References

Table 1. Scale 1: Reluctance to Prescribe Opioids for Chronic Pain

Questions Agree (%) Disagree (%)
Chronic pain of unknown cause should not be treated with narcotics even if this is the only way to obtain pain relief. 22.8 66.3
It is appropriate to escalate a dose of narcotics above the usual range if the prognosis is less than 1 year. 77.2 10.6
If a chronic pain patient is active on the job, there is no possible justification for prescribing narcotics for pain. 10.7 79.7
Narcotics should be restricted to treatment of severe intractable pain. 30.5 64.4
Persons who fit the "profile" of a likely drug abuser should never be treated with narcotics. 26.1 65.5
Prognosis should be the primary factor in deciding whether a patient should receive opiates. 14.5 73.6
Patients who complain of pain out of proportion to its cause are usually drug abusers. 21.8 59.3
Using narcotics to relieve the pain of benign conditions is ill-advised. 31.5 57.5
Even if patients have severe chronic pain, they should be treated with narcotics only when their illness has reached a terminal phase. 9.5 82.2
The presence of a physiologic basis for pain should be the primary factor when deciding to prescribe opiates. 42.6 41.4
I would never prescribe narcotics for a patient with chronic pain who is able to work. 8.8 79.1

Questions	Agree (%)	Disagree (%)
Chronic pain of unknown cause should not be treated with narcotics even if this is the only way to obtain pain relief.	22.8	66.3
It is appropriate to escalate a dose of narcotics above the usual range if the prognosis is less than 1 year.	77.2	10.6
If a chronic pain patient is active on the job, there is no possible justification for prescribing narcotics for pain.	10.7	79.7
Narcotics should be restricted to treatment of severe intractable pain.	30.5	64.4
Persons who fit the "profile" of a likely drug abuser should never be treated with narcotics.	26.1	65.5
Prognosis should be the primary factor in deciding whether a patient should receive opiates.	14.5	73.6
Patients who complain of pain out of proportion to its cause are usually drug abusers.	21.8	59.3
Using narcotics to relieve the pain of benign conditions is ill-advised.	31.5	57.5
Even if patients have severe chronic pain, they should be treated with narcotics only when their illness has reached a terminal phase.	9.5	82.2
The presence of a physiologic basis for pain should be the primary factor when deciding to prescribe opiates.	42.6	41.4
I would never prescribe narcotics for a patient with chronic pain who is able to work.	8.8	79.1

Table 2. Scale 2: Questions Measuring Fear of Patient Addiction

Questions Agree (%) Disagree (%)
Any patient who is given narcotics for pain relief is at significant risk for addiction. 27.9 64.6
I would be extremely concerned about possible addiction if a member of my family were given morphine for chronic pain. 39.2 53.3
I must exercise caution when prescribing potentially addictive medications to patients with chronic pain. 92.8 5.1
When narcotics are used to control chronic pain, addiction is a common outcome. 41.4 49.2
More than 5% of patients who receive narcotics for pain subsequently become addicts. 22.0 44.5

Questions	Agree (%)	Disagree (%)
Any patient who is given narcotics for pain relief is at significant risk for addiction.	27.9	64.6
I would be extremely concerned about possible addiction if a member of my family were given morphine for chronic pain.	39.2	53.3
I must exercise caution when prescribing potentially addictive medications to patients with chronic pain.	92.8	5.1
When narcotics are used to control chronic pain, addiction is a common outcome.	41.4	49.2
More than 5% of patients who receive narcotics for pain subsequently become addicts.	22.0	44.5

Table 3. Scale 3: Questions Measuring Fear of Drug Regulatory Agencies

Questions Agree (%) Disagree (%)
If I prescribe opiates for several months for a patient with chronic pain due to cancer, I am violating state law. 2.4 87.6
My colleagues are more willing to give narcotics for cancer pain than I am. 10.3 52.7
Prescribing narcotics for patients with chronic pain is likely to trigger a drug enforcement agency investigation. 26.4 59.4
Too many narcotic prescriptions lead to utilization reviews. 49.5 22.6
Pharmacists who receive several opiate prescriptions from a doctor are likely to report the doctor to a state review board. 22.6 44.8
If I follow the same prescribing practices as other doctors in my field, I will not be investigated by a regulatory agency. 47.7 18.6
There are limits to the number of narcotics tablets a patient should be prescribed. 67.1 21.7
I give patients a limited supply of pain medications to avoid being investigated. 23.8 53.6

Questions	Agree (%)	Disagree (%)
If I prescribe opiates for several months for a patient with chronic pain due to cancer, I am violating state law.	2.4	87.6
My colleagues are more willing to give narcotics for cancer pain than I am.	10.3	52.7
Prescribing narcotics for patients with chronic pain is likely to trigger a drug enforcement agency investigation.	26.4	59.4
Too many narcotic prescriptions lead to utilization reviews.	49.5	22.6
Pharmacists who receive several opiate prescriptions from a doctor are likely to report the doctor to a state review board.	22.6	44.8
If I follow the same prescribing practices as other doctors in my field, I will not be investigated by a regulatory agency.	47.7	18.6
There are limits to the number of narcotics tablets a patient should be prescribed.	67.1	21.7
I give patients a limited supply of pain medications to avoid being investigated.	23.8	53.6

Table 4. Questions Measuring Knowledge About Pain and Pain Treatment

Questions Agree (%) Disagree (%)
Almost all chronic pain can be relieved with treatment. (True) 67.6 26.4
The majority of patients having chronic pain are undermedicated. (True) 56.5 22.1
Psychologic dependence on narcotics very frequently results from legitimate prescriptions. (False) 53.9 37.3
Suicide with an overdose of narcotics prescribed for pain occurs very frequently. (False) 9.8 73.8
The best judge of pain intensity is the patient. (True) 79.3 14.0
The health care provider is the best judge of pain intensity. (False) 13.2 76.1
Pain in a cancer patient is most likely due to treatment. (False) 3.9 84.0
The tumor itself is most likely the cause of pain in a cancer patient. (True) 67.0 21.5
Preexisting conditions not related to the cancer cause the most pain for cancer patient. (False) 7.6 65.3
Increasing requests for analgesics indicate unrelieved pain. (True) 54.1 30.7
Increasing requests for analgesics indicate tolerance to the analgesic. (False) 62.4 24.7
Almost all cancer patients suffer pain. (True) 53.9 30.7
Almost all cancer patients should receive opiates to relieve chronic pain. (True) 38.3 37.1

Questions	Agree (%)	Disagree (%)
Almost all chronic pain can be relieved with treatment. (True)	67.6	26.4
The majority of patients having chronic pain are undermedicated. (True)	56.5	22.1
Psychologic dependence on narcotics very frequently results from legitimate prescriptions. (False)	53.9	37.3
Suicide with an overdose of narcotics prescribed for pain occurs very frequently. (False)	9.8	73.8
The best judge of pain intensity is the patient. (True)	79.3	14.0
The health care provider is the best judge of pain intensity. (False)	13.2	76.1
Pain in a cancer patient is most likely due to treatment. (False)	3.9	84.0
The tumor itself is most likely the cause of pain in a cancer patient. (True)	67.0	21.5
Preexisting conditions not related to the cancer cause the most pain for cancer patient. (False)	7.6	65.3
Increasing requests for analgesics indicate unrelieved pain. (True)	54.1	30.7
Increasing requests for analgesics indicate tolerance to the analgesic. (False)	62.4	24.7
Almost all cancer patients suffer pain. (True)	53.9	30.7
Almost all cancer patients should receive opiates to relieve chronic pain. (True)	38.3	37.1

Table 5. Questions Measuring Psychologic Attributes Related to Pain and Pain Treatment

Questions Agree (%) Disagree (%)
Compliant patients are entitled to more of my time than noncompliant ones. 46.3 38.6
Those who contribute the most to society should get better health care. 19.5 61.1
I do not like being referred patients with doubtful diagnoses. 21.3 54.7
Life would be better if homosexuals and IV drug abusers were segregated into special groups. 16.3 65.8
If I knew that a prospective patient had an untreatable disease, I would avoid taking that patient if I could. 9.1 79.1
I resent tax money being spent on patients with self-inflicted diseases. 50.2 34.6
A doctor whose practice has few surprises has a lot to be grateful for. 34.7 42.9
It "bugs me" if a consultant I am working with after carefully reviewing a patient says, "I'm not sure." 8.3 73.6
When laboratory reports give conflicting information, I get upset. 27.7 51.1
Conscientious patients deserve better health care than those with self-inflicted problems. 33.0 53.2
It bothers me when even a pathologist cannot find the cause of death. 35.3 41.5
More "health-care dollars" should be spent on those who contribute most to society. 26.2 55.5
I do not enjoy treating patients whose illness is unlikely to respond to treatment. 50.7 37.7
I get irritated by inconsistent medical reports. 41.7 34.7
When the time comes that medical care will have to be rationed, those with high IQs should get the best care. 4.1 81.4
I dislike having patients whose outcomes "don't follow the book." 19.7 52.1
Undiagnosable illnesses are something I'd rather not get involved with. 31.9 47.7

Questions	Agree (%)	Disagree (%)
Compliant patients are entitled to more of my time than noncompliant ones.	46.3	38.6
Those who contribute the most to society should get better health care.	19.5	61.1
I do not like being referred patients with doubtful diagnoses.	21.3	54.7
Life would be better if homosexuals and IV drug abusers were segregated into special groups.	16.3	65.8
If I knew that a prospective patient had an untreatable disease, I would avoid taking that patient if I could.	9.1	79.1
I resent tax money being spent on patients with self-inflicted diseases.	50.2	34.6
A doctor whose practice has few surprises has a lot to be grateful for.	34.7	42.9
It "bugs me" if a consultant I am working with after carefully reviewing a patient says, "I'm not sure."	8.3	73.6
When laboratory reports give conflicting information, I get upset.	27.7	51.1
Conscientious patients deserve better health care than those with self-inflicted problems.	33.0	53.2
It bothers me when even a pathologist cannot find the cause of death.	35.3	41.5
More "health-care dollars" should be spent on those who contribute most to society.	26.2	55.5
I do not enjoy treating patients whose illness is unlikely to respond to treatment.	50.7	37.7
I get irritated by inconsistent medical reports.	41.7	34.7
When the time comes that medical care will have to be rationed, those with high IQs should get the best care.	4.1	81.4
I dislike having patients whose outcomes "don't follow the book."	19.7	52.1
Undiagnosable illnesses are something I'd rather not get involved with.	31.9	47.7

Table 6. Questions Measuring Bias About Sex and Age

Questions Agree (%) Disagree (%)
It is easier for a male patient to become addicted to narcotics than a female. 3.8 65.0
Men are less likely to report pain to their doctor than women. 47.8 32.7
Females are more likely to experience pain than males. 23.0 45.0
Young adults are more likely to become addicted to narcotics than the elderly. 24.1 48.4
Older patients are less likely to report pain than younger patients. 30.9 38.6

Questions	Agree (%)	Disagree (%)
It is easier for a male patient to become addicted to narcotics than a female.	3.8	65.0
Men are less likely to report pain to their doctor than women.	47.8	32.7
Females are more likely to experience pain than males.	23.0	45.0
Young adults are more likely to become addicted to narcotics than the elderly.	24.1	48.4
Older patients are less likely to report pain than younger patients.	30.9	38.6

Table 7. Effect of Community Size on Scales Measuring Physician Attitudes Toward Pain and the Use of Opioid Drugs to Treat Pain

Community Size Mean Score
Scale 1^a Scale 2^b Scale 3^c Knowledge^d Psychologic Attribute^e Sex/Age^f
>1 million 2.97 3.82* 3.48 3.09 3.17^† 3.69
250,000 to 1 million 3.00 3.97 3.54 3.11 3.34^† 3.71
100,000 to 250,000 3.08 4.00 3.55 3.15 3.17^† 3.71
<100,000 3.20 4.31* 3.70 3.21 3.55^† 3.74
^a Scale 1: reluctance to prescribe opioids for chronic pain.
^b Scale 2: fear of patient addiction.
^c Scale 3: fear of scrutiny by drug regulatory agency.
^d Knowledge about pain and pain treatment.
^e Psychologic profile questions indicating respondent's attributes such as authoritarianism and intolerance of ambiguity.
^f Questions assessing sex and age bias.
* Differed significantly at P < .05.
^† Mean scores in areas with populations >1 million and 100,000-250,000 differed significantly (P < .05) from scores in other two community size classifications, which did not differ significantly from each other.

Community Size	Mean Score
Scale 1^a	Scale 2^b	Scale 3^c	Knowledge^d	Psychologic Attribute^e	Sex/Age^f
>1 million	2.97	3.82*	3.48	3.09	3.17^†	3.69
250,000 to 1 million	3.00	3.97	3.54	3.11	3.34^†	3.71
100,000 to 250,000	3.08	4.00	3.55	3.15	3.17^†	3.71
<100,000	3.20	4.31*	3.70	3.21	3.55^†	3.74

Table 8. Effect of Physician Medical Discipline on Scales Measuring Physician Attitudes Toward Pain and the Use of Opioid Drugs to Treat Pain

Medical Discipline Mean Score
Scale 1^a Scale 2^b Scale 3^c Knowledge^d Psychologic Attribute^e Sex/Age^f
Psychiatry 2.81* 3.66* 3.67 3.19 2.88** 3.64
Internal medicine 3.06* 4.12* 3.47^† 3.08 3.26** 3.70
Surgery/Anesthesia 3.20* 4.03* 3.71^† 3.17 3.56** 3.75
Other 3.20* 3.88* 3.47 3.28 3.43** 3.76
^a Scale 1: reluctance to prescribe opioids for chronic pain.
^b Scale 2: fear of patient addiction.
^c Scale 3: fear of scrutiny by drug regulatory agency.
^d Knowledge about pain and pain treatment.
^e Psychologic profile questions indicating respondent's attributes such as authoritarianism and intolerance of ambiguity.
^f Questions assessing sex and age bias.
* Within column, differences between psychiatry and other three medical disciplines approach significance.
^† Difference between marked medical disciplines approaches significance.
** Differences between psychiatry and other three medical disciplines are statistically significant at P < .05.

Medical Discipline	Mean Score
Medical Discipline	Scale 1^a	Scale 2^b	Scale 3^c	Knowledge^d	Psychologic Attribute^e	Sex/Age^f
Psychiatry	2.81*	3.66*	3.67	3.19	2.88**	3.64
Internal medicine	3.06*	4.12*	3.47^†	3.08	3.26**	3.70
Surgery/Anesthesia	3.20*	4.03*	3.71^†	3.17	3.56**	3.75
Other	3.20*	3.88*	3.47	3.28	3.43**	3.76