Which of the following best describes your primary practice setting? *

Solo Practice

Group Practice

Government

University/teaching system

Community Hospital

HMO/managed care

Non-profit/community

I do not actively practice

Other, please specify:

Which of the following best describes your primary practice setting? Other, please specify:

How long have you been in practice? *

More than 20 years

11-20 years

6-10 years

1-5 years

Less than 1 year

I do not directly provide care

How many patients with chronic pain do you currently see each week? *

Less than 5

5-15

16-25

26-35

36-45

46-55

56 or more

I do not directly provide care

Using the scale below, please rate this CME activity. *

	Very Poor	Poor	Neutral	Good	Excellent
Overall Evaluation	Overall Evaluation - Very Poor	Overall Evaluation - Poor	Overall Evaluation - Neutral	Overall Evaluation - Good	Overall Evaluation - Excellent
Content	Content - Very Poor	Content - Poor	Content - Neutral	Content - Good	Content - Excellent
Usefulness	Usefulness - Very Poor	Usefulness - Poor	Usefulness - Neutral	Usefulness - Good	Usefulness - Excellent
Quality	Quality - Very Poor	Quality - Poor	Quality - Neutral	Quality - Good	Quality - Excellent

Please rate each of the following statements as they relate to your knowledge/skill level PRIOR TO viewing this webinar. *

	Excellent	Very good	Good	Fair	Poor	N/A
Knowledge of the 3 C’s that characterize addiction	Knowledge of the 3 C’s that characterize addiction - Excellent	Knowledge of the 3 C’s that characterize addiction - Very good	Knowledge of the 3 C’s that characterize addiction - Good	Knowledge of the 3 C’s that characterize addiction - Fair	Knowledge of the 3 C’s that characterize addiction - Poor	Knowledge of the 3 C’s that characterize addiction - N/A
Knowledge of characteristics of a PDMP profile that suggest abuse or diversion of drugs	Knowledge of characteristics of a PDMP profile that suggest abuse or diversion of drugs - Excellent	Knowledge of characteristics of a PDMP profile that suggest abuse or diversion of drugs - Very good	Knowledge of characteristics of a PDMP profile that suggest abuse or diversion of drugs - Good	Knowledge of characteristics of a PDMP profile that suggest abuse or diversion of drugs - Fair	Knowledge of characteristics of a PDMP profile that suggest abuse or diversion of drugs - Poor	Knowledge of characteristics of a PDMP profile that suggest abuse or diversion of drugs - N/A
Knowledge of strategies that complement use of PDMP reports to provide a more complete picture of a patient’s use of prescription meds when the PDMP report suggests abuse or diversion	Knowledge of strategies that complement use of PDMP reports to provide a more complete picture of a patient’s use of prescription meds when the PDMP report suggests abuse or diversion - Excellent	Knowledge of strategies that complement use of PDMP reports to provide a more complete picture of a patient’s use of prescription meds when the PDMP report suggests abuse or diversion - Very good	Knowledge of strategies that complement use of PDMP reports to provide a more complete picture of a patient’s use of prescription meds when the PDMP report suggests abuse or diversion - Good	Knowledge of strategies that complement use of PDMP reports to provide a more complete picture of a patient’s use of prescription meds when the PDMP report suggests abuse or diversion - Fair	Knowledge of strategies that complement use of PDMP reports to provide a more complete picture of a patient’s use of prescription meds when the PDMP report suggests abuse or diversion - Poor	Knowledge of strategies that complement use of PDMP reports to provide a more complete picture of a patient’s use of prescription meds when the PDMP report suggests abuse or diversion - N/A
Ability/likelihood to obtain a PDMP report prior to the first controlled substance prescription for a patient	Ability/likelihood to obtain a PDMP report prior to the first controlled substance prescription for a patient - Excellent	Ability/likelihood to obtain a PDMP report prior to the first controlled substance prescription for a patient - Very good	Ability/likelihood to obtain a PDMP report prior to the first controlled substance prescription for a patient - Good	Ability/likelihood to obtain a PDMP report prior to the first controlled substance prescription for a patient - Fair	Ability/likelihood to obtain a PDMP report prior to the first controlled substance prescription for a patient - Poor	Ability/likelihood to obtain a PDMP report prior to the first controlled substance prescription for a patient - N/A
Ability/likelihood to obtain a PDMP report at least annually for every patient for whom I prescribe controlled substances	Ability/likelihood to obtain a PDMP report at least annually for every patient for whom I prescribe controlled substances - Excellent	Ability/likelihood to obtain a PDMP report at least annually for every patient for whom I prescribe controlled substances - Very good	Ability/likelihood to obtain a PDMP report at least annually for every patient for whom I prescribe controlled substances - Good	Ability/likelihood to obtain a PDMP report at least annually for every patient for whom I prescribe controlled substances - Fair	Ability/likelihood to obtain a PDMP report at least annually for every patient for whom I prescribe controlled substances - Poor	Ability/likelihood to obtain a PDMP report at least annually for every patient for whom I prescribe controlled substances - N/A
Ability/likelihood to appropriately differentiate between physical dependence, tolerance and addiction for patients who are requesting an increase in pain medication dosage	Ability/likelihood to appropriately differentiate between physical dependence, tolerance and addiction for patients who are requesting an increase in pain medication dosage - Excellent	Ability/likelihood to appropriately differentiate between physical dependence, tolerance and addiction for patients who are requesting an increase in pain medication dosage - Very good	Ability/likelihood to appropriately differentiate between physical dependence, tolerance and addiction for patients who are requesting an increase in pain medication dosage - Good	Ability/likelihood to appropriately differentiate between physical dependence, tolerance and addiction for patients who are requesting an increase in pain medication dosage - Fair	Ability/likelihood to appropriately differentiate between physical dependence, tolerance and addiction for patients who are requesting an increase in pain medication dosage - Poor	Ability/likelihood to appropriately differentiate between physical dependence, tolerance and addiction for patients who are requesting an increase in pain medication dosage - N/A

Please rate each of the following statements as they relate to your knowledge/skill level AFTER viewing this webinar. *

	Excellent	Very good	Good	Fair	Poor	N/A
Knowledge of the 3 C’s that characterize addiction	Knowledge of the 3 C’s that characterize addiction - Excellent	Knowledge of the 3 C’s that characterize addiction - Very good	Knowledge of the 3 C’s that characterize addiction - Good	Knowledge of the 3 C’s that characterize addiction - Fair	Knowledge of the 3 C’s that characterize addiction - Poor	Knowledge of the 3 C’s that characterize addiction - N/A
Knowledge of characteristics of a PDMP profile that suggest abuse or diversion of drugs	Knowledge of characteristics of a PDMP profile that suggest abuse or diversion of drugs - Excellent	Knowledge of characteristics of a PDMP profile that suggest abuse or diversion of drugs - Very good	Knowledge of characteristics of a PDMP profile that suggest abuse or diversion of drugs - Good	Knowledge of characteristics of a PDMP profile that suggest abuse or diversion of drugs - Fair	Knowledge of characteristics of a PDMP profile that suggest abuse or diversion of drugs - Poor	Knowledge of characteristics of a PDMP profile that suggest abuse or diversion of drugs - N/A
Knowledge of strategies that complement use of PDMP reports to provide a more complete picture of a patient’s use of prescription meds when the PDMP report suggests abuse or diversion	Knowledge of strategies that complement use of PDMP reports to provide a more complete picture of a patient’s use of prescription meds when the PDMP report suggests abuse or diversion - Excellent	Knowledge of strategies that complement use of PDMP reports to provide a more complete picture of a patient’s use of prescription meds when the PDMP report suggests abuse or diversion - Very good	Knowledge of strategies that complement use of PDMP reports to provide a more complete picture of a patient’s use of prescription meds when the PDMP report suggests abuse or diversion - Good	Knowledge of strategies that complement use of PDMP reports to provide a more complete picture of a patient’s use of prescription meds when the PDMP report suggests abuse or diversion - Fair	Knowledge of strategies that complement use of PDMP reports to provide a more complete picture of a patient’s use of prescription meds when the PDMP report suggests abuse or diversion - Poor	Knowledge of strategies that complement use of PDMP reports to provide a more complete picture of a patient’s use of prescription meds when the PDMP report suggests abuse or diversion - N/A
Ability/likelihood to obtain a PDMP report prior to the first controlled substance prescription for a patient	Ability/likelihood to obtain a PDMP report prior to the first controlled substance prescription for a patient - Excellent	Ability/likelihood to obtain a PDMP report prior to the first controlled substance prescription for a patient - Very good	Ability/likelihood to obtain a PDMP report prior to the first controlled substance prescription for a patient - Good	Ability/likelihood to obtain a PDMP report prior to the first controlled substance prescription for a patient - Fair	Ability/likelihood to obtain a PDMP report prior to the first controlled substance prescription for a patient - Poor	Ability/likelihood to obtain a PDMP report prior to the first controlled substance prescription for a patient - N/A
Ability/likelihood to obtain a PDMP report at least annually for every patient for whom I prescribe controlled substances	Ability/likelihood to obtain a PDMP report at least annually for every patient for whom I prescribe controlled substances - Excellent	Ability/likelihood to obtain a PDMP report at least annually for every patient for whom I prescribe controlled substances - Very good	Ability/likelihood to obtain a PDMP report at least annually for every patient for whom I prescribe controlled substances - Good	Ability/likelihood to obtain a PDMP report at least annually for every patient for whom I prescribe controlled substances - Fair	Ability/likelihood to obtain a PDMP report at least annually for every patient for whom I prescribe controlled substances - Poor	Ability/likelihood to obtain a PDMP report at least annually for every patient for whom I prescribe controlled substances - N/A
Ability/likelihood to appropriately differentiate between physical dependence, tolerance and addiction for patients who are requesting an increase in pain medication dosage	Ability/likelihood to appropriately differentiate between physical dependence, tolerance and addiction for patients who are requesting an increase in pain medication dosage - Excellent	Ability/likelihood to appropriately differentiate between physical dependence, tolerance and addiction for patients who are requesting an increase in pain medication dosage - Very good	Ability/likelihood to appropriately differentiate between physical dependence, tolerance and addiction for patients who are requesting an increase in pain medication dosage - Good	Ability/likelihood to appropriately differentiate between physical dependence, tolerance and addiction for patients who are requesting an increase in pain medication dosage - Fair	Ability/likelihood to appropriately differentiate between physical dependence, tolerance and addiction for patients who are requesting an increase in pain medication dosage - Poor	Ability/likelihood to appropriately differentiate between physical dependence, tolerance and addiction for patients who are requesting an increase in pain medication dosage - N/A

Based upon your participation in this activity, do you intend to change your practice behavior? *

I do plan to implement changes in my practice based on the information presented.

My current practice has been reinforced by the information presented.

I need more information before I will change my practice.

If you plan to change your practice behavior, how confident are you that you will be able to make your intended changes? *

	Very confident	Somewhat confident	Unsure	Not very confident	Not applicable
Obtain a PDMP report prior to the first controlled substance prescription for a patient.	Obtain a PDMP report prior to the first controlled substance prescription for a patient. - Very confident	Obtain a PDMP report prior to the first controlled substance prescription for a patient. - Somewhat confident	Obtain a PDMP report prior to the first controlled substance prescription for a patient. - Unsure	Obtain a PDMP report prior to the first controlled substance prescription for a patient. - Not very confident	Obtain a PDMP report prior to the first controlled substance prescription for a patient. - Not applicable
Obtain a PDMP report at least annually for every patient for whom I prescribe controlled substances.	Obtain a PDMP report at least annually for every patient for whom I prescribe controlled substances. - Very confident	Obtain a PDMP report at least annually for every patient for whom I prescribe controlled substances. - Somewhat confident	Obtain a PDMP report at least annually for every patient for whom I prescribe controlled substances. - Unsure	Obtain a PDMP report at least annually for every patient for whom I prescribe controlled substances. - Not very confident	Obtain a PDMP report at least annually for every patient for whom I prescribe controlled substances. - Not applicable
Appropriately differentiate between physical dependence, tolerance and addiction for patients who are requesting an increase in pain medication dosage.	Appropriately differentiate between physical dependence, tolerance and addiction for patients who are requesting an increase in pain medication dosage. - Very confident	Appropriately differentiate between physical dependence, tolerance and addiction for patients who are requesting an increase in pain medication dosage. - Somewhat confident	Appropriately differentiate between physical dependence, tolerance and addiction for patients who are requesting an increase in pain medication dosage. - Unsure	Appropriately differentiate between physical dependence, tolerance and addiction for patients who are requesting an increase in pain medication dosage. - Not very confident	Appropriately differentiate between physical dependence, tolerance and addiction for patients who are requesting an increase in pain medication dosage. - Not applicable

If you plan to change your practice behavior another way, please specify.

Do you feel the activity was fair balanced and free of commercial bias? *

Yes

No

If no, please explain.

Which of the following do you anticipate will be the primary barrier to implementing these changes?

Formulary restrictions

Insurance/financial issues

Time constraints

Lack of multidisciplinary support

System constraint

Treatment related adverse events

Patient adherence/compliance

Other, please specify:

Which of the following do you anticipate will be the primary barrier to implementing these changes? Other, please specify:

What topics would you like to see in future CME activities?

Do you wish to be notified by email when new educational programs are offered by Elsevier? *

Yes

No

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