As of 2014 it was estimated that as many as 3 billion prescriptions were being written annually in the United States, and the number of people using prescription medication has been rising steadily for years. For example, according to Centers for Disease Control and Prevention statistics, the percentage of U.S. residents who had used “at least one prescription drug in the past month” rose from 44% to 48% over a span of about nine years, from 1999–2000 to 2007–2008. During the same time frame, the percentage of those using two or more drugs rose from 25% to 31%, and the use of five or more drugs nearly doubled, jumping from 6% to 11%.
However, not all drugs end up being used by patients. Prescribed medications are often wasted. There are several reasons for this.
- A medication may not be effective, or it has adverse effects that the patient is unable to tolerate or doesn't want to deal with; in such cases, the prescription may be changed.
- A patient's medication may expire before the supply is used up.
- A patient may not adhere to a prescribed therapy.
- In a health care facility, a patient may be discharged or die, leaving behind a supply of unused medications.
According to the best estimates, the amount of wasted medication in this country is huge. Hospitals and long-term care facilities dispose of at least 125 million pounds of pharmaceuticals each year. We can't even track waste in the community because data aren't kept. But in one study, published by Kevin T. Bain in the July–September 2010 issue of Medical Waste Management, consumers returned approximately 17,000 drugs to just one Houston-based community pharmacy over a six-month period, and a disposal program in Alberta, Canada, collected more than 204 tons of unused drugs during an eight-year period.
The problem of unused and wasted drugs is becoming increasingly urgent and has enormous environmental, public health, and cost implications. For example, pharmaceutical drug contamination in the groundwater, rivers, estuaries, lakes, and bays is an emerging issue throughout the nation. Drugs enter wastewater from a variety of sources, such as sewer systems—as unused medications are flushed down the toilet or poured down the drain—and even human and animal excrement. Sewage treatment plants, septic systems, and drinking water infrastructures are not designed to remove this type of contaminant. “Take any stream or waterway that's downstream from a wastewater treatment plant, and you're going to find pharmaceuticals in the water,” said Margaret Shield, PhD, policy liaison for the hazardous waste–management program in King County, Washington. “There are quite a few studies showing how, even in tiny amounts, pharmaceuticals affect aquatic life.” They can affect how algae grow, Shield said, and poison fish. And they can adversely affect human health.
During 1999 and 2000, samples from 139 streams in 30 states were tested for the presence of 95 chemicals by the U.S. Geological Survey, and as reported by the Watershed Council, “82 of the 95 chemicals were detected at least once.” The analysis also showed that more than 80% of the waterways tested had traces of a cornucopia of pharmaceuticals, including acetaminophen, hormones, hypertension drugs, codeine, and antibiotics.
A 2008 investigation by the Associated Press found that a wide array of pharmaceuticals have been detected in the drinking water of at least 41 million Americans. Drugs were detected in the drinking water supplies of 24 major metropolitan areas. Although the concentrations of pharmaceuticals have been found to be tiny, there is growing concern about their possible long-term effects on human health.
Although the scope of the problem continues to be defined and studied, multifaceted solutions are needed immediately to curb waste and keep drugs out of the environment. But consumers are often confused as to what protocols to follow, according to Shield.
“We get calls from people saying that it ‘doesn't seem right to be flushing drugs down the toilet or throwing them into the trash—what should I do?’ And that's because the information that they've gotten about disposing of unused drugs has changed.”
One important method of keeping drugs out of the environment involves prevention: reduce the amount of medication being prescribed in the first place. Erika Kimball, RN, a health care sustainability consultant who works primarily on the “greening” of hospitals and physicians’ offices, explained that, first and foremost, providers need to discuss prescriptions with patients. “When a patient is prescribed a new drug, it may not be effective or may have adverse effects,” she said, and the patient may just take it for a few days and then ask for something else because it's not working or because the patient can't tolerate it.
Instead of prescribing 30 or 60 pills, a prescriber can use a smaller quantity, thereby reducing waste if the drug doesn't work out, Kimball said. “Just giving them five or seven pills to start—that's a best practice for sustainability.”
Educating patients on the best practices for the disposal of leftover medication is where nurses can play a particularly valuable role. “Discussing options for disposing of unused drugs can be a routine part of discharge instructions in the hospital,” said Kimball. “And it can be done in the physician's office as well, when a patient is given a prescription.”
The best options for disposing of leftover drugs are drug take-back programs, which designate places, and often times, people can take unused medications for safe disposal. The collected drugs are then disposed of using high-temperature incineration at a secure, permitted facility. This approach is the most environmentally sound, ensuring that the chemicals are completely destroyed. The downside is that not all communities have locations where drugs can conveniently be dropped off.
Curbing waste is a piecemeal process, but communities across the country are creating dedicated programs and taking steps to implement them. Laws and regulations are beginning to place the responsibility of collecting unused drugs on the manufacturer. In 2012, Alameda County in California adopted the Safe Drug Disposal Ordinance, the first municipal law in the country to hold pharmaceutical companies responsible for safely collecting unused medications from the public and disposing of them. King County in Washington took a similar step a year later and created a drug take-back system for residents that will be funded and operated by the drug manufacturers. Both ordinances were challenged in the courts but were upheld.
The U.S. Food and Drug Administration has a list of a small number of drugs that should be flushed if take-back programs are unavailable, because a single dose could be harmful or even fatal. Drugs not on that list should be disposed of in the household trash, preferably mixed in an unpalatable substance such as kitty litter or coffee grounds.
One organization has launched an innovative program that allows unused drugs to be donated, rather than destroyed, if they might benefit other patients. The California-based nonprofit group SIRUM, which stands for Supporting Initiatives to Redistribute Unused Medicine, is working to stop waste by passing the drugs along to people who are unable to afford them. The program allows health facilities, manufacturers, wholesalers, and pharmacies to donate unused medicine by finding a match for the product. SIRUM's online system produces a list of all recipient clinics in the SIRUM network that need medications matching those a donor facility has in surplus. It is then up to the donor to choose the recipient clinic and SIRUM takes care of the logistics of shipping.
“If we can recycle a can with the flick of a wrist in this country, we should be able to recycle the $5 billion plus worth of perfectly good, unused medicine we discard each year,” said George Wang, PhD, one of SIRUM's cofounders and codirectors. “By keeping that medicine out of our waste streams, we can do more than prevent environmental harm—we can actually improve patient health and save taxpayers money.”
According to SIRUM, about $700 million worth of medications could be salvaged each year, accounting for about 10 million prescriptions. “All too often, people skipping their medications do so simply because they cannot afford them,” Wang explained. “By passing clear, strong laws protecting drug donation in more states and increasing awareness about donation as a viable alternative to drug destruction, we should be able to get every unused pill to a patient in need.”—Roxanne Nelson