Date of Award

Summer 8-20-2020

Degree Type


Degree Name

PhD Health Sciences


Health and Medical Sciences


Ning J. Zhang, Ph.D.

Committee Member

Terrance Cahill, Ed.D.

Committee Member

Genevieve P. Zipp, Ed.D.


CDC Guideline, opioid epidemic, primary care management, guideline adherence.


Statement of Problem: Opioid epidemic in United States has been, in part, linked to prescribing practices of practitioners who treat chronic pain. The increase in morbidity and mortality associated with widespread prescription of opioid pain relievers (OPRs) has been the driving force in the reassessment of clinical prescribing guidelines. Given the enormity and urgency of the problem, in 2016, the Centers for Disease Control and Prevention (CDC) introduced guidelines for prescribing opioids to chronic noncancer pain to primary care practitioners. The introduction of the clinical guidelines sparked much concerns from providers and activist groups. There is little known in the literature relating to providers’ knowledge, belief, attitudes relating to practices that utilize the 2016 CDC opioid guidelines for chronic pain. Therefore, the purpose of this study was to explore and understand the relationships among providers’ (physician, nurse practitioner and physician assistant) knowledge, belief, attitudes, and practices regarding 2016 CDC opioid prescribing guidelines, A secondary aim of the study was identifying the presence of mediating variable between knowledge and practice.

Theories: The constructs addressed in the study are knowledge, belief, attitude, innovation, and practice adherence. The study is built upon a novel framework created by the researcher based on well-established works of Diffusion of Innovation Theory (DOI) by E. M. Rogers and Knowledge-Attitude-Practice (KAP) model. Integrated elements of both theories are supporting pillars of the study.

Methods: The design was descriptive, cross-sectional, and correlational utilizing previously published quantitative survey tool (McCalmont et al., 2018). The sample consisted of 243 practitioners of 47 Physicians, 57 Physician Assistants and 55 Nurse Practitioners. A letter of solicitation was emailed through national professional organizations of American Academy of Nurse Practitioners (AANP) and American Academy of Physician Assistants (AAPA).

Results: Survey respondents demonstrated varied knowledge recall of the 2016 opioid prescribing guidelines. Knowledge was a statistically significant predictor of belief variable (r= .294, p < 0.001). A statistically significant bivariate relationship emerged between belief and individual attitude (r = .831, p < 0.001). Aligned with an increase on the belief scale, a provider’s individual attitude scale score increased regarding implementation of the guidelines to improve patient outcomes. Knowledge was a significant predictor of the Belief Scale, Beta = .16, p = 0.002. As the knowledge variable increased, the belief variable also increased. Knowledge was a significant predictor of the Individual Attitude Scale, Beta = .26, p < 0.001. As knowledge increased, scores on the individual Attitude Scale increased. Knowledge did not directly predict either of the practice variables (Practice Scale I or Practice Scale II).

Belief was a statistically significant predictor of Practice Scale I (harm reduction), Beta = 0.47, p < 0.001. As a provider’s belief increased, their Practice Scale (harm reduction) increased. However, belief was not a predictor for Practice Scale II (using nonopioid modalities). Individual attitude was a significant predictor of harm reduction, Beta = 0.20, p = 0.008. As individual attitude increased, practicing attitudes of harm reduction also increased.

Individual attitude was a significant predictor of Practice Scale in using nonopioid modalities, Beta = 0.56, p < 0.001. As individual attitude increased, a provider’s practice of using nonopioid modalities also increased. The study concludes knowledge effects were completely mediated through individual attitude and belief.

Conclusion: Complexity of pain requires multidisciplinary approach to management. Multidisciplinary practitioners include providers from nursing, physician assistant and medical colleagues. All these practitioners have varied training philosophies and they share a common practice of managing patients with chronic pain in the primary care arena.

Perceptions influence practices and thus further understanding of perceptions will better steer practitioner guidance. Subjective construct of belief and attitude are interrelated, and they are significant drivers of professional autonomous practice. This study signals that subjective variable of belief and attitude have mediating effect and influence on acceptance and implementation of guidelines and thus exploring subjective constructs through qualitative methods may further illuminate participant characteristics, as barriers to guideline adoption.