As part of these contracts, the program will assist with the refilling of opiates and provide temporary housing. Patients must agree to make scheduled medical and substance abuse appointments. CASE INFORMATION: The patient is a 47-year-old woman with a history of admissions for CHF secondary to cocaine dependence. Her care has been complicated by a history of borderline personality disorder, chronic back pain, a history of upper GI bleeds, major depression and homelessness. The patient's stated goals on enrollment include housing and sobriety. The patient signed a contract that included opiate pain medications, temporary housing, substance abuse treatment and money management. Over the course of the next few months the patient would repeatedly binge on cocaine after receiving her general assistance check at the beginning of each month. The case management program terminated the housing and medication contract and asked the patient to see her primary care physician for all opiate refills. While the patient continued to binge on cocaine, the case manager continued to assist the patient with non-opiate medication refills, appointments with her primary care physician and applications for both housing and a money management. The patient eventually enrolled herself in a residential drug treatment program. She was restarted on her pain medication contract after seeing her primary care provider and is awaiting housing. IMPLICATIONS/DISCUSSION: While we believe that contracts for housing and pain medication refills may be useful in providing external control for seriously medically ill patients, these contracts poses important ethical questions. These contracts may challenge the principle of patient autonomy in patients who retain the legal ability to make medical decisions. These contracts also use housing and pain medications as incentives, items that many feel should be viewed as rights. Therefore these contracts should never deny patients access to the usual standard of care. Instead they should be voluntary and provide additional services that are contingent on the patient's adherence to a care plan. It is also important that contracts be done as part of an ongoing patient provider relationship to insure patient safety. Finally these contracts have the potential to reduce morbidity and mortality, which remains an important ethical imperative. A 48 year old male presented with crushing chest pain of several hours duration and a worsening of his chronic headaches (which had started 8 months ago after a closed head injury). In the previous 30 hours, he had taken 14 tablets of clonidine to try to relieve the headache which he thought was due to his hypertension. On review of systems, he noted a 35 pound weight loss over the past 8 months and admitted to sexual activity with several prostitutes. The only other medication he takes is ibuprofen. His vitals revealed he was afebrile with a pulse of 42 and a blood pressure of 205/133. His exam showed some temporal wasting and grade III hypertensive retinopathy without papilledema. He had an S4 present, but the remainder of his initial cardiac, respiratory, abdominal, neurologic and musculoskeletal exam was unremarkable. Serial ECGs showed sinus bradycardia, left ventricular hypertrophy, and T-wave inversions in the lateral and inferior leads. Initial electrolytes, CBC and serial cardiac biomarkers were also unremarkable. A head CT without contrast showed grey-white matter changes consistent with hypertension. The patient was admitted to the cardiac care unit. A CT scan with IV contrast of the abdomen and thorax showed no evidence of an arotic dissection. His blood pressure was controlled with IV nitroglycerine initially, but then required fenoldopam and nicardipine drips, parenteral hydralazine, procardia, clonidine, and labetolol. He developed a third cranial nerve palsy on the right and his serum sodium dropped from 137 mmol/liter on admission to 121 mmol/liter three days later. CT scans of the head were repeated twice with and without contrast with no change from the initial CT scan. A lumbar puncture was performed and cryptococcal meningitis was diagnosed. A subsequent HIV test was positive. His CD4 count was 12. Amphotericin B was started. Elevated intracranial pressure was controlled by serial lumbar punctures. The patient's cranial nerve palsy showed minimal improvement, but his hypertension improved. IMPLICATIONS/DISCUSSION: The presence of intractable hypertension, bradycardia, and headache suggests increased intracranial pressure as a cause for his hypertension. It is a wellknown cause of hypertension but rarely considered. In this case, his bradycardia was initially thought to be secondary to clonidine. He also lacked any focal neurologic deficits or papilledema on initial presentation to suggest an intracranial pathology. A retrospective casecontrol study published in 1992 showed an increased incidence of diastolic hypertension in AIDS patients with cryptocccal meningitis.