Physician Pain Management Questionnaire

Form Approved

OMB No. 0920-1030

Exp. Date: 06/30/2023

Physician Pain Management Questionnaire

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Physician Pain Management Questionnaire

The purpose of this survey is to understand physician’s awareness and use of various clinical practice guidelines for managing pain. The survey should only be completed by the physician to whom it is addressed. Your participation in this survey is voluntary and greatly appreciated. Your answers are completely confidential. If you have any questions or comments about this survey, please call 301-458-4220. Please return your questionnaire in the envelope provided.

1. What is your specialty?

□1 General practice/family medicine

□2 Internal medicine

□3 Obstetrics and Gynecology

□5 Anesthesiology (Pain Medicine)

□6 Emergency Medicine

□7 General Surgery

□8 Surgical Specialty (please specify):________________________

□9 Other (please specify): ______________________________

2. Do you provide direct care for patients?

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□1 Yes

Please stop here and return the questionnaire in the envelope provided. Thank you for your time.

questionnaire in the envelope provided. Thank you for your time.

□2 No

□3 I am no longer

in practice.

3. In what setting do you typically provide care to the most patients? CHECK ALL THAT APPLY.

□1 Solo or group practice (inpatient and/or outpatient)

□2 Freestanding clinic or urgent care center

□3 Pain management center or clinic

□4 Community health center (e.g., Federally Qualified ____ Health Center (FQHC), federally funded clinics or ____ “look-alike” clinics

□5 Mental health center

□6 Emergency Room

□7 Non-federal government clinic (e.g., state, county)

___

4. How many of your patients are you currently treating for pain?

□1 None If you answered “None” to question 4, please stop here and return the questionnaire in the envelope provided. Thank you for your time. □4 Almost All

□2 Few □5 All

□3 Some

Of the following categories of clinical practice guidelines for pain management, select those you are aware of and select those that you use when treating pain patients. CHECK ALL THAT APPLY.	I am aware of these guidelines(s)	I use these guideline(s) to treat pain
Guidelines from professional medical organizations or societies (e.g., the American Academy of Pain Medicine Guidelines)	□1	□2
Guidelines established by the state where you primarily provide care	□1	□2
The CDC Guideline for Prescribing Opioids for Chronic Pain also known as The U.S. Centers for Disease Control and Prevention Opioid Guideline	□1	□2
Hospital or practice-based guidelines; that is guidelines established by the organization where you provide care.	□1	□2
Guidelines established by the Department of Health and Human Services or Veteran Administration	□1	□2

If you answered “Never” to question 6b, please skip to question 8.

When managing your pain patients, how often do you?	Never	Rarely	Some-times	Often	Always
Establish treatment goals with your recently diagnosed pain patients? (e.g., less pain, improved function, increased social activities, better sleep quality, etc.)	□1	□2	□3	□4	□5
Recommend non-pharmacological approaches to your recently diagnosed pain patients before or instead of opioid therapy	□1	□2	□3	□4	□5

7. What types of non-opioid medications do you currently recommend to pain patients? CHECK ALL THAT APPLY.

   □1 Acetaminophen □3 Antidepressants □5 Non-steroidal anti- ____ inflammatory ____(NSAIDS)

   □2 Anticonvulsants □4 Benzodiazepines □6 Other non-opioid drugs

8. How confident are you in successfully treating/managing pain?

□1 Not confident at all □3 Very confident

□2 Somewhat confident □4 Completely confident

The next series of questions ask about the use of opioid therapy to treat pain patients.

7. How many of your pain patients are currently being treated with opioids prescribed by you?

□1 None □4 Almost All

□2 Few □5 All

□3 Some

If you answered “None” to question 9, please stop here and return the questionnaire in the envelope provided. Thank you for your time.

Prior to starting opioids for pain management, how often do you do the following?	Never	Rarely	Some-times	Often	Always
Screen patients for depression and other mental health disorders	□1	□2	□3	□4	□5
Discuss risks and benefits of using opioids for pain treatment	□1	□2	□3	□4	□5

7. After you start opioid therapy on a pain patient, when do you re-evaluate him/her?

   □1 Within 1 week □3 Within 3 months	□2 Within 4 weeks □4 Within 1 year
   □5 I don’t re-evaluate patients after starting opioid therapy

8. When you prescribe opioids to your pain patients, how many days on average does the prescription cover?

□1 Fewer than 4 days □3 8 to 14 days □5 More than 30 days

□2 4 to 7 days □4 15 to 30 days

7. On average, how often do you re-evaluate pain patients to whom you have prescribed long-term opioids (more than 3 months)?

□1 Once per week

□2 Once per month

□3 Once every 3 months

□4 Once every 6 months

□5 Once per year

□6 Less than once per year

□7 I don’t prescribe long-term opioids to my pain patients

When prescribing opioid therapy to your pain patients, how often do you?	Never	Rarely	Some-times	Often	Always
Perform a substance abuse risk assessment before prescribing opioids (e.g., CAGE, COWS, TAPS)	□1	□2	□3	□4	□5
Establish an opioid treatment plan with your patients	□1	□2	□3	□4	□5
Review the patient’s history of substance use	□1	□2	□3	□4	□5
Perform a urine toxicology screening before starting opioid therapy	□1	□2	□3	□4	□5
Review your U.S. state’s prescription drug monitoring program database (PDMP)	□1	□2	□3	□4	□5
Prescribe naloxone to patients receiving opioids	□1	□2	□3	□4	□5
Perform a random urine toxicology screening quarterly for long-term opioid therapy	□1	□2	□3	□4	□5

7. What type of non-pharmacological approaches do you currently recommend to your recently diagnosed pain patients? CHECK ALL THAT APPLY.

□1 Acupuncture/Massage ____ therapy □5 Mind-body techniques (e.g., biofeedback) □9 None

□2 Chiropractic care □6 Occupational/Physical ____ therapy □10 Other __________________

□3 Exercise and/or ……. ……. stretching □7 Talk therapy (CBT, ____ …….group therapy)

□4 Local heat/cold therapy □8 Yoga, Tai-Chi, Qi Gong

If you have misplaced the envelope, please send the questionnaire to: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics –AHCSB, 3311 Toledo Road, Room 3409 Hyattsville, MD 20782

Boxes for Administrative Use

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