Evaluation of Loma Linda University Health Physicians’ Attitude and Beliefs Regarding Pain Management

Evaluation of Loma Linda University Health Physicians’ Attitude and Beliefs Regarding Pain Management | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Evaluation of Loma Linda University Health Physicians’ Attitude and Beliefs Regarding Pain Management Paul Gavaza, Wonha Kim, Gregory Olson This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8715087/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background Effective pain management and safe opioid prescribing remain major challenges in healthcare delivery. Prior research demonstrates that primary care clinicians often manage chronic pain with little or no formal training in pain management, contributing to low confidence and apprehension when prescribing opioids. Surveys also show that insufficient knowledge and inadequate preparation are among the most common barriers to adopting evidence-based opioid-prescribing practices. This study examined physicians’ knowledge, attitudes, and perceptions regarding pain management and opioid prescribing at a large academic health system. Methods A cross-sectional survey was administered to physicians across multiple specialties at Loma Linda University Health (LLUH). A 54-item survey instrument developed primarily from existing medical and pharmacy education literature was used to assess physicians’ beliefs, knowledge, and experiences related to pain management. Descriptive statistics summarized demographic and clinical characteristics. Independent t-tests and correlation analyses evaluated associations between training, experience, and attitudes toward pain management and opioid prescribing. Results Of 262 surveys returned, 255 complete responses were included. Respondents averaged 8.3 years in clinical practice and worked approximately 48 hours weekly. Only 34.6% reported receiving formal pain-management training. Most clinicians (76.1%) believed opioid misuse is a major community problem, and 71.4% agreed that medical education devotes insufficient time to pain-management topics. Confidence in opioid-related counseling was moderate; however, fewer than half felt adequately trained or knowledgeable to manage chronic pain safely. Physicians with formal training reported significantly higher confidence in counseling about pain, opioid use, and opioid misuse (p < 0.001). Residents were more likely than attending physicians to view their institution’s pain-management resources positively, while attendings rated their own knowledge and training more favorably. Years of clinical experience correlated positively with perceived adequacy of training and knowledge, but negatively with perceived need for more education on opioid misuse. Conclusions Physicians reported limited formal training in pain management, modest confidence in opioid prescribing, and concern about the adequacy of pain-management education. These findings mirror national evidence showing that primary care clinicians frequently feel underprepared and apprehensive about opioid prescribing. Enhancing institutional support, expanding access to structured pain-management curricula, and integrating standardized opioid-education strategies may strengthen clinician preparedness and improve the quality and safety of pain care within academic health systems. Pain management Opioid prescribing Physician attitudes Medical education Chronic pain Prescription drug monitoring programs Health services research Opioid misuse Highlights Physicians reported substantial gaps in formal pain‑management training, with only one‑third having received dedicated education in this area—mirroring national evidence that many primary care clinicians have little or no formal preparation in pain management. Clinicians expressed apprehension and limited confidence in opioid prescribing, consistent with previous surveys showing inadequate knowledge and low confidence as major barriers to safe opioid stewardship. Most physicians believed opioid misuse is a major community problem, and over 70% agreed that medical education devotes insufficient time to pain‑management topics. Formal pain‑management training was strongly associated with higher confidence and competence, including greater comfort discussing pain, prescribing opioids, and counseling about opioid misuse. Attitudinal differences emerged across demographic groups, with residents more positive about institutional pain‑management resources and attendings reporting higher perceived knowledge and training adequacy. Introduction Pain is one of the most common reasons patients seek medical care in the United States, yet its management remains one of the most complex and debated aspects of clinical practice. National data indicate that opioid prescribing has declined by more than 50% since 2012, reflecting ongoing stewardship efforts; yet patients still face barriers to multimodal, non-opioid pain care due to restrictive coverage and fragmented access to comprehensive services. 1 – 3 Despite advances in analgesic therapies and multimodal pain strategies, disparities and inconsistencies in pain treatment persist across clinical disciplines. 4 , 5 Physicians play a pivotal role in assessing, diagnosing, and managing pain, but their decisions are shaped by a combination of clinical knowledge, personal beliefs, institutional policies, and broader societal expectations. 6 , 7 Despite progress, physicians continue to report persistent obstacles to delivering guideline-concordant pain care, including limited interdisciplinary resources, insufficient time for the complexity of chronic pain, and ongoing uncertainty around opioid prescribing and monitoring. 8 , 9 In recent decades, concerns over opioid misuse and overprescription have intensified scrutiny of physicians’ prescribing behaviors and attitudes toward pain control. 10 , 11 This shift has created a delicate balance between ensuring adequate pain relief and preventing harm from inappropriate opioid use. Provider hesitancy persists even in clinical scenarios where opioids remain standard of care. Among prescribers treating chronic cancer pain, substantial proportions report reluctance to prescribe and describe pharmacy-level dispensing challenges—effects likely related to policy shifts and safety concerns. 12 , 13 Beyond pharmacotherapy, clinicians identify implementation gaps in pain assessment and outcome tracking. Physicians report low confidence interpreting patient-reported outcome measures (PROMs) scores and difficulty integrating PROMs into routine workflow, 8 and pain medicine clinicians describe regulatory constraints, educational gaps, and mixed sentiment about progress in the field. 14 – 17 Studies have shown that physicians often experience tension between clinical guidelines and patient expectations, as well as uncertainty in interpreting pain subjectivity. 18 , 19 Consequently, physicians’ individual attitudes—ranging from empathy and trust in patient-reported pain to perceptions of misuse risk—significantly influence management decisions. Specialty-specific perspectives also shape care patterns; for example, palliative physicians report positive attitudes toward collaboration with pain medicine specialists but relatively low referral rates, suggesting opportunities for interprofessional education and co-management pathways. 1 , 20 Institutional and cultural factors also shape approaches to pain management. Loma Linda University Health (LLUH), a faith-based academic medical center with a long-standing emphasis on whole-person care, presents a unique environment in which spiritual, ethical, and professional values may collectively influence attitudes toward pain management. Although LLUH has a strong reputation for compassionate, evidence-based care, little is known about its physicians’ opinions and attitudes toward pain management and how these may align with or diverge from broader national trends. Therefore, the present study aims to investigate the attitudes and opinions of physicians at LLUH regarding pain management. Methods This cross-sectional survey study was approved by the LLUH Institutional Review Board (IRB). A 54-item survey instrument was developed primarily from existing medical and pharmacy education literature to assess physicians’ beliefs, knowledge, and experiences related to pain management. An email describing the purpose of the study and containing a link to the online survey was distributed to all practicing LLUH physicians via the LLUH physician mailing list by a college administrator. The mailing list included email addresses for all actively practicing LLUH physicians numbering approximately 500 physicians in Spring 2018. Physicians were asked to complete the survey within one week of the initial email. A reminder email, which included a revised study description and the survey link, was sent three weeks after the initial invitation. The estimated time to complete the questionnaire was approximately 10 minutes. Data collection occurred over a six-week period. As incentives, physicians were offered an aggregated summary of study results and entry into a drawing to win one of ten $ 25 Amazon gift cards and one iPad II. Non-active or retired LLUH healthcare providers were excluded. Survey Instrument The survey included 36 belief items assessing physicians’ opinions regarding pain management. Responses to the first 21 of these 36 items which addressed pain management in general were recorded on a 7-point Likert scale ranging from strongly disagree (1) to strongly agree (7) whereas responses to the remaining 15 items which specifically addressed pain management practices at LLUH were recorded on a 5-point Likert scale ranging from strongly disagree (1) to strongly agree (5). The survey also included 18 items assessing practice characteristics, including the number of opioid prescriptions written for acute and chronic pain, the percentage of time devoted to palliative care, registration status for accessing a prescription drug monitoring program (PDMP), and frequency of PDMP use when prescribing pain medications (always/sometimes/rarely/never), among other practice-related variables. Items captured demographic and professional characteristics, including gender (male/female/decline to answer), practice status (full-time/part-time/not practicing), current job title at the primary place of employment (resident/fellow/attending), medical specialty, and years in clinical practice. Respondents were also provided an open-ended item to share any additional comments about pain management. Data Analysis Survey data were downloaded and analyzed using PASW Statistics (SPSS Inc., Chicago, IL). Descriptive statistics (frequencies, means, and standard deviations) were computed for all variables. Group comparisons were conducted using analysis of variance (ANOVA), t-tests, and chi-square tests, as appropriate. Statistical significance was set at an alpha level of 0.05 (two-sided). Results A total of 262 responses were received. However, 255 complete responses were analyzed after 7 incomplete responses were excluded. Table 1 summarizes the demographic and professional characteristics of the respondents. Most participants were male (n = 135, 53.1%) and represented a wide range of medical specialties including internal medicine, pediatrics, and surgery among others. Nearly half were residents (n = 123, 48.4%), and the majority practiced full-time (n = 239, 94.1%). Although two‑thirds of respondents reported treating patients with chronic pain (terminal, non‑terminal, or both), only about one-third had received formal training in pain management (n = 88, 34.6%). On average, respondents had over eight years of clinical experience and worked approximately 48 hours per week in clinical settings. Use of prescription drug monitoring programs (PDMPs) varied widely, with more than one‑third reporting that they never used a PDMP when prescribing opioids (n = 89, 35.5%). (Table 1 appears here) Table 2 presents physicians’ attitudes and perceptions regarding pain management and opioid prescribing. Overall, physicians agreed (somewhat to strongly agreed) that opioid misuse and opioid‑related deaths are significant problems in the community (n = 151, 59.2%). Respondents generally felt moderately comfortable counseling patients about pain management and opioid use, although fewer believed they had adequate training or knowledge in this area. Many agreed that medical education devotes insufficient time to pain management (n = 182, 71.4%). Physicians also expressed greater willingness to prescribe opioids for acute or terminal pain than for chronic non‑terminal pain (n = 182, 71.7%). Perceived effectiveness of opioids for chronic pain was low, with most respondents disagreeing (somewhat to strongly disagreeing) that opioids are highly effective for long‑term use (n = 165, 64.9%). (Table 2 appears here) Table 3 summarizes physicians’ views about pain management within the LLUH system. Ratings suggested that chronic pain management is perceived as suboptimal, whereas acute pain management received somewhat more favorable evaluations. Respondents expressed mixed views about the adequacy of institutional support, consultation resources, and data collection on pain management quality. While most agreed that PDMPs are useful (n = 199, 79.6%) and that open communication may reduce opioid misuse, many also reported needing additional information on managing opioid abuse and endorsed the need for improved physician education in pain management (n = 162, 64.5). Self‑assessed knowledge remained modest (n = 86, 34.7% agreed they had adequate knowledge while 75 (30.2%) disagreed), and most participants believed that many physicians lack adequate understanding of effective pain management. Associations between physicians’ views and demographic characteristics a. Gender Although 32 of the 36 items showed no gender differences, males reported higher scores on four items. For example, comfort counseling about pain management was higher in men (Mean = 5.1 vs. 4.6; p = 0.018). Men also rated their training (4.3 vs. 3.8; p = 0.01) and knowledge (3.2 vs. 2.8; p = 0.001) higher than women, and expressed greater confidence counseling about misuse (5.0 vs. 4.6; p = 0.03). b. Current Job Title Across 28 of the 36 items, there were no statistically significant mean attitude differences between residents and attending physicians. However, residents scored significantly higher than attending physicians on five items, including perceptions that opioid abuse is a problem in their practice (4.9 vs. 4.2; p = 0.005) and that acute pain is well managed at LLUH (3.8 vs. 3.5; p = 0.001). Conversely, attendings rated themselves higher on three items, such as adequacy of pain‑management training (4.4 vs. 3.7; p = 0.001) and adequate knowledge (3.2 vs. 2.9; p = 0.004). c. Training on Pain Management There were no statistically significant differences in mean attitude scores between those who had formal pain management training and those who did not across 23 of the 36 items (see table 4). Formal training was, however, associated with significantly greater comfort, confidence, and perceived competence. For example, trained physicians reported much higher adequacy of training (4.9 vs. 3.6; p < 0.001) and more confidence discussing appropriate opioid use (5.4 vs. 4.6; p < 0.001). Those with training were also significantly more likely to counsel patients about risks and side effects (5.8 vs. 5.2; p = 0.001). (Table 4 appears here) Mean Attitudes Scores and Years of Practice There was no statistically significant correlation between a physician’s years of practice experience and attitude on 26 of the 36 items investigated (p > 0.05). However, there was a statistically significant correlation between a physician’s years of practice experience and attitude on the remaining 10 items (p < 0.05). Six items were negatively correlated, indicating that more experienced physicians were less likely to endorse concerns about opioid misuse or the need for education: Prescription opioid abuse is a problem in my practice setting (r = -0.251, p<0.001); Prescription opioid abuse is a problem in my society/area/community (r = -0.148, p = 0.021); Little time is devoted to pain management topics in medical education (r = -0.197, p = 0.002); Utilizing a prescription drug monitoring program is useful in helping to combat the epidemic of prescription opioid misuse and death (r = -0.170, p = 0.09); I need more information on how to manage the opioid abuse.(r = -0.241, p <0.001) and There is need for improved physician education in pain management including the use of opioids (r = -0.131, p = 0.043). Four items were positively correlated, suggesting that more experienced clinicians felt more confident in their training and patient responsibility: I feel that I have adequate training in pain management (r =0.206, p = 0.001); Benefits of opioids outweigh side-effects of opioids (r = 0.161, p = 0.013); Most of my patients responsibly take their prescribed opioids (r = 0.169, p = 0.009) and I have adequate knowledge about pain management (r = 0.176, p =0.006). Discussion This study provides a comprehensive evaluation of physicians’ knowledge, attitudes, and practices related to pain management and opioid prescribing at a large academic medical center at the time of study. The study highlights a familiar but consequential pattern in contemporary pain care: clinicians widely recognize prescription opioid misuse as a major community problem, yet many report gaps in training, mixed confidence in key counseling tasks, substantial reluctance to prescribe opioids for chronic non-terminal pain, and inconsistent use of prescription drug monitoring programs (PDMPs). Collectively, these findings suggest that improving pain care will likely require paired interventions—strengthening clinician education/skills and improving system supports (e.g., consultation pathways, workflow-integrated risk mitigation tools, and consistent measurement of pain-care quality). Perceived burden of opioid misuse and implications for practice Consistent with previous literature, many physicians in this study reported concerns about opioid misuse in both their immediate practice setting and the broader community. National evidence shows that healthcare professionals frequently struggle with balancing adequate pain control against fears of opioid misuse and regulatory scrutiny, contributing to clinical inertia and inconsistent adherence to prescribing guidelines. In our sample, the strong agreement that opioid misuse is a community problem aligns with well-documented national public health concerns regarding opioid overuse, diversion, and overdose. 21 , 22 The American Academy of Family Physicians similarly emphasizes the dual crises of undertreated pain and opioid misuse faced by clinicians across the United States. 21 , 22 Importantly, the CDC’s 2022 guideline emphasizes balancing benefits and risks, shared decision-making, and individualized care across acute, subacute, and chronic pain. 23 Training gaps align with low confidence and selective risk-mitigation behaviors A central finding of this study is that a substantial proportion of respondents felt inadequately trained and insufficiently knowledgeable about pain management. Many clinicians reported limited formal instruction, low perceived competence, and strong agreement that medical education devotes too little time to pain-related topics. These results mirror longstanding national concerns that pain education—particularly in the areas of chronic pain, opioid stewardship, and complex risk-benefit decision-making—has historically been insufficient in both undergraduate and graduate medical training. 24 – 27 The associations observed in our study between prior pain-management training and higher comfort in counseling patients, greater confidence discussing opioid use and misuse, and more frequent counseling about risks and side effects are clinically meaningful. They suggest that strengthening structured educational interventions—such as evidence-based opioid-prescribing curricula, patient-communication training, and risk-mitigation strategies—could enhance clinician self-efficacy while promoting more consistent, high-quality counseling practices. 28 Recent policy changes in California further underscore the movement toward expanded education: as of 2023, all DEA-licensed practitioners are required to complete eight hours of training focused on the treatment and management of patients with opioid and other substance-use disorders, an effort that directly addresses many of the gaps identified in this study. At the same time, education alone is unlikely to close all gaps. For example, even among trained clinicians, pain care can be constrained by time, limited access to interdisciplinary resources, and fragmented follow-up—issues that are better addressed by system-level supports such as standardized pathways, consult services, and decision-support embedded in the electronic health record (EHR). The present findings also highlight meaningful differences in attitudes based on gender, level of training, and pain-management education. Male physicians and attending physicians tended to rate their knowledge and training more favorably than female physicians or residents. These patterns may reflect greater cumulative clinical exposure or differences in perceived preparedness, though the literature suggests that confidence in opioid prescribing does not always correlate with guideline adherence. 21 Importantly, physicians who had received formal pain-management training consistently exhibited higher confidence and competence in multiple dimensions of opioid counseling and risk assessment. This finding aligns closely with national recommendations calling for enhanced training and improved education standards in medical curricula and continuing professional development. Both the American Society of Interventional Pain Physicians (ASIPP) and the Federation of State Medical Boards (FSMB) have emphasized the need for updated, evidence-based training to support safe and effective opioid prescribing. 28 , 29 Attitudes toward opioids for chronic pain reflect evolving evidence Respondents generally preferred opioids for acute rather than chronic pain and were reluctant to use opioids for moderate-to-severe chronic non-terminal pain. This stance is consistent with the broader evidence base showing limited long-term benefit of opioids for common chronic pain conditions, with meaningful risks and uncertain functional improvement. Notably, the SPACE randomized clinical trial found that opioid therapy was not superior to nonopioid therapy for pain-related function over 12 months in chronic back pain or hip/knee osteoarthritis. 30 Evidence syntheses have similarly emphasized small-to-modest benefits with dose-dependent harms and the importance of careful selection, monitoring, and multimodal strategies. 31 However, reluctance can have unintended consequences if it leads to undertreatment, avoidance of difficult conversations, or abrupt changes in therapy without adequate support. The CDC guideline cautions against inflexible thresholds and underscores the importance of ongoing assessment, careful tapering when indicated, and access to nonopioid and nonpharmacologic options. 23 PDMP access and utilization remain inconsistent despite perceived utility PDMP registration and use varied widely, with more than one-third reporting never using a PDMP when prescribing opioids. This is notable because respondents also largely agreed that PDMPs are useful for addressing prescription opioid misuse. Low or inconsistent utilization has been documented previously, often due to workflow barriers, limited integration into EHRs, uncertainty about indications for checking, and variable state requirements. 32 Evidence on PDMP impact is mixed overall, although mandated-access policies and stronger PDMP features have been associated with improved prescribing outcomes and, in some studies, reductions in opioid-related harms. 33 In California, the PDMP is known as the Controlled Substance Utilization Review and Evaluation System (CURES). CURES is a statewide database that tracks all Schedule II–V controlled substances dispensed in California and supports public health efforts, regulatory oversight, and law-enforcement functions. California began requiring prescribers to consult CURES before issuing prescriptions for controlled substances in October 2018, a policy designed to address many of the concerns identified in this study. This mandate helps resolve the issues highlighted in our findings and promotes consistent use of CURES by reducing reliance on clinician motivation alone. Differences by role, gender, and experience point to targeted strategies Residents reported higher perceived concern about opioid misuse in practice and greater need for information on opioid abuse management, but lower perceived adequacy of training and knowledge relative to attendings. This pattern is consistent with a training-stage effect: residents may face high exposure and uncertainty while still developing skills and supervisory supports. Structured curricula and supervised practice (e.g., coached patient conversations, case-based reviews, and feedback on prescribing decisions) may be particularly beneficial in residency. Male physicians reported higher self-rated comfort and knowledge on several items compared with female physicians. While the study cannot determine the reasons, this difference could reflect variation in confidence, differential training experiences, or differences in clinical roles. Ensuring equitable access to pain-management education, mentorship, and supportive feedback (particularly for high-stakes conversations about opioids and misuse) may help reduce disparities in perceived competence. More years of practice correlated with higher perceived training/knowledge and lower perceived need for more information, while also correlating with reduced perception of opioid misuse as a problem. This could indicate increasing confidence over time, but it may also signal a risk of complacency or reduced perceived relevance of evolving best practices. Periodic refreshers and audit-and-feedback (e.g., prescribing dashboards, case reviews) can help maintain alignment with current evidence and guidelines across experience levels. Institutional pain management and signals for quality improvement Respondents were less confident that chronic pain is well managed at LLUH than acute pain. Many physicians believed that institutional commitment and available referral resources were insufficient. This finding mirrors national concerns that U.S. healthcare systems remain poorly equipped to manage chronic pain comprehensively, often lacking integrated, multidisciplinary care pathways. The AAFP notes that chronic pain care remains fragmented across settings, with insufficient coordination and limited availability of specialized services—challenges consistent with those identified by physicians who participated in our study. 22 These findings support the need for a quality-improvement approach that couples education with accessible specialty support (e.g., interdisciplinary pain clinic, addiction medicine pathways, palliative care support, behavioral health, physical therapy) and explicit institutional metrics (e.g., guideline-concordant monitoring, PDMP checking rates where applicable, naloxone co-prescribing when indicated, functional outcomes, and patient-reported pain interference). The Institute of Medicine’s call to transform pain care emphasizes integrated, interdisciplinary models and improved education—both relevant to these institutional signals. Together, these findings underscore a clear need for improved institutional support, enhanced pain-management training, and ongoing professional development tailored to the diverse needs of clinicians. Strengthening education, promoting consistent PDMP engagement, and expanding access to multidisciplinary resources may not only improve physician confidence but also enhance patient outcomes and reduce opioid-related harms. Limitations of the study Several limitations should be considered when interpreting these findings. First, the study relied on self-reported data, which may be subject to recall bias, social desirability bias, or inaccuracies in estimating clinical behaviors such as opioid prescribing or PDMP use. Second, the sample was drawn from a single academic health system, potentially limiting generalizability to other settings with different practice cultures, resources, or patient populations. Third, the cross-sectional design precludes causal inference regarding the relationships between demographics, training, and attitudes. Fourth, the analyses involved multiple comparisons across many attitude items, increasing the risk of type I error. Fifth, the study findings reflect the situation only at the time of data collection. It is likely that physicians’ knowledge and practice patterns have evolved since then, given the implementation of several statewide interventions in California. Notably, California began requiring prescribers to consult CURES before prescribing controlled substances effective October 2018, and as of 2023, all DEA-licensed practitioners must complete eight hours of training on the treatment and management of patients with opioid and other substance use disorders. Our data collection occurred before these requirements were in place. Finally, variations in respondents’ clinical roles (e.g., resident vs. attending) and exposure to pain-management curricula over time may influence attitudes in ways not fully captured by this study. Future research incorporating qualitative data, multi-institutional samples, and longitudinal designs may help further clarify the evolving landscape of pain-management attitudes and identify effective strategies for improving clinician preparedness and patient safety. Conclusion Physicians at LLUH recognize prescription opioid misuse as a significant community problem and report substantial patient frustration related to opioid restrictions, yet many report limited formal training in pain management and inconsistent use of PDMPs despite perceiving PDMPs as useful. Training was associated with greater comfort and confidence in counseling and risk communication, suggesting that structured education is a practical lever for improvement. To strengthen chronic pain care and opioid stewardship at LLUH, interventions should combine targeted clinician education (especially for trainees) with workflow-integrated PDMP access, clear consultation/referral pathways, and measurable institutional quality indicators for pain management. Declarations Data availability Individual participant level information is not available to preserve anonymity but research material and sample level information is available from the corresponding author on reasonable request. Ethics approval and consent to participate This study has been approved by the Loma Linda University Health Institutional review Board. Informed consent was obtained from all participants prior to their completion of the survey. Data collection was conducted anonymously, ensuring that no personally identifiable information was recorded. Participants were informed of their right to withdraw from the study at any time without facing any penalties. All procedures adhered to the ethical principles set forth in the Declaration of Helsinki. Consent for publication Not applicable. Availability of data and materials Individual participant level information is not available to preserve anonymity but research material and sample level information is available from the corresponding author upon reasonable request. Competing interests The authors claim that there is no competitive interest in this research. Funding No external funding was obtained for this study. Authors’ contributions PG performed research design, data collection and analysis, interpretation of results, and manuscript preparation. WK and GO assisted with the interpretation of results, contributed to the research idea and designed, advised the whole research process, and helped prepare the manuscript. All authors read and approved the final manuscript. Acknowledgments The author thanks the medical staff who participated in this study. In addition, we are grateful for the hard work of the editors and the valuable suggestions of the reviewers. References Del Pozo B, Park JN, Taylor BG, et al. Knowledge, Attitudes, and Beliefs About Opioid Use Disorder Treatment in Primary Care. JAMA Netw Open 2024;7(6):e2419094. Baker MB, Liu EC, Bully MA, et al. Overcoming Barriers: A Comprehensive Review of Chronic Pain Management and Accessibility Challenges in Rural America. Healthcare (Basel) 2024;12(17):1765. Pristell C, Byun H, Huffstetler AN. Opioid Prescribing Has Significantly Decreased in Primary Care. Am Fam Physician 2024;110(6):572–73. Green CR, Anderson KO, Baker TA, et al. The unequal burden of pain: confronting racial and ethnic disparities in pain. Pain Med 2003;4(3):277–94. Leonard C, Ayele R, Ladebue A, et al. Barriers to and Facilitators of Multimodal Chronic Pain Care for Veterans: A National Qualitative Study. Pain Med 2021;22(5):1167–73. Mezei L, Murinson BB, Johns Hopkins Pain Curriculum Development T. Pain education in North American medical schools. J Pain 2011;12(12):1199–208. Upshur CC, Luckmann RS, Savageau JA. Primary care provider concerns about management of chronic pain in community clinic populations. J Gen Intern Med 2006;21(6):652–5. Kaseweter K, Nazemi M, Gregoire N, et al. Physician perspectives on chronic pain management: barriers and the use of eHealth in the COVID-19 era. BMC Health Serv Res 2023;23(1):1131. Ashcraft LE, Hamm ME, Omowale SS, et al. The perpetual evidence-practice gap: addressing ongoing barriers to chronic pain management in primary care in three steps. Front Pain Res (Lausanne) 2024;5:1376462. Volkow ND, McLellan AT. Opioid Abuse in Chronic Pain--Misconceptions and Mitigation Strategies. N Engl J Med 2016;374(13):1253–63. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA 2016;315(15):1624–45. Arthur J, Edwards T, Lu Z, et al. Healthcare provider perceptions and reported practices regarding opioid prescription for patients with chronic cancer pain. Support Care Cancer 2024;32(2):121. Edens EL, Garcia Vassallo G, Heimer R. How Should the Use of Opioids Be Regulated to Motivate Better Clinical Practice? AMA J Ethics 2024;26(7):E551–61. Marotta PL, Biaid M, Heimer R, et al. Rural providers' attitudes toward integrating harm reduction strategies and PrEP prescribing into rural primary care settings in the US. Southeast and Midwest. Addict Sci Clin Pract 2025;20(1):73. Khawagi WY, Bansal N, Shang N, Chen L-C. A Systematic Review of Potential Opioid Prescribing Safety Indicators. Pharmacoepidemiology 2025;4(1):4. Punwasi R, de Kleijn L, Rijkels-Otters JBM, et al. General practitioners' attitudes towards opioids for non-cancer pain: a qualitative systematic review. BMJ Open 2022;12(2):e054945. American Academy of Pain Medicine. Pain Pulse Survey 2024. https://painmed.org/wp-content/uploads/2024/04/Pain-Pulse-Booklet_web.pdf; 2024. Matthias MS, Johnson NL, Shields CG, et al. "I'm Not Gonna Pull the Rug out From Under You": Patient-Provider Communication About Opioid Tapering. J Pain 2017;18(11):1365–73. Darnall BD, Carr DB, Schatman ME. Pain Psychology and the Biopsychosocial Model of Pain Treatment: Ethical Imperatives and Social Responsibility. Pain Med 2017;18(8):1413–15. Partain DK, Santivasi WL, Kamdar MM, et al. Attitudes and Beliefs Regarding Pain Medicine: Results of a National Palliative Physician Survey. J Pain Symptom Manage 2024;68(2):115–22. Rash JA, Buckley N, Busse JW, et al. Healthcare provider knowledge, attitudes, beliefs, and practices surrounding the prescription of opioids for chronic non-cancer pain in North America: protocol for a mixed-method systematic review. Syst Rev 2018;7(1):189. American Academy of Family Physicians (AAFP). Opioid Use and Misuse: A Public Health Concern (Position Paper); 2025. Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022. MMWR Recomm Rep 2022;71(3):1–95. Council NR. Relieving pain in America: A blueprint for transforming prevention, care, education, and research. Washington, DC 2011;22553896. Tobin DG, Andrews R, Becker WC. Prescribing opioids in primary care: Safely starting, monitoring, and stopping. Cleve Clin J Med 2016;83(3):207–15. Sohn N, Lai B, Deyo-Svendsen M. Buprenorphine Prescribing Among Primary Care Clinicians for Chronic Pain and Opioid Use Disorder. J Am Board Fam Med 2025;38(5):933–39. Jamison RN, Scanlan E, Matthews ML, Jurcik DC, Ross EL. Attitudes of Primary Care Practitioners in Managing Chronic Pain Patients Prescribed Opioids for Pain: A Prospective Longitudinal Controlled Trial. Pain Med 2016;17(1):99–113. Manchikanti L, Kaye AM, Knezevic NN, et al. Comprehensive, Evidence-Based, Consensus Guidelines for Prescription of Opioids for Chronic Non-Cancer Pain from the American Society of Interventional Pain Physicians (ASIPP). Pain Physician 2023;26(7S):S7–S126. Federation of State Medical Boards (FSMB). Strategies for Prescribing Opioids for the Management of Pain. Adopted by FSMB House of Delegates, April 2024; 2024. Krebs EE, Gravely A, Nugent S, et al. Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial. JAMA 2018;319(9):872–82. Chou R, Selph S, Wagner J, et al. Systematic review on opioid treatments for chronic pain: surveillance report 3: literature update period: December 2021 to March 16 2022. 2023. Haffajee RL, Jena AB, Weiner SG. Mandatory use of prescription drug monitoring programs. JAMA 2015;313(9):891–2. Puac-Polanco V, Chihuri S, Fink DS, et al. Prescription Drug Monitoring Programs and Prescription Opioid-Related Outcomes in the United States. Epidemiol Rev 2020;42(1):134–53. Tables Tables 1 to 4 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Tables.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 19 Mar, 2026 Reviews received at journal 05 Mar, 2026 Reviewers agreed at journal 23 Feb, 2026 Reviewers agreed at journal 20 Feb, 2026 Reviews received at journal 16 Feb, 2026 Reviewers agreed at journal 13 Feb, 2026 Reviewers invited by journal 04 Feb, 2026 Editor invited by journal 04 Feb, 2026 Editor assigned by journal 03 Feb, 2026 Submission checks completed at journal 03 Feb, 2026 First submitted to journal 27 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8715087","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":587537472,"identity":"cbbd8014-a0e1-4b56-92ac-94109b99c144","order_by":0,"name":"Paul Gavaza","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAr0lEQVRIiWNgGAWjYBADOT52EMVGghZjNmZStSS2Ea3FnH/xM4kff+zS25h5DBg+lB0mrMVyxjMzyR6e5FyQFsYZ54jQYnDjgLEBjwQzWAszbxtRWo5/NvxjUJ/OBtLylygt53sMH/MkHE4Aa2EkRovlDJ7CxzIHjhu2MbMVHOw5l05Yizn/8Q0H3/ypludnb9744EeZNREOk0hAcA4QVg/Swk+culEwCkbBKBjJAADcszQnA5MB3AAAAABJRU5ErkJggg==","orcid":"","institution":"Loma Linda University School of Pharmacy","correspondingAuthor":true,"prefix":"","firstName":"Paul","middleName":"","lastName":"Gavaza","suffix":""},{"id":587537475,"identity":"b6adf866-36ca-4427-90cb-e3c409056551","order_by":1,"name":"Wonha Kim","email":"","orcid":"","institution":"Loma Linda University Health Care","correspondingAuthor":false,"prefix":"","firstName":"Wonha","middleName":"","lastName":"Kim","suffix":""},{"id":587537477,"identity":"5ea69acf-c9ca-4ae4-b2f3-9446c6140d95","order_by":2,"name":"Gregory Olson","email":"","orcid":"","institution":"The University of Texas Health Science Center at Houston","correspondingAuthor":false,"prefix":"","firstName":"Gregory","middleName":"","lastName":"Olson","suffix":""}],"badges":[],"createdAt":"2026-01-28 01:23:37","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8715087/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8715087/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102235931,"identity":"6159c796-1c61-4844-b8b3-a376f47ce2ee","added_by":"auto","created_at":"2026-02-09 16:18:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":723958,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8715087/v1/ff616388-9401-4dd1-81fa-6b9e29ba855c.pdf"},{"id":102235848,"identity":"d8be639c-f3d9-479c-b9ad-e119464c6574","added_by":"auto","created_at":"2026-02-09 16:18:02","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":37328,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-8715087/v1/a03c4bf8a0a8174d1c6d5057.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Evaluation of Loma Linda University Health Physicians’ Attitude and Beliefs Regarding Pain Management","fulltext":[{"header":"Highlights","content":"\u003cul\u003e\n \u003cli\u003ePhysicians reported substantial gaps in formal pain‑management training, with only one‑third having received dedicated education in this area\u0026mdash;mirroring national evidence that many primary care clinicians have little or no formal preparation in pain management.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eClinicians expressed apprehension and limited confidence in opioid prescribing, consistent with previous surveys showing inadequate knowledge and low confidence as major barriers to safe opioid stewardship.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMost physicians believed opioid misuse is a major community problem, and over 70% agreed that medical education devotes insufficient time to pain‑management topics.\u003c/li\u003e\n \u003cli\u003eFormal pain‑management training was strongly associated with higher confidence and competence, including greater comfort discussing pain, prescribing opioids, and counseling about opioid misuse.\u003c/li\u003e\n \u003cli\u003eAttitudinal differences emerged across demographic groups, with residents more positive about institutional pain‑management resources and attendings reporting higher perceived knowledge and training adequacy.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Introduction","content":"\u003cp\u003ePain is one of the most common reasons patients seek medical care in the United States, yet its management remains one of the most complex and debated aspects of clinical practice. National data indicate that opioid prescribing has declined by more than 50% since 2012, reflecting ongoing stewardship efforts; yet patients still face barriers to multimodal, non-opioid pain care due to restrictive coverage and fragmented access to comprehensive services.\u003csup\u003e\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Despite advances in analgesic therapies and multimodal pain strategies, disparities and inconsistencies in pain treatment persist across clinical disciplines.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Physicians play a pivotal role in assessing, diagnosing, and managing pain, but their decisions are shaped by a combination of clinical knowledge, personal beliefs, institutional policies, and broader societal expectations.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eDespite progress, physicians continue to report persistent obstacles to delivering guideline-concordant pain care, including limited interdisciplinary resources, insufficient time for the complexity of chronic pain, and ongoing uncertainty around opioid prescribing and monitoring.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e In recent decades, concerns over opioid misuse and overprescription have intensified scrutiny of physicians\u0026rsquo; prescribing behaviors and attitudes toward pain control.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e This shift has created a delicate balance between ensuring adequate pain relief and preventing harm from inappropriate opioid use.\u003c/p\u003e \u003cp\u003eProvider hesitancy persists even in clinical scenarios where opioids remain standard of care. Among prescribers treating chronic cancer pain, substantial proportions report reluctance to prescribe and describe pharmacy-level dispensing challenges\u0026mdash;effects likely related to policy shifts and safety concerns.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Beyond pharmacotherapy, clinicians identify implementation gaps in pain assessment and outcome tracking. Physicians report low confidence interpreting patient-reported outcome measures (PROMs) scores and difficulty integrating PROMs into routine workflow,\u003csup\u003e8\u003c/sup\u003e and pain medicine clinicians describe regulatory constraints, educational gaps, and mixed sentiment about progress in the field.\u003csup\u003e\u003cspan additionalcitationids=\"CR15 CR16\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eStudies have shown that physicians often experience tension between clinical guidelines and patient expectations, as well as uncertainty in interpreting pain subjectivity.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e Consequently, physicians\u0026rsquo; individual attitudes\u0026mdash;ranging from empathy and trust in patient-reported pain to perceptions of misuse risk\u0026mdash;significantly influence management decisions. Specialty-specific perspectives also shape care patterns; for example, palliative physicians report positive attitudes toward collaboration with pain medicine specialists but relatively low referral rates, suggesting opportunities for interprofessional education and co-management pathways.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eInstitutional and cultural factors also shape approaches to pain management. Loma Linda University Health (LLUH), a faith-based academic medical center with a long-standing emphasis on whole-person care, presents a unique environment in which spiritual, ethical, and professional values may collectively influence attitudes toward pain management. Although LLUH has a strong reputation for compassionate, evidence-based care, little is known about its physicians\u0026rsquo; opinions and attitudes toward pain management and how these may align with or diverge from broader national trends. Therefore, the present study aims to investigate the attitudes and opinions of physicians at LLUH regarding pain management.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e This cross-sectional survey study was approved by the LLUH Institutional Review Board (IRB). A 54-item survey instrument was developed primarily from existing medical and pharmacy education literature to assess physicians\u0026rsquo; beliefs, knowledge, and experiences related to pain management. An email describing the purpose of the study and containing a link to the online survey was distributed to all practicing LLUH physicians via the LLUH physician mailing list by a college administrator. The mailing list included email addresses for all actively practicing LLUH physicians numbering approximately 500 physicians in Spring 2018.\u003c/p\u003e \u003cp\u003ePhysicians were asked to complete the survey within one week of the initial email. A reminder email, which included a revised study description and the survey link, was sent three weeks after the initial invitation. The estimated time to complete the questionnaire was approximately 10 minutes. Data collection occurred over a six-week period. As incentives, physicians were offered an aggregated summary of study results and entry into a drawing to win one of ten \u003cspan\u003e$\u003c/span\u003e25 Amazon gift cards and one iPad II.\u003c/p\u003e \u003cp\u003eNon-active or retired LLUH healthcare providers were excluded.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSurvey Instrument\u003c/h2\u003e \u003cp\u003eThe survey included 36 belief items assessing physicians\u0026rsquo; opinions regarding pain management. Responses to the first 21 of these 36 items which addressed pain management in general were recorded on a 7-point Likert scale ranging from strongly disagree (1) to strongly agree (7) whereas responses to the remaining 15 items which specifically addressed pain management practices at LLUH were recorded on a 5-point Likert scale ranging from strongly disagree (1) to strongly agree (5).\u003c/p\u003e \u003cp\u003eThe survey also included 18 items assessing practice characteristics, including the number of opioid prescriptions written for acute and chronic pain, the percentage of time devoted to palliative care, registration status for accessing a prescription drug monitoring program (PDMP), and frequency of PDMP use when prescribing pain medications (always/sometimes/rarely/never), among other practice-related variables.\u003c/p\u003e \u003cp\u003eItems captured demographic and professional characteristics, including gender (male/female/decline to answer), practice status (full-time/part-time/not practicing), current job title at the primary place of employment (resident/fellow/attending), medical specialty, and years in clinical practice. Respondents were also provided an open-ended item to share any additional comments about pain management.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eSurvey data were downloaded and analyzed using PASW Statistics (SPSS Inc., Chicago, IL). Descriptive statistics (frequencies, means, and standard deviations) were computed for all variables. Group comparisons were conducted using analysis of variance (ANOVA), t-tests, and chi-square tests, as appropriate. Statistical significance was set at an alpha level of 0.05 (two-sided).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 262 responses were received. \u0026nbsp;However, 255 complete responses were analyzed after 7 incomplete responses were excluded. Table 1 summarizes the demographic and professional characteristics of the respondents. Most participants were male (n = 135, 53.1%) and represented a wide range of medical specialties including internal medicine, pediatrics, and surgery among others. Nearly half were residents (n = 123, 48.4%), and the majority practiced full-time (n = 239, 94.1%). Although two‑thirds of respondents reported treating patients with chronic pain (terminal, non‑terminal, or both), only about one-third had received formal training in pain management (n = 88, 34.6%). On average, respondents had over eight years of clinical experience and worked approximately 48 hours per week in clinical settings. Use of prescription drug monitoring programs (PDMPs) varied widely, with more than one‑third reporting that they never used a PDMP when prescribing opioids (n = 89, 35.5%).\u003c/p\u003e\n\u003cp\u003e(Table 1 appears here)\u003c/p\u003e\n\u003cp\u003eTable 2 presents physicians\u0026rsquo; attitudes and perceptions regarding pain management and opioid prescribing. Overall, physicians agreed (somewhat to strongly agreed) that opioid misuse and opioid‑related deaths are significant problems in the community (n = 151, 59.2%). Respondents generally felt moderately comfortable counseling patients about pain management and opioid use, although fewer believed they had adequate training or knowledge in this area. Many agreed that medical education devotes insufficient time to pain management (n = 182, 71.4%). Physicians also expressed greater willingness to prescribe opioids for acute or terminal pain than for chronic non‑terminal pain (n = 182, 71.7%). Perceived effectiveness of opioids for chronic pain was low, with most respondents disagreeing (somewhat to strongly disagreeing) that opioids are highly effective for long‑term use (n = 165, 64.9%).\u003c/p\u003e\n\u003cp\u003e(Table 2 appears here)\u003c/p\u003e\n\u003cp\u003eTable 3 summarizes physicians\u0026rsquo; views about pain management within the LLUH system. Ratings suggested that chronic pain management is perceived as suboptimal, whereas acute pain management received somewhat more favorable evaluations. Respondents expressed mixed views about the adequacy of institutional support, consultation resources, and data collection on pain management quality. While most agreed that PDMPs are useful (n = 199, 79.6%) and that open communication may reduce opioid misuse, many also reported needing additional information on managing opioid abuse and endorsed the need for improved physician education in pain management (n = 162, 64.5). Self‑assessed knowledge remained modest (n = 86, 34.7% agreed they had adequate knowledge while 75 (30.2%) disagreed), and most participants believed that many physicians lack adequate understanding of effective pain management.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAssociations between physicians\u0026rsquo; views and demographic characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ea. Gender\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAlthough 32 of the 36 items showed no gender differences, males reported higher scores on four items. For example, comfort counseling about pain management was higher in men (Mean = 5.1 vs. 4.6; p = 0.018). Men also rated their training (4.3 vs. 3.8; p = 0.01) and knowledge (3.2 vs. 2.8; p = 0.001) higher than women, and expressed greater confidence counseling about misuse (5.0 vs. 4.6; p = 0.03).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eb. Current Job Title\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAcross 28 of the 36 items, there were no statistically significant mean attitude differences between residents and attending physicians. However, residents scored significantly higher than attending physicians on five items, including perceptions that opioid abuse is a problem in their practice (4.9 vs. 4.2; p = 0.005) and that acute pain is well managed at LLUH (3.8 vs. 3.5; p = 0.001). Conversely, attendings rated themselves higher on three items, such as adequacy of pain‑management training (4.4 vs. 3.7; p = 0.001) and adequate knowledge (3.2 vs. 2.9; p = 0.004).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ec. Training on Pain Management\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere were no statistically significant differences in mean attitude scores between those who had formal pain management training and those who did not across 23 of the 36 items (see table 4). Formal training was, however, associated with significantly greater comfort, confidence, and perceived competence. For example, trained physicians reported much higher adequacy of training (4.9 vs. 3.6; p \u0026lt; 0.001) and more confidence discussing appropriate opioid use (5.4 vs. 4.6; p \u0026lt; 0.001). Those with training were also significantly more likely to counsel patients about risks and side effects (5.8 vs. 5.2; p = 0.001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(Table 4 appears here)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMean Attitudes Scores and Years of Practice\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere was no statistically significant correlation between a physician\u0026rsquo;s years of practice experience and attitude on 26 of the 36 items investigated (p \u0026gt; 0.05). However, there was a statistically significant correlation between a physician\u0026rsquo;s years of practice experience and attitude on the remaining 10 items (p \u0026lt; 0.05). Six items were negatively correlated, indicating that more experienced physicians were \u003cem\u003eless\u003c/em\u003e likely to endorse concerns about opioid misuse or the need for education: Prescription opioid abuse is a problem in my practice setting (r = -0.251, p\u0026lt;0.001); Prescription opioid abuse is a problem in my society/area/community (r = -0.148, p = 0.021); Little time is devoted to pain management topics in medical education (r = -0.197, p = 0.002); Utilizing a prescription drug monitoring program is useful in helping to combat the epidemic of prescription opioid misuse and death (r = -0.170, p = 0.09); I need more information on how to manage the opioid abuse.(r = -0.241, p \u0026lt;0.001) and There is need for improved physician education in pain management including the use of opioids (r = -0.131, p = 0.043).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFour items were positively correlated, suggesting that more experienced clinicians felt more confident in their training and patient responsibility: I feel that I have adequate training in pain management (r =0.206, p = 0.001); Benefits of opioids outweigh side-effects of opioids (r = 0.161, p = 0.013); Most of my patients responsibly take their prescribed opioids (r = 0.169, p = 0.009) and I have adequate knowledge about pain management (r = 0.176, p =0.006).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study provides a comprehensive evaluation of physicians\u0026rsquo; knowledge, attitudes, and practices related to pain management and opioid prescribing at a large academic medical center at the time of study. The study highlights a familiar but consequential pattern in contemporary pain care: clinicians widely recognize prescription opioid misuse as a major community problem, yet many report gaps in training, mixed confidence in key counseling tasks, substantial reluctance to prescribe opioids for chronic non-terminal pain, and inconsistent use of prescription drug monitoring programs (PDMPs). Collectively, these findings suggest that improving pain care will likely require paired interventions\u0026mdash;strengthening clinician education/skills and improving system supports (e.g., consultation pathways, workflow-integrated risk mitigation tools, and consistent measurement of pain-care quality).\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003ePerceived burden of opioid misuse and implications for practice\u003c/h2\u003e \u003cp\u003eConsistent with previous literature, many physicians in this study reported concerns about opioid misuse in both their immediate practice setting and the broader community. National evidence shows that healthcare professionals frequently struggle with balancing adequate pain control against fears of opioid misuse and regulatory scrutiny, contributing to clinical inertia and inconsistent adherence to prescribing guidelines. In our sample, the strong agreement that opioid misuse is a community problem aligns with well-documented national public health concerns regarding opioid overuse, diversion, and overdose.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e The American Academy of Family Physicians similarly emphasizes the dual crises of undertreated pain and opioid misuse faced by clinicians across the United States.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e Importantly, the CDC\u0026rsquo;s 2022 guideline emphasizes balancing benefits and risks, shared decision-making, and individualized care across acute, subacute, and chronic pain.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eTraining gaps align with low confidence and selective risk-mitigation behaviors\u003c/h2\u003e \u003cp\u003eA central finding of this study is that a substantial proportion of respondents felt inadequately trained and insufficiently knowledgeable about pain management. Many clinicians reported limited formal instruction, low perceived competence, and strong agreement that medical education devotes too little time to pain-related topics. These results mirror longstanding national concerns that pain education\u0026mdash;particularly in the areas of chronic pain, opioid stewardship, and complex risk-benefit decision-making\u0026mdash;has historically been insufficient in both undergraduate and graduate medical training.\u003csup\u003e\u003cspan additionalcitationids=\"CR25 CR26\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e The associations observed in our study between prior pain-management training and higher comfort in counseling patients, greater confidence discussing opioid use and misuse, and more frequent counseling about risks and side effects are clinically meaningful. They suggest that strengthening structured educational interventions\u0026mdash;such as evidence-based opioid-prescribing curricula, patient-communication training, and risk-mitigation strategies\u0026mdash;could enhance clinician self-efficacy while promoting more consistent, high-quality counseling practices.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e Recent policy changes in California further underscore the movement toward expanded education: as of 2023, all DEA-licensed practitioners are required to complete eight hours of training focused on the treatment and management of patients with opioid and other substance-use disorders, an effort that directly addresses many of the gaps identified in this study.\u003c/p\u003e \u003cp\u003eAt the same time, education alone is unlikely to close all gaps. For example, even among trained clinicians, pain care can be constrained by time, limited access to interdisciplinary resources, and fragmented follow-up\u0026mdash;issues that are better addressed by system-level supports such as standardized pathways, consult services, and decision-support embedded in the electronic health record (EHR).\u003c/p\u003e \u003cp\u003eThe present findings also highlight meaningful differences in attitudes based on gender, level of training, and pain-management education. Male physicians and attending physicians tended to rate their knowledge and training more favorably than female physicians or residents. These patterns may reflect greater cumulative clinical exposure or differences in perceived preparedness, though the literature suggests that confidence in opioid prescribing does not always correlate with guideline adherence.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e Importantly, physicians who had received formal pain-management training consistently exhibited higher confidence and competence in multiple dimensions of opioid counseling and risk assessment. This finding aligns closely with national recommendations calling for enhanced training and improved education standards in medical curricula and continuing professional development. Both the American Society of Interventional Pain Physicians (ASIPP) and the Federation of State Medical Boards (FSMB) have emphasized the need for updated, evidence-based training to support safe and effective opioid prescribing.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eAttitudes toward opioids for chronic pain reflect evolving evidence\u003c/h2\u003e \u003cp\u003eRespondents generally preferred opioids for acute rather than chronic pain and were reluctant to use opioids for moderate-to-severe chronic non-terminal pain. This stance is consistent with the broader evidence base showing limited long-term benefit of opioids for common chronic pain conditions, with meaningful risks and uncertain functional improvement. Notably, the SPACE randomized clinical trial found that opioid therapy was not superior to nonopioid therapy for pain-related function over 12 months in chronic back pain or hip/knee osteoarthritis.\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e Evidence syntheses have similarly emphasized small-to-modest benefits with dose-dependent harms and the importance of careful selection, monitoring, and multimodal strategies.\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eHowever, reluctance can have unintended consequences if it leads to undertreatment, avoidance of difficult conversations, or abrupt changes in therapy without adequate support. The CDC guideline cautions against inflexible thresholds and underscores the importance of ongoing assessment, careful tapering when indicated, and access to nonopioid and nonpharmacologic options.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003ePDMP access and utilization remain inconsistent despite perceived utility\u003c/h2\u003e \u003cp\u003ePDMP registration and use varied widely, with more than one-third reporting never using a PDMP when prescribing opioids. This is notable because respondents also largely agreed that PDMPs are useful for addressing prescription opioid misuse. Low or inconsistent utilization has been documented previously, often due to workflow barriers, limited integration into EHRs, uncertainty about indications for checking, and variable state requirements.\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e Evidence on PDMP impact is mixed overall, although mandated-access policies and stronger PDMP features have been associated with improved prescribing outcomes and, in some studies, reductions in opioid-related harms.\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn California, the PDMP is known as the Controlled Substance Utilization Review and Evaluation System (CURES). CURES is a statewide database that tracks all Schedule II\u0026ndash;V controlled substances dispensed in California and supports public health efforts, regulatory oversight, and law-enforcement functions. California began requiring prescribers to consult CURES before issuing prescriptions for controlled substances in October 2018, a policy designed to address many of the concerns identified in this study. This mandate helps resolve the issues highlighted in our findings and promotes consistent use of CURES by reducing reliance on clinician motivation alone.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eDifferences by role, gender, and experience point to targeted strategies\u003c/h2\u003e \u003cp\u003eResidents reported higher perceived concern about opioid misuse in practice and greater need for information on opioid abuse management, but lower perceived adequacy of training and knowledge relative to attendings. This pattern is consistent with a training-stage effect: residents may face high exposure and uncertainty while still developing skills and supervisory supports. Structured curricula and supervised practice (e.g., coached patient conversations, case-based reviews, and feedback on prescribing decisions) may be particularly beneficial in residency.\u003c/p\u003e \u003cp\u003eMale physicians reported higher self-rated comfort and knowledge on several items compared with female physicians. While the study cannot determine the reasons, this difference could reflect variation in confidence, differential training experiences, or differences in clinical roles. Ensuring equitable access to pain-management education, mentorship, and supportive feedback (particularly for high-stakes conversations about opioids and misuse) may help reduce disparities in perceived competence.\u003c/p\u003e \u003cp\u003eMore years of practice correlated with higher perceived training/knowledge and lower perceived need for more information, while also correlating with reduced perception of opioid misuse as a problem. This could indicate increasing confidence over time, but it may also signal a risk of complacency or reduced perceived relevance of evolving best practices. Periodic refreshers and audit-and-feedback (e.g., prescribing dashboards, case reviews) can help maintain alignment with current evidence and guidelines across experience levels.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eInstitutional pain management and signals for quality improvement\u003c/h2\u003e \u003cp\u003eRespondents were less confident that chronic pain is well managed at LLUH than acute pain. Many physicians believed that institutional commitment and available referral resources were insufficient. This finding mirrors national concerns that U.S. healthcare systems remain poorly equipped to manage chronic pain comprehensively, often lacking integrated, multidisciplinary care pathways. The AAFP notes that chronic pain care remains fragmented across settings, with insufficient coordination and limited availability of specialized services\u0026mdash;challenges consistent with those identified by physicians who participated in our study.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e These findings support the need for a quality-improvement approach that couples education with accessible specialty support (e.g., interdisciplinary pain clinic, addiction medicine pathways, palliative care support, behavioral health, physical therapy) and explicit institutional metrics (e.g., guideline-concordant monitoring, PDMP checking rates where applicable, naloxone co-prescribing when indicated, functional outcomes, and patient-reported pain interference). The Institute of Medicine\u0026rsquo;s call to transform pain care emphasizes integrated, interdisciplinary models and improved education\u0026mdash;both relevant to these institutional signals.\u003c/p\u003e \u003cp\u003eTogether, these findings underscore a clear need for improved institutional support, enhanced pain-management training, and ongoing professional development tailored to the diverse needs of clinicians. Strengthening education, promoting consistent PDMP engagement, and expanding access to multidisciplinary resources may not only improve physician confidence but also enhance patient outcomes and reduce opioid-related harms.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eLimitations of the study\u003c/h2\u003e \u003cp\u003eSeveral limitations should be considered when interpreting these findings. First, the study relied on self-reported data, which may be subject to recall bias, social desirability bias, or inaccuracies in estimating clinical behaviors such as opioid prescribing or PDMP use. Second, the sample was drawn from a single academic health system, potentially limiting generalizability to other settings with different practice cultures, resources, or patient populations. Third, the cross-sectional design precludes causal inference regarding the relationships between demographics, training, and attitudes. Fourth, the analyses involved multiple comparisons across many attitude items, increasing the risk of type I error. Fifth, the study findings reflect the situation only at the time of data collection. It is likely that physicians\u0026rsquo; knowledge and practice patterns have evolved since then, given the implementation of several statewide interventions in California. Notably, California began requiring prescribers to consult CURES before prescribing controlled substances effective October 2018, and as of 2023, all DEA-licensed practitioners must complete eight hours of training on the treatment and management of patients with opioid and other substance use disorders. Our data collection occurred before these requirements were in place. Finally, variations in respondents\u0026rsquo; clinical roles (e.g., resident vs. attending) and exposure to pain-management curricula over time may influence attitudes in ways not fully captured by this study.\u003c/p\u003e \u003cp\u003eFuture research incorporating qualitative data, multi-institutional samples, and longitudinal designs may help further clarify the evolving landscape of pain-management attitudes and identify effective strategies for improving clinician preparedness and patient safety.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePhysicians at LLUH recognize prescription opioid misuse as a significant community problem and report substantial patient frustration related to opioid restrictions, yet many report limited formal training in pain management and inconsistent use of PDMPs despite perceiving PDMPs as useful. Training was associated with greater comfort and confidence in counseling and risk communication, suggesting that structured education is a practical lever for improvement. To strengthen chronic pain care and opioid stewardship at LLUH, interventions should combine targeted clinician education (especially for trainees) with workflow-integrated PDMP access, clear consultation/referral pathways, and measurable institutional quality indicators for pain management.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIndividual participant level information is not available to preserve anonymity but research material and sample level information is available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study has been approved by the Loma Linda University Health Institutional review Board. Informed consent was obtained from all participants prior to their completion of the survey. Data collection was conducted anonymously, ensuring that no personally identifiable information was recorded. Participants were informed of their right to withdraw from the study at any time without facing any penalties. All procedures adhered to the ethical principles set forth in the Declaration of Helsinki.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. \u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIndividual participant level information is not available to preserve anonymity but research material and sample level information is available from the corresponding author upon reasonable request.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors claim that there is no competitive interest in this research. \u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo external funding was obtained for this study. \u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePG performed research design, data collection and analysis, interpretation of results, and manuscript preparation. WK and GO assisted with the interpretation of results, contributed to the research idea and designed, advised the whole research process, and helped prepare the manuscript. All authors read and approved the final manuscript. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe author thanks the medical staff who participated in this study. In addition, we are grateful for the hard work of the editors and the valuable suggestions of the reviewers.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eDel Pozo B, Park JN, Taylor BG, et al. Knowledge, Attitudes, and Beliefs About Opioid Use Disorder Treatment in Primary Care. JAMA Netw Open 2024;7(6):e2419094.\u003c/li\u003e\n\u003cli\u003eBaker MB, Liu EC, Bully MA, et al. Overcoming Barriers: A Comprehensive Review of Chronic Pain Management and Accessibility Challenges in Rural America. Healthcare (Basel) 2024;12(17):1765.\u003c/li\u003e\n\u003cli\u003ePristell C, Byun H, Huffstetler AN. Opioid Prescribing Has Significantly Decreased in Primary Care. Am Fam Physician 2024;110(6):572\u0026ndash;73.\u003c/li\u003e\n\u003cli\u003eGreen CR, Anderson KO, Baker TA, et al. The unequal burden of pain: confronting racial and ethnic disparities in pain. Pain Med 2003;4(3):277\u0026ndash;94.\u003c/li\u003e\n\u003cli\u003eLeonard C, Ayele R, Ladebue A, et al. Barriers to and Facilitators of Multimodal Chronic Pain Care for Veterans: A National Qualitative Study. Pain Med 2021;22(5):1167\u0026ndash;73.\u003c/li\u003e\n\u003cli\u003eMezei L, Murinson BB, Johns Hopkins Pain Curriculum Development T. Pain education in North American medical schools. J Pain 2011;12(12):1199\u0026ndash;208.\u003c/li\u003e\n\u003cli\u003eUpshur CC, Luckmann RS, Savageau JA. Primary care provider concerns about management of chronic pain in community clinic populations. J Gen Intern Med 2006;21(6):652\u0026ndash;5.\u003c/li\u003e\n\u003cli\u003eKaseweter K, Nazemi M, Gregoire N, et al. Physician perspectives on chronic pain management: barriers and the use of eHealth in the COVID-19 era. BMC Health Serv Res 2023;23(1):1131.\u003c/li\u003e\n\u003cli\u003eAshcraft LE, Hamm ME, Omowale SS, et al. The perpetual evidence-practice gap: addressing ongoing barriers to chronic pain management in primary care in three steps. Front Pain Res (Lausanne) 2024;5:1376462.\u003c/li\u003e\n\u003cli\u003eVolkow ND, McLellan AT. Opioid Abuse in Chronic Pain--Misconceptions and Mitigation Strategies. N Engl J Med 2016;374(13):1253\u0026ndash;63.\u003c/li\u003e\n\u003cli\u003eDowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain\u0026mdash;United States, 2016. JAMA 2016;315(15):1624\u0026ndash;45.\u003c/li\u003e\n\u003cli\u003eArthur J, Edwards T, Lu Z, et al. Healthcare provider perceptions and reported practices regarding opioid prescription for patients with chronic cancer pain. Support Care Cancer 2024;32(2):121.\u003c/li\u003e\n\u003cli\u003eEdens EL, Garcia Vassallo G, Heimer R. How Should the Use of Opioids Be Regulated to Motivate Better Clinical Practice? AMA J Ethics 2024;26(7):E551\u0026ndash;61.\u003c/li\u003e\n\u003cli\u003eMarotta PL, Biaid M, Heimer R, et al. Rural providers\u0026apos; attitudes toward integrating harm reduction strategies and PrEP prescribing into rural primary care settings in the US. Southeast and Midwest. Addict Sci Clin Pract 2025;20(1):73.\u003c/li\u003e\n\u003cli\u003eKhawagi WY, Bansal N, Shang N, Chen L-C. A Systematic Review of Potential Opioid Prescribing Safety Indicators. Pharmacoepidemiology 2025;4(1):4.\u003c/li\u003e\n\u003cli\u003ePunwasi R, de Kleijn L, Rijkels-Otters JBM, et al. General practitioners\u0026apos; attitudes towards opioids for non-cancer pain: a qualitative systematic review. BMJ Open 2022;12(2):e054945.\u003c/li\u003e\n\u003cli\u003eAmerican Academy of Pain Medicine. Pain Pulse Survey 2024. https://painmed.org/wp-content/uploads/2024/04/Pain-Pulse-Booklet_web.pdf; 2024.\u003c/li\u003e\n\u003cli\u003eMatthias MS, Johnson NL, Shields CG, et al. \u0026quot;I\u0026apos;m Not Gonna Pull the Rug out From Under You\u0026quot;: Patient-Provider Communication About Opioid Tapering. J Pain 2017;18(11):1365\u0026ndash;73.\u003c/li\u003e\n\u003cli\u003eDarnall BD, Carr DB, Schatman ME. Pain Psychology and the Biopsychosocial Model of Pain Treatment: Ethical Imperatives and Social Responsibility. Pain Med 2017;18(8):1413\u0026ndash;15.\u003c/li\u003e\n\u003cli\u003ePartain DK, Santivasi WL, Kamdar MM, et al. Attitudes and Beliefs Regarding Pain Medicine: Results of a National Palliative Physician Survey. J Pain Symptom Manage 2024;68(2):115\u0026ndash;22.\u003c/li\u003e\n\u003cli\u003eRash JA, Buckley N, Busse JW, et al. Healthcare provider knowledge, attitudes, beliefs, and practices surrounding the prescription of opioids for chronic non-cancer pain in North America: protocol for a mixed-method systematic review. Syst Rev 2018;7(1):189.\u003c/li\u003e\n\u003cli\u003eAmerican Academy of Family Physicians (AAFP). Opioid Use and Misuse: A Public Health Concern (Position Paper); 2025.\u003c/li\u003e\n\u003cli\u003eDowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022. MMWR Recomm Rep 2022;71(3):1\u0026ndash;95.\u003c/li\u003e\n\u003cli\u003eCouncil NR. Relieving pain in America: A blueprint for transforming prevention, care, education, and research. Washington, DC 2011;22553896.\u003c/li\u003e\n\u003cli\u003eTobin DG, Andrews R, Becker WC. Prescribing opioids in primary care: Safely starting, monitoring, and stopping. Cleve Clin J Med 2016;83(3):207\u0026ndash;15.\u003c/li\u003e\n\u003cli\u003eSohn N, Lai B, Deyo-Svendsen M. Buprenorphine Prescribing Among Primary Care Clinicians for Chronic Pain and Opioid Use Disorder. J Am Board Fam Med 2025;38(5):933\u0026ndash;39.\u003c/li\u003e\n\u003cli\u003eJamison RN, Scanlan E, Matthews ML, Jurcik DC, Ross EL. Attitudes of Primary Care Practitioners in Managing Chronic Pain Patients Prescribed Opioids for Pain: A Prospective Longitudinal Controlled Trial. Pain Med 2016;17(1):99\u0026ndash;113.\u003c/li\u003e\n\u003cli\u003eManchikanti L, Kaye AM, Knezevic NN, et al. Comprehensive, Evidence-Based, Consensus Guidelines for Prescription of Opioids for Chronic Non-Cancer Pain from the American Society of Interventional Pain Physicians (ASIPP). Pain Physician 2023;26(7S):S7\u0026ndash;S126.\u003c/li\u003e\n\u003cli\u003eFederation of State Medical Boards (FSMB). Strategies for Prescribing Opioids for the Management of Pain. Adopted by FSMB House of Delegates, April 2024; 2024.\u003c/li\u003e\n\u003cli\u003eKrebs EE, Gravely A, Nugent S, et al. Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial. JAMA 2018;319(9):872\u0026ndash;82.\u003c/li\u003e\n\u003cli\u003eChou R, Selph S, Wagner J, et al. Systematic review on opioid treatments for chronic pain: surveillance report 3: literature update period: December 2021 to March 16 2022. 2023.\u003c/li\u003e\n\u003cli\u003eHaffajee RL, Jena AB, Weiner SG. Mandatory use of prescription drug monitoring programs. JAMA 2015;313(9):891\u0026ndash;2.\u003c/li\u003e\n\u003cli\u003ePuac-Polanco V, Chihuri S, Fink DS, et al. Prescription Drug Monitoring Programs and Prescription Opioid-Related Outcomes in the United States. Epidemiol Rev 2020;42(1):134\u0026ndash;53.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 4 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Pain management, Opioid prescribing, Physician attitudes, Medical education, Chronic pain, Prescription drug monitoring programs, Health services research, Opioid misuse","lastPublishedDoi":"10.21203/rs.3.rs-8715087/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8715087/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eEffective pain management and safe opioid prescribing remain major challenges in healthcare delivery. Prior research demonstrates that primary care clinicians often manage chronic pain with little or no formal training in pain management, contributing to low confidence and apprehension when prescribing opioids. Surveys also show that insufficient knowledge and inadequate preparation are among the most common barriers to adopting evidence-based opioid-prescribing practices. This study examined physicians\u0026rsquo; knowledge, attitudes, and perceptions regarding pain management and opioid prescribing at a large academic health system.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA cross-sectional survey was administered to physicians across multiple specialties at Loma Linda University Health (LLUH). A 54-item survey instrument developed primarily from existing medical and pharmacy education literature was used to assess physicians\u0026rsquo; beliefs, knowledge, and experiences related to pain management. Descriptive statistics summarized demographic and clinical characteristics. Independent t-tests and correlation analyses evaluated associations between training, experience, and attitudes toward pain management and opioid prescribing.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOf 262 surveys returned, 255 complete responses were included. Respondents averaged 8.3 years in clinical practice and worked approximately 48 hours weekly. Only 34.6% reported receiving formal pain-management training. Most clinicians (76.1%) believed opioid misuse is a major community problem, and 71.4% agreed that medical education devotes insufficient time to pain-management topics. Confidence in opioid-related counseling was moderate; however, fewer than half felt adequately trained or knowledgeable to manage chronic pain safely. Physicians with formal training reported significantly higher confidence in counseling about pain, opioid use, and opioid misuse (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Residents were more likely than attending physicians to view their institution\u0026rsquo;s pain-management resources positively, while attendings rated their own knowledge and training more favorably. Years of clinical experience correlated positively with perceived adequacy of training and knowledge, but negatively with perceived need for more education on opioid misuse.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003ePhysicians reported limited formal training in pain management, modest confidence in opioid prescribing, and concern about the adequacy of pain-management education. These findings mirror national evidence showing that primary care clinicians frequently feel underprepared and apprehensive about opioid prescribing. Enhancing institutional support, expanding access to structured pain-management curricula, and integrating standardized opioid-education strategies may strengthen clinician preparedness and improve the quality and safety of pain care within academic health systems.\u003c/p\u003e","manuscriptTitle":"Evaluation of Loma Linda University Health Physicians’ Attitude and Beliefs Regarding Pain Management","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-09 16:16:41","doi":"10.21203/rs.3.rs-8715087/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-19T07:04:04+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-06T04:11:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"79366008675562246498937201887527963605","date":"2026-02-23T05:24:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"246445103949512635952821543800248082686","date":"2026-02-20T15:16:31+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-16T15:25:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"65307999146663330485544111465854078840","date":"2026-02-13T20:33:19+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-04T14:03:10+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-04T12:13:08+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-03T09:46:08+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-03T09:43:25+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2026-01-28T01:16:03+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1081164b-0b07-4059-913a-41a9b5f7aee3","owner":[],"postedDate":"February 9th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-11T20:53:16+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-09 16:16:41","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8715087","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8715087","identity":"rs-8715087","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}