consultation. Pain, mood, and function were assessed at baseline and 3 months using the Brief Pain Inventory (BPI), the Center for Epidemiological Studies-Depression Scale scale (CESD) and the Pain Disability Index (PDI). Patients were monitored for substance misuse. Results Eighty-five patients were enrolled. Mean age was 51 years, 60% were male, 78% were Caucasian, and 93% were receiving opioids. Baseline average pain was 6.5 on an 11 point scale. The average CESD score was 24.0, and the mean PDI score was 47.0. Sixty-three patients (73%) completed 3 month follow-up. Fifteen withdrew from the program after identification of substance misuse. Among those completing 3 month follow-up, the average pain score improved to 5.5 (p = 0.003). The mean PDI score improved to 39.3 (p < 0.001). Mean CESD score was reduced to 18.0 (p < 0.001), and the proportion of depressed patients fell from 79% to 54% (p = 0.003). Substance misuse was identified in 27 patients (32%). Conclusions A primary care disease management program improved pain, depression, and disability scores over three months in a cohort of opioid-treated patients with chronic non-cancer pain. Substance misuse and depression were common, and many patients who had substance misuse identified left the program when they were no longer prescribed opioids. Effective care of patients with chronic pain should include rigorous assessment and treatment of these comorbid disorders and intensive efforts to insure follow up.

Objective: To describe the use of the lidocaine patch 5% (Lidoderm), a targeted peripheral analgesic, in treatment of patients with chronic low back pain., Design: This retrospective case series examines four patients with pain secondary to spinal degeneration and complications from failed back surgery syndrome, who were prescribed the lidocaine patch as an add-on to their analgesic regimen., Setting: Bay Area Pain Medical Associates, Mill Valley, California., Patients: Patients (age range: 33-64 years) were all complicated cases in which multiple analgesics had been prescribed with varying degrees of success. Intervention. Lidocaine patch 5%., Results: The addition of the lidocaine patch helped relieve varying characteristics of pain, including general pain, shooting pain, burning pain, and allodynia, and had a significant impact on the quality of life of all patients. Some patients were able to reduce or altogether stop some medications. No adverse events were reported from the lidocaine patch., Conclusions: Based on our experience with the four cases presented here and with other patients in our clinic, we believe that addition of the lidocaine patch 5% to the analgesic regimen in chronic low back pain may be beneficial. Prospective, controlled clinical trials are planned to further evaluate the efficacy and safety of the lidocaine patch for treatment of chronic low back pain with or without a neuropathic component.

The authors conducted a national survey to investigate the current status of psychiatric training in primary care/internal medicine residencies. Fifty-four residency training directors completed and returned the survey. The survey results show that an average of 99 hours (69.5 hours clinical plus 29.8 hours didactics) is devoted to psychiatric training during the 3 years of primary care/internal medicine residency training. Responding residency training directors indicated that psychiatric training is important (an average of 7 out of 10 on a 10-point rating scale), and 63% of respondents indicated that more training in psychiatry is needed.