Until recently, the recommended means for medication disposal has been to discard the unused or expired medications to sewerage.1 In the United States, poison control centers have long recommended discarding medications in this manner to prevent accidental and purposeful poisonings from occurring.2 As part of their job responsibilities, hospice home care nurses are required to teach their patients and caregivers how to manage, store, and dispose medications in a safe manner. Sometimes, it is the nurse who disposes of the medications upon death of the patient. In fact, nurses who abide by these recommended disposal means are acting responsibly to prevent accidental ingestion by anyone for whom the drugs were not intended and the diversion of the drug for illegal usage and sale.1 According to nurses Carpenter and Condon,3 although flushing unused medications down the toilet or sink is convenient, it is not an environmentally sustainable practice.
For the past decade or so, there have been numerous reports revealing pharmaceuticals in groundwater, lakes, rivers, and drinking water.2 These pharmaceuticals may have a potential effect on aquatic and human health. According to Daughton and Ruhoy,4 the environmental scientific community is becoming more aware of the environmental impact from pharmaceuticals found in the water.
In 2007, the White House Office of National Drug Control Policy (ONDCP) published the first federal guidelines5 for the disposal of prescription drugs. While citing rising trends in prescription drug abuse, the joint press release issued by the ONDCP, the Department of Health and Human Services (DHHS), and the Environmental Protection Agency (EPA) asserted that the guidelines were created with the intention of protecting the environment while reducing the possibility of illegal diversion of prescription drugs (ONDCP, 2007). According to EPA administrator, Stephen L. Johnson, "While EPA continues to research the effects of pharmaceuticals in water sources, one thing is clear: Improper drug disposal is a prescription for environmental and societal concern."5
In March 2008, the Associated Press (AP)6 announced the findings of a 5-month investigation, revealing that pharmaceuticals were found in drinking water supplies of at least 41 million Americans. Although these findings sparked new public concern and interest, pharmaceuticals in our drinking water are not a new finding or occurrence. Christian Daughton, EPA scientist, has been quoted as saying, "If drugs are in drinking water now, you can be guaranteed they've been there as long as the drugs have been in use."7 Among pharmaceutical agents found in the water, estrogens, antidepressants, and antibiotics have been linked to abnormalities in aquatic life.8
The purpose of this article is to provide a discourse about (1) pharmaceutical agents in the water, (2) environmental pathways and aquatic exposure, (3) potential human health exposure, (4) gaps in data about hospice nursing knowledge and practice, and (5) recommendations for hospice nursing practice, research, and advocacy.
The conversation about pharmaceuticals in the water supply is a complex one. This section provides a brief overview of the federal government's recommendations for drug disposal by consumers along with an overview of research of active pharmaceutical ingredients (APIs) in the water, environmental pathways, aquatic exposure, and the potential impact to human health. Gaps in research about related hospice home care nursing practice and knowledge are discussed as well.
White House Office of Drug Control Policy
While citing rising trends in prescription drug abuse, a 2007 joint press release issued by the ONDCP, the DHHS, and the EPA asserted that the first federal guidelines for drug disposal were created with the intention of protecting the environment while reducing the possibility of illegal diversion of prescription drugs.5 The ONDCP recommendations include a list of medications that should be flushed. New guidelines updated in October of 2009, include a link to the FDA website9 for recommendations on a select list of controlled substances to be flushed. The list of medications include Actiq, Avinza, Daytrana, Demerol, Diastat/Diastat AcuDial, Dilaudid, Dolophine Hydrochloride, Duragesic, Embeda, Fentora, Kadian, Methadone Hydrochloride, Methadose, Morphine Sulfate, MS Contin, Onsolis, Opana, Opana ER, Oramorph SR, Oxycontin, Percocet, Percodan, and Xyrem.
The ONDCP recommendations include the following instructions:
- Removing unused, unneeded, or expired prescription drugs from their original containers;
- Mixing the prescription were drugs with an undesirable substance, such as used coffee grounds or kitty litter, and putting them in impermeable, nondescript containers, such as empty cans or sealable bags, further ensuring that the drugs are not diverted or accidentally ingested by children or pets;
- Throwing these containers in the trash;
- Flushing prescription drugs down the toilet only if the accompanying patient information specifically instructs it is safe to do so; and
- Returning unused, unneeded, or expired prescription drugs to pharmaceutical take-back locations for safe disposal.5
In 2009, the ONDCP issued revised guidelines that removed the list of medications to be flushed as well as encouraged the use of community take-back programs and waste collection events as an alternative to disposal. In addition, the use of a margarine tub was suggested to place prescription drugs in prior to placing in the trash. Recommendations also included directions for concealing or removing any personal information including the prescription number on the containers by using a marker or duct tape or by scratching it off.10
Active Pharmaceutical Ingredients in the Water
For the past 30 years, water pollutants of concern to citizens, environmental organizations, and regulatory bodies have included chemicals and heavy metals that are actually or potentially harmful to wildlife or human health. A lesser understood but growing area of concern is APIs found in the water. An API is a chemical constituent having pharmacological activity or other useful effect in the diagnosis, cure, mitigation, treatment, or prevention of disease or that affects the structure or function of the body.1
Numerous studies have detected APIs in surface water, groundwater, and treated drinking water.2 In March 2008, the AP issued a press release, PharmaWater I, which detailed findings of a 5-month investigation by an AP National Investigative Team that revealed APIs present in drinking water supplies of at least 41 million Americans.7 Pharmaceuticals included antibiotics, anticonvulsants, mood stabilizers, and hormones.7 Drugs were detected in the drinking water supplies of 24 major metropolitan areas, from southern California to northern New Jersey, and from Detroit to Louisville.7
However alarming this news was to concerned citizens in the United States, research had discovered APIs in the water for more than a decade. In 1997, Ternes11 summarized one of the first major European studies of German groundwater and surface waters that detected cholesterol regulators, analgesics, and anticonvulsants. From 1999-2000, the US Geological Survey conducted the first national investigation of pharmaceuticals, hormones, and other organic contaminants in the water. Of the 139 streams that were analyzed in 30 states, 82 chemicals were identified, and many were pharmaceuticals. Eighty percent of streams had one or more contaminant, and an average of seven contaminants was identified per stream.12
More recent studies include locations in the United States and United Kingdom that revealed treatment plants were not entirely effective in removing APIs from finished water. In 2004, a drinking water treatment plant in the United States and two streams serving the facility were analyzed for 106 contaminants in 24 samples. Some prescription and nonprescription drugs and their metabolites were detected in finished water.13 Also in 2004, a UK wastewater treatment plant's (WWTP's) source waters were analyzed, and 10 pharmaceutical compounds including ibuprofen, mefenamic acid, diclofenac, propranolol, dextropropoxyphene, erythromycin, trimethoprim, tamoxifen, sulfamethoxazole, and acetylsulfamethoxazole were identified. Eight pharmaceutical compounds were found in the receiving waters, including ibuprofen, mefenamic acid, diclofenac, propranolol, dextropropoxyphene, erythromycin, trimethoprim, and acetylsulfamethoxazole.14 While markers of human fecal contamination were being surveyed, low levels of APIs were identified both upstream and downstream from WWTPs in Michigan, including acetaminophen and methyl salicylate.15 For most of the chemicals, there was an increase in the frequency of detection and concentration in the WWTP effluent sample as compared with the water sample collected upstream. In addition, the chemical concentrations and occurrences decreased downstream with distance from the WWTPs.15 In 2004, clofibric acid, propyphenazone, and diclofenac were found in groundwater in Germany.16 In 2007, research revealed APIs in samples of finished water, which indicated substantial but incomplete degradation or removal of the compounds through the drinking water treatment plant.17
Prior to the AP report in 2008, the fact that APIs have been discovered in the water was not well known. Research that has been ongoing for more than the last decade revealed that many of the streams and drinking water carry a multitude of APIs. Although it is well known that APIs are in the water, and from what sources they exit, the volume and percentage of each pathway are unclear.
The United States is by far the largest consumer of medications in developed countries, if not the world. According to a report from the DHHS to Congress, from 1999 to 2000, 44% of all Americans were taking at least one or two prescription drugs during a prior month, and nearly one in five were taking three or more. Nearly 84% of all Americans aged 65 years and older were taking at least one or two prescription drugs, and nearly half were taking three or more.18 In the United States, the use of prescription and over-the-counter medications continues to increase. According to IMS Health,19 the United States is the biggest user of pharmaceuticals in the world, with sales of both over-the- counter and prescription medication above $200 billion in 2007. Purchases from the United States nearly equaled the total purchased quantity in the other 12 countries where sales figures are tracked.2
Active pharmaceutical ingredients enter the water supply through numerous pathways. Although there are other pathways, such as outputs from agricultural and veterinarian practices, the focus of this discussion is on primary routes for household pharmaceuticals to enter the environment: (1) excretion after ingestion, injection, or infusion; (2) removal of topical medications during bathing; and (3) disposal of unused or unwanted pharmaceuticals.20 According to Ruhoy and Daughton,20 deposits of unmetabolized APIs from parenteral and enteral drugs are excreted in feces and urine, and topically applied medications are washed from skin during bathing. Active pharmaceutical ingredients enter the water supply from the disposal of unwanted medications directly to sewers by flushing them down the toilets and into drains and by being placed in the trash. However, the significance of this route when compared with excretion and bathing is not fully understood and has been subject to much debate.4
While the discussion of pharmaceutical disposal primarily concerns leftover unused medications, partially used medications (especially delivery systems or devices used frequently in hospice) also serve as a source of APIs during disposal. These can represent a significant portion of the amount present in new, unused devices. For instance, transdermal and transmucosal devices are two examples; after 3 days of use, fentanyl patches are reported to retain 28% to 84% of their original fentanyl content, more than sufficient for a lethal oral dose.21 Second, while most unmetabolized parent APIs are excreted by feces and urine, unknown quantities can also be excreted by sweat and can then be introduced to sewers during bathing (or can be transferred to other surfaces during bodily contact). Although this route of excretion has been investigated primarily for drugs of abuse,22 therapeutic medications are also excreted.23 While the concentrations of APIs in the aqueous environment are generally very low when compared with therapeutic human dosages, it is not known what the relative contributions are from excretion versus disposal.4
Nevertheless, an assortment of other entry modes exists including agricultural and veterinarian practices. Other potential routes include leachate from municipal landfills, runoff from confined animal feeding operations, pet or farm animal excretions, loss from aquaculture application, spray drift and runoff from agricultural use, direct discharge from raw sewage (occurring with combined sewage overflow and straight piping), sewage discharge from cruise ships, and illegal laboratories (especially methamphetamine), to name a few.24
Although there have been varying opinions about the effect of small concentrations of APIs found in water, new concerns are being raised about effects that occur, even at low levels.25 Active pharmaceutical ingredients have been found in the ambient environment at concentrations that not long ago were considered infinitesimally low. These low concentrations of APIs may be responsible for environmental effects such as the development of female characteristics in male fish affecting reproduction, sex, and genital abnormalities in fish and even fish population collapse.2
Unlike other well-understood pollutants, APIs are engineered to intentionally have a significant biological action upon humans, making them exceptionally dangerous substances for living organisms. As pharmaceuticals are designed to have an effect at a prescribed dose, the potential exists for impact at low concentrations.25 With thousands of distinct APIs, there is also the potential for cumulative and synergistic effects.
While controversy may exist over whether the primary entry mode of APIs into the water supply is excretion or direct disposal, there is no debate concerning the fact that pharmaceuticals are negatively impacting the aquatic life cycle. Three classes of drugs that pose especially serious threats are nonsteroidal anti-inflammatory drugs (NSAIDs), hormones, and antibiotics.
Nonsteroidal anti-inflammatory drugs are the most commonly consumed class of drugs.26 This class of pharmaceuticals reduces inflammation through the inhibition of the synthesis and release of inflammation-mediating hormones known as prostaglandins. Examples of NSAIDs include acetylsalicylic acid (aspirin), diclofenac, and ibuprofen. This class of pharmaceuticals has demonstrated kidney-damaging effects in more than one animal exposed to traces of these drugs in the water.26
Another class of pharmaceuticals generating significant concern among the scientific community is hormones. Hormones are a member of a large group of chemicals known as endocrine modifiers or endocrine-disrupting chemicals (EDCs). This group of chemicals has the ability to effect the normal functioning of the endocrine system. Concern over EDCs is not a new issue. As early as 1994 (Purdom et al27) and 1996 (Harries et al28), male fish exposed to sewage effluent in receiving waters were shown to have developed a female-specific protein, vitellogenin. In 1999, a report documented widespread sexual disruption in wild populations and indicated that reproductive and developmental effects resulted from exposure to ambient levels of chemicals present in typical British rivers.29 The reproductive changes, which demonstrated a high incidence of intersexuality in wild fish found in rivers throughout the United Kingdom, were consistent with exposure to EDCs associated with discharges from sewage treatment plants that were known to contain estrogenic compounds.29
The focus on endocrine disruption arose in the 1970s, when Theo Colborn, zoologist and former pharmacist, reviewed hundreds of studies examining the health consequences of the contamination of wildlife in the Great Lakes. Colborn realized the common theme was disruption of hormonal control of development. The term endocrine disrupting chemical was coined at a Wingspread conference when a group of scientists was brought together by researcher Theo Colborn in 1991. The result was a unified consensus statement asserting that synthetic chemicals could interfere with the hormones of animals and, possibly, people. Fetuses and the young were at the greatest risk for disease, abnormalities, and reproductive problems that were already manifesting in wildlife.30
The newer findings of the reproductive effects of aquatic species caused by synthetic hormones at background levels might confirm Colborn's hypothesis that hormonal effects could take place with low concentrations of chemicals. Many aquatic species are continuously exposed over long periods or even over their entire life cycle.31 A study in 2001 revealed the reproductive effects in fathead minnows exposed to low concentrations of synthetic steroid EE2 over their life cycle.32 When fish were exposed over their life cycle to low concentrations of EE2, effects included decreased egg fertilization, sex ratio changes skewed toward females, and demasculinization of males.33,34 Also alarming are the observed abnormalities in gonadal development and sexual disruption of fish exposed to EDCs. Over three summers, researchers added estradiol, a hormone used in contraceptives, to a pristine study lake in Canada at a concentration similar to that found in municipal wastewaters and in downstream rivers. Some of the first adverse effects the researchers noted were delayed sperm cell development in male fathead minnows. Within 1 year, the male minnows were producing eggs and stopped reproducing. Within 3 years, all of the minnows disappeared from the lake. The fathead minnow was not the only fish to sustain the effects from the hormone. Lake trout populations also fell by about 30% because they lost their source of food.35
Another pressing concern regarding the disposal of APIs is that of potential antibiotic resistance of bacteria that may arise out of chronic low-level exposure of bacteria to ubiquitous antibiotics found in water. Several studies have shown a decrease in the effectiveness of antibiotics because of its ever-present nature in the environment.36-38 As demonstrated in the case of the lake trout in the intentionally contaminated lake, damage from APIs may occur directly or indirectly through the food chain, which ultimately may have an effect on human health.
Potential Human Impacts
There is much debate in the scientific community about human health effects from low-level APIs found in the water. Some arguments are based on the fact that the amounts of APIs have, for the most part, short half-lives and when found in drinking water are at low concentrations when compared with therapeutic doses. However, Daughton1 questions this opinion, suggesting that as APIs are introduced to the environment on a continual basis by treated and untreated sewage, there may be a quality of persistence to compounds that otherwise may not possess any inherent environmental constancy. Because of the continual introduction (persistence) of APIs from sewage treatment facilities and from septic systems, the potential for adverse effects on all organisms in a given area is largely unknown, especially for aquatic life and for humans.
Another pressing concern regarding the disposal of APIs is that of potential antibiotic resistance of bacteria that may arise out of chronic low-level exposure of bacteria to ubiquitous antibiotics found in water. Several studies have shown a decrease in the effectiveness of antibiotics because of their ever-present nature in the environment.36-38 Documented ecological impacts of drug residues in ambient water include the development of antibiotic-resistant bacteria in rivers.39 A 2002 study found widespread culturable antibiotic-resistant bacteria in nonconcentrated water samples from many US rivers; gram-negative organisms were isolated with high levels of resistance to ampicillin, cefotaxime, and ceftazidime.39 Other studies have correlated an increased incidence of antibiotic resistance among bacteria in sewage and sludge40 and in groundwater.41
It is known that APIs can inflict damage upon aquatic life. In the case of the lake trout in the intentionally contaminated lake, the damage that occurs by nature's observance of the food chain may also impact others farther up the food chain. The question remains whether such bacteria are leading to outbreaks of multidrug-resistant infections that are increasing in number in global human populations.
Not only do resistant microbes continue to cause a large number of infections and deaths, especially in developing countries, but the emergence and spread of antimicrobial resistance are now threatening to undermine our ability to treat infections and save lives. Some of the most lethal deadliest infections in which first-line drug resistance has been detected include respiratory infections, HIV/AIDS and communicable diseases linked to diarrhea, tuberculosis and malaria.42 In some cases, the level of resistance has forced a change to costly second- or third-line agents. When resistance against these second- or third-line drugs emerge, the world will run out of treatment options.42 According to the World Health Organization (WHO),43 "Drug resistance can be considered as a natural response to the selective pressure of the drug. However, it is exacerbated by several factors, including abuse, underuse, or misuse of antimicrobials, poor patient compliance, and poor quality of available drugs." In 2008, WHO43 developed a six-point Global Strategy for Containment of Antimicrobial Resistance in response to the problem; the strategy includes disease prevention, access and appropriate use of antimicrobials, surveillance, appropriate legislation, and focused research.
In 2008, Daughton and Ruhoy11 questioned the significance of antibiotic residues found in the environment with respect to the rising level of resistance among human pathogens. In addition, they pondered the impact of trace levels of antimicrobials found in the water (or the higher levels in biosolids) on the development of resistant bacteria, viruses, and other microorganisms outside the body, in particular those that can play roles in human disease.
Medicare and Medicaid have recently promulgated new standards for the disposal of pharmaceuticals. The new (2008) Hospice Conditions of Participation by the Centers for Medicare and Medicaid44 (CMS) provides a standard for the labeling, disposal, and storage of drugs and biologicals in the patient's home. One section, Safe Use and Disposal of Controlled Drugs in the Patient's Home, mandates the hospice have written policies and procedures for the management and disposal of controlled drugs in the patient's home. In addition, the hospice must provide a copy of its written policies and procedures to the patient or the patient's representative and family. In addition, it requires the policies and procedures be explained to the family in a language and manner they understand to ensure that they are educated regarding the safe use and disposal of controlled drugs. This must also be documented in the patient's clinical record.44
Currently, the Resource Conservation Recovery Act (RCRA), enacted by the EPA in 1976, constitutes key legal guidelines overseeing disposal methods of pharmaceuticals.45 Within this act, the EPA mandates procedures for disposing of hazardous materials. Those substances deemed potentially hazardous to animals fall into one of the two following categories: U type (harmful) or P type (more harmful). The RCRA imposes fines upon those institutions who fail to dispose of classified substances properly. The RCRA only claims jurisdiction over institutions that generate kilograms of hazardous waste monthly, leaving the disposal practices of individual drug users entirely unregulated. The RCRA does not regulate any household waste, which includes medications/pharmaceutical waste generated in a household.45 The EPA has specific criteria that apply to classify substances as hazardous.46 The four qualities used to define a hazardous substance are ignitability, toxicity, corrosivity, and reactivity. Only 10 of the substances deemed hazardous because of toxicity by RCRA are pharmaceuticals. Because of the current definition of hazardous substances, only a few pharmaceuticals meet the criteria of corrosivity; thus, current definitions of hazardous materials are not sufficient to define the characteristics of pharmaceuticals. Only one pharmaceutical substance is classified as hazardous, and that is nitroglycerine. Additionally, RCRA regulations apply to only substances that contain one of the U- or P-listed substances as its sole active component, leaving a great deal of substances that contain significant amounts of hazardous materials unregulated.
Another relevant piece of legislation regarding pharmaceutical disposal is the Federal Drug Enforcement Agency's (DEA) Controlled Substance Act of 1970.47 Under this act, controlled substances (substances with a high potential for abuse and precursors to them) are classified into one of five schedules. Schedule I controlled substances are those with no therapeutic application. Immediately following prescription, a controlled substance may not legally be transferred to any other entity, other than a registered DEA official. Hence, it is not permissible for any disposal intermediary (such as a hospice nurse) or even a take-back program to receive these drugs.1
Currently, there is a pending legislation to address citizen concerns. House resolution (HR) 1191,48 the Safe Drug Disposal Act of 2009, directs the DEA to develop five model state programs for consumer returns and prohibits the Food and Drug Administration from allowing medication labeling to state that medications must be flushed. The Secure and Responsible Drug Disposal Act of 2009 (HR 1359)49 provides for disposal of controlled substances in specific instances. The Drug Free Water Act of 2009 (HR 276)50 directs the EPA to convene a task force to develop recommendations on proper disposal and to develop a strategy for educating the public on recommendations. The Water Quality Investment Act (HR 1262)51 requires federal agencies to study the presence of pharmaceuticals and personal care products in the waters of the United States. This bill also requires EPA to convene a task force to develop drug disposal recommendations for consumers and healthcare institutions.
Alternatives to Flushing Medications
Although guidelines recommended by the ONDCP provide a better alternative to flushing pharmaceuticals, there are other options, such as consumer collection through community programs or pharmacies, and mail-back programs. Some of these programs have been grant funded and as of yet have not provided financially sustainable solutions to disposal of unused, unwanted, or expired medications. However, in each of these approaches, the pharmaceuticals are ultimately incinerated. Except for incinerators designed and approved for hazardous wastes (which require constant extremely high temperatures to avoid toxic emissions), incinerators with improper or insufficient methods could lead to emissions of unaltered parent drug entities or toxic by-products.52 Daughton52 uses two cases to demonstrate the hazards of incineration of pharmaceuticals: small incinerators that have been used in humanitarian relief efforts when donated medications were not used and the on-site incineration of drugs confiscated by law enforcement. However, safe solutions need to be investigated. Leftover drugs not disposed of immediately but rather stored in a household or other locations, as well as that portion discarded to the trash, are possibly subject to diversion unless methods are put into place to render the drug unrecognizable or usable.52
A variety of drug waste management options are available to some consumers and practitioners. Mail-in programs are beginning to be used in several communities. A grant-funded mail-in program is ongoing in Maine and in Wisconsin. Other programs include community collection events, some in conjunction with local pharmacies and others involved at the community or county level. There are programs currently operating in California and Washington. Several proposed options, together with advantages and disadvantages of each, appear in the Appendix.
Daughton53 proposes a more "upstream" approach when he suggests that progress in green chemistry design could lead to reducing the impacts of APIs in the environment while having the potential to improve outcomes. Daughton53 recommends an interdisciplinary approach involving social psychologists, risk communicators, physicians, pharmacologists, pharmacists, drug designers, and health insurers to frame the issue to develop a national conversation about how healthcare practices are linked to environmental contamination. Nurses are a natural choice to be part of the conversation.
Although an established practice of hospice home care nurses has been to dispose of prescription medications by flushing, there is a paucity of literature that details this practice. In addition, the level of knowledge of hospice home care nurses about APIs in the water is not known; no reports of nurses' knowledge have been published.
There have been debate and criticism over the focus on drug disposal as a source contributing to APIs in the environment.4 However, at this point, because limited data have been gathered, it is difficult to know the volume for any source point (such as excretion vs disposal) as well as to determine how much each source point contributes to the entire volume of APIs in the water.4 Because of this lack of data, Ruhoy and Daughton4 completed a survey of coroner medication inventory data upon death of a patient, which was one of the first surveys of medication usage of its kind. For a 13-month period, Clark County, Las Vegas, coroners completed a survey of medications they disposed of by flushing. For that period, the coroners flushed more than 325,000 medications or about 225 lb of APIs. Extrapolating from those data, Daughton and Ruhoy4 estimated that orphaned medications from the deceased population alone account for as many as 19.7 tons of APIs disposed of into US sewage systems annually.
On a similar note, the general lack of data regarding the pharmaceutical disposal practices of healthcare facilities prompted the US EPA to develop a survey (in progress) of the drug disposal practices of hospitals and long-term-care facilities.54 The data gathered will be used to characterize the national practices in pharmaceutical disposal and alternatives to drain disposal and flushing, as well as economic impacts of disposal policies.
RECOMMENDATIONS FOR NURSING RESEARCH AND PRACTICE
The ONDCP5 guidelines for drug disposal were published initially in 2007 and updated in 2009, while the new CMS Hospice Conditions of Participation,55 effective in December 2008, provides a new standard about hospices ensuring the safety of patients and families in regard to drugs in the home and drug disposal. Nursing curriculum has not been developed that addresses incorporating the new federal guidelines with the new Hospice Conditions of Participation. The CMS requirement mandates the hospice nurse to not only have a conversation with the family in terms they can understand about safe medication use and disposal, but also the hospice must provide a copy of its written policies and procedures to the patient or patient representative and family. It is not known what hospice home care nurses' knowledge is of the ONDCP guidelines or the change in the CMS Hospice Conditions of Participation, yet it is the hospice home care nurses, as members of the hospice interdisciplinary team, who will teach the patient and caregivers about safe medication administration, storage, and disposal. These factors point to a need to study hospice home care nurses regarding their knowledge of APIs in the water, the ONDCP guidelines, and the CMS Hospice Conditions of Participation rule, as well as their drug disposal practices. Information gathered could be used to characterize hospice home care nursing knowledge and drug disposal practices, as well as provide a needs assessment that will inform future curriculum and policy development. In addition, information about best practices could be gathered and incorporated into the curriculum.
Future study could also focus on a targeted group of hospice home care nurses for audit of disposed medications, similar to the coroner's study. Findings could be used to characterize hospice medication ordering practices, which may be useful to understand if there were variances between hospices or regions. Some hospices are beginning to observe and study ordering patterns to determine if there might be new ways to reduce pharmaceutical waste.
The problem of safe drug disposal presents the need for education of hospice patients and their families. Nurses would benefit from the development of teaching materials and methods that address APIs in the environment, for use with patients and their caregivers. As the only group of professionals regularly welcomed into a hospice family's home, these nurses have a unique opportunity to identify hazards and educate families about how to protect their health and improve their environment. A good time to have this conversation is upon admission, when medications are being reconciled. This provides an opportunity for the nurse to assess the patient's and caregiver's knowledge of proper medication use, storage, and disposal as well as to assess for any possible diversion issues. Given that the issue of APIs in the water is so complex, and much remains unknown at this point, it is important to frame the message in a way so as not to alarm the patient or caregivers.
Hospice nurses are well prepared to provide community education on the topic of proper drug disposal. This would provide another opportunity for the hospice to improve the health of the community.
The issue of APIs in the water and concomitant threat of harm to the environment and human health is complex and without easy answers. According to Daughton,52 although these issues have gained the attention of many scientists in many different fields, the topic generates more questions than answers. Daughton posits that findings of chemicals, perhaps more than any other group of pollutants, in our water that are by-products of human healthcare illustrate an immediate, intimate, and inseparable connection of the actions of the individual with the environment.
A cautioned approach might be the best alternative as the science is unfolding. Nurses could consider the precautionary approach, adopted by the American Nurses Association in 1998.55 The precautionary approach,55 based on the precautionary principle,56 states that we, as nurses who are educated in disease prevention, can understand and should advocate for a safer approach when it may prevent injuries and illness. The precautionary principle, adopted at the Wingspread Conference in 1998,56 states that if it is within one's power, there is an ethical imperative to prevent rather than merely treat disease, even in the face of scientific uncertainty. In other words, although cause and effect have not been proven, action to prevent harm should be taken. Nursing actions consistent with the precautionary approach are to read new findings as they are published, so as to become an informed consumer and patient educator. The EPA publishes a Web site devoted to literature and research about the pharmaceuticals and personal care products.57 Other nursing actions using this approach could include advocacy.
Nursing advocacy can be viewed as case advocacy (when advocating for an individual patient) or class advocacy (aimed at changing conditions that are injurious to populations or have the potential to be injurious).58 Nurses can practice case advocacy when providing information about the management of medications, which includes the recommending the best disposal practice to patients and caregivers. Nurses can advocate on a class level by advocating for policy and procedure changes within their hospice that incorporate both the ONDCP guidelines and new CMS Hospice Conditions of Participation. Other ways for nurses to provide class advocacy is by becoming involved with community groups deciding best practices for drug disposal on a community level, serving on boards investigating alternative practices, partnering with other disciplines to develop innovative solutions, providing expert testimony, and being involved in program development and community education. Hospice home care nurses can participate in the development of drug disposal options, as they are community health experts and have an intimate understanding of what might or might not be burdensome to individuals, families, or communities. Hospice nurses have an opportunity to be a strong voice and advocate with their patients, families, and communities as well as within the healthcare industry in seeking new ways to decrease the environmental footprint of our healthcare practices.
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