Hello all, Im a currently in my fellowship and had an interesting clinical situation while performing inpatient consults. I am seeking your advice and opinion of what you would do. Background: The patient is someone that we routinely follow in our office. He is an pleasant 80 year old male, WWII vet, with chronic low back pain; spinal stenosis, DDD, failed lumbar spine surgery. We are treating him with SCS and meds (MS Contin 100 mg TID, MSIR 30 q6, lyrica, flexeril). He was doing fairly well with this regimen. He has good family support and a loving wife. He was a successful man who is now somewhat disabled and has to depend on his wife for some ADL's. No history of psychiatric disease. We were consulted to see him in the hospital after an apparent medication overdose. When I spoke with him he stated that he took all of his medications trying to kill himself. When I asked him how he felt when he woke up and his reply was, "Sh**, Im still alive." He said that he has increased pain in his coccyx and could not take it anymore. There was no new trauma. Exam was fairly benign. Work up with lumbar and abd/pelvis CT scans showed no issues with his coccyx or sacrum. Psychiatry was consulted and they said he was fit to go home with his wife since, "he has good family support in place." Plus this is not a psych issue, its a PAIN issue! After speaking with the psychiatrist I informed him that the patient has no remorse or regret for his actions and is likely to try again. When I pressed him as to a guarantee that he would not try this again, he hedged and is now talking the pt into a voluntary admission vs. committing him. The patient continues to have severe pain and is requesting more and more medications and is agitated. We are trying to wean him since he is not safe to have the medications unsupervised and this is an good time to monitor him during weaning. So.. Questions: 1. What do you do when your patient attempts suicide secondary to his pain when you cannot trust the patient with the medications? Pump? He already has an SCS. 2. Should we buy the assessment that the suicide attempt is due to only his pain or should we press psych to look into depression and anxiety as bigger motivators and the LBP being a convenient focus for him to project his pain. Any thing else you could add on the subject would be great.. thanks.