What is the Transdermal Fentanyl Patch and How Can We Stop People From Dying? Dr. Rebecca DeMoss
Do you trust your doctor enough to take the medications prescribed for you? Why or why not? Do you ever read the paper that comes with your prescription to learn what you are taking? Furthermore do you know the side effects? Do you ask questions of the pharmacist when you pick up your prescription? Some medications can be silent killers. How can we stop people from dying due to their medications?
What is the role of the pharmacist?
A pharmacist is a health care professional licensed to prepare, compound, and dispense drugs. However, the pharmacist must do the above under the written order of a prescription.
Furthermore it is very important for a pharmacist to cooperate with, consult and advise the licensed health-care provider concerning drugs.
Rebecca DeMoss (AKA Rebecca Van Vleck DeMoss) knew at a young age that she wanted to serve her community. Pursuing anything with blood or trauma was not a career choice. Hence becoming a doctor was out of the question. But Rebecca still wanted to be in the medical field.
Rebecca finds her niche in the world of pharmacy.
At only 28, Dr. Rebecca DeMoss is a doctor of pharmacy specializing in the area of long-term care pharmacy.
It was brought to her attention that a prescription for a narcotic patch seemed inappropriate for a specific patient. Dr. Rebecca did research. Consequently her findings show an increase in inappropriate prescribing of transdermal fentanyl.
In fact, she created education and presentations regarding this medication. She provides education and research to the healthcare providers regarding the prescribing of transdermal (TD) fentanyl. As a result lives are saved.
What is the transdermal fentanyl patch and how can we stop people from dying? Dr. Rebecca DeMoss
Catherine: Hello, this is Catherine, your host of your positive imprint. This is a free podcast, but please support me with feedback, positive reviews and by hitting those five stars. Today's guest is a doctor of pharmacy. Her positive imprints are the action she's taking and bringing awareness to inappropriate prescribing of transdermal fentanyl. This is an extremely potent narcotic patch. Listen how she is saving lives. Dr Rebecca van blech. DeMoss. Thank you so much for joining me. Well,
Dr. Rebecca DeMoss: hi. Good morning. Thank you for having me. This is just such a great, great day.
Catherine: It is. and, we're ending up sitting in a car for this because the a little cafe we were in had music playing and we can't have.
Rebecca: and it's much more fun though. Just being you and me just talking about positive things.
Catherine: well and you have a definite positive imprint. You have had this, Oh my gosh, you just have whatever force inside of you to bring awareness to health care providers with regard to this narcotic patch. But first tell me, tell the listeners what got you into wanting to be in the pharmacy world.
Rebecca: Well, my mother was actually a pharmacist and she graduated from KU, Kansas university. And I think when we started through high school and kind of talking about future careers, I ended up with pharmacy because it was the perfect blend of science, human anatomy and helping people.
Dr. Rebecca DeMoss: So as I started my prerequisites, it just was that that really great fit of not having so much responsibility of a physician not having to deal with blood and you know, surgeries or whatever the case may be, but still having that amazing aspect of science and at the end helping people.
Catherine: So that was what really drove you was not just having a career and making money and having, you know, making a living, but you really wanted to be in some career where you were helping people from the get go.
Rebecca: Yeah. And I was really fortunate from knowing that right out of high school. So this is why I'm so young as a pharmacist. And I graduated when I was 28 as a pharmacist.
Catherine: And you're a doctor, ofpharmacy. So you obviously the schooling was quite a bit and your mom obviously was a fabulous positive imprint on you.
Dr. Rebecca DeMoss: Well, what's interesting is she actually did not practice pharmacy for much for long. It was, it was about a year. And then she ended up not enjoying it and then she went to be a lawyer and now she's a judge for the social security administration. So not only has she done an amazing positive imprint for me, but she's also this amazing, um, woman to, to model of that, that you can really do anything you put your mind to.
Catherine: Oh, that is, Oh, that's great. And so looking at you, and so what does it take to go through pharmacy school?
Rebecca: Yeah. Well, um, so it's as between a six and an eight year program. Most individuals now are starting to get their undergraduate degree. So I actually have a bachelor's of science and biology before I even entered into the doctorate program of pharmacy school. So pharmacy school then is another four years after your undergrad.
Dr. Rebecca DeMoss: And, but the prerequisites are about two years. So if you want to do the bare minimum of the prerequisites and then apply, you have to do what's called the (Pharmacy College Admissions Test), which is an entrance exam for the pharmacy school, pass the P cat and then apply.
Catherine: Okay. So there's a process. And so the schooling could be four years plus the two years. But if you want to be a doctor of pharmacy, then of course you're taking an additional four. Okay. So that, that's plenty of schooling, And that brings you to where you are today. And I know that you, because of your experience and your true warm, caring heart, you do programs around New Mexico and around the country. You are a speaker. Yeah. And you do seminars. And I think you said some, I think in our conversation you mentioned that you also teach pharmacy classes.
Catherine: Where do you teach those?
Rebecca: So I'm actually teaching at the UNM college, of Pharmacy at university of New Mexico at the university of New Mexico. And uh, it's one of their first year pharmacy courses. It's a communications course. And one of the professors, we just have hit it off ever since during school and graduation and I've been five years postgraduate and this for some reason there was something inside of me that spoke to me to start giving back. So this year has been really about volunteerism, really about working with the college and also these presentations regarding the transdermal fentanyl. And so it's just been this amazing whirlwind of fun with the college, with the students, with all of these organizations that have now a part of that. The communications course. It's just been an amazing experience and I'm, I'm learning stuff from [inaudible].
Catherine: makes it so much fun as you are doing everything.
Catherine: You're actually, Oh this is funny.
Rebecca: And that's what I was actually telling them cause I teach every Thursday morning with them. And I actually told them like this course I am learning something and I'm that pharmacy nerd. Well I go back to my coworkers and I say, guess what I learned in class today guys. and the professor that I've been working with, her name is dr Krista Dominguez Salazar and she actually taught me, so it's this amazing full circle of positive imprints and the family of the college of pharmacy.We've created this environment where you can always come back that it's an always an open door and whatever life pulls you in and directs you, there's, there's always something you can do to leave a positive imprint. And how long have you been practicing? So it's been five years.
Dr. Rebecca DeMoss: I graduated in 2014.
Catherine: So then that brings us to well First, let's learn what this transdermal fentanyl patch is because this is what your blog was about and that's how I found you. And it wasn't me actually. It was actually a very caring person out there in the world who emailed me and said, you have got to meet this person. She has just an amazing positive imprint.
Rebecca: Yes my husband So yes, my, my loving husband. Um, so the, the tr, the fentanyl transdermal patch, it's under the brand name.Duragesic. So the brand name is Duragesic and the generic is fentanyl.
Dr. Rebecca DeMoss: And this is an extremely potent narcotic patch. And the, the, the problem that I recognized as the year of 2017 to 2018 my pharmacy PharMerica pharmacy, we detected about 18 inappropriate prescriptions that would have ended in a patient's death.
Catherine: How could you foresee that?
Rebecca: What, so there is an amazing tool that we have access to that healthcare providers, doctors, pharmacists. It's called the prescription monitoring drug program. And so what that means,
Catherine: Is that government, is that, what is, does that come from?
Rebecca: Yes and no. It is governed by the New Mexico board of pharmacy. Okay. Do is this do other, yeah, this is a nationwide push for helping misuse and abuse of medications, specifically narcotics and benzodiazepines.
Catherine: Okay. And do you know if it goes across the borders? So like does Canada have something like this?
Rebecca: Good question. And I just listeners, yeah, and I'm not sure if they've but it would be a great program for them to adopt because in my personal life it has saved so many lives.
Catherine: Okay. So if it's, if it's not there, somebody can implement. Yes, exactly right. So now go back and start, explain that.
Rebecca: the prescription drug monitoring program allows for healthcare providers to look at a particular patient and you can see their history of narcotic medications and benzodiazepines, which are like Diazo Pam Adavan, Xanax. So what we've found is grouping those medications together potentially causes addiction and can potentially cause overdoses. So looking at the patient's history, we can identify the use or potentially misuse of their prescriptions. But what I've been using it for is to detect if they are a candidate for this extremely potent narcotic medication. They have got to meet certain criteria of past history to even start therapy. And what we're finding is they don't meet that criteria. That's why it's so dangerous and it will cause an overdose and a death.
Dr. Rebecca DeMoss: So using the system, we can see the patient's fill history and be like they're not, they're not a candidate, they will overdose. Okay. Yeah.
Catherine: And is the patch meant to wean somebody off of narcotics? So is it meant to medicate?
Rebecca: It's actually meant to medicate those that have experienced long term pain, chronic chronic pain. And so they have to have gone through a series of different medications such as morphine or oxymorphone or hydromorphone, which are the top narcotics that are used. They have to have been through and use those medications before they can even start this medication.
Catherine: And why is that? Is it the body recognizes?
Rebecca: So it's about tolerance. It's called opiate tolerance versus opiate naivity. So opiate tolerance is when they've been on some sort of narcotic for at least one week or longer to show that our body can absorb the narcotic or the opiate and then not overdose.
Dr. Rebecca DeMoss: And so if you think about it, fentanyl is about 75 to a hundred times more potent than morphine. Wow. So if they've never been on any of those morphine, oxycodone oxymorphone and they go straight to that fentanyl patch, they will overdose.
Catherine: Okay. So what did you do when you started seeing this and doing your background? Yes. So search on these patients.
Rebecca: It was a push through all of the pharmacists cause I work with four pharmacists at any given time. And what we started doing is running that prescription drug monitoring program every time we have a patient, a new start patient on fentanyl. So fortunately here in Albuquerque, the retail pharmacies have this prescription drug monitoring program embedded in their order entry system. So anytime they're running a prescription, it'll come up with their fill history. But since I work in what's called longterm care pharmacy, we're exempt from running.
Dr. Rebecca DeMoss: So it's something that we don't even see unless we personally run the report.
Catherine: Oh, so you had to do extra work, which is truly saving lives with the knowledge that you had of this drug. Now did the pharmaceutical company teach you this? I mean, how did you know this or was it ..
Rebecca: well it was actually one of my coworkers who, um, I, I don't, I don't remember why she ran it. Cause we can look at the fill history. So we know a little bit about the potency and.
Catherine: how do you, you know, because these drugs, there's new drugs coming up on the market all of the time. Do you do research on all of the drugs that go? You do. So it was something, was there something in fine print that the pharmaceutical company wrote or was it just the fact that your background knowledge told you that the dosage, okay.
Dr. Rebecca DeMoss: Is background law. So Duragesic has been on the market since the 90s. Okay. So most pharmacists coming out of school know that it is extremely potent and needs to only be used for people who have chronic pain and are opiate tolerant. So that's like bare minimum knowledge, how you use it and how you implement that knowledge is up to the individual pharmacist. So considering that we know that as we're reviweing a patient profile, some red flags go off from time to time. And then it kind of gets us to, I call it the pharma sense instead of spidey sense, it's your pharmacist, something is not right and I need to do, I need to stop and do a little bit more. And so it was actually my coworker who started seeing these and then as we all started to talk about it, then together as a team, we started doing more and more.
Dr. Rebecca DeMoss: And then I created a protocol for our pharmacy with information on the criteria to start the transdermal patch, you know, different, um, aspects of how to speak to the physician or what we can change it to or convert it to. . So this is what started the campaign for educating regarding appropriate prescribing of the transdermal fentanyl.
Catherine: And so the doctors, do they have access to that? They do. They do access to the pharmaceuticals that a patient is using. And so you, what did you do? What was your step? You called the physicians and how did these physicians react?
Rebecca: Well, most of them are grateful, but the, the one patient that stands out in my mind was, from an emergency room physician and [inaudible].
Dr. Rebecca DeMoss: We really fought back and forth. And this one was, it shook me to my core because if we would have dispensed it, I know this patient would have died. And so trying to get that across to this emergency room physician. And he continued to fight with me that this patient was in fact a candidate when in fact he was not. So I was able to utilize the patient's care system. He was in an assisted living facility to further facilitate the discussion with this emergency room physician to get it changed. But I kind of feel that physicians only get maybe a semester or two a pharmacology. We get four years. So putting that into perspective is we're, whereas we as pharmacists are trying to give knowledge that we have to any healthcare provider because at the end of the day, we're a team.
Catherine: And I think that that's a wonderful way to look at it because collaborating with every entity that can make a stronger healthcare system to me would be imperative for anybody's health, betterment of their health.
Dr. Rebecca DeMoss: So considering we saw so many last year, this is what brought me to creating this educational presentation that I've been giving, creating my blog, coming to you as the podcast to really spread this vital information regarding this extremely potent narcotic patch. Because I feel that there's missing information. I'm not sure if it's just glossed over and there are different modalities, but this is something that I'm seeing in my practice to reinforce the education that they might've forgotten, might not have known and trying to educate. Pharmacists are now becoming one of the most accessible healthcare providers and that's great. But on the flip side, I feel that the other healthcare modalities, nurses, physicians, PAs, nurse practitioners, they are overworked, just overworked.
Dr. Rebecca DeMoss: But this is where that team approach comes in, is that when they're prescribing, they need to know their deficits and knowledge and be able to work with someone that might know a little bit more, call the pharmacy and take that extra time. And so I, I know it's not these healthcare providers fault, I think it's a system breakdown, but that's when we all come together as a team to make sure we're taking care of our patients.
Catherine: And so that's where the collaboration and the discussions and what you're doing, bringing the knowledge and the information to the healthcare system through your seminars, through your blog.
Rebecca: And what's interesting is I had a wild, wild hair to do a little bit more investigation. So that was 2017 to 2018 this past year, 2018 to 2019 we've only detected six. Oh, that's great. Right. So I'm not sure if it's, you know, it's, it's happenstance, but I know that what we've tried to do with my coworkers and with what I'm doing is that education part.
Dr. Rebecca DeMoss: So whenever we detect an inappropriate, we try and take that time to go over why it was inappropriate and to get it changed so that the doctor doesn't feel that it was too well. And we're hoping that they remember that. And so the next time that they feel that it is appropriate, they, they take a moment and pause and think about is this patient a candidate?
Catherine: Oh, interesting. And now here's something, a question that may be a doctor might have is I had this great conversation, recorded conversation on my podcast. Her name is Kristy Sobel and she's known as the prize fighter. She was in a horrific car accident that left her spinal cord crushed and she had surgery, I mean long story short, chronic pain and she did not want to be on narcotics because it didn't, you know, the feeling of it. Yeah. But she also understands because she was on narcotics and she's doing a lot of lobbying now in our country and United States with regard to opioids.
Catherine: But she says, and these are strong words, powerful and true. She said, if we're going to remove something, we have to replace it with something. So that might be what a patient will ask. Well, I really needed the patch because I had this chronic pain. Or a doctor might say, well, what can we replace it with? So how do you work through that?
Rebecca: That's a very loaded question because it is very patient specific. Okay. And and what I would, what I would personally approach that situation with is look at the patient's history. What type of pain are they experiencing? What are they, what are they willing to try? Because there's so many different approaches to chronic pain. And I know that's a huge discussion in many different healthcare areas right now of of using other types of medications such as antidepressants. There's an antiepileptic medications that are being used to treat chronic pain. So there's a lot that could be discussed. So that would be on a patient to patient basis. Does that answer your question?
Catherine: That does. That does. I'm one, Oh my gosh. Narcotics. I can't, I can't do narcotics. I had my tonsils removed when I was an adult in 2005 it was the best thing I ever did because I was, anyway, but I was put on, I cannot remember the name of it, but it was a, it was an opioid and Oh my gosh, I couldn't stop throwing up and I was so nauseated. And then at night, one night, it just took, one night I woke up and I could not breathe. Yeah. And my husband got the medical book out and he said, well maybe that's, what is that called? Sleep apnea? I said, that didn't feel like sleep apnea. I mean, I literally couldn't breathe. So then I called my dad, you know, it's the middle of the night, dad. I woke up, I couldn't breathe. And my dad said, honey, you are on a narcotic. Yeah, I think it's suppressed your respiratory system.
Catherine: Call your doctor and talk to him tomorrow. So I did. And the doctor said, okay, no more narcotics. So.
Rebecca: Well, what's interesting that you say you experienced those? The side effects I and the presentation I give, it's interesting. I believe it was a pharmacy times article, a 30 to 50% of patients who receive an opioid medication will experience nausea, dizziness, and, but it actually resolves in about five to 10 days, which I do not blame you, but that is, that is the epitome of the side effects, unfortunately, of that class of medication.
New Speaker: Oh, it was awful. So I went to a plain ordinary, what is Advil? What is the medicine? Ibuprofen. So I went to a plant, ordinary ibuprofen, and that took care of it. I mean, that was enough for me to take care of it because I just,
Rebecca: and that's another good point about pain, is to really understand the levels of pain. And I think that there's a, unfortunately, I believe it was two years ago that pain became the fifth vital sign, which was good because what do you mean? So there, so within a hospital when a patient is hospitalized or in the clinic, we take these vital signs, blood pressure, temperature, look at their eyes. Um, and it's, it's different. It's a,
Dr. Rebecca DeMoss: it is an approach to overall health. Okay. So when we added pain as an additional vital sign, I think that's what pushed us further into this opiate epidemic. And so when we're questioning about pain, sometimes there's individuals who expect to be pain free. And so when you're looking at being pain free on an opiate regimen, you're going to push yourself to overdose. So identifying that it's okay to be at a level one, it's okay to be at a level two that you might not get pain-free.
Dr. Rebecca DeMoss: That needs to be part of the discussion. Or on the flip side, can your pain be managed with Tylenol or ibuprofen before we even touch into an opiate regimen? And what's interesting, I think it was about three years ago, they looked at longterm care facilities, so like skilled nursing facilities or rehab facilities. And if a patient was on an opioid regimen for longer than a week, they were on that same opioid regimen for a year and some even longer and some even longer.
Catherine: Yeah. And I feel for people who live with chronic pain.
Catherine: how, how does an opioid work with regard to pain? Cause I've been told things, you know, I have friends that are on opioids and other friends who won't take opioids because they say it really doesn't manage pain. So tell me the physicality. Yeah. How it works.
Rebecca: So most opioids hit a receptor called the mew or Kappa or Delta receptor. And that's what blocks the pain signals. Okay. But when you're getting into blocking these receptors, that's how you also get the side effects. So you have opiate receptors within your GI tract. That's what causes the terrible constipation. We also have opiate receptors in our lungs. That's what causes the respiratory depression. So it definitely, and so that's, so you had mentioned that potentially opiates are not the best answer for a type of pain, which is true. So like ibuprofen for example, works on the inflammatory mediators.
Dr. Rebecca DeMoss: So if you're having an inflammation, it's best to use something like that. So it'll just depend on the type of pain. But usually the opiates are used because they are so good at removing the pain if you're in an acute or chronic pain situation.
Catherine: Now, I understand why the ibuprofen worked because it wasn't so much I was in, it was the inflammation and the fever. I had a fever and opioids aren't going to take care of the fever, but the ibuprofen took care of her fever and once the fever was gone, I was fine. I, and I was, yeah.
Rebecca: So I know there's a huge push with trying to use other medications first before an opiate is even considered.
Catherine: Okay. Oh, and so what are your next steps here in your, in what you're doing?
Rebecca: Well, I hope to continue to give the fentanyl presentation.
Dr. Rebecca DeMoss: So I've given that presentation to the New Mexico Pharmacists' Association. And to the New Mexico Health Systems Pharmacist Association. And then I wrote the, the blog for TLDR pharmacy simplified. And then so the next few steps I have is I'm going to be working with the New Mexico medical society, so hopefully that'll get to more physicians. And then I also reached out to a society called the Institute of safe medication practices. So it's simplified to ism P and ISMP puts out notifications and alerts and does this amazing job of helping disseminate vital information of errors that are occurring.
Catherine: Okay. And is that national?
Catherine: You've had thousands of visitors on that blog. Some of them are probably worldwide.
Rebecca: And then the extra, the other additional is there's a continuing education website called free ce.com so they say that one more time free C e.com or it used to be under pharmcom, which was their, their title.
Dr. Rebecca DeMoss: And they're going to be putting, I'm going to be an adjunct faculty for them here in January has another CE for pharmacists and healthcare providers.
Catherine: Oh fabulous. You have a lot going on and just in providing that and not just information on on pharmaceuticals, but also just helping patients and the healthcare system to understand the medicines. That's, that's wonderful. I really, I really enjoyed listening to you and it's something that obviously I was effected by when I had, and we could,
Rebecca: we could probably talk about it all day cause it, it has definitely become one of my passions and will, and.
Catherine: there's an epidemic worldwide.
Rebecca: Yeah. Yeah. And I kind of, and I feel that the situation with the patient that I experienced, it struck me to my core that, that, that life was in my hands and that that moment has changed my perspective forever. This is why I do what I do. And this is what gives me this passion is because we are so focused on the didactic information of pharmacy or healthcare. But what we all need to do as healthcare providers or as people in general, is to take that step back and to realize that we have lives and we touch lives every day.
Catherine: Dr Rebecca Von, blech. DeMoss. Thank you so much for your positive imprints and for joining me here, sitting in the car and for sharing your fabulous story. I so much appreciate, you.
New Speaker: No, I appreciate you and what you do. It was a pleasure. Thank you. Thank you.