title: Less is more: limiting narcotic prescription quantities for common orthopedic procedures.
abstract: BACKGROUND
  Clinicians are now appreciating that the perception of pain is a multifaceted, biopsychosocial construct. Expectation of postsurgical pain is part of this construct and should be considered preoperatively. It is our belief that by establishing reasonable expectations with preoperative teaching, we can minimize narcotic use and lessen untoward issues that can potentially follow. With this goal in mind, we have been using a comprehensive pre- and postoperative program for our outpatient orthopedic surgery patients for the last 5 years, which includes physical, pharmacologic, and simple sport psychological techniques.
  
  
  METHODS
  We reviewed postoperative prescription narcotic purchases in 133 consecutive surgical patients during the last year (2013). All patients were given a prescription postoperatively for 10 hydrocodone 5-mg/acetaminophen 500-mg tablets, with 1 refill. We then contacted the patients' pharmacies to assess the actual amount purchased.
  
  
  RESULTS
  Data were available for 100 patients. Of these, 62 patients had undergone "simple" arthroscopies and 38 had had "open" procedures, including 25 anterior cruciate ligament reconstructions, 4 tibial tubercle osteotomies, and various other surgeries. Of the 62 arthroscopies, 24 patients (39%) refilled their prescriptions, with 4 patients (6%) needing > 1 refill. Of the 38 open procedures, 16 patients (42%) refilled their medications, 2 (5%), more than once. Thus, 89% of patients required ≤ 20 narcotic tablets after undergoing common orthopedic operations. No patient needed chronic narcotic medication.
  
  
  CONCLUSIONS
  Pain is a complex issue and patient expectation of postoperative pain is one aspect that can potentially affect the amount of narcotics used. By preparing the patient both physically and psychologically, we believe the amount of narcotics used postoperatively can be decreased without affecting pain control. As a result, the multiple possible detriments of having more narcotics available than actually necessary would be lessened. By limiting the overall number of narcotic tablets prescribed, decreased use by the patient when such a medication may no longer be appropriate, and minimized use by others in the household who might have access to it would decrease.
authors.affiliation: The Alpine Clinic, PLLC, a division of Littleton Regional Healthcare, Plymouth, NH. doneill@lrhcares.org.
authors.forename: Daniel Fulham
authors.initials: DF
authors.lastname: O'Neill
authors.forename: Christopher
authors.initials: C
authors.lastname: Webb Thomas
mesh_terms: D000082:Acetaminophen / Q000627:therapeutic use*; D000293:Adolescent; D000328:Adult; D000368:Aged; D000701:Analgesics, Opioid / Q000627:therapeutic use*; D001182:Arthroscopy; D004338:Drug Combinations; D005260:Female; D006801:Humans; D006853:Hydrocodone / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D019637:Orthopedic Procedures; D010149:Postoperative Pain / Q000517:prevention & control*; D010818:Practice Patterns, Physicians'; D012189:Retrospective Studies; D013607:Tablets; D055815:Young Adult
chemical_list: D000701:Analgesics, Opioid; D004338:Drug Combinations; D013607:Tablets; C083640:acetaminophen, hydrocodone drug combination; D000082:Acetaminophen; D006853:Hydrocodone