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Prakash Chandran (Host): If you've ever studied the side of a prescription bottle, you'll see a wealth of information contained in the fine print. It can sometimes be a little confusing to understand. So, today we'll learn more about best practices around prescription medication. We're joined by Dr. Kennedy Fan, the Market Manager of Pharmacy Operations at Tenet Health Central Coast.

This is Healthy Conversations. The podcast from Tenet Health Central Coast. My name is Prakash Chandran. And so Dr. Fan, really great to have you here today, before we get into the basics of prescriptions, I just wanted to start by asking what is the difference between a hospital pharmacist and a drugstore pharmacist?

Kennedy Fan, PharmD, BCPS (Guest): Well, I've worked at both settings, as a drugstore pharmacist and also hospital pharmacist. And I actually really enjoyed both of them. They are a little bit different, but the basic similarities are that they both make sure that patient gets the correct medication, at the right time, at the right dose.

There are differences of course, with these two positions and the hospital pharmacists usually takes care of medications for patients that are admitted to the hospital. And then a drugstore pharmacist is for patients that are ambulatory. So, they're able to walk in and out of the drugstore.

For hospital pharmacists, medications are usually stored in what we call the automatic dispensing machine. So, they package medication in unit dose. So, nurses are able to pull out one dose at a time and administer those to patients. And hospital pharmacists are also part of a multi-disciplinary team, which means that we work with providers and providers of different specialties on the patient's treatment plan. A hospital pharmacist also takes care of clinical pharmacy protocols, which means we took over the dosing of medications for patients because of sometimes the complexity of these dosings and monitoring required for these medications.

Host: Okay. That's very helpful, but just another clarification by way of training, are hospital pharmacists and drug store pharmacists, the same, like have you gone through the same training and education?

Dr. Fan: Yup. Hospital pharmacists and drug store pharmacists go through the same training. Basically all pharmacists will go through pharmacy school for either three or four years. And afterwards there may be additional fellowship or residency that hospital pharmacists may be able to be involved in. And there's additional certification as well, if there's a specialty that a pharmacist would want to be specialized in. For example, I'm certified in pharmacotherapy. Which means that I have advanced knowledge and experience to improve patient outcome in a multi-disciplinary approach in a hospital.

Host: So, I want to move on to best practices around prescriptions or prescription medication. And I think the first question I wanted to ask was, is it okay to take expired prescriptions with food, sometimes people are like, oh, that expiration date is just, just a suggestion, but I imagine that, with prescriptions it's different. So, maybe you can speak to that a little bit?

Dr. Fan: Of course. In California, pharmacy can either put the original expiration date of the drug bottle or a year from the day of the dispense, providing the date is sooner than the original expiration date. So, there is a chance that the actual prescription medication you've got from the pharmacy will have an expiration date longer than what is on the bottle. That being said, it's never safe to take any expired medication because it's often less effective. And then you might also experience side effects that you may not experience if that wasn't expired. If you have an expired prescription at home and you feel like you need to take it, the best thing to do is to contact your pharmacy for a refill, or to contact your provider for another prescription, if there's no more refill. Because a lot of times your doctor may want to reassess you to make sure that your condition and a medication dose needs to be adjusted.

Host: So, related to that, if you do have an expired or old prescription laying around, what is the best way to dispose of it?

Dr. Fan: Before you dispose of any medication, the first thing we need to do is to remove and or scratch out any personal information on the container. We definitely don't want any person to have access to that information. The best thing to do after that, is to drop off these prescription medications at a drug take-back site. A lot of police stations will take them. And then there's also a DEA website that you can go on there and they'll have information regarding the location of these sites. And sometimes they'll offer, an envelope for people to mail the medications back. So, that's the best way to dispose of medication.

Host: Yeah, it's so interesting. I imagine that the majority of people either throw it in the trash, flush it down the toilet. They don't scratch out their personal information. Maybe you can speak to why it's so important to take these steps. And with the take-back program that you're talking about, what happens, when they receive the medication back.

Dr. Fan: Sure. When medications are received back at the sites, they will be incinerating those medications and make sure that it doesn't get into the environment in a way that we don't want them to. When medications are disposed, like let's say flushing the toilet, is more likely to end up in rivers and in the ocean where we don't want other living organisms to be exposed to these. And then if they're tossed into the trash, sometimes animals or children can get to them. And it's most likely going to cause harm to them.

Host: Yeah, completely makes sense. I guess this is kind of related to another question I was going to ask. Is it okay to share medication with other people? Like, let's say you have a pain reliever. You see that our friend or a loved one is in pain. Is it okay to share your medication with them?

Dr. Fan: It's actually illegal to share a prescription medication with others. And it's not something you would want to do anyway, because one, you're not sure if they have the same condition. And even if they did, whether they're going to require the same dose or if they have any other condition or they're have a other diet that they're currently on that might interact with that medication.

So, none of those information has been screened by your doctor or your pharmacist. So, it's definitely not safe to share medication. Sharing medication with others is also insurance fraud if that medication is paid by your insurance, because the insurance paying for that medication, meaning for that medication for that prescribed patient only.

Host: Okay. So I knew that it was a no-no, but I did not know that it was illegal. So, definitely do not share your prescription medication. One thing that's fresh on my mind, especially having a newborn, is the precautions that you take when working with infants and especially infants that need the medicine, like those that are in the neonatal intensive care unit. Can you speak to some of the precautions that you take when giving them prescription medication?

Dr. Fan: At Sierra Vista Regional Medical Center, at the hospital that I'm at right now, we have a NICU population and they are neonatal intensive care unit, and they're often really small. They can weigh as little as half a pound. So, the corresponding dose of the medication, we often need to dilute it or even serial dilute it, which means we dilute the medication multiple times to get a dose that is appropriate for the patient. So, what pharmacists do when we receive these medication orders and we scrutinize all of these orders in detail, we pay special attention to all these medications. Because an extra zero or a decimal point can mean life or death for these patients. We also like to independent double-check and these medications.

So what that means is, when a technician prepares the medication, there's another technician that checked it and then the pharmacist will also check it again and then double check again by another pharmacist. So, there are many checks we have prior to dispensing medication. And before these medications are administered, there's also additional checks by the providers and the nurses, just to make sure that medication is provided correctly the first time that they are administered. These patients also have a different calculation method for the dose. We calculate their medication dose based on body surface area instead of weight. So, there is additional complexity to be accounted for.

Host: Yeah, it seems like so many precautions are put in place, and the way you've described it all totally makes sense to me. I want to move over to as a new patient or when you're receiving a new prescription, the questions that you may want to ask your pharmacist, whether they be a hospital or drugstore pharmacist, what should you be asking them when you have a new prescription?

Dr. Fan: So, when you get a new prescription, the prescription label will already indicate what the medication is for and how to take it. All pharmacists are obligated to counsel patients on new medications . So when this counseling occurs, information such as indication, directions, frequent side effects and how to avoid them, is something that they will discuss with the patient. Pharmacists will also try to motivate patients to learn about the treatment, and be an active participant in the care. So, questions such as can I take this medication with other medications? Is there other food or drinks that I should avoid taking when on this medication? Is there any drug interaction that you should know about? And then any more information that the pharmacist is able to tell you, ask them to share that. So, I think those were really helpful questions to know before you start taking a new medication.

Host: So, one of the things that you mentioned was drug interaction. Can you at a high level, tell the audience what that is and how often it happens?

Dr. Fan: Sure. Drug interactions actually happen a lot more often than we think. And what that is, is drugs can often interact with other drugs, other food or drinks, or even a condition. So, when drug interactions occur it may exacerbate certain conditions, or it might cause the effect of one medication to be amplified in a way that is not desired. So, when pharmacists reviews medication and dispense medication, there's often tens and twenties of medications that interactions that we have to sort through. Most of these interactions are not really that significant enough to alter your treatment, but then for the ones that are, pharmacists will often discuss and escalate that to the provider, to make sure that, if there's an alternate plan needed that we have that in place, or if anything needs to be adjusted, the patient is made aware of.

Host: Understood, but it really does seem like it's something a patient getting a new prescription should be proactive about and talk to their pharmacist about especially informing them if they are taking other drugs to ensure or to minimize the chance of that drug interaction. Is that correct?

Dr. Fan: Definitely. If there are times when you are taking any over-the-counter medication, a lot of times pharmacists don't have access to that information in your electronic health record. So, making sure the pharmacist is aware of that is really important.

Host: So, you know, one thing that we hear about a lot, especially in the news is that, sometimes people get addicted to their medication, especially when it comes to the pain prescriptions. So, how does one manage their pain prescription without getting addicted? Is do you have best practices or things that you can tell us about?

Dr. Fan: Definitely. Pain medications are usually taken on a as needed basis, meaning that you only take them if you have pain. So, always making sure that taking them as prescribed on the label and let your doctor know if you ever feel like you need to take more or are already taking more than needed. If you have a condition that causes pain, often it's better to use pain medication to control the pain to a manageable level instead of using it to completely get rid of the pain. So, using this mindset when taking pain medication will help patients not to take more than it was needed. And also if you've been taking pain medication, most likely you have a condition that is causing the pain. So, talking to the doctor with regards to how to address the source of the pain, whether it's surgery or any other intervention that the doctor may be able to offer could be a better option.

Host: So, yeah, Dr. Fan, we've been talking about pain prescriptions and medication to help minimize the pain. But what about antibiotics, which are used to treat bacterial infections and assist the body to heal? How should a person avoid antibiotic overuse?

Dr. Fan: To avoid antibiotic overuse, we, I think we first need to know what antibiotic is. So, bacteria can develop resistance to antibiotics gradually over time as they mutate. Antibiotics used to treat these infections. So, when bacterias are exposed to them, either through livestock or through human consumption, they will slowly become resistant to antibiotics.

And antibiotic overuse is becoming more of a problem. Now we're seeing the impact of antibiotic use in hospital with infections caused by these bacteria that are really resistant to a lot of the commonly used antibiotics. So, our patients that have these infections, they have very few choices of treatment. And a lot of these treatments can often cause harm and because the commonly used and safe antibiotics are no longer effective. So, to answer your question, to avoid overusing these antibiotics, which is important for these costs, want to make sure that if you have a viral infection, if your doctor says you have a viral infection, don't pressure your doctor to get antibiotics, because that's not going to help in any way.

If you have a mild illness, if you have a sore throat or a runny nose that is pretty mild in severity, a lot of times, just letting the illness runs its course, your immune system will be able to take care of those. And then if you are prescribing antibiotics, make sure that they're taken for the full prescribed amount of time prescribed by the doctor, and then don't use any leftover antibiotics or save them for next time.

I remember when I was a kid, my parents would always give me antibiotics that they saved from the last time I got sick thinking that that's going to help. So, making sure that if you are sick to get assessed by a physician and get new prescription if needed, and also never share antibiotics with anyone else, including your family members.

Host: It seems like the same rules apply of everything we talked about around prescription safety apply to antibiotics as well, right?

Dr. Fan: Yeah.

Host: Totally makes sense. So, Dr. Fan, anything else you would like to leave our audience with before we close here today?

Dr. Fan: Just that pharmacists are like any other healthcare providers. They've worked very long hours, and especially now with the pandemic. So, next time, if you do see a pharmacist at your neighborhood drugstore, making sure to thank them because they did do a lot.

Host: I think that's really great advice. So,so much for your time and everything you do for the community Dr. Fan.

Dr. Fan: Thank you for having me.

Host: That's Dr. Kennedy Fan, the Market Manager of Pharmacy Operations at Tenet Health Central Coast. Thanks for checking out this episode of Healthy Conversations. For a referral to a board certified physician, please call the Sierra Vista Regional Medical Center and Twin Cities Community Hospital physician referral line at 866-966-3680.

If you found this podcast to be helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of interest to you at Tenethealthcentralcoast.com/about/podcasts. This has been Healthy Conversations, the podcast from Tenet Health Central Coast. My name is Prakash Chandran and we'll talk next time.