Impact of an Educational Intervention on the Opioid Knowledge and Prescribing Behaviors of Resident Physicians.

OBJECTIVES: The opioid epidemic is a multifactorial issue, which includes pain mismanagement. Resident physician education is essential in addressing this issue. We aimed to analyze the effects of an educational intervention on the knowledge and potential prescribing habits of emergency medicine (EM), general surgery (GS), and internal medicine residents (IM).
METHODS: Resident physicians were provided with educational materials and were given pre-tests and post-tests to complete. Descriptive statistics were used to analyze pre-test and post-test responses. Chi-squared analysis was used to identify changes between the pre-tests and post-tests. A p < 0.05 value was considered statistically significant. 
Results: Following the educational intervention, we observed improvement in correct prescribing habits for acute migraine management among emergency medicine residents (from 14.8% to 38.5%). Among general surgery residents, there was a significant improvement in adherence to narcotic amounts determined by recent studies for sleeve gastrectomy (p= 0.01) and laparoscopic cholecystectomy (p= 0.002). Additionally, we observed a decrease in the number of residents who would use opioids as a first-line treatment for migraines, arthritic joint pain, and nephrolithiasis. DISCUSSION: Resident physicians have an essential role in combating the opioid epidemic. There was a significant improvement in various aspects of opioid-related pain management among emergency medicine, internal medicine, and general surgery residents following the educational interventions. We recommend that medical school and residency programs consider including opioid-related pain management in their curricula.

Introduction

The United States (US) opioid epidemic is a multifactorial crisis, with prescription opioids identified as a key contributor to opioid misuse and overdose deaths [1]. At the medical provider level, harm reduction techniques have focused on preventing an excess of prescription opioids from circulating in the community. Approaches to this have included legislative limits on prescription amounts for certain patient populations and state-mandated use of prescription drug monitoring programs (PDMPs) to regulate opioid dispensing [2-3]. While recent studies have provided specialty- and procedure-specific opioid prescribing recommendations based on patient consumption patterns and pain relief requirements, no formal prescribing guidelines exist to eradicate the provider uncertainty that stems from the fear of undermanaging patient pain [4-7]. Additionally, medical school and residency program curricula dedicated to key opioid and pain management topics are underwhelming in the context of the severity of the opioid epidemic. This has been attributed partly to a limited pool of faculty who feel qualified to teach these concepts and to a lack of standardized competencies driving curricular design [7,8].

Accordingly, residents across all medical disciplines are often underprepared to prescribe opioids for patient pain or respond to various opioid-related patient management scenarios [9-11]. The magnitude of this deficit is well-exemplified in a recent study surveying surgical residents at a large academic institution: 90% reported no formal training in best practices of pain management or opioid prescribing, despite reliance on opioids for postoperative pain management [11]. In response to this insufficiency in medical trainee preparation, residency programs have begun to incorporate opioid and pain management material into their curricula. Programs have used various educational models, and some have quantified the effectiveness of these didactics through methods such as survey data collection [11-13]. However, these interventions are typically implemented in a specialty-specific cohort, which limits group knowledge comparisons and the potential to evaluate standardized intervention effectiveness across a variety of medical disciplines. Raheemullah et al. conducted an opioid education intervention using pre-tests and post-tests among internal medicine residents and found improvement in knowledge and prescribing habits [14].

The purpose of this study was to investigate the impact of an educational presentation on resident knowledge and attitudes related to opioid prescribing and pain management, in internal medicine (IM), general surgery (GS), and emergency medicine (EM) residents. By implementing a standardized intervention designed to educate trainees on key concepts such as opioid crisis statistics, opioid prescribing laws, opioid-related complications, and evidence-based opioid prescribing guidelines, we aimed to measure the success of this intervention at content delivery while simultaneously collecting data on the opioid and pain management education of our residents. The goal was to compare the effectiveness of this educational model at improving resident opioid and pain management knowledge, attitudes, and behaviors across several specialties and assess the feasibility of a generalized institutional approach to resident opioid education.

This article was previously posted on Research Square as a Preprint on August 17, 2021.

Materials and methods

This study was determined to be exempt from institutional review board review by the Review Board of Thomas Jefferson University. A total of 46 IM, 17 GS, and 27 EM residents from all postgraduate years (PGYs) at Thomas Jefferson University Hospital in Philadelphia, Pennsylvania, were recruited by email to voluntarily participate in this study. The intervention was designed as a seven-minute pre-recorded lecture with accompanying pre-tests and post-tests. Tests were intended to assess resident opioid and pain management knowledge, attitudes, and behaviors at baseline and upon presentation completion. Lecture content consisted of opioid crisis statistics, opioid prescribing laws, opioid-related complications, and evidence-based opioid prescribing guidelines with practice recommendations modified for each specialty. The pre-tests and post-tests were designed by a team of physicians and medical students. Each test was identical for each group of residents, with differences only in case vignette content and prescribing guidelines between the three cohorts to provide residents with recommendations and scenarios relevant to their specific fields (see Appendix). The post-tests were taken shortly after the pre-tests. The complete pre-tests and post-tests for each specialty are available in the Appendix. The data from the pre-tests and post-tests were organized and we performed descriptive statistics to quantify the responses. We used a Chi-squared analysis to identify resident changes between baseline and completion of the educational intervention using IBM SPSS Statistics for Windows, Version 26.0 (Released 2019; IBM Corp, Armonk, New York). Additionally, we generated comparisons of performance measures across the three cohorts to identify specialty-specific trends. A p < 0.05 value was considered statistically significant.

Results

A total of 90 residents completed the pre-tests; there were 27 residents from EM, 17 from GS, and 46 from IM. There were 46 post-test responses from 13 EM residents, 13 GS, and 20 IM residents. The response rates between pre-test and post-test for EM, GS, and IM were 48%, 76%, and 43% respectively. The demographics for the residents are listed in Table 1.

Table 1

Resident demographics

PGY: post-graduate year; DEA: Drug Enforcement Administration

Emergency Medicine
	Pre-test	Post-test
Year in Residency
PGY1	8 (30%)	5 (38%)
PGY2	8 (30%)	2 (15%)
PGY3	11 (41%)	6 (46%)
DEA License
Yes	0 (0%)	0 (0%)
No	27 (100%)	27 (100%)
General Surgery
	Pre-test	Post-test
Year in Residency
PGY1	2 (12%)	0 (0%)
PGY2	2 (12%)	3 (23%)
PGY3	3 (18%)	3 (23%)
PGY4	5 (29%)	4 (31%)
PGY5	4 (24%)	3 (23%)
DEA License
Yes	15 (88%)	13 (100%)
No	2 (12%)	0 (0%)
Internal Medicine
	Pre-test	Post-test
Year in Residency
PGY1	18 (39%)	9 (45%)
PGY 2	12 (26%)	8 (40%)
PGY3	16 (35%)	3 (15%)
DEA License
Yes	4 (9%)	0 (0%)
No	42 (91%)	20 (100%)

EM residents reported receiving education about opioids from various avenues and stages of training, including personal reading (10 residents (37%)), medical school (16 residents (59.3%)), and residency (22 residents (81.5%)). Regarding training previously received, four residents were very satisfied (14.8%), eight were satisfied (29.6%), 11 were neutral (40.7%), three were unsatisfied (11.1%), and one was very unsatisfied (3.7%). The EM resident prescribing habits and opioid knowledge are listed in Table 2. After receiving the educational intervention, the attitudes of EM residents to the statement “If I suspect someone is abusing opioids, I do not prescribe opioids to them” significantly changed (p=0.04).

Table 2

EM resident knowledge and attitudes

NSAID: non-steroidal anti-inflammatory drug

	Pre-test	Post-test	P-value
For an adult patient that presents to the emergency room with acute pain, according to current PA state guidelines, what is the maximum duration (days) for which an opioid prescription should be given?
7 days	6 (22.2%)	4 (30.8%)	0.56
For an adult presenting to the ED with acute low back pain, I would typically prescribe:
0-10 tablets of 5mg oxycodone + NSAID	0 (0%)	2 (15.4%)	0.54
A 25-year-old female presents to the office with an acute episodic migraine According to the American Headache Society 2015 Guidelines, what treatment has Level A evidence?
Naratriptan	4 (14.8%)	5 (38.5%)	0.09
I feel comfortable in my knowledge of non-opioid pain management.
Agree	15 (55.5%)	7 (53.8%)	0.06
Strongly agree	5 (18.5%)	3 (23.1%)
If I suspect someone is abusing opioids, I do not prescribe opioids to them.
Agree	12 (44.4%)	2 (15.4%)	0.04
Strongly agree	7 (25.9%)	2 (15.4%)
For patients experiencing moderate pain, I usually initially prescribe:
Tylenol	5 (18.5%)	5 (38.5%)	0.17
NSAIDs	22 (81.5%)	8 (61.5%)
Opioid	0 (0%)	0 (0%)

Comparatively, GS residents received opioid training from personal reading (five residents, 29%) medical school (nine residents, 53%), and residency (17 residents, 100%). Regarding prior opioid training, one resident felt unsatisfied, four residents felt neutral, nine residents felt satisfied (52.9%), and three felt very satisfied (17.6%). Following this educational intervention, one resident felt unsatisfied (7.7%), seven felt satisfied (53.8%), and five felt very satisfied (38.5%) with their opioid-prescribing abilities. Furthermore, there was a significant improvement in prescribing knowledge following a sleeve gastrectomy (p=0.01) and a laparoscopic cholecystectomy (p=0.002). The GS resident prescribing habits are listed in Table 3.

Table 3

General surgery specific questions

*= correct answer

		Correct responses (%)	Incorrect responses (%)
For a patient being discharged home after a sleeve gastrectomy, I would typically prescribe:
0-10 tablets 5mg oxycodone*	9 (52.9%)			13 (100%)		0.01*
For a patient being discharged home after a laparoscopic cholecystectomy, I would typically prescribe:
0-15 tablets*	1 (5.9%)			7 (53.8%)		0.002*
For a patient being discharged home after an open small bowel resection, I would typically prescribe:
0-15 tablets*	6 (35.3%)			8 (61.5%)		0.16
For a patient being discharged home after a major hernia repair, I would typically prescribe
0-10 tablets*	4 (23.5%)			9 (69.2%)		0.04*

The IM residents reported receiving opioid training from personal reading (14, 30.4%), medical school (28, 60.9%), residency (33, 71.7%), or in some cases, never received training (4, 8.7%). Regarding their previous opioid training, one resident was very unsatisfied (4.3%), 21 residents (45.7%) were unsatisfied, 19 (41.3%) were neutral, three (6.5%) were satisfied, and two were very satisfied (4.3%). Following the study training, nine residents were unsatisfied (45%), nine were neutral (45%), and two were satisfied (10%). Following the educational intervention, there was an improvement in responses to multiple treatment scenarios, though none of this reached significance. These included treatment of acute episodic migraines according to American Headache Society 2015 Guidelines (45.7% to 70% prescribing naratriptan, p=0.11), improvement in prescribing habits for joint pain in a patient with a history of osteoarthritis (23.9% to 45%, p=0.14), and an increase in non-opioid management of nephrolithiasis in a patient with no history of GI bleed (62.2% to 70%, p=0.59) (Table 4).

Table 4

Internal medicine specific questions

*= correct answer

If I suspect someone is abusing opioids, I do not prescribe opioids to them.
Agree	25 (54.3%)	9 (45%)	0.22
Strongly Agree	8 (17.4%)	9 (45%)
I think that proper pain management is associated with better patient outcomes.
Agree	25 (54.3%)	14 (70%)	0.11
Strongly Agree	20 (43.5%)	6 (30%)
A 25-year-old female presents to the office with an acute episodic migraine According to the American Headache Society 2015 Guidelines, what treatment has Level A evidence?
Naratriptan*	21 (45.7%)	14 (70%)	0.11
A 65-year-old man returns to the clinic for joint pain in his knees. He has a history of osteoarthritis and states that it is difficult for him to complete daily tasks. His pain was not treated by NSAIDs or weight loss. What should be the next line of treatment?
Tramadol*	11 (23.9%)	9 (45%)	0.14

All three groups of residents were asked questions about opioid background knowledge and attitudes. In response to “Which three states have the highest percentage of opioid-related deaths per capita?”, there was a significant improvement in GS (p=0.001) and IM (p=0.003) responses following the intervention. Furthermore, there was an increase in knowledge of the number of drug overdose deaths that occurred from opioids, though it did not reach statistical significance, in both GS (41% to 77%, p=0.07) and IM (45.7% to 65%, p=0.15). Lastly, there was a significant improvement in all specialties regarding knowledge of the number of deaths that were a result of heroin overdose (GS p<0.001, IM p<0.001, EM p=0.015) (Figure 1).

Figure 1

Correct responses to the number of deaths due to heroin overdose in 2017

EM: emergency medicine; IM: internal medicine

Regarding the level of satisfaction with prior opioid training, there was a significant difference between specialties (p<0.0001). Almost half of all IM residents felt unsatisfied with their prior opioid training (unsatisfied or very unsatisfied - 47.9%). Comparatively, 5.9% of GS residents and 14.8% of EM residents felt unsatisfied or very unsatisfied with their training. There was also a significant difference across specialties in the initial management of mild pain (p=0.005) and moderate pain (p<0.001). For moderate pain, GS residents (35.5%) were more likely to prescribe opioids than their colleagues in IM (2.2%) and EM (0%).

Discussion

The opioid epidemic in the US has progressively worsened. There are several historical factors that contributed to the rise of the opioid epidemic, including the classification of pain management as a human right [15] and a fifth vital sign [16], pharmaceutical marketing [17], and postoperative pain mismanagement [18]. To combat the epidemic, there has been growth in non-opioid treatments in pain management, such as nerve blocks, non-steroidal anti-inflammatory drugs (NSAIDs), and ketamine [19]. This study aimed to assess the baseline responses and the effect of a brief educational intervention on the knowledge and attitudes of EM, GS, and IM residents at a single institution.

This study found many significant opportunities for improvement in resident opioid education. Regarding previous opioid knowledge training, 45.7% of IM residents were unsatisfied with the quality of training they had received. This suggests an area of potential collaboration between residents and hospital administration to better equip trainees with the practical information and skills they need to safely and effectively manage pain.

With this brief intervention, there was an improvement of prescribing habits across all specialties. In EM, we observed a greater percentage of residents indicating knowledge that, per Pennsylvania state guidelines, seven days is the maximum duration of opioids that should be prescribed to an adult patient presenting to the ED with acute pain (22.2% to 30.8%). Additionally, there was an increase in the correct use of naratriptan for acute migraine management in the ED (from 14.8% to 38.5%). This particular scenario represents a key opportunity to reduce opioid use in exchange for a more efficacious medication. A study conducted by Colman et al. found that more than half of all patients presenting with migraines were treated with opioids as first-line therapy across four different hospitals [20]. Focusing on common clinical presentations like this, where treatment algorithms may be ambiguous for many providers, could greatly reduce the unnecessary use of opioids. Additionally, this effort is not meant to create a divide between providers and patients. Patients who have a history of drug misuse should receive the appropriate pharmacotherapy and psychosocial counseling to equip them with the tools to make effective change [21].

From the provider perspective, it is imperative to keep the patient’s best interest in mind when treating someone struggling with drug dependence, without letting biases affect your judgement. We observed a change in perspective among EM residents. Initially, majority of residents would not prescribe opioids to someone who appeared to be misusing drugs (70.3%). After our intervention, the number of residents who agreed with this statement decreased to 30.8% (p=0.04). This change in perspective highlights the multifaceted and individualized approach needed for each patient, considering the dangers of both over and under-prescribing. Walter et al. observed significant improvement in knowledge and management of opioid use disorder among EM residents following an educational intervention [22].

In our study, we observed significant improvement for GS in prescribing habits, better conforming to narcotic amounts determined by recent papers, following common procedures such as sleeve gastrectomy (p= 0.01), and laparoscopic cholecystectomy (p= 0.002) [23,24]. A similar study conducted by Hill et al. found that an educational intervention effectively decreased the number of opioids prescribed to patients following general surgery procedures [25].

Among IM residents, there was a decrease in participants who wanted to use opioids as a first-line treatment for migraines, arthritic joint pain, and nephrolithiasis. While these findings may not reach statistical significance, the increased percentage of correct responses indicates improvement of knowledge. The recommended first-line treatment for acute migraine includes NSAIDs and triptans. Opioid use in migraine treatment has not shown to have significant improvement so they are not recommended as initial treatment [26]; however, studies such as Bigal et al. have found that opioids were commonly used in clinical practice for migraine treatment (20.8%) [27]. A possible solution in this gap between recommendations and clinical practice can be educational interventions such as this study to target specific clinical situations that are confusing for providers or commonly treated inappropriately with opioids when good alternatives exist.

Potential limitations in this study can be attributed to the study design. Since our study focused on survey responses, the data largely depended on completion of both pre-tests and post-tests. There was a discrepancy in response rates between the two tests, likely due to survey fatigue and the demands of residents’ schedules. Additionally, this study took place during the coronavirus disease 2019 (COVID-19) pandemic, which placed considerable stress on resident physicians [28]. In order to boost survey responses, we sent reminders via email, had participating residents from each department make announcements at weekly meetings, and sent other team members to attend departmental conferences. Despite our best efforts, however, we were unable to improve these response rates. Additionally, our data is from survey answers and not real-world clinical actions. Given residents are largely constrained in their medication prescribing practices by the desires and preferences of supervising attendings, we did not feel studying their prescribing behaviors would yield meaningful results. Resident physicians are an integral component in battling the opioid epidemic. With these findings, we encourage medical schools and residency programs to integrate training on the effective use of non-opioid pain treatments into their curricula.

Conclusions

The opioid epidemic is a multifaceted issue that can be attributed to many causes. Resident physicians are a key resource in combating the opioid epidemic. We observed significant improvement in opioid knowledge and prescribing habits among all residents following the specialty-specific educational interventions. Therefore, we recommend that medical school and residency programs consider integrating opioid-related pain management strategies throughout their curricula.

Table 5

Emergency medicine pre-test

PGY: post-graduate year; DEA: Drug Enforcement Administration; PDMP: prescription drug monitoring program; PA: Pennsylvania; NSAID: non-steroidal anti-inflammatory drug

Emergency medicine resident knowledge and attitudes pre-test

Resident background

Please select your current level of training:

PGY1

PGY2

PGY3

Do you hold a DEA License?

Yes

No

How satisfied are you with your current level of opioid-prescribing training?

Very satisfied

Satisfied

Neutral

Unsatisfied

Very unsatisfied

When did you receive your opioid-prescribing training? (Select all that apply)

College

Medical School

Residency

Personal reading

Never received any formal training

For the following questions, answer as if you are the prescriber even if you do not currently hold a DEA license. Select only ONE answer unless specified otherwise.

General opioid knowledge

What are the three most common chief complaints for adults in the ED that were discharged with opioids? (select three)

Headache

Dental pain

Chest pain

Abdominal pain

Urolithiasis

Back pain

Which three states have the highest percentage of opioid-related deaths per capita: (circle 3 states)

Alabama

California

Kentucky

New York

Ohio

Pennsylvania

South Carolina

West Virginia

In 2017, how many drug overdose deaths were due to opioids?

15,000

25,000

45,000

75,000

In 2017, how many deaths were a result of heroin overdose?

15,000

25,000

45,000

75,000

Nearly half of all opioid related overdoses are due to valid prescription opioids.

True

False

What is the PDMP?

Physician Drug Medical Plan

Prescribing Directory of Medical Providers

Prescription Drug Monitoring Program

Planned Drug Movement Plan

How often should the PDMP be referenced?

Once a day

Once a month

Once a year

Anytime an opioid prescription is given.

Case-based scenarios

For an adult patient that presents to the emergency room with acute pain, according to current PA state guidelines, what is the maximum duration (days) for which an opioid prescription should be given?

0 day

1 day

3 days

7 days

14 days

No limit

When prescribing opioids to a minor, according to current PA state guidelines, the provider should:

Discuss possible risks with both the minor and parent/guardian

Document if the patient is an emancipated minor

Document the consent given

All of the above

For an adult presenting with noncancer pain, what should be the first course of action prior to formulating a pain control plan?  (circle only one)

Only non-opioid pain medications

Short acting opioids

Consult the state monitoring program (PDMP)

Extended-released schedule II products

For an adult presenting to the ED with acute low back pain, I would typically prescribe: (circle only one)

Only non-opioid pain medications

0-10 tablets of 5mg oxycodone + NSAID

11-20 tablets of 5mg oxycodone + NSAID

21-30 tablets of 5mg oxycodone + NSAID

31-40 tablets of 5mg oxycodone + NSAID

41-50 tablets of 5mg oxycodone + NSAID

Over 50 tablets of 5mg oxycodone

A 25-year-old female presents to the office with an acute episodic migraine According to the American Headache Society 2015 Guidelines, what treatment has Level A evidence?

Chlorpromazine IV 12.5 mg

Celecoxib 400 mg

Codeine/acetaminophen 25/400 mg

Naratriptan 2.5 mg

Codeine 30 mg

A 30-year-old male who actively uses IV heroin presents to the ED for a localized skin infection. After several hours, he begins to complain of anxiety and GI upset. You suspect opioid withdrawal and calculate his Clinical Opiate Withdrawal Score (COWS), which at 30 is rated “moderately severe”. How would you treat his current withdrawal symptoms?

NSAIDs

Buprenorphine-naloxone to bridge him to outpatient treatment

Oral morphine

Extended-release oxycodone

Tylenol

For patients experiencing mild pain, I initially prescribe (circle one)

NSAIDs

Tylenol

Opioid

For patients experiencing moderate pain, I initially prescribe

(circle one)

NSAIDs

Tylenol

Opioid

For patients experiencing severe pain, I initially prescribe

(circle only one)

NSAID

Tylenol

Opioid

Resident attitudes

Opioids are effective in pain management.

Strongly agree

Agree

Undecided

Disagree

Strongly disagree

Every patient that presents to the ED with pain should receive opioids.

Strongly agree

Agree

Undecided

Disagree

Strongly disagree

I feel comfortable in my knowledge of non-opioid pain management.

Strongly agree

Agree

Undecided

Disagree

Strongly disagree

If I suspect someone is abusing drugs, I will not prescribe them short-acting opioids.

Strongly agree

Agree

Undecided

Disagree

Strongly disagree

Patient gender may affect my judgement of a patient's pain intensity

Strongly agree

Agree

Undecided

Disagree

Strongly disagree

Patient race may affect my judgement of a patient's pain intensity

Strongly agree

Agree

Undecided

Disagree

Strongly disagree

If a patient presents to the ED repeatedly asking for more pain medication, this could be due to a missed diagnosis of the underlying pain source.

Strongly agree

Agree

Undecided

Disagree

Strongly disagree

I ask my patients about the severity of their pain.

Strongly agree

Agree

Undecided

Disagree

Strongly disagree

I include patient-reported pain levels in my notes.

Strongly agree

Agree

Undecided

Disagree

Strongly disagree

Table 6

General surgery pre-test

PGY: post-graduate year; DEA: Drug Enforcement Administration; PDMP: prescription drug monitoring program; PA: Pennsylvania; NSAID: non-steroidal anti-inflammatory drug

General surgery resident knowledge and attitudes pre-test

Resident background

Please select your current level of training:

PGY1

PGY2

PGY3

PGY4

PGY5

Do you hold a DEA License?

Yes

No

How satisfied are you with your current level of opioid-prescribing training?

Very satisfied

Satisfied

Neutral

Unsatisfied

Very unsatisfied

When did you receive your opioid-prescribing training? (Select all that apply)

College

Medical School

Residency

Personal reading

Never received any formal training

For the following questions, answer as if you are the prescriber even if you do not currently hold a DEA license. Select only ONE answer unless specified otherwise.

General opioid knowledge

Which three states have the highest percentage of opioid-related deaths per capita: (circle 3 states)

Alabama

California

Kentucky

New York

Ohio

Pennsylvania

South Carolina

West Virginia

In 2017, how many drug overdose deaths were due to opioids?

15,000

25,000

45,000

75,000

In 2017, how many deaths were a result of heroin overdose?

15,000

25,000

45,000

75,000

Nearly half of all opioid related overdoses are due to valid prescription opioids.

True False

What is the PDMP?

Physician Drug Medical Plan

Prescribing Directory of Medical Providers

Prescription Drug Monitoring Program

Planned Drug Movement Plan

How often should the PDMP be referenced?

Once a day

Once a month

Once a year

Anytime an opioid prescription is given

Resident attitudes

Opioids are effective in pain management.

Strongly agree

Agree

Undecided

Disagree

Strongly disagree

Every patient should receive opioids following surgery.

Strongly agree

Agree

Undecided

Disagree

Strongly disagree

I feel comfortable in my knowledge of non-opioid pain management.

Strongly agree

Agree

Undecided

Disagree

Strongly disagree

If I suspect someone is abusing opioids, I do not prescribe opioids to them.

Strongly agree

Agree

Undecided

Disagree

Strongly disagree

Patient gender may affect my judgement of a patient's pain intensity

Strongly agree

Agree

Undecided

Disagree

Strongly disagree

Patient race may affect my judgement of a patient's pain intensity

Strongly agree

Agree

Undecided

Disagree

Strongly disagree

I ask my patients about the severity of their pain.

Strongly agree

Agree

Undecided

Disagree

Strongly disagree

I include patient-reported pain levels in my notes.

Strongly agree

Agree

Undecided

Disagree

Strongly disagree

Case-based scenarios

For a patient being discharged home after an open appendectomy, I would typically prescribe: (circle only one)

Only non-opioid pain medications

0-10 tablets of 5mg Oxycodone

11-20 tablets of 5mg Oxycodone

21-30 tablets of 5mg Oxycodone

31-40 tablets of 5mg Oxycodone

41-50 tablets of 5mg Oxycodone

Over 50 tablets of 5mg Oxycodone

For a patient being discharged home after a sleeve gastrectomy, I would typically prescribe: (circle only one)

Only non-opioid pain medications

0-10 tablets of 5mg Oxycodone

11-20 tablets of 5mg Oxycodone

21-30 tablets of 5mg Oxycodone

31-40 tablets of 5mg Oxycodone

41-50 tablets of 5mg Oxycodone

Over 50 tablets of 5mg Oxycodone

For a patient being discharged home after a laparoscopic cholecystectomy, I would typically prescribe: (circle only one)

0-5 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

0-20 tablets of 5mg Oxycodone

0-25 tablets of 5mg Oxycodone

Over 25 tablets of 5mg Oxycodone

For a patient being discharged home after a laparoscopic Nissen fundoplication, I would typically prescribe: (circle only one)

0-5 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

0-20 tablets of 5mg Oxycodone

0-25 tablets of 5mg Oxycodone

Over 25 tablets of 5mg Oxycodone

For a patient being discharged home after an open small bowel resection, I would typically prescribe: (circle only one)

0-5 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

0-20 tablets of 5mg Oxycodone

0-25 tablets of 5mg Oxycodone

Over 25 tablets of 5mg Oxycodone

For a patient being discharged home after an open colectomy, I would typically prescribe: (circle only one)

0-5 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

0-20 tablets of 5mg Oxycodone

0-25 tablets of 5mg Oxycodone

Over 25 tablets of 5mg Oxycodone

For a patient being discharged home after a major hernia repair, I would typically prescribe: (circle only one)

0-5 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

0-20 tablets of 5mg Oxycodone

0-25 tablets of 5mg Oxycodone

Over 25 tablets of 5mg Oxycodone

For patients experiencing mild pain, I usually initially prescribe (circle one)

NSAIDs

Tylenol

Opioid

For patients experiencing moderate pain, I usually initially prescribe

(circle one)

NSAIDs

Tylenol

Opioid

For patients experiencing severe pain, I usually initially prescribe

(circle only one)

NSAID

Tylenol

Opioid

Table 7

Internal medicine pre-test

PGY: post-graduate year; DEA: Drug Enforcement Administration; PDMP: prescription drug monitoring program; PA: Pennsylvania; NSAID: non-steroidal anti-inflammatory drug

Internal medicine resident knowledge and attitudes pre-test

Resident background

Please select your current level of training:

PGY1

PGY2

PGY3

Do you hold a DEA License?

Yes

No

How satisfied are you with your current level of opioid-prescribing training?

Very satisfied

Satisfied

Neutral

Unsatisfied

Very unsatisfied

When did you receive your opioid-prescribing training? (Select all that apply)

College

Medical School

Residency

Personal reading

Never received any formal training

For the following questions, answer as if you are the prescriber even if you do not currently hold a DEA license. Select only ONE answer unless specified otherwise.

General opioid knowledge

Which three states have the highest percentage of opioid-related deaths per capita: (circle 3 states)

Alabama

California

Kentucky

New York

Ohio

Pennsylvania

South Carolina

West Virginia

In 2017, how many drug overdose deaths were due to opioids?

15,000

25,000

45,000

75,000

In 2017, how many deaths were a result of heroin overdose?

15,000

25,000

45,000

75,000

Nearly half of all opioid related overdoses are due to valid prescription opioids.

True False

What is the PDMP?

Physician Drug Medical Plan

Prescribing Directory of Medical Providers

Prescription Drug Monitoring Program

Planned Drug Movement Plan

How often should the PDMP be referenced?

Once a day

Once a month

Once a year

Anytime an opioid prescription is given.

Resident attitudes

Opioids are effective in pain management.

Strongly agree

Agree

Undecided

Disagree

Strongly disagree

Every patient that presents to the office with pain should receive opioids.

Strongly agree

Agree

Undecided

Disagree

Strongly disagree

I feel comfortable in my knowledge of non-opioid pain management.

Strongly agree

Agree

Undecided

Disagree

Strongly disagree

If I suspect someone is abusing opioids, I do not prescribe opioids to them.

Strongly agree

Agree

Undecided

Disagree

Strongly disagree

Patient gender may affect my judgement of a patient's pain intensity

Strongly agree

Agree

Undecided

Disagree

Strongly disagree

Patient race may affect my judgement of a patient's pain intensity

Strongly agree

Agree

Undecided

Disagree

Strongly disagree

If a patient presents to the ED repeatedly asking for more pain medication, this could be due to a missed diagnosis of the underlying pain source.

Strongly agree

Agree

Undecided

Disagree

Strongly disagree

I ask my patients about the severity of their pain.

Strongly agree

Agree

Undecided

Disagree

Strongly disagree

I include patient-reported pain levels in my notes.

Strongly agree

Agree

Undecided

Disagree

Strongly disagree

I think that proper pain management is associated with better patient outcomes.

Strongly agree

Agree

Undecided

Disagree

Strongly disagree

Case-based scenarios

For an adult presenting with chronic low back pain, I would initially prescribe: (circle only one)

NSAIDs

Tramadol

Duloxetine

Oxycodone

A 25-year-old female presents to the office with an acute episodic migraine According to the American Headache Society 2015 Guidelines, what treatment has Level A evidence?

Chlorpromazine IV 12.5 mg

Celecoxib 400 mg

Codeine/acetaminophen 25/400 mg

Naratriptan 2.5 mg

Codeine 30 mg

A 65-year-old man returns to the clinic for joint pain in his knees. He has a history of osteoarthritis and states that it is difficult for him to complete daily tasks. His pain was not treated by NSAIDs or weight loss. What should be the next line of treatment?

0-10 tablets of 5mg Tramadol

0-10 tablets of 5mg Oxycodone

Acetaminophen

Exercise

Continue NSAIDS and weight loss therapy

A 35-year-old male presents to the office with nephrolithiasis. His eGFR is >90ml/min and he has no history of GI bleed. How would you initially treat his pain?

No pain medication

NSAIDS

0-10 tablets of 5mg Oxycodone

For patients experiencing mild pain, I usually initially prescribe (circle one)

NSAIDs

Tylenol

Opioid

For patients experiencing moderate pain, I usually initially prescribe

(circle one)

NSAIDs

Tylenol

Opioid

For patients experiencing severe pain, I usually initially prescribe

(circle only one)

NSAID

Tylenol

Opioid

Table 8

EM resident pre-test data

PGY: post-graduate year; DEA: Drug Enforcement Administration; PDMP: prescription drug monitoring program; PA: Pennsylvania; NSAID: non-steroidal anti-inflammatory drug; EM: emergency medicine

1. Please select your current level of training:

2. Do you hold a DEA License?

3. How satisfied are you with your current level of opioid-prescribing training?

4. When did you receive your opioid-prescribing training? (Select all that apply)

5. What are the three most common chief complaints for adults in the ED that were discharged with opioids? (select three)

6. Which three states have the highest percentage of opioid-related deaths per capita:  (circle 3 states)

7. In 2017, how many drug overdose deaths were due to opioids?

8. In 2017, how many deaths were a result of heroin overdose?

9. Nearly half of all opioid related overdoses are due to valid prescription opioids.

10. What is the PDMP?

11. How often should the PDMP be referenced?

12. For an adult patient that presents to the emergency room with acute pain, according to current PA state guidelines, what is the maximum duration (days) for which an opioid prescription should be given?

13. When prescribing opioids to a minor, according to current PA state guidelines, the provider should:

14. For an adult presenting with noncancer pain, what should be the first course of action prior to formulating a pain control plan?  (circle only one)

15. For an adult presenting to the ED with acute low back pain, I would typically prescribe: (circle only one)

16. A 25-year-old female presents to the office with an acute episodic migraine According to the American Headache Society 2015 Guidelines, what treatment has Level A evidence?

17. A 30-year-old male who actively uses IV heroin presents to the ED for a localized skin infection. After several hours, he begins to complain of anxiety and GI upset. You suspect opioid withdrawal and calculate his Clinical Opiate Withdrawal Score (COWS), which at 30 is rated “moderately severe”. How would you treat his current withdrawal symptoms?

18. For patients experiencing mild pain, I initially prescribe (circle one)

19. For patients experiencing moderate pain, I initially prescribe (circle one)

20. For patients experiencing severe pain, I initially prescribe  (circle only one)

21. Opioids are effective in pain management.

22. Every patient that presents to the ED with pain should receive opioids.

23. I feel comfortable in my knowledge of non-opioid pain management.

24. If I suspect someone is abusing drugs, I will not prescribe them short-acting opioids.

25. Patient gender may affect my judgement of a patient's pain intensity

26. Patient race may affect my judgement of a patient's pain intensity

27. If a patient presents to the ED repeatedly asking for more pain medication, this could be due to a missed diagnosis of the underlying pain source.

28. I ask my patients about the severity of their pain.

29. I include patient-reported pain levels in my notes.

PGY2

No

Neutral

Medical School, Residency

Urolithiasis, Back pain

Kentucky, Pennsylvania, West Virginia

25,000

45,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

7 days

All of the above

Consult the state monitoring program (PDMP)

Only non-opioid pain medications

Chlorpromazine IV 12.5 mg

Extended-release oxycodone

NSAIDs

NSAIDs

Opioid

Agree

Disagree

Agree

Agree

Agree

Agree

Undecided

Agree

Undecided

PGY2

No

Neutral

Never received any formal training

Headache, Abdominal pain, Back pain

California, New York, Pennsylvania

75,000

25,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

7 days

All of the above

Short acting opioids

Only non-opioid pain medications

Chlorpromazine IV 12.5 mg

Buprenorphine-naloxone to bridge him to outpatient treatment

NSAIDs

NSAIDs

NSAID

Agree

Strongly disagree

Agree

Agree

Disagree

Disagree

Agree

Strongly agree

Strongly agree

PGY2

No

Very satisfied

Medical School, Residency, Personal reading

Headache, Abdominal pain, Back pain

New York, Pennsylvania, West Virginia

25,000

45,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

3 days

All of the above

Consult the state monitoring program (PDMP)

Only non-opioid pain medications

Chlorpromazine IV 12.5 mg

Buprenorphine-naloxone to bridge him to outpatient treatment

NSAIDs

NSAIDs

NSAID

Disagree

Strongly disagree

Strongly agree

Agree

Agree

Agree

Agree

Strongly disagree

Strongly disagree

PGY1

No

Neutral

Residency

Dental pain, Urolithiasis

Alabama, Pennsylvania, West Virginia

45,000

45,000

FALSE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

7 days

All of the above

Consult the state monitoring program (PDMP)

Only non-opioid pain medications

Chlorpromazine IV 12.5 mg

Buprenorphine-naloxone to bridge him to outpatient treatment

Tylenol

NSAIDs

Opioid

Agree

Disagree

Strongly disagree

Agree

Disagree

Disagree

Agree

Agree

Agree

PGY3

No

Unsatisfied

Residency, Personal reading

Dental pain, Urolithiasis, Back pain

Alabama, Kentucky, West Virginia

45,000

25,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

7 days

All of the above

Only non-opioid pain medications

Only non-opioid pain medications

Celecoxib 400 mg

Buprenorphine-naloxone to bridge him to outpatient treatment

Tylenol

Tylenol

Opioid

Agree

Strongly disagree

Undecided

Disagree

Disagree

Disagree

Agree

Agree

Undecided

PGY1

No

Unsatisfied

Medical School, Residency

Dental pain, Urolithiasis, Back pain

Kentucky, South Carolina, West Virginia

75,000

45,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

14 days

All of the above

Only non-opioid pain medications

Only non-opioid pain medications

Chlorpromazine IV 12.5 mg

Buprenorphine-naloxone to bridge him to outpatient treatment

Tylenol

Tylenol

Opioid

Agree

Undecided

Undecided

Disagree

Agree

Strongly agree

Agree

Agree

Agree

PGY3

No

Neutral

Medical School, Residency, Personal reading

Dental pain, Abdominal pain, Back pain

Alabama, Kentucky, West Virginia

75,000

45,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

3 days

All of the above

Only non-opioid pain medications

Only non-opioid pain medications

Codeine/acetaminophen 25/400 mg

Buprenorphine-naloxone to bridge him to outpatient treatment

Tylenol

NSAIDs

Opioid

Agree

Disagree

Agree

Undecided

Agree

Agree

Agree

Agree

Undecided

PGY2

No

Satisfied

Medical School, Residency, Personal reading

Dental pain, Urolithiasis, Back pain

Kentucky, Pennsylvania, West Virginia

45,000

25,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

3 days

All of the above

Consult the state monitoring program (PDMP)

Only non-opioid pain medications

Naratriptan 2.5 mg

Buprenorphine-naloxone to bridge him to outpatient treatment

NSAIDs

NSAIDs

Opioid

Agree

Strongly disagree

Agree

Agree

Disagree

Disagree

Agree

Agree

Agree

PGY3

No

Satisfied

Residency

Dental pain, Urolithiasis, Back pain

Alabama, Kentucky, West Virginia

25,000

45,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

3 days

All of the above

Only non-opioid pain medications

Only non-opioid pain medications

Naratriptan 2.5 mg

Buprenorphine-naloxone to bridge him to outpatient treatment

Tylenol

NSAIDs

NSAID

Undecided

Strongly disagree

Agree

Agree

Disagree

Disagree

Agree

Disagree

Undecided

PGY3

No

Satisfied

Personal reading

Dental pain, Urolithiasis, Back pain

Delaware, Pennsylvania, West Virginia

75,000

25,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

3 days

All of the above

Consult the state monitoring program (PDMP)

Only non-opioid pain medications

Chlorpromazine IV 12.5 mg

Buprenorphine-naloxone to bridge him to outpatient treatment

NSAIDs

NSAIDs

Opioid

Agree

Disagree

Agree

Strongly agree

Strongly disagree

Strongly disagree

Agree

Strongly agree

Agree

PGY2

No

Very satisfied

Medical School, Residency

Dental pain, Urolithiasis, Back pain

Kentucky, Pennsylvania, West Virginia

45,000

45,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

3 days

All of the above

Consult the state monitoring program (PDMP)

Only non-opioid pain medications

Naratriptan 2.5 mg

Oral morphine

NSAIDs

NSAIDs

NSAID

Strongly agree

Strongly disagree

Agree

Strongly disagree

Strongly agree

Strongly agree

Strongly agree

Strongly disagree

Strongly disagree

PGY2

No

Unsatisfied

Medical School, Residency

Back pain

California, New York, Pennsylvania

25,000

45,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

3 days

All of the above

Only non-opioid pain medications

Only non-opioid pain medications

Celecoxib 400 mg

Buprenorphine-naloxone to bridge him to outpatient treatment

Tylenol

NSAIDs

NSAID

Strongly agree

Disagree

Strongly agree

Strongly agree

Strongly disagree

Strongly disagree

Agree

Strongly agree

Agree

PGY3

No

Satisfied

Medical School, Residency

Urolithiasis

Kentucky, Pennsylvania, West Virginia

45,000

45,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

3 days

All of the above

Only non-opioid pain medications

Only non-opioid pain medications

Chlorpromazine IV 12.5 mg

Buprenorphine-naloxone to bridge him to outpatient treatment

NSAIDs

NSAIDs

Opioid

Agree

Strongly disagree

Agree

Agree

Strongly disagree

Strongly disagree

Agree

Strongly agree

Agree

PGY3

No

Neutral

Medical School, Residency

Dental pain, Urolithiasis, Back pain

Alabama, Pennsylvania, South Carolina

45,000

15,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

No limit

All of the above

Consult the state monitoring program (PDMP)

Only non-opioid pain medications

Chlorpromazine IV 12.5 mg

Buprenorphine-naloxone to bridge him to outpatient treatment

Tylenol

NSAIDs

NSAID

Disagree

Strongly disagree

Undecided

Strongly agree

Strongly disagree

Strongly disagree

Agree

Agree

Undecided

PGY1

No

Satisfied

Medical School, Residency, Personal reading

Dental pain, Urolithiasis, Back pain

Kentucky, Pennsylvania, West Virginia

75,000

45,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

3 days

All of the above

Only non-opioid pain medications

Only non-opioid pain medications

Naratriptan 2.5 mg

Buprenorphine-naloxone to bridge him to outpatient treatment

Tylenol

NSAIDs

Opioid

Strongly agree

Strongly disagree

Agree

Undecided

Strongly disagree

Strongly disagree

Agree

Strongly agree

Strongly agree

PGY1

No

Very unsatisfied

Personal reading

Dental pain, Abdominal pain, Urolithiasis

California, Pennsylvania, West Virginia

45,000

75,000

FALSE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

3 days

All of the above

Extended-released schedule II products

Only non-opioid pain medications

Chlorpromazine IV 12.5 mg

Oral morphine

Tylenol

Tylenol

Tylenol

Agree

Strongly disagree

Disagree

Disagree

Agree

Agree

Undecided

Strongly agree

Agree

PGY2

No

Neutral

Residency

Dental pain, Urolithiasis, Back pain

Kentucky, Pennsylvania, West Virginia

25,000

25,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

1 day

All of the above

Only non-opioid pain medications

Only non-opioid pain medications

Celecoxib 400 mg

Buprenorphine-naloxone to bridge him to outpatient treatment

NSAIDs

NSAIDs

NSAID

Agree

Disagree

Undecided

Strongly agree

Undecided

Undecided

Agree

Agree

Agree

PGY1

No

Neutral

Medical School

Dental pain, Abdominal pain, Back pain

Alabama, Pennsylvania, West Virginia

45,000

25,000

FALSE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

7 days

All of the above

Only non-opioid pain medications

Only non-opioid pain medications

Chlorpromazine IV 12.5 mg

Buprenorphine-naloxone to bridge him to outpatient treatment

Tylenol

NSAIDs

Opioid

Agree

Strongly disagree

Agree

Agree

Strongly disagree

Strongly disagree

Agree

Agree

Agree

PGY1

No

Neutral

Residency

Back pain

New York, Delaware, Pennsylvania

75,000

45,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

3 days

All of the above

Only non-opioid pain medications

Only non-opioid pain medications

Celecoxib 400 mg

Buprenorphine-naloxone to bridge him to outpatient treatment

Tylenol

Tylenol

Tylenol

Strongly agree

Strongly disagree

Strongly agree

Strongly agree

Strongly disagree

Strongly disagree

Disagree

Strongly agree

Strongly agree

PGY1

No

Satisfied

Medical School, Residency, Personal reading

Dental pain, Abdominal pain, Urolithiasis

Delaware, Pennsylvania, West Virginia

75,000

75,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

3 days

All of the above

Only non-opioid pain medications

Only non-opioid pain medications

Celecoxib 400 mg

Buprenorphine-naloxone to bridge him to outpatient treatment

Tylenol

NSAIDs

Opioid

Agree

Strongly disagree

Agree

Agree

Disagree

Disagree

Agree

Agree

Agree

PGY3

No

Neutral

Residency

Dental pain, Urolithiasis, Back pain

Kentucky, Pennsylvania, West Virginia

25,000

45,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

3 days

All of the above

Only non-opioid pain medications

31-40 tablets of 5mg Oxycodone + NSAID

Chlorpromazine IV 12.5 mg

Buprenorphine-naloxone to bridge him to outpatient treatment

NSAIDs

NSAIDs

Opioid

Agree

Disagree

Undecided

Disagree

Strongly disagree

Strongly disagree

Agree

Agree

Undecided

PGY1

No

Neutral

Never received any formal training

Abdominal pain, Urolithiasis, Back pain

Alabama, Kentucky, West Virginia

75,000

45,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

7 days

All of the above

Only non-opioid pain medications

Only non-opioid pain medications

Chlorpromazine IV 12.5 mg

Buprenorphine-naloxone to bridge him to outpatient treatment

NSAIDs

NSAIDs

Opioid

Agree

Strongly disagree

Agree

Agree

Strongly disagree

Strongly disagree

Agree

Strongly agree

Strongly agree

PGY3

No

Satisfied

Medical School, Residency, Personal reading

Abdominal pain, Urolithiasis, Back pain

Delaware, Pennsylvania, West Virginia

75,000

45,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

3 days

All of the above

Consult the state monitoring program (PDMP)

Only non-opioid pain medications

Celecoxib 400 mg

Buprenorphine-naloxone to bridge him to outpatient treatment

Tylenol

NSAIDs

Opioid

Agree

Strongly disagree

Agree

Agree

Disagree

Disagree

Agree

Agree

Agree

PGY3

No

Very satisfied

Residency

Dental pain, Abdominal pain, Back pain

California, Pennsylvania, South Carolina

75,000

25,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

3 days

All of the above

Only non-opioid pain medications

Only non-opioid pain medications

Chlorpromazine IV 12.5 mg

Buprenorphine-naloxone to bridge him to outpatient treatment

Tylenol

NSAIDs

Opioid

Agree

Disagree

Agree

Agree

Strongly disagree

Strongly disagree

Agree

Undecided

Agree

PGY2

No

Neutral

Medical School, Residency

Dental pain, Urolithiasis, Back pain

Delaware, Pennsylvania, West Virginia

75,000

45,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

No limit

All of the above

Consult the state monitoring program (PDMP)

Only non-opioid pain medications

Chlorpromazine IV 12.5 mg

Buprenorphine-naloxone to bridge him to outpatient treatment

NSAIDs

NSAIDs

Opioid

Agree

Strongly disagree

Agree

Strongly agree

Agree

Agree

Strongly agree

Strongly agree

Agree

PGY3

No

Satisfied

Medical School, Residency, Personal reading

Dental pain, Urolithiasis, Back pain

Kentucky, Pennsylvania, West Virginia

45,000

25,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

3 days

All of the above

Consult the state monitoring program (PDMP)

Only non-opioid pain medications

Chlorpromazine IV 12.5 mg

Buprenorphine-naloxone to bridge him to outpatient treatment

Tylenol

NSAIDs

Opioid

Strongly agree

Strongly disagree

Strongly agree

Strongly agree

Agree

Agree

Agree

Agree

Agree

PGY3

No

Very satisfied

Medical School, Residency

Urolithiasis

75,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

3 days

All of the above

Consult the state monitoring program (PDMP)

Only non-opioid pain medications

Chlorpromazine IV 12.5 mg

Buprenorphine-naloxone to bridge him to outpatient treatment

Tylenol

Tylenol

Tylenol

Strongly agree

Strongly disagree

Strongly agree

Strongly disagree

Strongly disagree

Strongly disagree

Agree

Agree

Agree

Table 9

EM resident post-test data

PGY: post-graduate year; DEA: Drug Enforcement Administration; PDMP: prescription drug monitoring program; PA: Pennsylvania; NSAID: non-steroidal anti-inflammatory drug; EM: emergency medicine

1. Please select your current level of training:

2. Do you hold a DEA License?

3. How satisfied are you with your current level of opioid-prescribing training?

4. When did you receive your opioid-prescribing training? (Select all that apply)

5. What are the three most common chief complaints for adults in the ED that were discharged with opioids? (select three)

6. Which three states have the highest percentage of opioid-related deaths per capita:  (circle 3 states)

7. In 2017, how many drug overdose deaths were due to opioids?

8. In 2017, how many deaths were a result of heroin overdose?

9. Nearly half of all opioid related overdoses are due to valid prescription opioids.

10. What is the PDMP?

11. How often should the PDMP be referenced?

12. For an adult patient that presents to the emergency room with acute pain, according to current PA state guidelines, what is the maximum duration (days) for which an opioid prescription should be given?

13. When prescribing opioids to a minor, according to current PA state guidelines, the provider should:

14. For an adult presenting with noncancer pain, what should be the first course of action prior to formulating a pain control plan?  (circle only one)

15. For an adult presenting to the ED with acute low back pain, I would typically prescribe: (circle only one)

16. A 25-year-old female presents to the office with an acute episodic migraine According to the American Headache Society 2015 Guidelines, what treatment has Level A evidence?

17. A 30-year-old male who actively uses IV heroin presents to the ED for a localized skin infection. After several hours, he begins to complain of anxiety and GI upset. You suspect opioid withdrawal and calculate his Clinical Opiate Withdrawal Score (COWS), which at 30 is rated “moderately severe”. How would you treat his current withdrawal symptoms?

18. For patients experiencing mild pain, I initially prescribe (circle one)

19. For patients experiencing moderate pain, I initially prescribe (circle one)

20. For patients experiencing severe pain, I initially prescribe  (circle only one)

21. Opioids are effective in pain management.

22. Every patient that presents to the ED with pain should receive opioids.

23. I feel comfortable in my knowledge of non-opioid pain management.

24. If I suspect someone is abusing drugs, I will not prescribe them short-acting opioids.

25. Patient gender may affect my judgement of a patient's pain intensity

26. Patient race may affect my judgement of a patient's pain intensity

27. If a patient presents to the ED repeatedly asking for more pain medication, this could be due to a missed diagnosis of the underlying pain source.

28. I ask my patients about the severity of their pain.

29. I include patient-reported pain levels in my notes.

PGY2

No

Satisfied

Medical School, Residency

Dental pain, Urolithiasis, Back pain

Delaware, Pennsylvania, West Virginia

75,000

45,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

7 days

All of the above

Consult the state monitoring program (PDMP)

Only non-opioid pain medications

Chlorpromazine IV 12.5 mg

NSAIDs

NSAIDs

NSAIDs

Opioid

Agree

Strongly disagree

Agree

Strongly agree

Agree

Agree

Strongly agree

Agree

Agree

PGY3

No

Very satisfied

Residency

Urolithiasis

Kentucky, Pennsylvania, West Virginia

75,000

25,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

3 days

All of the above

Only non-opioid pain medications

Only non-opioid pain medications

Chlorpromazine IV 12.5 mg

Buprenorphine-naloxone to bridge him to outpatient treatment

Tylenol

Tylenol

Tylenol

Strongly agree

Strongly disagree

Strongly agree

Disagree

Strongly disagree

Strongly disagree

Agree

Agree

Agree

PGY3

No

Very satisfied

Residency

Urolithiasis

Kentucky, Pennsylvania, West Virginia

75,000

25,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

3 days

All of the above

Only non-opioid pain medications

Only non-opioid pain medications

Chlorpromazine IV 12.5 mg

Buprenorphine-naloxone to bridge him to outpatient treatment

Tylenol

Tylenol

Tylenol

Strongly agree

Strongly disagree

Strongly agree

Disagree

Strongly disagree

Strongly disagree

Agree

Agree

Agree

PGY1

No

Satisfied

Medical School, Residency, Personal reading

Dental pain, Urolithiasis, Back pain

Kentucky, Delaware, Pennsylvania, West Virginia

75,000

15,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

3 days

All of the above

Only non-opioid pain medications

Only non-opioid pain medications

Naratriptan 2.5 mg

Buprenorphine-naloxone to bridge him to outpatient treatment

Tylenol

NSAIDs

Opioid

Agree

Strongly disagree

Agree

Undecided

Strongly disagree

Strongly disagree

Strongly agree

Strongly agree

Strongly agree

PGY3

No

Satisfied

Medical School, Residency, Personal reading

Dental pain, Abdominal pain, Urolithiasis

Delaware, Pennsylvania, West Virginia

75,000

45,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

7 days

All of the above

Consult the state monitoring program (PDMP)

0-10 tablets of 5mg Oxycodone + NSAID

Naratriptan 2.5 mg

Buprenorphine-naloxone to bridge him to outpatient treatment

Tylenol

NSAIDs

Opioid

Agree

Strongly disagree

Agree

Disagree

Disagree

Disagree

Agree

Agree

Agree

PGY2

No

Satisfied

Medical School, Residency

Abdominal pain, Urolithiasis, Back pain

California, New York, Pennsylvania

75,000

15,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

7 days

All of the above

Consult the state monitoring program (PDMP)

Only non-opioid pain medications

Naratriptan 2.5 mg

Buprenorphine-naloxone to bridge him to outpatient treatment

Tylenol

NSAIDs

Opioid

Strongly agree

Strongly disagree

Agree

Strongly agree

Disagree

Disagree

Agree

Strongly agree

Strongly agree

PGY1

No

Neutral

Medical School, Residency, Personal reading

Abdominal pain

California, South Carolina, West Virginia

25,000

15,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

3 days

All of the above

Only non-opioid pain medications

Only non-opioid pain medications

Naratriptan 2.5 mg

Buprenorphine-naloxone to bridge him to outpatient treatment

Tylenol

NSAIDs

Opioid

Strongly agree

Disagree

Agree

Disagree

Disagree

Disagree

Agree

Agree

Agree

PGY1

No

Neutral

Residency

Dental pain, Urolithiasis, Back pain

New York, Delaware, Pennsylvania

45,000

15,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

3 days

All of the above

Consult the state monitoring program (PDMP)

Only non-opioid pain medications

Chlorpromazine IV 12.5 mg

Buprenorphine-naloxone to bridge him to outpatient treatment

Tylenol

Tylenol

NSAID

Strongly agree

Strongly disagree

Undecided

Undecided

Undecided

Undecided

Agree

Agree

Agree

PGY3

No

Satisfied

Residency

Dental pain, Urolithiasis, Back pain

California, New York, Pennsylvania

45,000

25,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

3 days

All of the above

Only non-opioid pain medications

Only non-opioid pain medications

Celecoxib 400 mg

Buprenorphine-naloxone to bridge him to outpatient treatment

Tylenol

NSAIDs

Opioid

Agree

Strongly disagree

Agree

Agree

Strongly agree

Strongly agree

Agree

Disagree

Disagree

PGY1

Neutral

College

Abdominal pain

California, Kentucky, New York

15,000

25,000

FALSE

Prescribing Directory of Medical Providers

Anytime an opioid prescription is given.

3 days

All of the above

Short acting opioids

0-10 tablets of 5mg Oxycodone + NSAID

Codeine/acetaminophen 25/400 mg

Tylenol

Tylenol

Tylenol

Tylenol

Agree

Agree

Undecided

Undecided

Undecided

Undecided

Undecided

Undecided

Undecided

PGY1

No

Neutral

Never received any formal training

Dental pain, Abdominal pain, Urolithiasis

Kentucky, Pennsylvania, West Virginia

75,000

45,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

3 days

All of the above

Only non-opioid pain medications

Only non-opioid pain medications

Chlorpromazine IV 12.5 mg

Tylenol

NSAIDs

NSAIDs

Opioid

Strongly agree

Disagree

Disagree

Agree

Disagree

Disagree

Agree

Agree

Agree

PGY3

No

Satisfied

Medical School, Residency

Chest pain, Abdominal pain, Back pain

Kentucky, Delaware, Pennsylvania

25,000

25,000

FALSE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

3 days

All of the above

Only non-opioid pain medications

Only non-opioid pain medications

Chlorpromazine IV 12.5 mg

Buprenorphine-naloxone to bridge him to outpatient treatment

NSAIDs

NSAIDs

Opioid

Agree

Strongly disagree

Strongly agree

Undecided

Strongly disagree

Strongly disagree

Agree

Strongly agree

Agree

PGY3

No

Neutral

Residency

Dental pain, Urolithiasis, Back pain

Kentucky, Pennsylvania, West Virginia

45,000

25,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

7 days

All of the above

Only non-opioid pain medications

Only non-opioid pain medications

Naratriptan 2.5 mg

Buprenorphine-naloxone to bridge him to outpatient treatment

NSAIDs

Tylenol

Opioid

Strongly agree

Strongly disagree

Agree

Disagree

Agree

Agree

Agree

Strongly agree

Agree

Table 10

IM resident pre-test data

PGY: post-graduate year; DEA: Drug Enforcement Administration; PDMP: prescription drug monitoring program; PA: Pennsylvania; NSAID: non-steroidal anti-inflammatory drug; IM: internal medicine

1. Please select your current level of training:

2. Do you hold a DEA License?

3. How satisfied are you with your current level of opioid-prescribing training?

4. When did you receive your opioid-prescribing training? (Select all that apply)

5. Which three states have the highest percentage of opioid-related deaths per capita:(circle 3 states)

6. In 2017, how many drug overdose deaths were due to opioids?

7. In 2017, how many deaths were a result of heroin overdose?

8. Nearly half of all opioid related overdoses are due to valid prescription opioids.

9. What is the PDMP?

10. How often should the PDMP be referenced?

11. Opioids are effective in pain management.

12. Every patient that presents to the office with pain should receive opioids.

13. I feel comfortable in my knowledge of non-opioid pain management.

14. If I suspect someone is abusing opioids, I do not prescribe opioids to them.

15. Patient gender may affect my judgement of a patient's pain intensity

16. Patient race may affect my judgement of a patient's pain intensity

17. If a patient presents to the ED repeatedly asking for more pain medication, this could be due to a missed diagnosis of the underlying pain source.

17. If a patient presents to the ED repeatedly asking for more pain medication, this could be due to a missed diagnosis of the underlying pain source.

18. I ask my patients about the severity of their pain.

19. I include patient-reported pain levels in my notes.

20. I think that proper pain management is associated with better patient outcomes.

21. For an adult presenting with chronic low back pain, I would initially prescribe: (circle only one)

22. A 25-year-old female presents to the office with an acute episodic migraine According to the American Headache Society 2015 Guidelines, what treatment has Level A evidence?

23. A 65-year-old man returns to the clinic for joint pain in his knees. He has a history of osteoarthritis and states that it is difficult for him to complete daily tasks. His pain was not treated by NSAIDs or weight loss. What should be the next line of treatment?

24. A 35-year-old male presents to the office with nephrolithiasis. His eGFR is >90ml/min and he has no history of GI bleed. How would you initially treat his pain?

25. For patients experiencing mild pain, I usually initially prescribe (circle one)

26. For patients experiencing moderate pain, I usually initially prescribe (circle one)

27. For patients experiencing severe pain, I usually initially prescribe (circle only one)

PGY3

No

Unsatisfied

Never received any formal training

Alabama, Kentucky, West Virginia

75,000

45,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Strongly agree

Strongly disagree

Agree

Agree

Disagree

Disagree

Agree

Agree

Agree

Agree

NSAIDs

Celecoxib 400 mg

Continue NSAIDS and weight loss therapy

NSAIDS

Tylenol

Tylenol

Opioid

PGY2

No

Neutral

Never received any formal training

California, New York, Pennsylvania

75,000

45,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Undecided

Strongly disagree

Disagree

Agree

Disagree

Disagree

Agree

Agree

Agree

Agree

NSAIDs

Naratriptan 2.5 mg

0-10 tablets of 5mg Tramadol

0-10 tablets of 5mg Oxycodone

Tylenol

Tylenol

Opioid

PGY3

No

Very satisfied

Medical School, Residency, Personal reading

Alabama, Pennsylvania, West Virginia

75,000

45,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Undecided

Strongly disagree

Strongly agree

Agree

Disagree

Strongly disagree

Strongly agree

Strongly agree

Strongly agree

Strongly agree

NSAIDs

Chlorpromazine IV 12.5 mg

Continue NSAIDS and weight loss therapy

NSAIDS

Tylenol

NSAIDs

NSAIDs

PGY1

No

Unsatisfied

Medical School, Residency

Kentucky, New York, Pennsylvania

45,000

45,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Strongly agree

Strongly disagree

Disagree

Agree

Agree

Agree

Agree

Strongly agree

Strongly agree

Strongly agree

NSAIDs

Celecoxib 400 mg

Acetaminophen

NSAIDS

Tylenol

Tylenol

Opioid

PGY3

No

Neutral

Residency

California, Pennsylvania, West Virginia

45,000

25,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Agree

Disagree

Agree

Strongly agree

Disagree

Strongly disagree

Agree

Agree

Undecided

Agree

NSAIDs

Naratriptan 2.5 mg

Acetaminophen

NSAIDS

Tylenol

Tylenol

Opioid

PGY3

No

Very satisfied

Medical School, Residency, Personal reading

Kentucky, South Carolina, West Virginia

45,000

45,000

TRUE

Prescribing Directory of Medical Providers

Anytime an opioid prescription is given.

Disagree

Strongly disagree

Strongly agree

Agree

Agree

Agree

Agree

Agree

Disagree

Strongly agree

NSAIDs

Celecoxib 400 mg

Continue NSAIDS and weight loss therapy

NSAIDS

Tylenol

NSAIDs

Opioid

PGY3

No

Satisfied

Residency

New York, Delaware, Pennsylvania

75,000

45,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Strongly agree

Strongly disagree

Agree

Agree

Disagree

Disagree

Agree

Agree

Disagree

Agree

NSAIDs

Celecoxib 400 mg

Acetaminophen

NSAIDS

Tylenol

Tylenol

Tylenol

PGY3

No

Unsatisfied

Medical School, Residency, Personal reading

Pennsylvania, South Carolina, West Virginia

45,000

15,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Agree

Strongly disagree

Agree

Agree

Agree

Undecided

Agree

Agree

Agree

Strongly agree

NSAIDs

Naratriptan 2.5 mg

Exercise

NSAIDS

Tylenol

NSAIDs

Opioid

PGY2

No

Neutral

Medical School, Residency

Kentucky, Pennsylvania, West Virginia

75,000

45,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Strongly agree

Strongly disagree

Agree

Agree

Strongly disagree

Strongly disagree

Agree

Agree

Agree

Agree

NSAIDs

Naratriptan 2.5 mg

Acetaminophen

NSAIDS

NSAIDs

NSAIDs

Opioid

PGY2

No

Very unsatisfied

Medical School

California, New York, Pennsylvania

75,000

25,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Strongly disagree

Strongly disagree

Agree

Strongly disagree

Strongly disagree

Strongly disagree

Strongly agree

Strongly agree

Strongly agree

Strongly agree

NSAIDs

Chlorpromazine IV 12.5 mg

Acetaminophen

NSAIDS

NSAIDs

NSAIDs

NSAIDs

PGY2

No

Unsatisfied

Residency

California, Pennsylvania, West Virginia

25,000

45,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Agree

Strongly disagree

Agree

Agree

Agree

Agree

Agree

Agree

Agree

Strongly agree

NSAIDs

Naratriptan 2.5 mg

Exercise

NSAIDS

NSAIDs

NSAIDs

NSAIDs

PGY3

Yes

Neutral

Residency

New York, Pennsylvania, West Virginia

75,000

75,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Undecided

Disagree

Agree

Agree

Agree

Undecided

Agree

Agree

Agree

Agree

NSAIDs

Naratriptan 2.5 mg

Continue NSAIDS and weight loss therapy

0-10 tablets of 5mg Oxycodone

Tylenol

NSAIDs

Opioid

PGY1

No

Unsatisfied

Medical School

Kentucky, Pennsylvania, West Virginia

25,000

15,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Agree

Strongly disagree

Agree

Agree

Agree

Agree

Agree

Agree

Agree

Agree

NSAIDs

Celecoxib 400 mg

Continue NSAIDS and weight loss therapy

NSAIDS

Tylenol

NSAIDs

Opioid

PGY3

No

Satisfied

Medical School, Residency, Personal reading

Delaware, Pennsylvania, West Virginia

75,000

45,000

FALSE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Agree

Strongly disagree

Agree

Strongly agree

Agree

Agree

Agree

Strongly agree

Strongly agree

Strongly agree

NSAIDs

Chlorpromazine IV 12.5 mg

0-10 tablets of 5mg Tramadol

NSAIDS

Tylenol

NSAIDs

Tylenol

PGY1

No

Neutral

Medical School

California, Kentucky, West Virginia

75,000

45,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Agree

Strongly disagree

Agree

Disagree

Disagree

Strongly disagree

Strongly agree

Strongly agree

Strongly agree

Strongly agree

NSAIDs

Naratriptan 2.5 mg

Continue NSAIDS and weight loss therapy

0-10 tablets of 5mg Oxycodone

Tylenol

Tylenol

Tylenol

PGY2

No

Unsatisfied

Residency

California, New York, Pennsylvania

75,000

75,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Agree

Strongly disagree

Agree

Strongly agree

Agree

Agree

Undecided

Agree

Agree

Agree

NSAIDs

Celecoxib 400 mg

0-10 tablets of 5mg Tramadol

NSAIDS

Tylenol

NSAIDs

Opioid

PGY3

No

Unsatisfied

Medical School, Residency, Personal reading

Delaware, South Carolina, West Virginia

45,000

15,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Agree

Strongly disagree

Undecided

Agree

Disagree

Disagree

Agree

Agree

Undecided

Agree

NSAIDs

Celecoxib 400 mg

Exercise

0-10 tablets of 5mg Oxycodone

Tylenol

NSAIDs

Opioid

PGY3

No

Neutral

Medical School, Residency

California, New York, Pennsylvania

75,000

45,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Agree

Strongly disagree

Agree

Undecided

Strongly disagree

Undecided

Agree

Strongly agree

Strongly agree

Strongly agree

NSAIDs

Chlorpromazine IV 12.5 mg

Continue NSAIDS and weight loss therapy

NSAIDS

Tylenol

Tylenol

Opioid

PGY2

No

Neutral

Medical School, Residency, Personal reading

Alabama, Pennsylvania, West Virginia

45,000

15,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Agree

Strongly disagree

Disagree

Strongly agree

Undecided

Undecided

Agree

Agree

Agree

Agree

Chlorpromazine IV 12.5 mg

Acetaminophen

Tylenol

Tylenol

Opioid

PGY1

Yes

Satisfied

Medical School, Residency

New York, Delaware, Pennsylvania

45,000

25,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Agree

Strongly disagree

Undecided

Disagree

Undecided

Undecided

Agree

Strongly agree

Agree

Agree

NSAIDs

Celecoxib 400 mg

0-10 tablets of 5mg Tramadol

NSAIDS

Tylenol

Tylenol

Tylenol

PGY2

No

Unsatisfied

Never received any formal training

Alabama, Kentucky, South Carolina

45,000

25,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Agree

Disagree

Agree

Agree

Agree

Disagree

Agree

Agree

Agree

Agree

NSAIDs

Naratriptan 2.5 mg

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

Tylenol

Tylenol

Opioid

PGY3

No

Neutral

Medical School, Residency

Alabama, New York, Pennsylvania

45,000

25,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Agree

Strongly disagree

Agree

Agree

Strongly disagree

Strongly disagree

Agree

Disagree

Disagree

Agree

NSAIDs

Naratriptan 2.5 mg

Exercise

NSAIDS

Tylenol

Opioid

Opioid

PGY1

No

Neutral

Medical School, Residency

Alabama, Pennsylvania, West Virginia

75,000

45,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Undecided

Strongly disagree

Disagree

Undecided

Strongly disagree

Undecided

Agree

Agree

Agree

Strongly agree

NSAIDs

Celecoxib 400 mg

0-10 tablets of 5mg Tramadol

NSAIDS

Tylenol

Tylenol

Opioid

PGY1

No

Neutral

Medical School

Kentucky, Pennsylvania, West Virginia

45,000

45,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Agree

Strongly disagree

Agree

Undecided

Agree

Undecided

Agree

Agree

Agree

Strongly agree

NSAIDs

Naratriptan 2.5 mg

0-10 tablets of 5mg Tramadol

No pain medication

Tylenol

NSAIDs

NSAIDs

PGY1

No

Unsatisfied

Medical School

Kentucky, Pennsylvania, West Virginia

45,000

25,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Disagree

Strongly disagree

Undecided

Agree

Agree

Agree

Strongly agree

Agree

Disagree

Agree

NSAIDs

Naratriptan 2.5 mg

Acetaminophen

0-10 tablets of 5mg Oxycodone

Tylenol

NSAIDs

Opioid

PGY3

No

Neutral

Residency

California, New York, Pennsylvania

75,000

25,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Agree

Disagree

Agree

Agree

Disagree

Undecided

Undecided

Agree

Disagree

Agree

Duloxetine

Celecoxib 400 mg

Acetaminophen

NSAIDS

Tylenol

Tylenol

Tylenol

PGY1

No

Unsatisfied

Residency

Kentucky, Pennsylvania, West Virginia

45,000

15,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Undecided

Strongly disagree

Disagree

Agree

Strongly agree

Strongly agree

Agree

Strongly agree

Agree

Strongly agree

NSAIDs

Chlorpromazine IV 12.5 mg

Continue NSAIDS and weight loss therapy

NSAIDS

Tylenol

NSAIDs

Opioid

PGY1

No

Neutral

Medical School

New York, Delaware, West Virginia

75,000

75,000

FALSE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Agree

Strongly disagree

Undecided

Agree

Strongly disagree

Strongly disagree

Agree

Strongly agree

Agree

Agree

NSAIDs

Naratriptan 2.5 mg

Acetaminophen

0-10 tablets of 5mg Oxycodone

Tylenol

NSAIDs

Tylenol

PGY1

No

Unsatisfied

Residency

Kentucky, Pennsylvania, West Virginia

15,000

25,000

FALSE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Strongly agree

Strongly disagree

Disagree

Strongly agree

Strongly agree

Agree

Agree

Strongly agree

Strongly agree

Strongly agree

NSAIDs

Celecoxib 400 mg

0-10 tablets of 5mg Tramadol

NSAIDS

Tylenol

NSAIDs

Opioid

PGY3

No

Neutral

Residency

New York, Delaware, Pennsylvania

25,000

15,000

FALSE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Agree

Strongly disagree

Agree

Agree

Undecided

Disagree

Agree

Agree

Agree

Agree

NSAIDs

Celecoxib 400 mg

Continue NSAIDS and weight loss therapy

NSAIDS

Tylenol

Opioid

PGY1

No

Neutral

Never received any formal training

California, New York, Pennsylvania

75,000

45,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Agree

Strongly disagree

Disagree

Strongly agree

Undecided

Disagree

Strongly agree

Strongly agree

Strongly agree

Strongly agree

NSAIDs

Naratriptan 2.5 mg

0-10 tablets of 5mg Tramadol

0-10 tablets of 5mg Oxycodone

NSAIDs

NSAIDs

Opioid

PGY1

No

Unsatisfied

Medical School

Pennsylvania, West Virginia

45,000

25,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Disagree

Strongly disagree

Disagree

Agree

Agree

Agree

Agree

Agree

Agree

Strongly agree

Duloxetine

Naratriptan 2.5 mg

Exercise

0-10 tablets of 5mg Oxycodone

Tylenol

NSAIDs

Opioid

PGY3

No

Unsatisfied

Residency, Personal reading

Alabama

45,000

25,000

FALSE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Agree

Strongly disagree

Disagree

Undecided

Disagree

Agree

Agree

Agree

Agree

Agree

NSAIDs

Naratriptan 2.5 mg

Acetaminophen

0-10 tablets of 5mg Oxycodone

Tylenol

Tylenol

Opioid

PGY2

No

Neutral

Medical School, Residency, Personal reading

Alabama, Kentucky, Pennsylvania

45,000

45,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Agree

Agree

Undecided

Agree

Disagree

Agree

Strongly agree

Agree

Agree

NSAIDs

Codeine/acetaminophen 25/400 mg

Continue NSAIDS and weight loss therapy

0-10 tablets of 5mg Oxycodone

Tylenol

NSAIDs

Opioid

PGY1

No

Unsatisfied

Residency

New York, Pennsylvania, West Virginia

45,000

45,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Agree

Strongly disagree

Strongly disagree

Agree

Disagree

Disagree

Strongly agree

Agree

Agree

Strongly agree

NSAIDs

Chlorpromazine IV 12.5 mg

Acetaminophen

0-10 tablets of 5mg Oxycodone

Tylenol

NSAIDs

Opioid

PGY1

No

Neutral

Medical School, Residency

California, New York, Pennsylvania

75,000

25,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Agree

Strongly disagree

Undecided

Undecided

Disagree

Disagree

Agree

Agree

Disagree

Strongly agree

NSAIDs

Naratriptan 2.5 mg

0-10 tablets of 5mg Oxycodone

NSAIDS

Tylenol

Tylenol

Tylenol

PGY3

Yes

Neutral

Medical School, Residency, Personal reading

Kentucky, Delaware, West Virginia

75,000

45,000

FALSE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Agree

Disagree

Undecided

Strongly agree

Agree

Disagree

Strongly agree

Disagree

Disagree

Agree

NSAIDs

Naratriptan 2.5 mg

Continue NSAIDS and weight loss therapy

NSAIDS

Tylenol

NSAIDs

Opioid

PGY1

No

Unsatisfied

Residency, Personal reading

Kentucky, Pennsylvania, West Virginia

75,000

45,000

FALSE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Undecided

Strongly disagree

Disagree

Strongly disagree

Undecided

Undecided

Agree

Agree

Disagree

Agree

NSAIDs

Chlorpromazine IV 12.5 mg

Acetaminophen

0-10 tablets of 5mg Oxycodone

Tylenol

Tylenol

Tylenol

PGY1

No

Neutral

Medical School, Residency

Kentucky, Pennsylvania, West Virginia

75,000

45,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Agree

Strongly disagree

Undecided

Strongly agree

Undecided

Disagree

Undecided

Strongly agree

Strongly agree

Agree

NSAIDs

Naratriptan 2.5 mg

0-10 tablets of 5mg Tramadol

NSAIDS

Tylenol

NSAIDs

Opioid

PGY1

No

Unsatisfied

Residency

45,000

25,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Undecided

Strongly disagree

Disagree

Agree

Disagree

Disagree

Agree

Agree

Undecided

Strongly agree

NSAIDs

Naratriptan 2.5 mg

Continue NSAIDS and weight loss therapy

NSAIDS

Tylenol

Tylenol

Tylenol

PGY2

No

Unsatisfied

Medical School, Residency

Alabama, Kentucky, New York

45,000

45,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Agree

Strongly disagree

Agree

Agree

Disagree

Disagree

Agree

Agree

Agree

Strongly agree

NSAIDs

Celecoxib 400 mg

0-10 tablets of 5mg Tramadol

0-10 tablets of 5mg Oxycodone

Tylenol

Tylenol

Opioid

PGY2

No

Neutral

Medical School, Residency, Personal reading

Alabama, Pennsylvania, West Virginia

75,000

45,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Agree

Disagree

Disagree

Agree

Disagree

Disagree

Agree

Agree

Disagree

Agree

NSAIDs

Chlorpromazine IV 12.5 mg

Exercise

0-10 tablets of 5mg Oxycodone

Tylenol

NSAIDs

Opioid

PGY2

No

Unsatisfied

Medical School, Personal reading

Kentucky, Pennsylvania, West Virginia

75,000

15,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Agree

Disagree

Agree

Undecided

Agree

Agree

Strongly agree

Strongly agree

Strongly agree

Strongly agree

NSAIDs

Naratriptan 2.5 mg

Acetaminophen

NSAIDS

Tylenol

NSAIDs

Opioid

PGY3

Yes

Unsatisfied

Medical School, Residency, Personal reading

Kentucky, New York, Pennsylvania

45,000

15,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Disagree

Strongly disagree

Disagree

Disagree

Agree

Agree

Agree

Agree

Undecided

Undecided

NSAIDs

Chlorpromazine IV 12.5 mg

Continue NSAIDS and weight loss therapy

NSAIDS

Tylenol

NSAIDs

Opioid

PGY1

No

Unsatisfied

Medical School

New York, Pennsylvania, West Virginia

45,000

25,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Agree

Strongly disagree

Disagree

Undecided

Disagree

Disagree

Agree

Agree

Agree

Agree

NSAIDs

Celecoxib 400 mg

0-10 tablets of 5mg Tramadol

NSAIDS

Tylenol

Tylenol

Tylenol

PGY2

No

Unsatisfied

Residency, Personal reading

Alabama, Kentucky, New York

45,000

25,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Agree

Strongly disagree

Undecided

Agree

Strongly disagree

Strongly disagree

Agree

Agree

Agree

Agree

NSAIDs

Naratriptan 2.5 mg

Acetaminophen

0-10 tablets of 5mg Oxycodone

NSAIDs

Tylenol

Tylenol

Table 11

IM resident post-test data

PGY: post-graduate year; DEA: Drug Enforcement Administration; PDMP: prescription drug monitoring program; PA: Pennsylvania; NSAID: non-steroidal anti-inflammatory drug; IM: internal medicine

1. Please select your current level of training:

2. Do you hold a DEA License?

3. How satisfied are you with your current level of opioid-prescribing training?

4. When did you receive your opioid-prescribing training? (Select all that apply)

5. Which three states have the highest percentage of opioid-related deaths per capita:(circle 3 states)

6. In 2017, how many drug overdose deaths were due to opioids?

7. In 2017, how many deaths were a result of heroin overdose?

8. Nearly half of all opioid related overdoses are due to valid prescription opioids.

9. What is the PDMP?

10. How often should the PDMP be referenced?

11. Opioids are effective in pain management.

12. Every patient that presents to the office with pain should receive opioids.

13. I feel comfortable in my knowledge of non-opioid pain management.

14. If I suspect someone is abusing opioids, I do not prescribe opioids to them.

15. Patient gender may affect my judgement of a patient's pain intensity

16. Patient race may affect my judgement of a patient's pain intensity

17. If a patient presents to the ED repeatedly asking for more pain medication, this could be due to a missed diagnosis of the underlying pain source.

18. I ask my patients about the severity of their pain.

19. I include patient-reported pain levels in my notes.

20. I think that proper pain management is associated with better patient outcomes.

21. For an adult presenting with chronic low back pain, I would initially prescribe: (circle only one)

22. A 25-year-old female presents to the office with an acute episodic migraine According to the American Headache Society 2015 Guidelines, what treatment has Level A evidence?

23. A 65-year-old man returns to the clinic for joint pain in his knees. He has a history of osteoarthritis and states that it is difficult for him to complete daily tasks. His pain was not treated by NSAIDs or weight loss. What should be the next line of treatment?

24. A 35-year-old male presents to the office with nephrolithiasis. His eGFR is >90ml/min and he has no history of GI bleed. How would you initially treat his pain?

25. For patients experiencing mild pain, I usually initially prescribe (circle one)

26. For patients experiencing moderate pain, I usually initially prescribe (circle one)

27. For patients experiencing severe pain, I usually initially prescribe (circle only one)

PGY1

No

Unsatisfied

Medical School, Residency, Personal reading

Alabama, Kentucky, Pennsylvania, West Virginia

25,000

15,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Agree

Strongly disagree

Undecided

Agree

Agree

Agree

Agree

Agree

Agree

Strongly agree

NSAIDs

Naratriptan 2.5 mg

0-10 tablets of 5mg Oxycodone

NSAIDS

Tylenol

NSAIDs

Opioid

PGY2

No

Neutral

Medical School, Residency

Kentucky, Pennsylvania, West Virginia

45,000

15,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Agree

Strongly disagree

Undecided

Strongly agree

Disagree

Disagree

Agree

Agree

Agree

Agree

NSAIDs

Chlorpromazine IV 12.5 mg

Acetaminophen

0-10 tablets of 5mg Oxycodone

Tylenol

Tylenol

Opioid

PGY2

No

Neutral

Medical School, Residency

Kentucky, Pennsylvania, West Virginia

75,000

15,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Strongly agree

Strongly disagree

Agree

Undecided

Strongly disagree

Strongly disagree

Agree

Agree

Agree

Agree

NSAIDs

Naratriptan 2.5 mg

0-10 tablets of 5mg Tramadol

NSAIDS

NSAIDs

NSAIDs

Tylenol

PGY1

No

Unsatisfied

Medical School

Delaware, South Carolina, West Virginia

45,000

15,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Strongly agree

Strongly disagree

Disagree

Agree

Agree

Agree

Agree

Strongly agree

Strongly agree

Agree

NSAIDs

Naratriptan 2.5 mg

0-10 tablets of 5mg Tramadol

NSAIDS

Tylenol

NSAIDs

Opioid

PGY3

No

Neutral

Medical School, Residency

Alabama, Kentucky, Pennsylvania, West Virginia

75,000

15,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Undecided

Strongly disagree

Agree

Strongly agree

Strongly disagree

Strongly disagree

Agree

Agree

Disagree

Agree

NSAIDs

Naratriptan 2.5 mg

0-10 tablets of 5mg Tramadol

NSAIDS

NSAIDs

NSAIDs

Opioid

PGY2

No

Neutral

Medical School, Residency

Kentucky, Pennsylvania, West Virginia

45,000

15,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Agree

Strongly disagree

Undecided

Strongly agree

Disagree

Disagree

Agree

Agree

Agree

Agree

NSAIDs

Chlorpromazine IV 12.5 mg

Acetaminophen

0-10 tablets of 5mg Oxycodone

Tylenol

Tylenol

Opioid

PGY1

No

Neutral

Medical School

Kentucky, Delaware, West Virginia

25,000

15,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Disagree

Strongly disagree

Disagree

Strongly agree

Disagree

Agree

Agree

Strongly agree

Agree

Agree

NSAIDs

Naratriptan 2.5 mg

0-10 tablets of 5mg Tramadol

NSAIDS

Tylenol

NSAIDs

Opioid

PGY1

No

Unsatisfied

Medical School

Delaware, Pennsylvania, West Virginia

45,000

15,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Agree

Strongly disagree

Disagree

Agree

Disagree

Disagree

Agree

Agree

Agree

Agree

Tramadol

Naratriptan 2.5 mg

Acetaminophen

No pain medication

Tylenol

Tylenol

Tylenol

PGY3

No

Neutral

Residency

Delaware, Pennsylvania, West Virginia

75,000

15,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Agree

Strongly disagree

Agree

Agree

Undecided

Undecided

Agree

Agree

Agree

Strongly agree

NSAIDs

Naratriptan 2.5 mg

Exercise

NSAIDS

Tylenol

NSAIDs

Opioid

PGY2

No

Unsatisfied

Residency

Delaware, Pennsylvania, West Virginia

45,000

15,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Agree

Strongly disagree

Agree

Agree

Agree

Agree

Agree

Agree

Agree

Strongly agree

NSAIDs

Naratriptan 2.5 mg

0-10 tablets of 5mg Tramadol

NSAIDS

NSAIDs

NSAIDs

NSAIDs

PGY2

No

Unsatisfied

Residency

California, New York, Pennsylvania

45,000

25,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Strongly agree

Strongly disagree

Agree

Strongly agree

Strongly agree

Undecided

Agree

Strongly agree

Agree

Strongly agree

NSAIDs

Celecoxib 400 mg

Acetaminophen

NSAIDS

Tylenol

Tylenol

Opioid

PGY2

No

Unsatisfied

Residency

California, New York, Pennsylvania

45,000

25,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Strongly agree

Strongly disagree

Agree

Strongly agree

Strongly agree

Undecided

Agree

Strongly agree

Agree

Strongly agree

NSAIDs

Celecoxib 400 mg

Acetaminophen

NSAIDS

Tylenol

Tylenol

Opioid

PGY2

No

Neutral

Medical School, Residency

Kentucky, Pennsylvania, West Virginia

45,000

15,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Agree

Strongly disagree

Undecided

Strongly agree

Disagree

Disagree

Agree

Agree

Agree

Agree

NSAIDs

Chlorpromazine IV 12.5 mg

Acetaminophen

0-10 tablets of 5mg Oxycodone

Tylenol

Tylenol

Opioid

PGY1

No

Unsatisfied

Never received any formal training

Kentucky, New York, Pennsylvania

45,000

15,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Strongly agree

Strongly disagree

Disagree

Undecided

Disagree

Disagree

Agree

Agree

Agree

Agree

NSAIDs

Naratriptan 2.5 mg

Exercise

NSAIDS

Tylenol

Tylenol

NSAIDs

PGY1

No

Satisfied

Medical School, Residency

California, Delaware, West Virginia

45,000

15,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Agree

Strongly disagree

Agree

Agree

Disagree

Disagree

Agree

Agree

Agree

Agree

NSAIDs

Naratriptan 2.5 mg

0-10 tablets of 5mg Tramadol

NSAIDS

Tylenol

NSAIDs

Opioid

PGY3

No

Satisfied

Never received any formal training

Alabama, Kentucky, West Virginia

45,000

45,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Agree

Strongly disagree

Agree

Agree

Disagree

Strongly disagree

Agree

Agree

Agree

Agree

NSAIDs

Naratriptan 2.5 mg

Continue NSAIDS and weight loss therapy

0-10 tablets of 5mg Oxycodone

Tylenol

Tylenol

Opioid

PGY1

No

Neutral

Medical School, Residency

Alabama, Kentucky, West Virginia

45,000

15,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Agree

Strongly disagree

Agree

Strongly agree

Undecided

Agree

Agree

Strongly agree

Strongly agree

Strongly agree

NSAIDs

Naratriptan 2.5 mg

0-10 tablets of 5mg Tramadol

0-10 tablets of 5mg Oxycodone

Tylenol

NSAIDs

Opioid

PGY1

No

Neutral

Medical School

Kentucky, Pennsylvania, West Virginia

25,000

45,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Strongly agree

Strongly disagree

Agree

Agree

Agree

Disagree

Agree

Agree

Agree

Agree

NSAIDs

Naratriptan 2.5 mg

0-10 tablets of 5mg Tramadol

NSAIDS

Tylenol

NSAIDs

Opioid

PGY1

No

Unsatisfied

Never received any formal training

Delaware, Pennsylvania, West Virginia

45,000

15,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Agree

Strongly disagree

Undecided

Strongly agree

Undecided

Undecided

Agree

Agree

Agree

Agree

NSAIDs

Chlorpromazine IV 12.5 mg

Acetaminophen

NSAIDS

Tylenol

NSAIDs

NSAIDs

PGY2

No

Unsatisfied

Residency, Personal reading

Delaware, Pennsylvania, West Virginia

75,000

15,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given.

Agree

Strongly disagree

Agree

Agree

Disagree

Disagree

Agree

Agree

Agree

Agree

NSAIDs

Naratriptan 2.5 mg

0-10 tablets of 5mg Tramadol

NSAIDS

NSAIDs

Tylenol

Tylenol

Table 12

GS pre-test data

PGY: post-graduate year; DEA: Drug Enforcement Administration; PDMP: prescription drug monitoring program; PA: Pennsylvania; NSAID: non-steroidal anti-inflammatory drug; GS: general surgery

1. Please select your current level of training:

2. Do you hold a DEA License?

3. How satisfied are you with your current level of opioid-prescribing training?

4. When did you receive your opioid-prescribing training? (Select all that apply)

5. Which three states have the highest percentage of opioid-related deaths per capita:(circle 3 states)

6. In 2017, how many drug overdose deaths were due to opioids?

7. In 2017, how many deaths were a result of heroin overdose?

8. Nearly half of all opioid related overdoses are due to valid prescription opioids.

9. What is the PDMP?

10. How often should the PDMP be referenced?

11. Opioids are effective in pain management.

12. Every patient should receive opioids following surgery.

13. I feel comfortable in my knowledge of non-opioid pain management.

14. If I suspect someone is abusing opioids, I do not prescribe opioids to them.

15. Patient gender may affect my judgement of a patient's pain intensity

16. Patient race may affect my judgement of a patient's pain intensity

17. I ask my patients about the severity of their pain.

18. I include patient-reported pain levels in my notes.

19. For a patient being discharged home after an open appendectomy, I would typically prescribe: (circle only one)

20. For a patient being discharged home after a sleeve gastrectomy, I would typically prescribe: (circle only one)

21. For a patient being discharged home after a laparoscopic cholecystectomy, I would typically prescribe: (circle only one)

22. For a patient being discharged home after a laparoscopic Nissen fundoplication, I would typically prescribe: (circle only one)

23. For a patient being discharged home after an open small bowel resection, I would typically prescribe: (circle only one)

24. For a patient being discharged home after an open colectomy, I would typically prescribe: (circle only one)

25. For a patient being discharged home after a major hernia repair, I would typically prescribe: (circle only one)

26. For patients experiencing mild pain, I usually initially prescribe (circle one)

27. For patients experiencing moderate pain, I usually initially prescribe (circle one)

28. For patients experiencing severe pain, I usually initially prescribe (circle only one)

PGY4

Yes

Satisfied

Medical School, Residency, Personal reading

Kentucky, New York, South Carolina

45,000

25,000

TRUE

Prescribing Directory of Medical Providers

Anytime an opioid prescription is given

Agree

Disagree

Disagree

Disagree

Undecided

Disagree

Agree

Disagree

0-10 tablets of 5mg Oxycodone

11-20 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

Tylenol

Opioid

Opioid

PGY3

Yes

Very satisfied

Medical School, Residency

California, New York, Pennsylvania

75,000

45,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given

Strongly agree

Disagree

Strongly agree

Disagree

Disagree

Disagree

Strongly agree

Disagree

0-10 tablets of 5mg Oxycodone

11-20 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

0-25 tablets of 5mg Oxycodone

0-25 tablets of 5mg Oxycodone

0-25 tablets of 5mg Oxycodone

Tylenol

Tylenol

Opioid

PGY4

Yes

Very satisfied

Medical School, Residency, Personal reading

New York, Pennsylvania, West Virginia

75,000

45,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given

Agree

Strongly disagree

Strongly agree

Strongly agree

Strongly disagree

Strongly disagree

Strongly agree

Strongly agree

0-10 tablets of 5mg Oxycodone

11-20 tablets of 5mg Oxycodone

0-5 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

0-20 tablets of 5mg Oxycodone

0-20 tablets of 5mg Oxycodone

Tylenol

Opioid

Opioid

PGY2

Yes

Neutral

Residency

California, New York, Pennsylvania

25,000

15,000

FALSE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given

Agree

Disagree

Agree

Agree

Strongly disagree

Strongly disagree

Agree

Agree

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

Tylenol

Tylenol

Opioid

PGY4

Yes

Neutral

Residency

Alabama, California, New York

45,000

45,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given

Agree

Strongly disagree

Agree

Undecided

Agree

Agree

Strongly agree

Undecided

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

Tylenol

Opioid

Opioid

PGY4

Yes

Neutral

Residency

Alabama, Kentucky, West Virginia

75,000

75,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given

Agree

Disagree

Strongly disagree

Disagree

Undecided

Undecided

Agree

Undecided

Only non-opioid pain medications

Only non-opioid pain medications

0-5 tablets of 5mg Oxycodone

0-5 tablets of 5mg Oxycodone

0-5 tablets of 5mg Oxycodone

0-5 tablets of 5mg Oxycodone

0-5 tablets of 5mg Oxycodone

NSAIDs

Tylenol

Tylenol

PGY1

No

Satisfied

Medical School, Residency

Alabama, South Carolina, West Virginia

25,000

25,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given

Strongly agree

Undecided

Undecided

Disagree

Agree

Disagree

Strongly agree

Agree

11-20 tablets of 5mg Oxycodone

11-20 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

0-20 tablets of 5mg Oxycodone

0-20 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

Tylenol

Tylenol

Tylenol

PGY3

Yes

Very satisfied

Medical School, Residency

Alabama, Pennsylvania, West Virginia

75,000

45,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given

Strongly agree

Strongly disagree

Strongly agree

Undecided

Strongly disagree

Strongly disagree

Strongly agree

Agree

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-20 tablets of 5mg Oxycodone

Tylenol

Tylenol

Tylenol

PGY2

No

Satisfied

Medical School, Residency, Personal reading

New York, Pennsylvania, South Carolina

45,000

75,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given

Agree

Disagree

Agree

Undecided

Strongly disagree

Strongly disagree

Agree

Agree

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

Tylenol

NSAIDs

Opioid

PGY4

Yes

Satisfied

Residency

California, New York, Pennsylvania

45,000

45,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given

Agree

Disagree

Agree

Agree

Agree

Agree

Agree

Agree

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-5 tablets of 5mg Oxycodone

0-5 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

Tylenol

Opioid

Opioid

PGY1

Yes

Neutral

Residency

California, New York, Pennsylvania

25,000

15,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given

Agree

Disagree

Agree

Disagree

Agree

Agree

Agree

Disagree

0-10 tablets of 5mg Oxycodone

21-30 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

0-5 tablets of 5mg Oxycodone

Tylenol

Opioid

Opioid

PGY5

Yes

Satisfied

Medical School, Residency, Personal reading

Kentucky, New York, Pennsylvania

45,000

75,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given

Agree

Disagree

Agree

Undecided

Strongly disagree

Strongly disagree

Agree

Agree

0-10 tablets of 5mg Oxycodone

11-20 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

0-20 tablets of 5mg Oxycodone

0-20 tablets of 5mg Oxycodone

0-20 tablets of 5mg Oxycodone

Tylenol

Opioid

Opioid

PGY3

Yes

Unsatisfied

Medical School, Residency, Personal reading

California, New York, Pennsylvania

45,000

25,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given

Disagree

Strongly disagree

Undecided

Agree

Strongly disagree

Strongly disagree

Strongly agree

Strongly agree

Only non-opioid pain medications

0-10 tablets of 5mg Oxycodone

0-5 tablets of 5mg Oxycodone

0-5 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

Tylenol

NSAIDs

Opioid

PGY5

Yes

Satisfied

Medical School, Residency

Alabama, California, New York

45,000

25,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given

Agree

Disagree

Strongly agree

Agree

Disagree

Strongly disagree

Agree

Disagree

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

0-20 tablets of 5mg Oxycodone

Tylenol

NSAIDs

Opioid

PGY5

Yes

Satisfied

Residency

Kentucky, Delaware, West Virginia

75,000

45,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given

Agree

Disagree

Agree

Agree

Disagree

Strongly disagree

Agree

Agree

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-5 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-20 tablets of 5mg Oxycodone

0-20 tablets of 5mg Oxycodone

0-25 tablets of 5mg Oxycodone

Tylenol

NSAIDs

Opioid

PGY5

Yes

Satisfied

Residency

California, Delaware, Pennsylvania

75,000

15,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given

Agree

Disagree

Agree

Agree

Disagree

Disagree

Agree

Agree

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-5 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

NSAIDs

NSAIDs

Opioid

PGY2

Yes

Satisfied

Residency

California, New York, West Virginia

75,000

75,000

TRUE

Prescribing Directory of Medical Providers

Anytime an opioid prescription is given

Agree

Disagree

Agree

Agree

Disagree

Disagree

Agree

Agree

Only non-opioid pain medications

Only non-opioid pain medications

0-5 tablets of 5mg Oxycodone

0-5 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

0-20 tablets of 5mg Oxycodone

Tylenol

NSAIDs

Opioid

Table 13

GS post-test data

PGY: post-graduate year; DEA: Drug Enforcement Administration; PDMP: prescription drug monitoring program; PA: Pennsylvania; NSAID: non-steroidal anti-inflammatory drug; GS: general surgery

1. Please select your current level of training:

2. Do you hold a DEA License?

3. How satisfied are you with your current level of opioid-prescribing training?

4. When did you receive your opioid-prescribing training? (Select all that apply)

5. Which three states have the highest percentage of opioid-related deaths per capita:(circle 3 states)

6. In 2017, how many drug overdose deaths were due to opioids?

7. In 2017, how many deaths were a result of heroin overdose?

8. Nearly half of all opioid related overdoses are due to valid prescription opioids.

9. What is the PDMP?

10. How often should the PDMP be referenced?

11. Opioids are effective in pain management.

12. Every patient should receive opioids following surgery.

13. I feel comfortable in my knowledge of non-opioid pain management.

14. If I suspect someone is abusing opioids, I do not prescribe opioids to them.

15. Patient gender may affect my judgement of a patient's pain intensity

16. Patient race may affect my judgement of a patient's pain intensity

17. I ask my patients about the severity of their pain.

18. I include patient-reported pain levels in my notes.

19. For a patient being discharged home after an open appendectomy, I would typically prescribe: (circle only one)

20. For a patient being discharged home after a sleeve gastrectomy, I would typically prescribe: (circle only one)

21. For a patient being discharged home after a laparoscopic cholecystectomy, I would typically prescribe: (circle only one)

22. For a patient being discharged home after a laparoscopic Nissen fundoplication, I would typically prescribe: (circle only one)

23. For a patient being discharged home after an open small bowel resection, I would typically prescribe: (circle only one)

24. For a patient being discharged home after an open colectomy, I would typically prescribe: (circle only one)

25. For a patient being discharged home after a major hernia repair, I would typically prescribe: (circle only one)

26. For patients experiencing mild pain, I usually initially prescribe (circle one)

27. For patients experiencing moderate pain, I usually initially prescribe (circle one)

28. For patients experiencing severe pain, I usually initially prescribe (circle only one)

PGY2

Yes

Satisfied

Medical School, Residency, Personal reading

Delaware, Pennsylvania, West Virginia

75,000

75,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given

Agree

Agree

Agree

Disagree

Strongly disagree

Strongly disagree

Agree

Agree

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

Tylenol

NSAIDs

Opioid

PGY5

Yes

Satisfied

Medical School, Residency, Personal reading

Delaware, Pennsylvania, West Virginia

45,000

15,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given

Agree

Disagree

Agree

Agree

Strongly disagree

Strongly disagree

Strongly agree

Agree

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

Tylenol

NSAIDs

Opioid

PGY3

Yes

Very satisfied

Medical School, Residency

Delaware, Pennsylvania, West Virginia

45,000

15,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given

Strongly agree

Disagree

Strongly agree

Disagree

Disagree

Disagree

Strongly agree

Disagree

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

Tylenol

Tylenol

Opioid

PGY4

Yes

Very satisfied

Medical School, Residency

Delaware, Pennsylvania, West Virginia

45,000

15,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given

Agree

Strongly disagree

Strongly agree

Agree

Strongly disagree

Strongly disagree

Strongly agree

Strongly agree

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

0-20 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

Tylenol

Opioid

Opioid

PGY3

Yes

Very satisfied

Medical School, Residency

Delaware, Pennsylvania, West Virginia

75,000

25,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given

Strongly agree

Strongly disagree

Strongly agree

Agree

Strongly disagree

Strongly disagree

Strongly agree

Strongly agree

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

Tylenol

Tylenol

Tylenol

PGY4

Yes

Very satisfied

Residency

Delaware, Pennsylvania, West Virginia

45,000

15,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given

Agree

Strongly disagree

Agree

Undecided

Strongly disagree

Strongly disagree

Strongly agree

Agree

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

Tylenol

Opioid

Opioid

PGY2

Yes

Satisfied

Residency

Delaware, Pennsylvania, West Virginia

45,000

15,000

FALSE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given

Agree

Disagree

Agree

Undecided

Strongly disagree

Strongly disagree

Agree

Agree

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

Tylenol

Tylenol

Opioid

PGY4

Yes

Satisfied

Residency

Alabama, Kentucky, Pennsylvania, West Virginia

75,000

15,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given

Agree

Strongly disagree

Agree

Disagree

Disagree

Disagree

Agree

Agree

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

NSAIDs

NSAIDs

Opioid

PGY4

Yes

Satisfied

Residency

Delaware, Pennsylvania, West Virginia

45,000

15,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given

Agree

Strongly disagree

Agree

Agree

Agree

Agree

Strongly agree

Strongly agree

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

Tylenol

NSAIDs

Opioid

PGY5

Yes

Very satisfied

Medical School, Residency

Delaware, Pennsylvania, West Virginia

45,000

15,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given

Agree

Strongly disagree

Agree

Agree

Disagree

Strongly disagree

Agree

Disagree

Only non-opioid pain medications

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

Tylenol

Opioid

Opioid

PGY2

Yes

Satisfied

Medical School, Residency, Personal reading

Delaware, Pennsylvania, West Virginia

45,000

15,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given

Agree

Disagree

Undecided

Agree

Strongly disagree

Strongly disagree

Agree

Undecided

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

Tylenol

Opioid

Opioid

PGY3

Yes

Satisfied

Medical School, Residency, Personal reading

Delaware, Pennsylvania, West Virginia

45,000

15,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given

Agree

Disagree

Disagree

Agree

Strongly disagree

Strongly disagree

Strongly agree

Agree

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

0-5 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

Tylenol

Opioid

Opioid

PGY5

Yes

Unsatisfied

Residency, Personal reading

Delaware, Pennsylvania, West Virginia

45,000

15,000

TRUE

Prescription Drug Monitoring Program

Anytime an opioid prescription is given

Agree

Strongly disagree

Agree

Agree

Disagree

Strongly disagree

Agree

Agree

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-15 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

0-10 tablets of 5mg Oxycodone

NSAIDs

Tylenol

Opioid