PLAN:
1. Nortriptyline 25 mg at night, increasing every three nights until either 100 mg is reached or a good night's sleep occurs.
2. Capsaicin cream 0.025 % to rub on four times a day.
3. Gabapentin 300 mg, increasing by 300 mg a day until 600 mg t.i.d.
4. Decrease his analgesics and consider opioids.
5. Tell him to stop his excessive alcohol intake.
6. Put him on slow taper schedule to withdraw the benzodiazepine.
7. See in 10 days.
The patient returned stating he was feeling slightly improved. His usual pain score over the previous two days was 7/10. He was sleeping much better on 50 mg nortriptyline but didn't like the side effects of dry mouth and constipation. He had stopped his alcohol intake. The capsaicin cream had been too uncomfortable to use as the intense burning had persisted for many hours after application. He was on gabapentin 300 mg t.i.d. When he increased it he had felt very drowsy. He had decreased his analgesics to six per day.
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