PLAN:
1. He was instructed on other TENS settings. He was using TENS in a conventional with burst mode. An acupuncture-like mode (low frequency, high intensity) over the acupuncture or trigger points of the wrist and forearm could give him a longer duration of relief He was concerned about wearing the TENS for too long a period. He was told he could use the TENS as long as he wanted, skin irritation was the only potential side effect.
2. As he had conformed to requests to come off alcohol and decrease his acetaminophen/codeine analgesics and had no prior history of drug abuse or chaotic home environment, a trial of opioids was started. He signed the opioid agreement and was commenced on methadone 5 mg every 8 hours and told not to expect any major improvement for two to four days as methadone has a slow onset of effect. He could continue his other analgesics but slowly taper them down over the next three to four days. Thereafter he was to take them on an "as needed" basis but to take note of how many he was requiring. He was given a prescription for laxatives and a prepared instruction sheet about the treatment of constipation.
3. He was maintained on his nortriptyline and gabapentin.
4. To see in one week.
He returned in one week delighted with his progress. His pain had decreased to 3/10 at best and 5/10 on average. He was requiring 3-4 extra analgesics per day. Mentally he stated he was feeling alert. He was taking 1-2 laxatives per day to maintain a daily bowel movement. He had started some carpentry which had been his hobby before the accident, but which he had not attempted since because of pain. The acupuncture type TENS was not as effective as the burst/conventional mode. He was wearing the TENS approximately 12 hours a day.
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