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In July 2016, the United States Senate passed the Comprehensive Addiction and Recovery Act in response to the growing opioid misuse epidemic (Gedzior & Kwong, 2017).  Recent data from the Centers for Disease Control (CDC) suggests that opioid related deaths in the United States has risen two hundred percent from year 2000 to 2014 (Rudd, Aleshire, Zibbell, & Matthew Gladden, 2016).  Florence, Zhou, Luo, & Xu (2013) estimated the economic burden of opioid misuse to be as high as 78.5 billion dollars in 2013.

Bates, Laciak, Southwick, & Bishoff (2011) in their study involving post- operative urology patients, reported that over-prescription at discharge is common among this specific patient population.  However, review of the relevant literature identified the paucity of studies that address opioid over-prescription among the urological surgery patient population.  Recommendations about discharge opioid regimen after surgical interventions are also ambiguous.  For instance, the Centers for Disease Control and Prevention (CDC) recommends prescribing no more than seven-days' worth of opioid at discharge to manage acute pain (Gedzior & Kwong, 2017; Wegrzyn, Chaghtai, Argoff, Fudin, 2018).  Depending on the prescribed dose and frequency of administration, there is a wide variation in the number of pills being dispensed at discharge using this recommendation.  This variation in practice contributes to opioid over-prescription (Bartels et al., 2016; Fujii et al., 2018).

The purpose of the DNP project is to decrease opioid prescription at discharge while providing safe and effective post-operative pain control using an evidence-based guideline.

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Review of literature through PubMed, CINAHL, and Google Scholar using the keywords “urology”, “opioid”, “post-operative pain”, and “opioid guideline” has yielded 47 relevant articles.  Fourteen of the 47 articles inform the DNP scholarly project.

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After review of the fourteen relevant articles, the articles were classified according to categories:

a.       Article that provide background information about the extent of the problem: Florence, C.S., Zhou, C., Luo, F., & Xu, L. (2013); Shah, A. S., Blackwell, R. H., Kuo, P. C., & Gupta, G. N. (2017).

b.       Articles that identify over-prescription: Bates, C., Laciak, R., Southwick, A., & Bischoff, J. (2011); Calcatera et al., (2015); Bartels et al., (2016).

c.       Articles that support guideline creation: del Portal, D.A., Healy, M.E., Saltz, W.A., & McNamara, R.M. (2016); Hill, M.V., Stucke, R.S., Billmier, S.E., Kelly, J.L., & Barth, R.J. (2017); Broida, R. I., Gronowski, T., Kalnow, A. F., Little, A. G., & Lloyd, C. M. (2017); Thiels et al., (2018).

d.       Articles that offer recommendations regarding discharge opioid regimen: Scully et al., (2018); Xu et al., (2015); Khater et al., (2017); Tong, C. M. C., Lucas, J., Shah, A., Foote, C., & Simhan, J. (2018); Large, T., Heiman, J., Ross, A., Anderson, B., & Krambeck, A. E. (2018).

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Research Design:  The studies found are predominantly retrospective in design.  Most are descriptive and observational.  Two are quasi-experimental before and after design.    Three are quasi-experimental comparing two groups, one is survey study design, and one is a relationship study design.

Sampling Methodology:  All of the studies utilized a non-probability, purposive sampling technique.  The samples were homogenous. All of the studies found did not perform power analysis. Sampling technique was appropriate according to the purpose of these studies.

Measurement and Instrument:  A few of the studies compared discharge prescription rate before and after guideline implementation.  They also looked at rate of refill, and patient’s pain control satisfaction.  Visual Analog Scale (VAS) scores is the most often used instrument by those studies that compare two groups.  Some also compared body mass index (BMI) difference between groups.

Data Analysis:   Most of the studies provided sample descriptive statistics.  Those that utilized quasi-experimental design, the difference in between group characteristics were statistically compared and visually presented using tables.  Although non-probability sampling technique was used in all of the studies, inferential statistics was also used to analyze the result.

Overall Impression:  These studies suffer from threat to in internal validity due to design limitations (most of it were retrospective review of electronic records).  External validity is also an issue.  That having said, these studies do not intend to generalize their results to the general population.  Rather, to a very specific patient population (urological surgery patients).  Except for the study by Shah, A. S., Blackwell, R. H., Kuo, P. C., & Gupta, G. N. (2017) which looked at risk factors for opioid dependence using ICD9-CM and CPT codes, most of these studies are modest if not good quality.

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The literature search yielded abundant research that examine over-prescription of opioid.  In fact, the literature is saturated with articles that support the existence of the current opioid crisis.  However, there is paucity of studies that examine measures to alleviate opioid over-prescription among urological surgery patient population.  There is also no clear recommendation about the quantity and duration of opioid regimen after discharge among specialty surgery patient population.

The purpose of this literature review is to search for research studies that inform the creation of discharge opioid prescription guideline.  Despite the fact that none of the studies actually investigated the effect of opioid prescription guideline among urological surgery patient population, I can extrapolate data and findings from these studies that will be useful to my scholarly project.  Also, after examining the details of these studies, I only found one article that suffer from serious design flaws that render its result unusable to my scholarly project. Lastly, the studies that were found useful and relevant to the scholarly project will be incorporated to the existing evidence table.

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Bartels, K., Mayes, L. M., Dingmann, C., Bullard, K. J., Hopfer, C. J., & Binswanger, I. A. (2016). Opioid use and storage patterns by patients after hospital discharge following
surgery. PLoS One, 11 (1), e0147972.  doi: 10.1371/journal.pone.0147972.

Bates, C., Laciak, R., Southwick, A., & Bischoff, J. (2011).  Overprescription of postoperative narcotics: A look at postoperative pain medication delivery, consumption, and disposal in
urological practice.  American Journal of Urology. 185, 551-555.
doi: 10.1016/j.juro.2010.09.088

Broida, R. I., Gronowski, T., Kalnow, A. F., Little, A. G., & Lloyd, C. M. (2017). State
emergency department opioid guidelines: current status. Western Journal of Emergency
Medicine, 18 (3), 340.

Calcatera, S.L., Yamashita, T.E., Sung-Joon, Min., Keniston, A., Frank, J.W., & Bindwanger, I.A. (2015).  Opioid prescribing at hospital discharge contributes to chronic opioid use.  Journal on General Internal Medicine, 31 (5), 478-485.

del Portal, D.A., Healy, M.E., Saltz, W.A., & McNamara, R.M. (2016).  Impact of an opioid prescribing guideline in the acute care setting.  The Journal of Emergency Medicine, 50 (1), 21–27.  doi: 10.1016/j.jermermed.2015.06.014

Florence, C.S., Zhou, C., Luo, F., & Xu, L. (2013).  The economic burden of prescription opioid overdose, abuse, and dependence in the United States, 2013.  Medical Care, 54 (10), 901-906.

Khater, N., Keheila, M., Lightfoot, M., Shen, J., Abourbih, S., Alsyouf, M., Li, R., & Baldwin, D. D. (2017). Predictors of narcotic use after percutaneous nephrolithotomy. The Canadian Journal of Urology, 24 (1), 8634-8640.

Hill, M.V., Stucke, R.S., Billmier, S.E., Kelly, J.L., & Barth, R.J. (2017).  Guideline for discharge opioid prescription after inpatient general surgical procedures.  Journal of the American College of Surgeons, 1-8.  doi: 10.1016/j.jamcollsurg.2017.10.012

Large, T., Heiman, J., Ross, A., Anderson, B., & Krambeck, A. E. (2018). Initial experience with narcotic free ureteroscopy: A feasibility analysis. Journal of Endourology, 1-17.  doi: 10.1089/end.2018.0459

Scully, R. E., Schoenfeld, A. J., Jiang, W., Lipsitz, S., Chaudhary, M. A., Learn, P. A.,
Koehlmoos, T., Haider, A.H., & Nguyen, L. L. (2018). Defining optimal length of opioid pain medication prescription after common surgical procedures. JAMA Surgery, 153 (1), 37-43.  doi: 10.1001/jamasurg.2017.3132

Shah, A. S., Blackwell, R. H., Kuo, P. C., & Gupta, G. N. (2017). Rates and risk factors for opioid dependence and overdose after urological surgery. The Journal of urology, 198 (5), 1130-1136. doi: 10.1016/j.juro.2017.05.237

Thiels, C. A., Ubl, D. S., Yost, K. J., Dowdy, S. C., Mabry, T. M., Gazelka, H. M., Cima, R. R. & Habermann, E. B. (2018). Results of a prospective, multicenter initiative aimed at
developing pioid-prescribing guidelines after surgery.  Annals of Surgery, 1-12.  doi: 10.1097/SLA.0000000000002919.

Tong, C. M. C., Lucas, J., Shah, A., Foote, C., & Simhan, J. (2018). Novel Multi-Modal Analgesia Protocol Significantly Decreases Opioid Requirements in Inflatable Penile Prosthesis Patients. The Journal of Sexual Medicine, 15, 1187-1194.

Wegrzyn, E. L., Chaghtai, A. M., Argoff, C. E., & Fudin, J. (2018). The CDC Opioid Guideline: proponent interpretation has led to misinformation. Clinical Pharmacology & Therapeutics, 103(6), 950-953.  doi:10.1002/cpt.1062