An example of this is a patient with an extensive history of aberrant drug-seeking behaviors who also has severe nociceptive and neuropathic cancer pain. Opioids are first line for cancer pain, but adjuvant medications are also effective for neuropathic pain. In this setting, I would prescribe an opioid along with an adjuvant therapy. Given the patient’s history, I would see the patient weekly and only give adequate medications until the next appointment.

TRENDING ON CPA: How to Overcome Pain Resource Challenges: Part 1 

The hope is that the opioid would provide effective analgesia, the adjuvant therapy would have opioid-sparing effects, and the limited medication supply and weekly appointments would minimize further aberrant drug-seeking behaviors. Importantly the end result is good patient care, and the pendulum is somewhere in the middle.

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CPA: How do you market your practice?

RA: On the Internet, the University of California San Diego’s intranet, through collaborations with other palliative care colleagues in our health system and in the community, and via our trainees who move on to other institutions who may refer patients with refractory symptoms or difficult-to-manage pain.

CPA: What other revenue sources are you investigating in order to offset the drop in reimbursements?

RA: Having a united voice in legislative settings and establishing patient care as the primary focus should help towards improved reimbursement. In the state of California Senate Bill 493 went into law October 2013 and recognized advanced practicing pharmacists as reimbursable providers. Some view this as creating competition for other existing providers, but in my opinion this bill will allow pharmacist like myself to be able to bill for clinical services as part of a multidisciplinary team. This strengthens the palliative care team and what it is able to offer its patients.

CPA: How have your opioid prescribing habits changed?

RA: I usually treat cancer pain, so I prescribe opioids quite often. Our service established a model a few years ago in which we apply the concept of universal precautions to all of our patients and set safe limits for prescribing controlled substances without compromising management of patients’ pain and symptoms.