Att J1_Screenshots_Patient Survey

Form Approval
OMB No: xxxx-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 (xxxx-xxxx).

Participating System Logo

Chronic Pain Study – Patient Survey
Introduction
Abt Associates is working with the Centers for Disease Control and Prevention (CDC) to
evaluate the effects of policies and guidelines on treating chronic pain including the using
opioids for chronic pain, and diagnosis and treatment of patients with opioid use disorder (OUD,
also known as an opioid addiction) when needed. For the purposes of this evaluation, “chronic
pain management policies/guidelines” refers to policies/guidelines that may include prescribing
of opioid medicines, nonpharmacologic (non-medicine) therapies like exercise, and/or nonopioid medicines like ibuprofen or acetaminophen for chronic pain, as well as diagnosing and
treating OUD.
This 10-minute survey aims to gain a better understanding of your knowledge and experience
with your clinic’s use of policies and guidelines about chronic pain management and opioid
prescribing, including access to treatment for opioid use disorder, and how you are doing related
to your pain and daily functioning. This study is funded by the CDC.

Consent – Please note the following:
•

•
•

•
•
•

This survey will take approximately 10 minutes.
Your participation is voluntary. You can skip any question(s) you do not wish to answer,
or quit the survey at any time.
It is OK if you do not wish to answer a specific question. Skipping any questions or quitting
the survey will not impact the care you receive from your doctor or health system. There
is a small risk of loss of confidentiality. We have many procedures in place to reduce this
risk.
We will keep your information and answers confidential. Your responses will remain
anonymous. Neither the CDC nor Abt Associates will have access to your personal
information, and your clinician will not be able to see your responses.
This study has a “Certificate of Confidentiality” from the CDC to protect your privacy.
Unless you consent and say it is okay, researchers cannot share or release information that
may identify you1, with a few exceptions2 (please see footnotes).
You will be given $5 as a token of our appreciation.

If you wish to continue with this survey, please click next page.

1

Unless you say it is okay, 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 say it is okay. 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.

Thank you for participating in this survey. First, we will start with some basic questions about
your background.

Patient characteristics (Source: OMB items; CAHPS)
1. In general, how would you rate your overall physical health?
o Excellent
o Very good
o Good
o Fair
o Poor

2. In general, how would you rate your overall mental health (e.g., emotional, psychological,
and social well-being)?
o Excellent
o Very good
o Good
o Fair
o Poor

3. What is the highest grade or level of school that you have completed?
o 8th grade or less
o Some high school, but did not graduate
o High school graduate or GED
o Some college or 2-year degree
o 4-year college graduate
o More than 4-year college degree

4. What is your age?
o 18-29 years
o 30-44 years
o 45-54 years
o 55-64 years
o 65 or older
o Prefer not to answer

5. How do you describe your gender identity?
o Male
o Female
o Male-to-female transgender (MTF)
o Female-to-male transgender (FTM)
o Other gender identity (specify)_____________________

6. Which of the following best represents how you think of yourself?
o Gay (lesbian or gay)
o Straight, this is not gay (or lesbian or gay)
o Bisexual
o Something else
o I don’t know the answer

7. What is your ethnicity?
o Hispanic or Latino
o Not Hispanic or Latino

8. What is your race?
o
o
o
o
o

American Indian or Alaskan Native
Asian
Black or African-American
Native Hawaiian or other Pacific Islander
White

9. What language do you mainly speak at home?
o
o
o
o
o
o
o
o

English
Spanish
Chinese
Russian
Vietnamese
Portuguese
German
Some other language (please print): ___________________________________

Chronic Pain Care History and Awareness of Health Systems’ Policies or Guidelines
10. If you are comfortable, would you mind sharing a little bit about your pain condition? Please
describe the condition for which you take (or used to take) prescription opioids that you last
saw your primary care clinician about. Examples of prescription opioids include oxycodone
(OxyContin®] or hydrocodone (Vicodin®).
____________________________________________________________________________
o I have never taken prescription opioids → SKIP TO Q13

11. How long have you been treated for this chronic pain condition with opioids?
o Less than 1 year
o 1-3 years
o 4-5 years
o 5-9 years
o 10+ years

12. Are you currently taking opioids for your chronic pain?
o Yes
o No

13. Did you know that [HEALTH SYSTEM] started a new chronic pain or opioid prescribing
policy or guideline in [insert month(s) and year]?
o No, I do not know about this.
o Yes, I know that there has been a new policy/guideline.

14. What changes have you noticed since [insert month(s) and year] in how your clinician
treats your chronic pain? Please check all that apply.
o My clinician started telling me that prescription opioids could be addictive and
dangerous.
o My clinician discussed and encouraged non-opioid medications like Tylenol®
(acetaminophen), Aleve® (naproxen), Advil® (ibuprofen), and/or steroid
injections, as a few examples.
o My clinician discussed and encouraged non-medication treatments like exercise,
cognitive behavioral therapy, physical therapy, occupational therapy, and/or
acupuncture, as a few examples.
o My clinician started asking me more often than before how well my pain was
controlled.
o My clinician started asking me more often than before how easily I was able to do
the things I like to do.
o I was asked to provide urine samples more often than I had to before.
o My clinician wanted to talk to me about reducing my opioids to a lower dosage.
o My clinician wanted to talk to me about reducing my opioids and stopping them
completely.
o I take medications like Xanax® (alprazolam), Valium® (diazepam), or
Klonopin® (clonazepam), and my clinician wanted to stop them.
o My clinician offered me a prescription for naloxone, a medication that can reverse
an opioid overdose, or told me where I could get naloxone.
o My clinician told me they were concerned that I might be developing opioid use
disorder (opioid addiction) and either offered me treatment for it (such as
buprenorphine (e.g., Suboxone), methadone, or naltrexone (e.g., Vivitrol)), or
offered to refer me to another clinician who could treat it.
o Other: __________________________________

15. Did you experience any of the following with your chronic pain since the new
policy/guideline was implemented in [insert month(s) and year]? Please check all that apply.
o I experienced more pain.
o I tried non-opioid medications to treat my pain, like acetaminophen (Tylenol®) or
ibuprofen (Motrin® or Advil®), as examples, but they did not help my pain.
o I take non-opioid drugs to treat my pain, like acetaminophen (Tylenol®) or
ibuprofen (Motrin® or Advil®), as examples, and I still take opioids too. My pain
is under control taking both kinds of medicines.I agreed to stop taking opioids,
and my pain is well managed with non-opioid medicines and/or
nonpharmacologic (non-medicine) methods.
o My chronic pain did not improve, and I tried other prescription opioid medicines
that I got from friends or family members to treat my pain, without my clinician’s
knowledge.
o My chronic pain did not improve, and I tried illicit drugs, such as heroin or pills I
bought on the street, to treat my pain.
o I changed clinicians, since my previous clinician would no longer treat my
chronic pain condition with opioids and I wanted a clinician that would.
o My clinician stopped prescribing opioids for pain completely, but I did not change
to a different clinician.
o My clinicians changed my opioid medicines without talking to me about it.
o I was taking prescription opioids for my pain, and I experienced symptoms of
opioid withdrawal because of reductions or stopping of my opioid medicines.
o My chronic pain has overall improved.
o My overall quality of life improved.
o I am able to do more without my chronic pain slowing me down.
o I agreed to reduce the dosage of opioids that I take to a lower dosage, and I still
take them.
o I agreed to reduce how often I take opioids, and I still take them.
o I was diagnosed with opioid use disorder (opioid addiction), and I am receiving
treatment for it (such as buprenorphine (e.g., Suboxone), methadone, or
naltrexone (e.g., Vivitrol))
o Yes, other: __________________________________

16.What is the level of satisfaction of your care related to your chronic pain?
o Very satisfied
o Satisfied
o Dissatisfied
o Very dissatisfied

17. Could you tell me more about your satisfaction or dissatisfaction with the care you received
for your chronic pain?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Your Care from Clinicians
In answering these questions, please think about how your primary care clinician has addressed
your chronic pain condition (Source: CAHPS3 adapted items)
18. Over the past 6 months, how often did your primary care clinician listen carefully to you
about your chronic pain?
o
o
o
o

Never
Sometimes
Usually
Always

19. Over the past 6 months, how often did your primary care clinician explain chronic pain
management in a way that was easy to understand?
o
o
o
o

Never
Sometimes
Usually
Always

20. Over the past 6 months, how often did your primary care clinician show respect for what you
had to say about your chronic pain?
o
o
o
o
3

Never
Sometimes
Usually
Always

https://www.ahrq.gov/cahps/index.html

Views on Clinician Communication Skills4
On a scale from 1 to 5, with 1=poor and 5=excellent, please rate your prescribing clinician on
their communication skills in your last encounter regarding your chronic pain condition:
Scale: 1 = poor; 2 = fair; 3 = good; 4 = very good; 5 = excellent.

4

1

2

3

4

5

21. Greeted me in a way that made me feel comfortable

⚪

⚪

⚪ ⚪

⚪

22. Treated me with respect

⚪

⚪

⚪ ⚪

⚪

23. Showed interest in my ideas about my health

⚪

⚪

⚪ ⚪

⚪

24.Understood my main health concerns

⚪

⚪

⚪ ⚪

⚪

25. Paid attention to me (looked at me, listened)

⚪

⚪

⚪ ⚪

⚪

26. Let me talk without interruptions

⚪

⚪

⚪ ⚪

⚪

27. Gave me as much information as I wanted

⚪

⚪

⚪ ⚪

⚪

28. Talked in terms I could understand

⚪

⚪

⚪ ⚪

⚪

29. Checked to be sure I understood everything

⚪

⚪

⚪ ⚪

⚪

30. Encouraged me to ask questions

⚪

⚪

⚪ ⚪

⚪

31. Involved me in decisions as much as I wanted

⚪

⚪

⚪ ⚪

⚪

32. Discussed next steps

⚪

⚪

⚪ ⚪

⚪

33. Showed care and concern

⚪

⚪

⚪ ⚪

⚪

34. Spent the right amount of time with me

⚪

⚪

⚪ ⚪

⚪

35. Staff treated me with respect

⚪

⚪

⚪ ⚪

⚪

Gregory Makoul, Edward Krupat , Chih-Hung Chang. “Measuring patient views of physician communication skills: Development and testing
of the Communication Assessment Tool.” Patient Education and Counseling 67 (2007) 333–342.

36. Is there anything that I haven’t asked you regarding your chronic pain and taking opioids that
would be important for me to know to help me understand your health system?
o No
o Yes:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

That completes the survey. Thank you for participating!