The association between chronic pain and prescription drug abuse in Veterans.

OBJECTIVE: We sought to investigate the association between chronic pain and self-reported prescription drug abuse in a large cohort of patients referred from primary care for a behavioral health assessment. DESIGN: We performed a cross-sectional analysis of responses to a telephone assessment administered to patients referred for a behavioral health evaluation between April 25, 2005 and October 31, 2007. We conducted descriptive statistics and investigated multivariable associations. Multivariable analyses included age, gender, race, financial status, employment, current smoking, drinking problem, past-year illicit drug use, depression, and chronic pain. PATIENTS: Veterans referred from primary care (N = 6,377). RESULTS: Mean age of the sample was 56.5 years with a range of 19-97. The majority of respondents was white, unmarried, and was unemployed. Nearly 5% of the sample reported past 6-month prescription drug abuse. On multivariable analysis, younger age, possible depression (odds ratio [OR] 1.9; 1.3-2.8), probable depression (OR 2.4; 1.6-3.4), smoking (OR 1.4; 1.1-1.8), illicit drug use (OR 2.8; 2.2-3.7), and chronic pain (OR 1.9; 1.4-2.5) were associated with prescription drug abuse. CONCLUSIONS: We have identified specific variables associated with self-reported prescription drug abuse in primary care patients. Chronic pain is associated both with an indication for prescribing opioids and with abuse of prescription medications. Clinicians are encouraged to follow treatment algorithms when managing patients with chronic pain as a method for reducing misuse.

A randomized controlled trial of a close monitoring program for minor depression and distress.

BACKGROUND: Minor depression is almost twice as common in primary care (PC) as major depression. Despite the high prevalence, few evidence-based algorithms exist for managing patients with minor depression or patients presenting solely with distress. OBJECTIVES: The aim of this study was to test the effectiveness of a telephone-based close monitoring program to manage PC patients with minor depression or distress. DESIGN: Subjects were randomly assigned to either the control arm (usual care; UC) or the intervention arm (close monitoring; CM). We hypothesized that those randomized to CM would exhibit less depression and be less likely to have symptoms progress to the point of meeting diagnostic criteria. SUBJECTS: Overall, 223 PC subjects with minor depression or distress consented to participation in this trial. MEASUREMENTS: At baseline, subjects completed a telephone-based evaluation comprised of validated diagnostic assessments of depression and other MH disorders. Outcomes were assessed at six months utilizing this same battery. Chart reviews were conducted to track care received, such as prescribed antidepressants and MH and primary care visits. RESULTS: Subjects in the CM arm exhibited fewer psychiatric diagnoses than those in the UC arm (chi(2) = 4.04, 1 df, p = 0.04). In addition, the intervention group showed improved overall physical health (SF-12 PCS scores) (M = 45.1, SD = 11.8 versus M = 41.5, SD = 12.4) (chi(2) = 5.90, 1 df, p = .02). CONCLUSIONS: Those randomized to CM exhibited less MH problems at the conclusion of the trial, indicating that the close monitoring program is effective, feasible and valuable. The findings of this study will allow us to enhance clinical care and support the integration of mental health services and primary care.