Form 0920- Primary Care Clinician Survey

Attachment A. Primary Care Clinician Survey

Form Approve

OMB No: 0920-xxxx

Exp. Date: xx-xx-xxxx

Public Reporting burden of this collection of information is estimated at 10 minutes, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data 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 Reports Clearance Officer, 1600 Clifton Road NW, MS D-74, Atlanta, GA 30333; Attn:  PRA (0920-xxxx).

Introduction

Abt Associates and AMGA (the American Medical Group Association) are working with the Centers for Disease Control and Prevention (CDC) to evaluate the effects of your health system’s implementation of policies and guidelines regarding chronic pain management and opioid prescribing, including access to medications for opioid use disorder (MOUD). This 10-minute survey aims to get a better understanding of your health system’s implementation of such policies and guidelines, and their effects on patient outcomes. This study is funded by the CDC.

When answering the following questions, please consider your adult (18 years and older) patients, including those with chronic pain and those who are currently or were previously prescribed long-term opioid therapy (LTOT), where LTOT is defined as use of opioids on most days for more than 3 months. Please consider only patients seen in primary care, outpatient settings. Please note that this survey is intended for clinicians who possess the necessary licensure and certification to prescribe opioids, or clinicians who work under the supervision of a physician with such licensure/certification.

For the purposes of this evaluation, “chronic pain management policies/guidelines” refers to policies/guidelines that may include prescribing of opioid medications, nonpharmacologic therapies, and/or non-opioid medications for chronic pain, as well as opioid use disorder (OUD) assessment and treatment.

Consent

• Your participation is voluntary, and you may quit at any time.

• This survey will last approximately 10 minutes.

• You can decline to answer any question without affecting your continued participation in the survey or your relationship with your organization or the CDC. There is a small risk of loss of confidentiality. We have many procedures in place to reduce this risk.

• Your responses will only be shared in aggregate with other responses with no individual attribution.

• This study has a “Certificate of Confidentiality” from the CDC to protect your privacy. Unless you consent, researchers cannot share or release information that may identify you¹, with a few exceptions² (please see footnotes).

• You will be given $25 as a token of our appreciation.
  
  

Care Provided to Patients with Chronic Pain

1. Approximately how large has your outpatient primary care panel of patients aged 18 years and older been over the past 6 months?

• Approximately ____ patients

2. In the last 6 months, approximately how many patients with chronic pain aged 18 years and older did you treat in an outpatient setting? Chronic pain is defined as pain lasting longer than 3 months, or past the time of normal tissue healing. This does not include patients receiving palliative care or with pain related to active cancer. This question asks about patients with chronic pain receiving any kind of treatment, including opioid or nonopioid treatments, or no treatment at all.

• Approximately ____ patients

3. In the last 6 months, approximately how many patients with chronic pain previously or currently prescribed LTOT aged 18 years and older did you see in an outpatient setting? Again, chronic pain is defined as pain lasting longer than three months, or past the time of normal tissue healing, and this does not include patients receiving palliative care or with pain related to active cancer. This question is specifically asking about patients with chronic pain currently under your care who have been prescribed opioids to treat chronic pain (including patients who may have been previously prescribed opioids by another clinician).

• Approximately ____ patients

4a. In the last 6 months, approximately how many patients aged 18 years and older did you newly start on opioid medication in an outpatient setting? This includes patients for whom opioids were prescribed for acute indications.

• Approximately ____ patients

4b. Approximately how many of these patients that were newly started on opioid medication (answer to 4a) were prescribed opioids specifically to treat chronic pain?

• Approximately ____ patients

5. Are you familiar with your health system’s chronic pain management policies/guidelines that were implemented [insert month(s) and year]?

• No, I am not aware of any of the chronic pain policies or guidelines

• Yes, I am aware of the chronic pain policies or guidelines.

Care Provided to Patients Who are Prescribed Opioids Including for Opioid Use Disorder

6. Do you regularly access your state Prescription Drug Monitoring Program (PDMP)?

• Yes, as a prescriber

• Yes, as a delegate

• No, SKIP TO Q8

• Not applicable, SKIP TO Q8

• Don’t know, SKIP TO Q8

• Other: ___________________________

7. If yes, when you check the PDMP, is it for:

• Every patient, every time

• Every patient, sometimes

• Some patients, every time

• Some patients, sometimes

7. Are you familiar with your health system’s opioid prescribing policies/guidelines that were implemented [insert month(s) and year]?

• No, I am not aware of any recently implemented opioid prescribing policies or guidelines.

• Yes, I am aware of recently implemented opioid prescribing policies or guidelines.

7. Do you have the required certification (i.e., X-waiver) to prescribe buprenorphine to patients with opioid use disorder (OUD)?

• Yes

• No  SKIP TO Q11

7. In the last 6 months, have you prescribed buprenorphine to patients with opioid use disorder (OUD)?

• Yes

• No

7. In the last 6 months, have you referred patients with OUD to another clinician for OUD treatment?

• Yes

• No

Management of Chronic Pain with Opioid Therapy

When answering the next set of questions, please think about how you have treated patients with chronic pain who are currently or were previously prescribed LTOT, both before and after changes in your health systems’ policies or guidelines implemented around [insert month and year]. (If your health system has implemented multiple policies/guidelines in recent years, in answering this question please consider the first change that occurred starting in 2016.)

7. When caring for patients with chronic pain previously or currently prescribed LTOT, did you or your team conduct these specific aspects of care before and after guideline implementation?

NOTE: If you were not working at the health system before implementation of the first change that occurred starting in 2016, please just respond to questions in the “Currently or After Implementation” column.

	Before Policy/Guideline Implementation	Currently or After Policy/Guideline Implementation
	1 (Never)..3 (Sometimes)..5 (Always)	1 (Never)..3 (Sometimes)..5 (Always)
Discussed risks and benefits of opioid therapy with patients	1 2 3 4 5	1 2 3 4 5
Discussed an opioid treatment agreement	1 2 3 4 5	1 2 3 4 5
Engaged in shared decision-making with patients regarding treatment of chronic pain	1 2 3 4 5	1 2 3 4 5
Referred patients to non-pharmacologic therapies for pain, when indicated (physical therapy, acupuncture, cognitive behavioral therapy, etc.)	1 2 3 4 5	1 2 3 4 5
Prescribed or recommended non-opioid pharmacologic pain treatment, when indicated (e.g., acetaminophen, NSAIDs)	1 2 3 4 5	1 2 3 4 5
Prescribed the lowest effective dosage when initiating opioids (e.g., “start low and go slow”)	1 2 3 4 5	1 2 3 4 5
Carefully reassessed evidence of risks and benefits when increasing opioid dosage to >50 morphine milligram equivalents (MME)/day	1 2 3 4 5	1 2 3 4 5
Avoided increasing opioid dosages to >90 MME/day, or carefully justified a decision to do so	1 2 3 4 5	1 2 3 4 5
Engaged in periodic re-evaluation of opioid therapy (i.e., dose change; benefits/risks of continued opioid treatment)	1 2 3 4 5	1 2 3 4 5
Referred patients to a pain management specialist or clinic	1 2 3 4 5	1 2 3 4 5
Checked patients’ records in the prescription drug monitoring program (PDMP) as per state regulations	1 2 3 4 5	1 2 3 4 5
Ordered and/or interpreted urine drug test results	1 2 3 4 5	1 2 3 4 5
Assessed for drug-drug interactions (e.g., benzodiazepines and opioids)	1 2 3 4 5	1 2 3 4 5
Assessed patients’ current and past use of benzodiazepines, other sedatives, and/or controlled substances	1 2 3 4 5	1 2 3 4 5
Assessed patients’ current use of alcohol or illicit drugs	1 2 3 4 5	1 2 3 4 5
Assessed patients’ past use of alcohol or illicit drugs	1 2 3 4 5	1 2 3 4 5
Assessed whether patients are taking more opioids than prescribed	1 2 3 4 5	1 2 3 4 5
Assessed patients for opioid use disorder	1 2 3 4 5	1 2 3 4 5
For patients with opioid use disorder, provided treatment yourself or in your health system	1 2 3 4 5	1 2 3 4 5
For patients with opioid use disorder, referred outside of your health system for treatment	1 2 3 4 5	1 2 3 4 5
Prescribed or referred patients for naloxone (overdose reversal drug) when indicated	1 2 3 4 5	1 2 3 4 5
Discussed safe storage and disposal of opioids with patients	1 2 3 4 5	1 2 3 4 5

Management of Acute Pain with Opioid Therapy

7. Recognizing that long-term opioid use often begins with the treatment of acute pain, please consider how you have managed acute pain with opioids before and after implementation of policies/guidelines in 2016 or later. When treating acute pain with opioids, how often did you or your team conduct these specific aspects of care before and after guideline implementation?

	Before Policy/Guideline Implementation	Currently or After Policy/Guideline Implementation
	1 (Never)..3 (Sometimes)..5 (Always)	1 (Never)..3 (Sometimes)..5 (Always)
Prescribed the lowest effective dose	1 2 3 4 5	1 2 3 4 5
Prescribed immediate-release opioids	1 2 3 4 5	1 2 3 4 5
Prescribed no greater quantity than needed for acute pain, usually 3 or less days	1 2 3 4 5	1 2 3 4 5

Confidence and Awareness

1. Confidence in Caring for Patients with Chronic Pain

7. On a scale from 1 to 5, how confident are you in your care team’s ability to conduct each of the following clinical care activities with patients with chronic pain on LTOT?

	1 (Not at all confident)	2	3	4	5 (Very confident)
Provide care according to evidence-based chronic pain guidelines for patients with chronic pain who may be receiving opioid therapy	⚪	⚪	⚪	⚪	⚪

7. On a scale from 1 to 5, how confident are you in your ability to conduct each of the following clinical care activities with patients with chronic pain on LTOT?

	1 Not at all confident	2	3	4	5 Very confident
Provide care according to evidence-based guidelines for patients with chronic pain who may be receiving LTOT	⚪	⚪	⚪	⚪	⚪
Engage in difficult conversations with patients (e.g., tapering, urine drug test or prescription drug monitoring program results)	⚪	⚪	⚪	⚪	⚪
Develop an opioid tapering plan collaboratively with the patient when the risks of LTOT outweigh the benefits	⚪	⚪	⚪	⚪	⚪
Diagnose co-occurring behavioral or mental health conditions among patients with chronic pain on opioids	⚪	⚪	⚪	⚪	⚪
Identify patients with chronic pain who are receiving opioids who are misusing opioids	⚪	⚪	⚪	⚪	⚪
Diagnose opioid use disorder (OUD), distinguishing it from physical dependence, among patients with chronic pain who receive opioids	⚪	⚪	⚪	⚪	⚪
Prescribe medications for opioid use disorder such as buprenorphine or naltrexone	⚪	⚪	⚪	⚪	⚪
Refer patients for OUD treatment such as methadone, buprenorphine or naltrexone	⚪	⚪	⚪	⚪	⚪

Observations of Patients

2. Observations of Patients with Chronic Pain

7. When caring for patients with chronic pain who are prescribed LTOT, how often have you noted the following with patients in the past 6 months?

	Always	Often	Sometimes	Rarely	Never
Misuse of opioidsa	⚪	⚪	⚪	⚪	⚪
Use of illicit opioids	⚪	⚪	⚪	⚪	⚪
Challenges with side effects related to opioids b	⚪	⚪	⚪	⚪	⚪
Patient experiencing poorly controlled pain	⚪	⚪	⚪	⚪	⚪
Patient leaving practice	⚪	⚪	⚪	⚪	⚪
Patient willing to try non-pharmacologic therapy for pain	⚪	⚪	⚪	⚪	⚪
Patient willing to try non-opioid pharmacologic treatments	⚪	⚪	⚪	⚪	⚪

a. Drug Misuse: The use of illegal drugs and/or the use of prescription drugs in a manner other than as directed by a doctor, such as use in greater amounts, more often, or longer than told to take a drug or using someone else’s prescription (CDC) https://www.cdc.gov/drugoverdose/opioids/terms.html

b. Side Effects: In addition to the serious risks of addiction, abuse, and overdose, the use of prescription opioids can have a number of side effects, even when taken as directed . https://www.cdc.gov/drugoverdose/opioids/prescribed.html#side-effects

Health System or Practice-Level Changes

Policies and Supports

7. Does your practice or health care system have a standardized opioid treatment agreement for patients with chronic pain on LTOT?

• Yes

• No

• Don’t know

7. Does your practice or health care system have electronic health record tools (e.g., note templates, order sets, alerts, clinical decision support tools) to support pain management for patients with chronic pain?

• Yes

• No

• Don’t know

3. Measures and Monitoring

7. Does your clinic use regular summary reports (e.g., data or quality performance reports) for clinicians to monitor your own opioid prescribing practices?

• Yes

• No

• Don’t know

7. What measures are included in the summary reports? [check all that apply]:

• Number of patients with chronic pain on long-term opioid therapy

• Patients’ opioid dosages (e.g., morphine equivalent dose [MED], or morphine milligram equivalents [MME])

• Prescription opioid refills

• Patient-reported pain and function (e.g., PEG scores)

• Patient-reported quality of life

• Co-prescribing of benzodiazepines

• Whether treatment agreement is up-to-date

• Other (please specify): _____________________________________________

4. Improvement Efforts

7. Since the time that policies and guidelines were implemented in your practice, have the strategies/interventions your health system has used for chronic pain management impacted your day-to-day work with patients with chronic pain on LTOT?

• Yes

• No (Skip to Q21)

• Don’t know (Skip to Q21)

7. How have these changes impacted your day-to-day work with patients with chronic pain on LTOT?

• Positively

• Somewhat positively

• Neither positively nor negatively

• Somewhat negatively

• Negatively

7. Please tell us a little more about how your day-to-day work has been impacted by implementation of these policies/guidelines.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

6. Challenges

7. In the last 6 months, have any of the following made it difficult for you to provide care aligned with your health system’s current policies and guidelines for patients with chronic pain especially those on LTOT? Please check all that apply.

• Insufficient time in office with patients with chronic pain

• Patient resistance to considering changes to opioid prescriptions

• Poor, cumbersome, or limited tools within the electronic health record (EHR)

• Alarm fatigue from the EHR

• Limited access to non-opioid pharmaceutical therapies for chronic pain

• Limited access to non-pharmacological therapies for chronic pain

• Poor or no coverage of non-pharmacologic therapies by insurance

• Limited access to medication for opioid use disorder, (e.g., buprenorphine, methadone, or naltrexone)

• Other clinicians abandoning patients who are receiving long-term opioids

• Working with new patients already receiving opioids long-term

• Limited education/knowledge on how to appropriately taper patients off of opioids

• Limited confidence/experience in having difficult conversations with patients (e.g., tapering)

• Patients using illicit opioids or other illicit drugs

• Not knowing if and/or when a patient overdosed on opioids or other drugs

• Social determinants of health factors (such as poverty, food insecurity, homelessness) affecting patients

• Too many other initiatives taking place that compete for time and/or resources

• Not enough resources to change my practice to be more concordant with evidence-based guidelines

• Other (please specify): ___________________________

Major Disruptions

7. Have there been any of the following major changes in your health system in the last 12 months?³

	No major disruption	One major disruption	More than one major disruption
New electronic health record (EHR) system	⚪	⚪	⚪
Moved practice to new location	⚪	⚪	⚪
Expanded or acquired additional clinics/practices/organizations	⚪	⚪	⚪
Lost one or more clinicians	⚪	⚪	⚪
Lost one or more office managers	⚪	⚪	⚪
Lost one or more head nurses	⚪	⚪	⚪
Been purchased by, or affiliated with, another organization	⚪	⚪	⚪
New billing system	⚪	⚪	⚪
COVID-19 pandemic had significant impact on our practice. Please describe________________________ _______________________________ _______________________________	⚪	⚪	⚪
Other: _________________________ _______________________________	⚪	⚪	⚪

Managing Work-Related Stress

7. In the last 6 months, how much did caring for patients with chronic pain who are on long-term opioid therapy, or for whom you are considering initiating opioid therapy, contribute to your overall level of stress at work? (please select one):

• Not at all

• Very little

• Somewhat

• Moderately

• Extremely

7. Do you engage in strategies to overcome stress and burnout?

• Yes

• No

• Don’t know

Respondent Characteristics

31.What is your age?

• 18-29 years

• 30-44 years

• 45-54 years

• 55-64 years

• 65 or older

• Prefer not to answer

32. How do you describe your gender identity?

• Male

• Female

• Male-to-female transgender (MTF)

• Female-to-male transgender (FTM)

• Other gender identity (specify)_____________________

33. Which of the following best represents how you think of yourself?

• Gay (lesbian or gay)

• Straight, this is not gay (or lesbian or gay)

• Bisexual

• Something else

• I don’t know the answer

34. What is your ethnicity?

• Hispanic or Latino

• Not Hispanic or Latino

35.What is your race?

• American Indian or Alaskan Native

• Asian

• Black or African-American

• Native Hawaiian or other Pacific Islander

• White

36. How long have you worked in this health system?

• Less than one year

• 1-5 years

• 6-10 years

• More than 10 years

37. When caring for patients with chronic pain, are you able to consult with a specialist, as needed, such as the following types of staff? Please select all that apply.

• Clinical pharmacist

• Pain management specialist

• Addiction specialist

• Mental health clinicians (e.g., therapists, psychologists, psychiatrists, social workers)

• Specialists in nonpharmacologic treatment for pain (e.g., acupuncture, physical therapy)

38. Is there anything else that would be helpful to understand about your experience providing care to patients with chronic pain generally, or for those on long-term opioid therapy?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

END OF SURVEY

Thank you for completing this survey! Your input is greatly appreciated.

1 Unless you consent, researchers cannot release information that may identify you for a legal action, a lawsuit, or as evidence. This protection applies to requests from federal, state, or local civil, criminal, administrative, legislative, or other proceedings. As an example, the Certificate would protect your information from a court subpoena.

2 The Certificate does not protect your information if a federal, state, or local law says it must be reported. For example, some laws require reporting of abuse, communicable (contagious, infectious) diseases, and threats of harm to yourself or others.  The Certificate cannot be used stop a federal or state government agency from checking records or evaluating programs. The Certificate does not stop reporting required by the U.S. Food and Drug Administration (FDA). The Certificate also does not stop your information from being used for other research if allowed by federal regulations.

Researchers may release your information when you consent. For example, you may give them permission to release information to insurers, your doctors, or any other person not connected with the research.  The Certificate of Confidentiality does not stop you from releasing your own information. It also does not stop you from getting copies of your own information. 

3 This item was used in AHRQ’s EvidenceNOW initiative, although the COVID-19 item was added. See: Balasubramanian BA, Marino M, Cohen DJ, Ward RL, Preston A, Springer RJ, Lindner SR, Edwards S, McConnell KJ, Crabtree BF, Miller WL. Use of quality improvement strategies among small to medium-size US primary care practices. The Annals of Family Medicine. 2018 Apr 1;16(Suppl 1):S35-43.

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