Unwanted, expired and improperly disposed of medicines pose a serious threat to people, animals and the environment. How can pharmacists play an active role in reducing the impacts?
How active are you when it comes to promoting the safe disposal of unwanted or expired medicines to your patients?
You may have a Return of Unwanted Medicines (RUM) bin at the back of your community pharmacy, and sometimes a patient or two may ask what to do with their old medicines.
But chances are hundreds of patients are coming and going without any knowledge of what to do with their old or unwanted medicines.
After researching the disposal of medicines among the general Australian population, Professor Amanda Wheeler from Griffith University came across some shocking results.
Of more than 4000 people surveyed for the in the National Return and Disposal of Unwanted Medicines Project Audit 2016, around 60% admitted they had unwanted medicines stored at home.
Participants reported having large proportions of medicines that were unwanted, expired or used infrequently—but only 18% had heard of RUM.
And the ways that most respondents disposed of medicines was even more concerning.
“The majority of survey respondents (65%) said they disposed of their unwanted medicines with the usual household garbage; followed by poured down the drain or toilet (23.3%). Less than a quarter (23%) of those interviewed actually disposed of their unwanted medicines by returning them to a community pharmacy,” said Professor Wheeler.
“If it’s liquid, I throw it down the toilet. If they are other pills, I wrap them up in a plastic bag and throw them in the garbage,” said one respondent.
Another said they believed if they brought their medicines to the pharmacy, the pharmacy would “probably flush it down the toilet or give it back to the manufacturer”.
The survey also found less than half of healthcare workers asked patients if they had unwanted medicines at home and, if they did, the most common recommendation was to dispose of these with the rubbish.
“I had no idea that old medicines were supposed to be brought back to the pharmacy,” a middle-aged consumer told the AJP. “I have never had one pharmacist tell me that.”
A global public health issue
The negative impacts of these forms of disposal amount to a “global public health issue”, argues Judith Singleton, a pharmacy lecturer at the Queensland University of Technology and former lecturer in the Quality Use of Medicines at the University of Queensland.
Her research shows that pharmaceuticals enter the environment through various pathways, most commonly patient excretion, followed by the disposal of unwanted medicines.
Pharmaceuticals can end up in water for agricultural re-use as well as in soil, groundwater, drinking water and the atmosphere.
“Even though pharmaceuticals appear in very low concentrations in the environment and thus appear to pose a negligible risk to humans, they have the potential to exert a cumulative effect on humans,” says Singleton.
“We know that consumers are tipping things (particularly liquids) down toilets and sinks or throwing away in rubbish destined for landfill. These methods for disposal create entry points for drugs to reach the environment.
“Ultimately, as it is a closed system, we are all imbibing those active pharmaceutical ingredients through the water we drink, food grown in soils watered with treated water, and fertilised with the solid sludge component obtained from sewerage treatment plants,” she says.
Dr Kristie Murdoch from the National Toxics Network says more than 200 different types of drugs including antibiotics, NSAIDs, analgesics, lipid-lowering drugs, oestrogens and others have been detected in environments around the world, including areas as remote as the Antarctic.
“Wastewater treatment plants are currently not designed to remove pharmaceutical compounds,” says Dr Murdoch.
“The discharge of treated wastewater into rivers and oceans or onto land, and the spreading of sewage sludge onto land as fertiliser, result in the pharmaceutical contamination of the environment,” she says.
In addition, the growing and concerning presence of antibiotics in the environment is one of the reasons behind antibiotic resistance—a looming public health threat for the 21st century.
Singleton says she finds the lack of concern pharmacists have for pharmaceuticals entering the environment “seriously disturbing”.
“Pharmacists don’t understand that pharmaceuticals have a major negative impact on the environment,” she says.
“The World Health Organization (WHO) has identified this as a significant issue. Pharmacists can’t call themselves medicines’ experts without having a knowledge and understanding of the fate of active pharmaceutical ingredients”.
Into the wrong hands
Unwanted or unnecessary medicines also pose a safety risk in the household, presenting a hazard for accidental ingestion or poisonings by vulnerable groups such as children and the elderly.
Aged consumers taking many medications can become confused which can lead to “medication mismanagement”, often needing hospital care.
Expired or out-of-date medicines may also become toxic or ineffective, increasing the risk of harm from toxicity as well as through delayed medical treatment when medicines are not effective.
“All medicines are of a concern when they find their way into the wrong hands,” says RUM project manager Toni Riley.
“Research has shown that having unwanted or unnecessary medicines in the home creates potential safety issues—these medicines can be accessed by children and adults alike and, when taken, can possibly lead to overdose and toxicity,” says Riley.
“There are many very potent medicines available today. Everyone needs to treat them with the appropriate precautions and only take medicines when prescribed for themselves and only for the purpose for which the medicine was prescribed.”
The importance of the RUM Project is twofold, explains Warwick Plunkett, PSA national councillor and chair of the RUM Board.
“From a safety point of view in providing a secure pathway for accumulated unwanted and expired medicines to be removed from households and pharmacies; and secondly in providing an environmentally friendly method of destruction of these poisons through high temperature incineration,” says Plunkett.
High temperature incineration of medicines is in accordance with WHO best practice guidelines.
While incineration is not a perfect method due to the risk of toxic emissions in the air, it aims to safely destroy the medicines and thus reduce the amount of active pharmaceutical compounds entering the environment.
“There currently appear to be no environmentally appropriate alternative methods for the disposal of unwanted pharmaceuticals,” admits Dr Murdoch.
“A potentially more environmentally benign method is likely to involve a chemical deactivation process. There is some indication that certain alkaline hydrolysis waste disposal methods may destroy certain pharmaceuticals, such as chemotherapeutic drugs, and this type of technology may be able to be applied to the disposal of unwanted pharmaceuticals more generally. However, this is, as yet, untested.”
While only 18% of respondents in Griffith University’s research had heard of the RUM project, the good news is 92% said they would use it now they knew about it.
Survey respondents also suggested a consumer media campaign and pharmacy reminders with their prescription medicine packs could be effect ways to promote safe disposal.
“People suggested other simple strategies that could be annual or six-monthly campaigns run by the pharmacy, such as reminder stickers on their prescription medicines and/or an information card placed in their bag when picking up medicines,” says Professor Wheeler.
While RUM is confident that most community pharmacies in Australia have RUM bins, Riley says what pharmacists and other pharmacy staff really need to do is start conversations with patients.
“We have a big job ahead of us to raise consumer awareness of RUM, and we are calling on the pharmacy industry to support our efforts,” she says.
“Pharmacists can take every opportunity to communicate with their customers about RUM availability and the appropriate disposal of all unwanted medicines.
“Every interaction with a pharmacy customer—especially at the dispensary counter—presents an opportunity to remind them to return their medicines back to the pharmacy, in the event it expires or is not used.”
“Most community pharmacies remain passive participants in the collection process, which contributes to the lack of awareness of the RUM program amongst the general public,” says Plunkett.
“While of course their participation is most valuable, this would be greatly enhanced with a more pro-active professional involvement in discussing the medication use with their patients including what to do with leftover medicines.”
Currently RUM collects more than 700 tonnes of medicines each year, although this is still estimated to represent only 10–20% of all medicines disposed by the public annually.
The role of hospital pharmacists
While RUM bins are commonly found in community pharmacies, what role do hospital pharmacists play in the disposal of medicines?
Singleton says hospital pharmacists play a vital role in the stewardship of medicines and the environmentally responsible handling of pharmaceutical waste.
This role may even be of greater importance compared with community pharmacy due to their wholesaler function in supplying medicines to various departments in the hospital, she says.
The Society of Hospital Pharmacists of Australia (SHPA) agrees that hospital pharmacists need to be aware of safe disposal procedures, although they have their own process of medicine collection for incineration.
“SHPA supports any Quality Use of Medicine initiative that improves patient safety and quality of care,” says SHPA CEO Kristin Michaels.
“While hospital pharmacies do not participate in the RUM program, they commonly handle the return of medicines by inpatients and outpatients, and similar reasons are cited: ceased or swapped by their doctors; obsolete due to changing dosages; or, upon self-assessment, no longer needed (such as post-surgery pain relief).
“Importantly, medicine disposal is done with the patient’s consent, whether at a hospital pharmacy or by an outreach pharmacist in the home, and according to medicine specific guidelines.”
PSA national president Joe Demarte says “pharmacists should, when appropriate, mention that RUM bins are available in the pharmacy as part of their standard patient counselling”.
“Accredited consultant pharmacists are in a good position to promote the RUM project with their patients. The project provides heavy duty plastic bags to consultant pharmacists so they can collect old and unwanted medicines while at home medicines reviews (HMRs).”
RUM is currently developing a pharmacy toolkit and other resources, adds Demarte.
“Once these resources become available I would urge all pharmacists to become familiar with them so they can promote the safe return of unwanted medicines with their patients. This is after all, an important part of the quality use of medicines.”
Emnet P, et al. Personal care products and steroid hormones in the Antarctic coastal environment associated with two Antarctic research stations, McMurdo Station and Scott Base. Environmental Research 2015 Jan;136:331-42.
Hughes S, et al. Global synthesis and critical evaluation of pharmaceutical data sets collected from river systems. Environmental Science and Technology 2013;47(2):661-77.
Murdoch K. Pharmaceutical pollution in the environment: issues for Australia, New Zealand and Pacific Island countries. Bangalow, NSW: National Toxics Network, 2015.
National Return and Disposal of Unwanted Medicines Project Audit 2016 conducted by Griffith University.
Return Unwanted Medicines (The RUM Project), returnmed.com.au.
Chartier Y, et al (eds). Safe management of wastes from health-care activities, 2nd edn. Geneva: World Health Organization, 2014.