PRAMS Opioid 2018

Attachment 1: PRAMS Opioid 2018 questions to be cognitively tested (English version)

Form Approved

OMB No. 0920-0222

Exp. Date 08/31/2021

Notice - CDC estimates the average public reporting burden for this collection of information as 85minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0222).

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The next questions are about the use of prescription pain relievers or painkillers during pregnancy. We only want to know about prescription medication that is not available over the counter.

1. During your most recent pregnancy, did you use any prescription pain relievers? Some examples include Codeine, Morphine, Lortab, Vicodin, Tylenol #3, Percocet, and OxyContin.

No  Go to Question 14

Yes

2. During your most recent pregnancy, which of the following prescription pain relievers did you use? For each one, please check No, if you did not use it, or Yes if you did.  

No Yes

1. Vicodin®, Norco®, or other pain reliever with hydrocodone

2. OxyContin®, Percodan®, Percocet® or other pain reliever with oxycodone

3. Tylenol #3® or other pain reliever with codeine

4. MS Contin® or other pain reliever with morphine

5. Dilaudid® or other pain reliever with hydromorphone

6. Opana® or other pain reliever with oxymorphone

7. Ultram®, Ultracet®, or tramadol

8. Duragesic®, Actiq®, or Fentanyl

9. Methadone

10. Some other prescription pain reliever

Please tell us: __________________________

3. What were the reasons that you used prescription pain relievers during your most recent pregnancy? Check ALL that apply

To treat pain from a condition I had before pregnancy

To treat pain from an injury or accident that happened during my pregnancy

To treat pain from surgery (not including oral surgery or dental procedures)

To treat pain from oral surgery or dental procedures

To treat pain from a pregnancy-related problem

Other  Please tell us: __________________

     

4. How did you get the prescription pain relievers that you used during your most recent pregnancy?  Check ALL that apply

I received a prescription from a primary care provider

I received a prescription from an ob-gyn or prenatal care provider

I received a prescription from a dentist or oral health care provider

I received a prescription from another type of medical specialist

I received a prescription from a pain clinic

I had pain relievers left over from an old prescription

I got the pain relievers from a friend or family member who had a prescription

I got the pain relievers without a prescription

Other  Please tell us: ______________________________

5. During your most recent pregnancy, did you ever use any prescription pain reliever in any way a health care provider did not direct you to use it? For example, used it in smaller or greater amounts, more or less often than prescribed, or used it for a shorter or longer time than you were told.

No  Go to Question 9

Yes

6. How would you describe the way you used the prescription pain relievers during your most recent pregnancy? Check all that apply

I used it less often than prescribed

I used it more often than prescribed

I used it for fewer days than prescribed

I used it for more days than prescribed

I used it in a lower dose than prescribed

I used it in a higher dose than prescribed

I used it for a reason different from the reason it was prescribed

7. What were the reasons you used the prescription pain reliever in a way other than prescribed?

To relieve pain, prescribed dose did not relieve pain

To avoid side effects, the prescribed dose was too high

To relieve other physical symptoms

To relieve anxiety

To relieve depression

To relieve stress or tension

To help me sleep

To feel good or get high

To go along with my husband or partner

To fit in with friends To experiment to see what it would be like

To prevent or relieve withdrawal symptoms

Other reason Please tell us: _____________________

8. During your most recent pregnancy, about how often did you use the prescription pain reliever in a way other than prescribed? Check ONE answer

Every day or nearly every day of my pregnancy

Several times a week throughout my pregnancy

Several times a month throughout my pregnancy

Several times during my pregnancy

Only once during my pregnancy

9. During your most recent pregnancy, did you try to cut down or stop using prescription pain relievers?

No Go to Question 14

Yes

10. What were your reasons for trying to cut down or stop using prescription pain relievers? Check ALL that apply

My prescription ran out

I felt that I didn’t need them any more

They were too expensive

I didn’t like the way they made me feel

I was worried about my health

I was worried about the health of my baby

I was worried about other members of my family

My doctor or health care provider recommended that I cut down or stop

A family member or friend suggested that I cut down or stop

Other Please tell us: ___________________

11. During your most recent pregnancy, did you have trouble cutting down or stopping use of the prescription pain relievers?

No

Yes

12. During your most recent pregnancy, did you get help from a doctor, nurse, or other health care worker to cut down or stop using prescription pain relievers?

No

Yes, but it was not enough or the right kind of help for me

Yes, I got the help I wanted  Go to Question 14

13. What were the reasons that you did not get help to cut down or stop using the prescription pain relievers? Check ALL that apply

I could not get an appointment or was put on a waiting list

I was able to cut down or stop using without help

I didn’t think I needed help

I didn’t have enough money or insurance to pay for the services

My insurance plan did not cover the services

I didn’t know where to go for help

I didn’t have transportation

I didn’t want people to think I had a problem

My partner did not want me to get help

I was afraid to lose custody of my new baby or children

I had too many other things going on

Other Please tell: __________________

14. How harmful do you think prescription pain relievers could be to a person’s health? Check ONE answer

Not harmful at all

Not harmful, if taken as prescribed

Harmful, even if taken as prescribed

Harmful, but only if used not as prescribed

I don’t know

15. How harmful do you think use of prescription pain relievers during pregnancy could be to a baby’s health? Check ONE answer

Not harmful at all

Not harmful, if taken as prescribed

Harmful, even if taken as prescribed

Harmful, but only if used in not as prescribed

I don’t know

16. At any time during your most recent pregnancy, did a doctor, nurse, or other health care worker talk with you about how using prescription pain relievers could affect you or your baby?

No

Yes

The last question is about the use of other medications or drugs during pregnancy.

17. During your most recent pregnancy, did you take or use any of the following drugs for any reason? For each item, check No if you did not use it or Yes if did.

No Yes

1. Over the counter pain medications relievers such as aspirin, Tylenol®, Advil®,

or Aleve®

2. Prozac®, Zoloft®, Lexapro®, Paxil®, Celexa®, or other selective serotonin reuptake inhibitors (SSRIs)

3. Valium®, Xanax®, Ativan®, Klonopin®, Restoril®, or other benzodiazepines

4. Adderall®, Ritalin® or another stimulant

5. Marijuana or hash                

6. Synthetic marijuana (K2, Spice)                                                           

7. Methadone, naloxone, Subutex® or Suboxone®

8. Heroin (smack, junk, Black Tar, Chiva)                                                

9. Amphetamines (uppers, speed, crystal meth, crank, ice, agua)     

10. Cocaine (crack, rock, coke, blow, snow, nieve)

11. Tranquilizers (downers, ludes)                                                              

12. Hallucinogens (LSD/acid, PCP/angel dust, Ecstasy, Molly, mushrooms, bath salts)

13. Sniffing gasoline, glue, aerosol spray cans, or paint to get high (huffing)

Thank you for answering these questions! Your answers will help us understand how to improve the health of mothers and babies.

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