Amanda Smolen, PharmD, BCPS Clinical Coordinator, Middleport Family Health Center Preceptor, PGY-1 Community Pharmacy Residency Program Adjunct Instructor, University at Buffalo School of Pharmacy and Pharmaceutical Sciences Middleport, New York
7/20/2011
US
Pharm. 2011;36(7):52-55.
Almost 40% of Americans receive prescriptions for four or more medications per year, and half of the medications taken by Americans each year are used incorrectly.1 As part of the health care team, pharmacists are in the forefront of tackling the issues of medication misuse and poor medication adherence, often labeled as “America’s other drug problem.”2
The Problem
What can pharmacists do about America’s actual drug problems? Prescription drugs, most commonly pain relievers, are second to marijuana as the most commonly abused drugs among teens aged 12 to 17 years.3 Almost 1 out of every 180 children aged 2 years has an emergency-room visit each year because of a medication overdose. Acetaminophen, opioids or benzodiazepines, cough and cold medicines, nonsteroidal anti-inflammatory drugs, and antidepressants are among the most common medications accidentally ingested by children.4 In addition, improper medication disposal has been reported to have environmental consequences and has led to traces of medications in our water supplies.5 These growing concerns call for a solution that enables the safe removal of unused or unwanted medications from households in order to prevent prescription drug abuse, accidental ingestion, and environmental pollution.
The Solution
As the most accessible health care professionals and medication experts, pharmacists can provide valuable education on proper medication disposal in an effort to address these unsettling statistics. Drug disposal programs and pharmaceutical collection events serve not only as resources to the community for safely disposing of unused or unwanted medications, but also as platforms for examining the causes of medication waste.
Several solutions to the problems surrounding the disposal of unused, unwanted, or expired medications have evolved. Previously, it was recommended that medications be poured down the sink or flushed down the toilet. For certain medications, this remains a recommended route of disposal. A list compiled by the FDA consists primarily of controlled substances wherein the risk of accidental ingestion or overdose outweighs the risk of flushing (SIDEBAR 1, resource 1). The FDA, in coordination with the Office of National Drug Control Policy, currently recommends that consumers consult the patient information for prescription products and the list compiled by the FDA to determine whether the medication should be flushed. The FDA also suggests that consumers consider participating in community drug take-back programs that collect medications for proper disposal. If a program is not available, federal guidelines recommend that consumers remove prescription medications from their original containers; mix these medications with something undesirable (e.g., cat litter or used coffee grounds); place the mixture in a sealed container such as a coffee can, plastic container, or sealable bag; remove or conceal personal health information and prescription numbers on the original containers; and place the sealed container and the original medication containers in the trash.6
Drug take-back programs and pharmaceutical collection events are responding to the needs of their communities, presenting themselves as a solution for patients with unused or unwanted prescription products. Community pharmacies and leaders, schools of pharmacy, and local business organizations are working together in this regard to provide alternatives to previous methods of disposal. Following is a closer look at two programs that are making a difference in the communities they serve (see resources 2-4 in SIDEBAR 1 for additional information).
DisposeMyMeds Program
The Sharps TakeAway Environmental Return System consists of TakeAway envelopes and 10-, 20-, and 40-gallon TakeAway drop-off systems for use in pharmacies. Noncontrolled and OTC medications may be deposited into the TakeAway system in their original containers and returned to the Sharps Compliance processing facility for destruction under the supervision of law-enforcement officials. Shipping and disposal costs are included in the price of the TakeAway system.7
In 2009, the National Community Pharmacists Association (NCPA) partnered with Sharps Compliance, Inc., to provide its members with a solution to the growing issue of medication waste. Since the initiation of the NCPA DisposeMyMeds program, well over 8,000 pounds of unused prescription medications have been properly disposed of and more than 1,000 independent community pharmacies in 47 states are currently participating. A study examining this program found that 70% of returned prescription containers contained half or more of the prescribed amount, 56% of prescriptions were expired, and the medications came from mail-order pharmacies in 1 in 5 cases.8
Middleport Family Health Center in Middleport, New York, is one example of the independent pharmacies that are taking advantage of the DisposeMyMeds program. Steve Giroux, pharmacy owner and past president of NCPA, sees the program as another opportunity for pharmacists to “take ownership of adherence.”9 As recommended by the program guidelines, Giroux has his pharmacists screen the medications brought in for disposal to ensure that there are no controlled substances among them. This allows the pharmacist to determine the cause of the medication waste, thus enabling the identification and resolution of medication-related problems and, in particular, a chance to address factors contributing to nonadherence. To date, Middleport Family Health Center has returned one 10-gallon disposal system for destruction, and it expanded its efforts during Earth Week in April 2011 by utilizing the marketing tools provided by the NCPA–Sharps partnership and raising public awareness in collaboration with local media.
Getting Started: First, it is important to check directly with your State Board of Pharmacy regarding any state regulations concerning a pharmacy’s participation in a medication disposal program. It is also essential to familiarize yourself and pharmacy staff with Drug Enforcement Administration (DEA) guidelines restricting the return of controlled substances without the direct involvement of law-enforcement officials. Taking these guidelines into consideration, NCPA—in collaboration with several State Boards of Pharmacy—has established a list of requirements that a medication take-back program in a pharmacy should have:
• Under no circumstances should controlled substances be returned.
• The medication take-back box should be in a secure area and not freely accessible to the public.
• The pharmacist should be directly involved to ensure that controlled substances are not being deposited into the return box. (This is also an excellent opportunity for patient education and medication-adherence counseling.)
• Once the box is full, return it immediately via UPS or the United States Postal Service for disposal.10
If your pharmacy is capable of meeting these requirements, the next step is to order the Sharps TakeAway Environmental Return System that best meets your pharmacy’s needs. Establish a secure location for drop-off boxes and review the regulatory requirements with pharmacy staff. Pharmacies can choose to simply offer the disposal option as a service to their customers, or they may establish a charge for the service. Finally, services can be marketed in coordination with events such as Earth Day and brought to the attention of the local media in order to raise awareness about the importance of proper medication disposal and the role of the pharmacist in these efforts.
National Take Back Day
The DEA National Take Back Day involves some of the nation’s largest single-day pharmaceutical collection events. On September 25, 2010, the DEA held its first-ever national prescription drug take-back campaign, which resulted in the collection and proper disposal of more than 242,000 pounds of prescription drugs at more than 4,000 sites across all 50 states.11 A second event, held on April 30, 2011, highlighted the growth, importance, and need for these programs, spurring the disposal of more than 376,000 pounds of prescription drugs at more than 5,300 sites.12
Karl Fiebelkorn, MBA, RPh, AE-C, Associate Dean of Student Affairs and Professional Relations at the State University of New York at Buffalo School of Pharmacy and Pharmaceutical Sciences, saw the DEA National Take Back Day as an opportunity to get students and the community involved in proper medication-disposal efforts. In coordination with the DEA, the Department of Health, local law-enforcement officers, and community leaders, Fiebelkorn organized several single-day events across Western New York State. Regarding the partnership in drug-disposal events between the University at Buffalo School of Pharmacy and a local adolescent drug and alcohol treatment center, Fiebelkorn stated, “Household pharmaceutical take-back programs…are an excellent way for pharmacists and student pharmacists to become involved in their own communities. These programs are easy to implement and can have a dramatic effect on reducing the number of unused, unwanted, or expired medications in peoples’ homes and illicit prescription medications available illegally on the street. This helps to protect the curious young children under 6 years of age, teenagers who feel experimentation with prescription medication is safe and preventing many unexpected adverse events in the senior population, not to mention preventing the harmful effects on the environment.”13
The six Western New York disposal sites participating in the DEA’s first National Take Back Day collected and destroyed more than 2,200 pounds of unused or unwanted medications. Of these, about 230 pounds were controlled substances with an approximate street value of $230,000 (FIGURE 1).14 Volunteers from local businesses ranging from pharmacies to car dealerships were present, representing their companies’ commitment to the community.
Getting Started: Establishing a single-day pharmaceutical collection event can seem overwhelming at first. Breaking tasks down and establishing a timeline render achievement of the event far more manageable:
• Form an event team. The first step is to form a collection-event team consisting of—but not limited to—local officials and law-enforcement officers, pharmacy personnel, and community sponsors. Local businesses may be willing to contribute resources ranging from volunteers and supplies to financial and marketing support.
• Determine the event location and format. Next, it is important to find a location and format for the event that are accessible and safe. Consider the resources available and the workflow of the location, including the availability of tables and chairs and the need to prepare or clean the site. Drive-through events, with participants remaining in their vehicles, are a safe and effective format.11
• Comply with federal and state regulations. Each state’s regulatory requirements vary, so check with the Department of Environmental Conservation, the Department of Health, and local law-enforcement officials regarding regulations. The DEA also must be notified of the event.
• Coordinate with the municipal-waste combustion facility. The next step is to make an appointment with a destruction facility for incineration of the disposed medications, which must be witnessed by law-enforcement officials. To facilitate this, provide the law-enforcement agency with a contact person and directions to the facility, as well as with arrangements for billing.
• Secure supplies and volunteer staff. Supplies, including boxes lined with plastic bags, packing tape, labels, scissors, markers, pens, and clipboards, may be gathered throughout the preparation period. Prior to the event, it is important to establish a point person at the site to coordinate access to the facility, organize volunteers, and arrange tables and chairs for staff and law-enforcement officers.
• Publicize the event. Contact local media and community leaders, who can help make the public aware of the event. Community pharmacies are key contacts for the distribution of flyers and event information.
• Set up the event site and transportation for collected waste. Finally, arrange for proper vehicle size and cargo space for law-enforcement officers to transport the collected pharmaceutical waste to the destruction facility.15
Conclusion
Some reasons that medications may accumulate for reasons include medication misuse, poor medication adherence, changes in therapy, complex medication regimens, polypharmacy, and patient death. Unused or unwanted medications pose a risk to our communities and have the potential for prescription drug abuse, accidental overdose, and environmental consequences. Pharmacists serve as drug-information resources for proper medication disposal, and, in collaboration with drug-disposal programs and pharmaceutical collection events, they can be part of the solution to the problem of medication waste. Whether choosing to establish a Sharps TakeAway Environmental Return System program in the pharmacy, getting involved in a DEA National Take Back Day event, or simply providing resources about proper medication disposal to consumers, pharmacists are making a difference in the communities they serve.
REFERENCES
1. A Call to Action: Preventing U.S. Citizens From Inappropriate Medication Use. A White Paper on Medication Safety in the U.S. and the Role of Community Pharmacists. Huntingdon Valley, PA: Institute for Safe Medication Practices; 2007.
2. The Other Drug Problem: Statistics on Medicine Use and Compliance. Bethesda, MD: National Council on Patient Information and Education; 1997.
3. Teens and Prescription Drugs: An Analysis of Recent Trends on the Emerging Drug Threat. Washington, DC: Office of National Drug Control Policy; 2007.
4. Reinberg S. Medicines top source of kids’ poisonings. http://health.usnews.com/ health-news/managing-your- healthcare/treatment/articles/ 2009/08/04/medicines-top- source-of-kids-poisonings. Accessed June 8, 2011.
5. New York State Department of Environmental Conservation. Drugs in New York’s waters: how drugs get into our waters and why DEC is concerned. www.dec.ny.gov/chemical/45083.html. Accessed June 8, 2011.
6. Office of National Drug Control Policy. Proper disposal of prescription drugs. October 2009. www.whitehousedrugpolicy.gov/publications/pdf/prescrip_disposal.pdf. Accessed March 23, 2011.
7. Sharps Compliance Inc. Unused medications. www.sharpsinc.com/unused-medications.htm. Accessed March 23, 2011.
8. National Community Pharmacists Association. Patients report high satisfaction with Dispose My Meds program; 8,000 pounds of prescription medication properly discarded. www.ncpanet.org/index.php/news-releases/103-patients-report-high-satisfaction-with-dispose-my-meds-program-8000-pounds-of-prescription-medication-properly-discarded. Accessed June 8, 2011.
9. Giroux S. Personal communication to the author.
10. National Community Pharmacists Association. Frequently asked questions on the NCPA Prescription Disposal Program. www.ncpanet.org/pdf/rxpatrol/NCPA_PDP_FAQs.pdf. Accessed March 23, 2011.
11. DEA Public Affairs. American public overwhelmingly responds to DEA prescription drug take-back effort. October 5, 2010. www.justice.gov/dea/pubs/pressrel/pr100510p.html. Accessed March 30, 2011.
12. Associated Press. DEA event collects 188 tons of unwanted drugs. May 6, 2011. www.buffalonews.com/wire-feeds/24-hour-national-news/article415632.ece. Accessed May 26, 2011.
13. Fiebelkorn K. Personal communication to the author.
14. Giroux R, Fiebelkorn K, Monte S, et al. Assessing the relationship between pharmacy supplier, third-party prescription coverage, and medication waste. Poster presented at 158th Annual Meeting of the American Pharmacists Association; Seattle, WA: March 2011.
15. New York State Department of Environmental Conservation. Collection planning checklist: helpful hints for event sponsors. www.dec.ny.gov/chemical/68620.html. Accessed March 22, 2011.
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