Second, I fully agree with Kevin, that one ought to be quite reluctant to use chronic opiates in such a patient - though we are coming in late in the game, and someone else has already crossed that threshhold (which may be good or bad).

Third, I also fully agree with Michael, that a full biopsychosocial database is critical in such difficult patients - As a pragmatist, I can't argue with a quick, narrow biomedical (or biological psychiatric) perspective and treatment if it works. But when it doesn't we have to broaden our inquiry - though a better approach would be to have a low threshhold for a broad inquiry and approach upfront, to try to avoid an unhelpful mess. This patient is chronically ill with a somatoform disorder -
1. She clearly has Pain Disorder
2. She has Multisomatoform Disorder -we have long known that the DSM criteria have real limits when used in primary care, which is rife with subsyndromal and mixed problems - the DSMIV PC (for primary care), coined the term "Multisomatoform Disorder," for the all too common chronic somatizer with too few sxs in our available database to meet criteria for Somatization Disorder.

(If we really had effective managed care, we could do as the British, and dx somatization disorder based on gross total chart weight in "stone.) I would approach her using the recommended management strategy for chronic somatization in primary care

1. She needs a continuity primary care (or med/psych) doctor
2. She needs to agree to a contract including:
     a.1 doctor who takes her chronic illness seriously
     b.regularly scheduled nonsymptom triggered visits of specified duration
     c.ER visits, walk in visits, phone calls only for true emergencies.
3. Frank discussion:
     a. pt has a chronic illness which is substantial and debilitating, but which is (thank God), not life-threatening, and requires no further dx tests
     b. chronic illness will not be cured
     c. narcotics aren't working and will be used only in long-acting form (possibly methadone in divided doses - not qd, which is not adequate for analgesia), with no dose escalation, and ultimate tapering
4. Each visit a full survey and listing of sxs, a focused physical exam (pt needs to be physically touched each visit), high threshhold for investigations beyond the H&P
5. Each visit, collaborative work on maximizing functioning given her chronic illness - physical functioning, functioning at home (children, family, significant other), functioning out of the home (hobbies/pleasureable activities, volunteer work in the community, participation in religion, paid work)
6. Physical Exercise on a daily basis to build conditioning, help with coping with negative emotions (anx, depr) and Physical Therapy to get her jump-started with physical approaches
7. Relaxation/Self-Hypnosis/Meditation
8. Support group
9. Urine toxicologies (some pts are selling narcotics and/or using other classes of CNS acting substances)
10. Substance Abuse Treatment, including AA or NA, if she has a problem in this area

Charlie Schwartz