Behind closed doors: medication storage and disposal in the home

Household Pharmaceutical Waste Disposal in Selangor, Malaysia-Policy, Public Perception, and Current Practices

Although pharmaceuticals treat illnesses and prevent diseases in humans and animals, ironically, they are now among the emerging pollutants in the environment. As individuals continue to consume medicines, households can become a primary source of pharmaceutical pollutants. This paper explains relevant Malaysian law and policy on the issue. Using a questionnaire survey, it also assesses public perception concerning the environmental impact of pharmaceutical waste and the current methods of disposal that are practiced in Selangor. The survey used a convenience sampling and the data collected were analysed using statistical descriptive analysis. Most of the participants were aware that pharmaceutical waste can have an adverse impact on the environment and public health. Half of the participants disposed of their pharmaceutical waste in trash bins. About 2.9% of the respondents poured their household pharmaceutical waste (HPW) directly down the drain, while 8.8% poured them down the sink in the kitchen or toilet. The study also discovered that while 73.8% of the respondents felt that HPW should be separated from other household solid waste, only 25.2% returned their medicinal waste through the medicine return-back programme. The majority of the respondents (82.5%) agreed that information concerning the proper disposal of HPW is insufficient. The study concludes that while the respondents were aware of the adverse impact of HPW, their practices to ensure proper disposal is discouraging. There is a need for effective unwanted medicines return-back programme as a more prudent disposal method of HPW to avoid any risk to the environment or human health.

Use of Antibiotics Without a Prescription in the U.S. Population: A Scoping Review

Background

Use of antibiotics without a prescription may increase unnecessary and inappropriate drug use or doses as well as global risk for antimicrobial resistance.

Purpose

To perform a scoping review of research on the prevalence of nonprescription antibiotic use in the United States and to examine the factors that influence it.

Data Sources

Searches of PubMed, EMBASE, CINAHL, Scopus, and relevant Web sites without language restrictions from January 2000 to March 2019.

Study Selection

Studies reporting nonprescription use of antibiotics, storage of antibiotics, intention to use antibiotics without a prescription, and factors influencing nonprescription use.

Data Extraction

Two reviewers independently screened citations and full texts and performed data abstraction.

Data Synthesis

Of 17 422 screened articles, 31 met inclusion criteria. Depending on population characteristics, prevalence of nonprescription antibiotic use varied from 1% to 66%, storage of antibiotics for future use varied from 14% to 48%, and prevalence of intention to use antibiotics without a prescription was 25%. Antibiotics were obtained without a prescription from various sources, including previously prescribed courses, local markets or stores, and family or friends. Reported factors contributing to nonprescription use included easy access through markets or stores that obtain antibiotics internationally for under-the-counter sales, difficulty accessing the health care system, costs of physician visits, long waiting periods in clinics, and transportation problems.

Limitation

Scarce evidence and heterogeneous methods and outcomes.

Conclusion

Nonprescription antibiotic use is a seemingly prevalent and understudied public health problem in the United States. An increased understanding of risk factors and pathways that are amenable to intervention is essential to decrease this unsafe practice.

Primary Funding Source

None.

Associations between personality traits and adequate home storage of drugs in older patients

The objective of this study was to investigate the association between personality traits of older patients and adequate home storage of drugs. Forty-four participating Dutch community pharmacists randomly selected each up to four community-dwelling elderly patients (≥65 years) who were using at least one prescription drug. The Big Five Inventory was used to assess the personality traits - 'openness', 'conscientiousness', 'extraversion', 'agreeableness' and 'neuroticism' - of patients. An assessment of adequate home storage of drugs was made using a summed composite score for each patient ranging from zero (adequate storage) to three (inadequate storage) was based on storage criteria representing quality, information and level of storage organization. A 51.2% of the patients stored drugs adequately in accordance with all quality ("Q") and information ("I") criteria. A high level of drug storage organization was found in 70.8% of patients. Forty-three patients (31.4%) stored their drugs adequately based on all storage criteria (composite storage score 0). No associations between personality dimensions and adequate drug storage were found. Having a lower number of drugs was associated with adequate drug home storage (OR_adjusted 0.86; 95% CI: 0.77-0.96). In conclusion, this study suggests that personality is not associated with adequate home storage of drugs in older patients.

Factors influencing the attention to home storage of medicines in China

BACKGROUND

Medicines are stored in most households around the world for a range of different purposes including emergency use and the treatment of acute or chronic illnesses. The presence of medicines in households is becoming a significant risk factor for irrational medicine storage, disposal, and use in developing countries due to limited information and knowledge offered on safe storage. This study examined how patients store medicines and highlighted factors which influence home storage behaviours for medicines in China.

METHOD

A cross-sectional survey of 625 households was undertaken. In each household, data were collected from the head of household present at home. The study covered six provinces in China including the North, Central, and Southern regions. Respondents were interviewed by doctors. The doctors were study assistants and data collectors. "Attention" was taken as the research focus and a five-point Likert scale was used to measure attitudes to medicine storage at home. Factor analysis, variance analysis, and the multivariable logistic regression models were employed in the present study.

RESULTS

Of the households investigated in this study, cold medications were the medicine most commonly stored at home. The majority of the respondents gave more attention to the expiration date of medicines compared to other factors. Only a few respondents thought humidity was important factor influencing home storage of medicines. Despite some attention being given to the location of storage for home medicines, considerably more information is needed to improve awareness. In addition, our data revealed that some attention had been paid to elimination and recycling mechanisms but similarly, increased awareness is needed. There were obvious differences between the populations used in the study, due to differences in socio-demographic characteristics of the study participants. Age is the most important factor influencing the attention paid to home storage of medicines in China.

CONCLUSION

A major improvement in the awareness of correct storage conditions of medicines for home use can be realized by increased education, and highlighting the importance of correct medicine storage, disposal methods and usages, which has high potential to deliver public health benefits in China. Some suggestions were provided to health care providers.

Safe Medication Disposal

Safe disposal of expired or unused medications is essential for individual and environmental safety, yet many patients report not having received education on proper medication disposal. Unused medications in homes and improper medication disposal create various risks including intentional or accidental misuse, overdose, addiction in humans, as well as toxic effects in pets. As part of their community health clinical experience, senior nursing students from the University of Pennsylvania School of Nursing visited patients of a large home care and hospice agency in a Philadelphia suburb throughout the semester. A survey conducted with a small number (N = 15) of home care patients suggested the majority of patients had inadequate knowledge about safe medication disposal. The nursing students created and presented a tip sheet on safe medication disposal and a list of local prescription medication disposal sites to home care patients. They also obtained and provided medication disposal bags for patients and caregivers who were unable to get to medication disposal sites.

Opioids in Adolescents' Homes: Prevalence, Caregiver Attitudes, and Risk Reduction Opportunities

OBJECTIVE

The most common source of misused opioids is pain relievers prescribed for family and friends. This study was conducted to assess knowledge, attitudes, and behaviors of adolescents' caregivers regarding prescribed opioids in the home.

METHODS

The self-administered survey was completed by caregivers in the waiting rooms of 12 pediatric practices in the Midwest. Eligibility required living in a home where youth age ≥10 years were frequently present. Out of 793 eligible caregivers, 700 (88.3%) completed the survey, 76.8% of whom were the parent.

RESULTS

Among the 700 caregiver respondents, 34.6% reported opioids in the home (13.6% active prescriptions, 12.7% leftover medications, 8.3% both). Of those with an active prescription, 66.0% intended to keep any leftover medications for future needs (for the patient, 60.1%; for someone else, 5.9%). Of those with leftover medications, 60.5% retained them for the same reason (for the patient, 51.0%; for someone else, 9.5%). Others kept medications unintentionally, either because they never got around to disposing of them (30.6%), they did not know how to dispose of them properly (15.7%), or it never occurred to them to dispose of the medications (7.5%). Many caregivers were unaware that adolescents commonly misuse opioids (30.0%) and use them to attempt suicide (52.3%), and that opioid use can lead to heroin addiction (38.6%). According to the surveys, 7.1% would give leftover opioid medications to an adolescent to manage pain and 5.9% might do so.

CONCLUSIONS

Opioids are prevalent in homes in our community, and many parents are unaware of the risks they pose. Study findings can inform strategies to educate parents about opioid risk and encourage and facilitate timely, safe disposal of unused medications.

'You don't throw these things out:' an exploration of medicines retention and disposal practices in Australian homes

BACKGROUND

Consumers most commonly discard unwanted medicines in household rubbish or drains, however, there are global concerns over the extent, environmental impact and health risks. When consumers procure or store medicines for future use, this can impact negatively on quality use of medicines and consumer safety. We sought greater insight into the extent of these practices by exploring the volume and types of medicines in Australian homes, and self-reported practices related to medicine accumulation, use and disposal. This qualitative study formed part of a larger project that included a general population survey on household medicine disposal practices.

METHODS

Semi-structured telephone interviews were undertaken with a subset of respondents (n = 166) from the survey. Participants were eligible if they were experienced medicine users, i.e. used five or more prescribed, over the counter, and/or complementary and alternative medicines. Participants were asked to collect and name all medicines in their household; further detail was obtained about medicines used only when required or no longer used, such as expiry dates and quantity remaining. The quantitative data on the number and type of medicines stored at home were analysed descriptively. All interviews were transcribed verbatim and thematically analysed.

RESULTS

A total of 2301 medicines were identified as 1424 medicines not in everyday use (unused, unwanted, expired or when required) in 166 households, and 877 regularly used medicines by 119 participants. Medicines were often stored in multiple locations, particularly kitchens. Although accidental ingestion in children and pets and decreased efficacy were recognised health risks, this did not always translate to appropriate storage, usage or disposal practices. Individual risk-benefit assessments were applied to decisions to retain, use or dispose of medicines, including expired medicines.

CONCLUSIONS

Inappropriate medicine storage, use, and/or disposal practices raises public health concerns, particularly as there is a free returned medicines scheme available, and that this particular participant group were considered experienced medicine users. Healthcare professionals must act to address consumer misconceptions around the quality use of medicines, including medicine retention, storage and disposal. Future research is warranted to explore consumer practices in this context and confirm these findings in a younger, or healthier population.

Older Patients' Compliance with Drug Storage Recommendations

Background

Whereas storage conditions are regulated and closely monitored in every stage of the drug supply chain before drug dispensing, it is unknown if patients store drugs at home according to storage recommendations.

Objective

The objective of this study was to investigate how older patients store their prescription drugs at home and to what extent they comply with drug storage recommendations.

Methods

We conducted a cross-sectional study between October 2015 and March 2016. Forty-four participating Dutch community pharmacies selected four home-dwelling patients (aged ≥ 65 years) using at least one prescription drug. A complete drug inventory at patients’ homes was performed. Drugs were considered to fulfill the storage recommendation when these met all drug quality (Q) and information (I) criteria: adequately stored according to drug product label storage recommendations for temperature, light, humidity (Q1); expiry date not passed (Q2); integer primary package (Q3); drug identifiability (I1); drug package insert or information leaflet availability (I2).

Results

One hundred and seventy patients [53.5% female, mean age 74.9 (standard deviation 7.3) years] were included and 1133 prescription drugs stored at home were registered. More than half of the patients (51.2%) complied with all storage quality and information criteria. Assessment of the individual criteria showed that 76.4% of patients were compliant with criterion Q1 while 90.6, 95.3, 97.1 and 71.2% of patients complied with criteria Q2, Q3, I1 and I2, respectively. 53.2% of drugs that should be kept refrigerated according to storage criterion Q1 were not stored between 2 and 8 °C.

Conclusion

This study illustrates that more than half of the older patients comply with general drug storage recommendations.

Electronic supplementary material

The online version of this article (10.1007/s40266-018-0524-8) contains supplementary material, which is available to authorized users.

Medication wasted - Contents and costs of medicines ending up in household garbage

BACKGROUND

Despite potentially considerable implications for public health, the environment and public funds, medicine waste is an under-researched topic. This study aims to analyse medicines drawn from household garbage in Vienna (Austria) and to assess possible financial implications for public payers.

METHODS

Four pharmaceutical waste samples collected by the Vienna Municipal Waste Department between April 2015 and January 2016 were investigated with regard to their content. The value of medicines was assessed at ex-factory, reimbursement and pharmacy retail price levels, and the portion of costs attributable to the social health insurance was determined. Data were extrapolated for Vienna and Austria.

RESULTS

The waste sample contained 1089 items, of which 42% were excluded (non-pharmaceuticals, non-Austrian origin and non-attributable medicines). A total of 637 items were further analysed. Approximately 18% of these medicines were full packs. 36% of the medicines wasted had not yet expired. Nearly two out of three medicines wasted were prescription-only medicines. The majority were medicines related to the 'alimentary tract and metabolism' (ATC code A), the 'nervous system' (ATC code N) and the 'respiratory system' (ATC code R). The medicines wasted had a total value of € 1965, € 2987 and € 4207, expressed at ex-factory, reimbursement and pharmacy retail price levels, respectively. Extrapolated for Vienna, at least € 37.65 million in terms of expenditure for public payers were wasted in household garbage, corresponding to € 21 per inhabitant.

CONCLUSION

This study showed that in Vienna some medicines end up partially used or even completely unused in household garbage, including prescription-only medicines, non-expired medicines and medicines for chronic diseases. While there might be different reasons for medicines being wasted, the findings suggest possible adherence challenges as one issue to be addressed.

Actual versus recommended storage temperatures of oral anticancer medicines at patients' homes

Background

Substantial quantities of unused medicines are returned by patients to the pharmacy each year. Redispensing these medicines would reduce medicinal waste and health care costs. However, it is not known if medicines are stored by patients as recommended in the product label. Inadequate storage may negatively affect the medicine and reduce clinical efficacy whilst increasing the risk for side effects.

Objective

To investigate the proportion of patients storing oral anticancer medicines according to the temperature instructions in the product label.

Methods

Consenting adult patients from six Dutch outpatient hospital pharmacies were included in this study if they used an oral anticancer medicine during February 2014 – January 2015. Home storage temperatures were assessed by inclusion of a temperature logger in the original cancer medicines packaging. The primary outcome was the proportion of patients storing oral anticancer medicines as specified in the Summary of Product Characteristics, either by recalculating the observed temperature fluctuations to a single mean kinetic temperature or by following the temperature instructions taking into account a consecutive 24-h tolerance period.

Results

Ninety (81.1%) of the 111 included patients (47.8% female, mean age 65.2 (SD: 11.1)) returned their temperature loggers to the pharmacy. None of the patients stored oral anticancer medicines at a mean kinetic temperature above 25℃, one patient stored a medicine requiring storage below 25℃ longer than 24 h above 25℃. None of the patients using medicines requiring storage below 30℃ kept their medicine above 30℃ for a consecutive period of 24 h or longer.

Conclusion

The majority of patients using oral anticancer medicines store their medicines according to the temperature requirements on the product label claim. Based on our results, most oral anticancer medicines will not be negatively affected by temperature conditions at patients’ homes for a maximum of three months and are likely to be suitable for redispensing.

Prevalence and risk factors of inadequate medicine home storage: a community-based study

OBJECTIVE

Assess the extent of inadequate home storage of medicines andidentify important risk factors.

METHODS

A cross-sectional survey based on a probability sample in the community, conducted in 267 households in Cuité, State of Paraíba, Northeast Brazil, in 2014. Logistic regression was used to study the risk factors.

RESULTS

The prevalence of households with inadequate storage was 76.0%. Problems with storage include direct exposure to sunlight in 10.9% of households, the presence of dust in 23.6%, and storage within reach of children in 76.0%. Medications no longer used are usually disposed of into the environment in 92.1% of households. Inadequate storage is more likely when home organization of medications is the responsibility of a male subject (OR = 1.729) or an older person (OR = 1.029), when out of date medicines are found (OR = 2.963), and in households with no children (OR = 2.088).

CONCLUSIONS

Physicians and pharmacists should advise patients on how to adequately store medicines at home, especially when the person in charge of medications is a male or an older adult, and if there are no children in the household.

Assessment of the association between drug disposal practices and drug use and storage behaviors

Objective

Keeping unnecessary drugs at home is a situation showing both causes and consequences of irrational use of medicine. This study aimed to evaluate the approaches of a company's employees regarding drug storage, use, and disposal.

Method

This online-based descriptive study was held in a multi-centered private-sector company in a voluntary basis. The survey assessing participants' drug handling and storage behaviors was answered by 1121 employees from across eight provinces of Turkey in 2016. Main outcome measures were storage and disposal of unused/unwanted drugs at home in a rational way.

Results

The percentage of participants who declared that they keep unused/unwanted drugs at home was 28.0%. About one-third of participants disposed their unused/unwanted drugs via the "garbage, sink, toilet, etc.". Participants ≥30 years old and living with <4 household members significantly tended to bring their unused/unwanted drugs to the company's drug-box. Nearly half of all participants (46.5%) stated a recent change in their disposal behavior. The vast majority of participants (94.6%) who previously took drugs back to the company's drug-box stated that they either had, or would, help their contacts adopt such behaviors. These participants were also significantly less likely to dispose of drugs inappropriately, practice self-medication, be unaware of expired drugs at home, or fail to store drugs according to the labelling.

Conclusion

While our findings showed that a substantial number of participants still had unused drugs at home and disposed of them inappropriately, it is understood that they started to exhibit more favorable behaviors in recent years.

Unused medications and disposal patterns at home: Findings from a Medicare patient survey and claims data

OBJECTIVE

To examine what medications are most frequently left unused by patients, how much is left unused, and how these medications are disposed of among Medicare beneficiaries.

DESIGN

Secondary data analysis combining insurance claims and telephone survey data of Medicare Advantage members.

SETTING

Regional health plan in Central Pennsylvania.

PARTICIPANTS

Seven hundred twenty-one Medicare Advantage members who had Part D coverage through the plan as of December 31, 2013, and completed the telephone survey in May 2014.

INTERVENTION

Telephone survey conducted by a survey research center.

MAIN OUTCOME MEASURE

Member survey response.

RESULTS

Of the 2,994 medications in the dataset, 247 (8%) were reported being left unused by patients. Of the 247, the most common medications were those for pain (15%), hypertension (14%), antibiotics (11%), and psychiatric disorders (9%). Approximately 15% of unused medications were controlled substances. The reasons for being unused varied by drug type. For example, for pain medications, adverse effects and overprescribing were the most commonly cited reasons; for hypertension medications, "dosage changed by doctor" was the most common reason. Most commonly, unused portions accounted for approximately 25% to 50% of the unused medications identified by patients. Approximately 11% of unused medication was disposed of via drug take-back programs, whereas the majority was kept in a cabinet (55%), thrown in the trash (14%), or flushed down the toilet (9%).

CONCLUSION

A lack of patient adherence alone does not explain unused medications and their improper disposal. Community-level interventions designed to improve prescription efficiency and patient awareness of appropriate disposal methods-particularly of controlled substances-are necessary to reduce the potentially harmful effects of improper disposal of unused medications.

A household survey of medicine storage practices in Gondar town, northwestern Ethiopia

Background

Household surveys are crucial to get accurate information on how medicines are acquired, and used by consumers, as they provide the best evidence in the area. The objective of this study was to document household medicine storage practices in Gondar town, northwestern Ethiopia.

Methods

A cross-sectional household survey was conducted from April 5 to May 6, 2015. In the study, 809 households were surveyed from four sub-cities in the town selected through multistage sampling with 771 included in the final analysis. Data on the extent of storage, storage conditions, sources of medicines and their current status among others were collected through structured interviews and observations. The data were entered in to Epidata version 3.1, exported to and analyzed using Statistical Packages for Social Sciences (SPSS) version 21.

Results

Of the 771 households in the study, 44.2% stored medicines. Presence of family members with chronic illness(es) and higher levels of household incomes predicted higher likelihood of medicine storage. In the households which allowed observation of stored medicines (n = 299), a mean of 1.85 [SD = 1.09] medicines per household were found. By category, anti-infectives for systemic use (23.9%), medicines for alimentary tract and metabolism (19.2%) and those for cardiovascular system (17.7%) ranked top. Among individual medicines stored, diclofenac (10.7%), paracetamol (9.9%) and amoxicillin (8.0%) were on top of the list. Dispensaries (97.8%) and physicians (83.5%) were almost exclusive sources of medicines and advices/orders for medicines respectively. Nearly two-thirds of the medicines found were on use and a vast majority (76.5%) were stored in chests of drawers. Proportion of expired medicines was very low (3.14%).

Conclusions

The use of physicians’ and pharmacists’ advice to get medicines; use of dispensaries as principal sources, large proportion of medicines being in use and very low proportion of expiry showed good practices. However, storage places of medicines were not purpose built. Encouraging good practices through continued medicine use education and advocating appropriate medicine storage in medicine cabinets is required to improve storage conditions and consequent use of medicines.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-017-4152-8) contains supplementary material, which is available to authorized users.

Disposal of Unused Drugs: Knowledge and Behavior Among People Around the World

The purpose of this systematic review was to determine the practice of medication disposal around the world and get insight into possible association between environmental awareness and people's behavior regarding this issue. A literature search (2005-2015) was performed to identify reports with quantitative data on disposal practices published in peer-reviewed literature. The most common method for disposal of unused medications in households is disposal in the garbage (Kuwait, United Kingdom, Lithuania, Qatar, Serbia, Ghana, Bangladesh, Malta and Saudi Arabia). The practice of flushing drugs into the sewage system still takes place in New Zealand, USA and Bangladesh. Only in Sweden and Germany, practice of returning drugs to pharmacy was practiced to a larger extent. The environmental impact of improper medication disposal is expected in countries with poorly functioning waste management schemes (Middle Eastern, Asian and African countries). Lack of the adequate information and clear instructions on proper manners of drug disposal was reported in many surveyed countries (USA, New Zealand, Bangladesh, Malta and Ireland). Clear and definite connection between knowledge about environmental detrimental effects of improper drug disposal and the preference towards disposal methods could not be established. Many respondents were generally concerned with issues of inadequate medicines discarding but the behavior regarding disposal of unused drugs often did not equate the awareness (Serbia, USA, Kuwait, Malta and UK). The current data emphasizes the global issue of improper medicine disposal, prevalent in environmentally-aware people.

Investigating dynamic sources of pharmaceuticals: Demographic and seasonal use are more important than down-the-drain disposal in wastewater effluent in a University City setting

Pharmaceutical pollution in surface waters poses risks to human and ecosystem health. Wastewater treatment facilities are primary sources of pharmaceutical pollutants, but little is known about the factors that affect drugs entering the wastewater stream. This paper investigates the effects of student pharmaceutical use and disposal behaviors and an annual demographic shift on pharmaceutical pollution in a university town. We sampled wastewater effluent during a ten-day annual spring student move-out period at the University of Vermont. We then interpreted these data in light of survey results that investigated pharmaceutical purchasing, use, and disposal practices among the university student population. Surveys indicated that the majority of student respondents purchased pharmaceuticals in the previous year. Many students reported having leftover drugs, though only a small portion disposed of them, mainly in the trash. We detected 51 pharmaceuticals in 80% or more of the wastewater effluent samples collected over the ten-day sampling period. Several increased in concentration after students left the area. Concentrations of caffeine and nicotine decreased weakly. Drug disposal among this university student population does not appear to be a major source of pharmaceuticals in wastewater. Increases in pharmaceutical concentration after the students left campus can be tied to an increase in the seasonal use of allergy medications directly related to pollen, as well as a demographic shift to a year-round older population, which supports national data that older people use larger volumes and different types of pharmaceuticals than the younger student population.

Unused opioid analgesics and drug disposal following outpatient dental surgery: A randomized controlled trial

BACKGROUND

Individuals who abuse prescription opioids often use leftover pills that were prescribed for friends or family members. Dental surgery has been identified as a common source of opioid prescriptions. We measured rates of used and unused opioids after dental surgery for a pilot program to promote safe drug disposal.

METHODS

We conducted a randomized controlled trial of opioid use patterns among patients undergoing surgical tooth extraction at a university-affiliated oral surgery practice. The primary objective was to describe opioid prescribing and consumption patterns, with the number of unused opioid pills remaining on postoperative day 21 serving as the primary outcome. The secondary aim was to measure the effect of a behavioral intervention (informing patients of a pharmacy-based opioid disposal program) on the proportion of patients who disposed or reported intent to dispose of unused opioids. (NCT02814305) Results: We enrolled 79 patients, of whom 72 filled opioid prescriptions. On average, patients received 28 opioid pills and had 15 pills (54%) left over, for a total of 1010 unused pills among the cohort. The behavioral intervention was associated with a 22% absolute increase in the proportion of patients who disposed or reported intent to dispose of unused opioids (Fisher's exact p=0.11).

CONCLUSION

Fifty-four percent of opioids prescribed in this pilot study were not used. The pharmacy-based drug disposal intervention showed a robust effect size but did not achieve statistical significance. Dentists and oral surgeons could potentially reduce opioid diversion by moderately reducing the quantity of opioid analgesics prescribed after surgery.

Assessment of Household Disposal of Pharmaceuticals in Lebanon: Management Options to Protect Water Quality and Public Health

Pharmaceuticals comprise an extensive group of compounds whose release into the environment has potential adverse impacts on human health and aquatic ecosystems. In many developing countries the extent of the problem and the occurrence of pharmaceuticals in water bodies are generally unknown. While thousands of tons of pharmaceutical substances are used annually, little information is known about their final fate after their intended use. This paper focuses on better understanding the management of human-use pharmaceutical wastes generated at the residential level within the Administrative Beirut Area. A survey encompassing 300 households was conducted. Results revealed that the majority of respondents were found to dispose of their unwanted medications, mainly through the domestic solid waste stream. Willingness to participate in a future collection program was found to be a function of age, medical expenditure, and the respondents' views towards awareness and the importance of establishing a collection system for pharmaceutical wastes. Respondents who stated a willingness to participate in a collection program and/or those who believed in the need for awareness programs on the dangers of improper medical waste disposal tended to favor more collection programs managed by the government as compared to a program run by pharmacies or to the act of re-gifting medication to people in need. Ultimately, collaboration and coordination between concerned stakeholders are essential for developing a successful national collection plan.

ANALYSIS OF HOUSEHOLD MEDICINE CHESTS: A SIGNIFICANT LEARNING EXPERIENCE FOR NURSING STUDENTS

This is an observational, descriptive, cross-sectional study in which 214 nursing students from the University of Barcelona participated, in order to examine and assess the state and management of their household medicine chests. A semi-structured questionnaire specifically prepared for the study was used to collect data. The results showed that only 18.2% of the medicine chests examined contained all the recommended dressing materials and medicines. Inspection frequency was less than 12 months in 66.4% of the cases. A high percentage of the nursing students' homes stored medications in unsuitable locations and held on to them beyond their expiration dates or without their package. In contrast, knowledge about the use of the medications and the habit of recycling was better. Carrying out an analysis of their own medicine chest can help nursing students improve their competences in this area.

Parental Report of Morphine Use at Home after Pediatric Surgery

OBJECTIVE

To describe the use of morphine at home for acute postoperative pain in children.

STUDY DESIGN

This was a prospective, descriptive study. Patients less than 12 years of age who underwent surgery and who received a discharge prescription for morphine between January and May 2014 were included. Parents were given a logbook to note their use of morphine at home. A follow-up call was performed 3 days after discharge. The primary outcome was whether or not parents administered morphine according to the discharge prescription. Prescription filling rates, storage at home, administration devices used, and disposal of remaining morphine were also evaluated.

RESULTS

A total of 243 subjects were recruited; 56% (95% CI, 46%-66%) of participants with a regular basis prescription administered the medication as prescribed. This number was 85% (95% CI, 78%-92%) in subjects receiving an as-needed prescription, including those who did not administer any morphine because of an absence of pain. Although 76% (95% CI, 68%-84%) of parents filled the morphine prescription when prescribed as needed, most administered two doses or less. In a subset of 77 subjects for whom we obtained detailed prescription data, only 9.2% of prescribed doses were administered.

CONCLUSION

We observed that large amounts of morphine have been prescribed and dispensed into homes without being administered. This study identified a need to re-evaluate the quantity of morphine prescribed and dispensed after pediatric surgery.

Analysis of Medications Returned During a Medication Take-Back Event

A medication take-back event was held in Lansing, MI, USA, for four hours in September 2013. The objective was to quantify medication waste by determining the ratio of medication units remaining versus dispensed and to identify therapeutic classes with greater ratios of remaining medication units. Drug name, strength, quantity remaining, quantity dispensed, dispensary source, and brand or generic were recorded from the label of each medication container returned. Out of the over 3600 medication containers collected, this study analyzed 2459 containers, which included 304 controlled substances. On average, 66 percent of the medications dispensed in these containers were unused, and therefore wasted. Immunologic medications had the lowest quantity of waste at 54%, while geriatrics/miscellaneous therapeutic class yielded the highest quantity of waste at 79%. The most common therapeutic classes collected were pain/spasm, cardiovascular, and mental health. Greater emphasis on patient education regarding medication adherence and health care professionals’ judicious prescribing habits is warranted to reduce the frequency of unused medications. The increased accessibility to medication return sites may alleviate the prevalence of medication accumulation, environmental damage, and medication misuse.

Quantification of an ongoing community-based medication take-back program

OBJECTIVE

To develop a medication take-back program to evaluate current medication disposal practices and to quantify medication waste.

METHODS

Seven medication take-back days have been held in a local community. The University of Findlay College of Pharmacy, local law enforcement, and municipal officials have collaborated to develop and sustain the events. All medications returned were quantified by documenting the drug name, dose, quantity, type, source, and estimated cost. Additionally, a participant survey was administered to determine demographics, prior disposal habits, and reason for disposal.

RESULTS

A total of 786,882 dosing units estimated to be worth $1,118,020 were collected. Participant surveys (n = 818) suggest common reasons for disposal were expired (50%) or discontinued (40%) medications. The average community pharmacy prescription contained 35 dosing units worth approximately $68, and the average mail-service prescription contained 95 dosing units worth approximately $205. Antihypertensive agents, gastrointestinal agents, and analgesics were the most common therapeutic categories returned.

CONCLUSION

Ongoing, collaborative medication take-back events are an effective method of removing unused medications from the community. Although the majority of medications collected were originally dispensed in community pharmacies, the average unused prescription from mail-service sources contained almost three times as many dosage units. These data suggest that the larger quantities more typically dispensed by mail-service pharmacies may contribute considerably to the problems associated with surplus medications. Further studies are needed to investigate this association.

What do patients do with unused opioid medications?

OBJECTIVES

The volume of opioid medications being prescribed in the United States is increasing rapidly. Problems associated with the misuse of opioid medications are also increasing, in part because of medication diversion from legitimate prescriptions. However, little is known about what patients do with any unused opioid medications. This paper uses a qualitative analysis of patients' self-report of medication storage and retention habits to begin to address this gap.

METHODS

We analyzed responses to the Prescription Drug Use Questionnaire in conjunction with other data on prescription opioid use in a sample of 191 Veteran patients (83% of whom had a preexisting factor associated with higher rates of opioid misuse) who received one or more opioid prescriptions in the previous 12 months.

RESULTS

Only 6.3% of participants disposed of extra medications and 24.1% reported having no extra opioids. A total of 65.4% of participants reported retaining some or all opioids even if they ceased taking the medication, and some participants accumulated large amounts of medication. A total of 34.0% of participants described engaging in sharing or diversion of opioids at least once, most often receiving them from a family member or a friend.

DISCUSSION

A majority of patients retain unused opioids, and medication sharing is common. Interventions to improve monitoring of patient experience with opioid medication, educate patients about the dangers of opioid use by nonprescribed others, and increase information about medication disposal options could decrease the supply of opioid medications available for misuse.

Polysubstance abuse: alcohol, opioids and benzodiazepines require coordinated engagement by society, patients, and physicians

The Centers for Disease Control and Prevention (CDC) has published significant data trends related to substance abuse involving opioid pain relievers (OPR), benzodiazepines and alcohol in the United States. The CDC describes opioid misuse and abuse as an epidemic, with the use of OPR surpassing that of illicit drugs. Alcohol has also been a persistent problem and is associated with a number of emergency department visits and deaths independent of other substances. The use of these drugs in combination creates an additive effect with increased central nervous system suppression and a heightened risk of an overdose. We present a summary of the findings from the Morbidity and Mortality Weekly Report (MMWR) with commentary on strategies to combat prescription drug and alcohol abuse.

An analysis of unused and expired medications in Mexican households

BACKGROUND

Unsafe storage of unused medications at home leads to an increased risk of toxicity, accidental childhood poisoning or risk for suicide, whereas an improper disposal of unwanted/expired medications from household raises concern about environmental pollution.

OBJECTIVE

The aim of the study was to characterize expired medications collected according to the types of therapeutic groups, pharmaceutical dosage forms, expiration dates and were prescribed or over the counter drugs, and whether they came from Mexican health system or purchased by patients themselves.

SETTING

The study was conducted in the metropolitan area of Monterrey during a 12-month period from March 2012 to February 2013.

METHOD

Unused/expired drugs were collected according to the collection and disposal of expired medication program instituted by the Department of Health of the State of Nuevo León. Pharmacists and students from The Autonomous University of Nuevo León recorded types of therapeutic groups, total of medicines in each group, among other classification criteria.

MAIN OUTCOME MEASURE

The proportion of every collected therapeutic group, type of dosage forms, and expiration date.

RESULTS

The amount of medications classified was 22,140 items corresponding to a 30 % of the total collected medications in that period of time; most of them belonged to the non-steroidal anti-inflammatory drugs (16.11 %). According to the pharmaceutical dosage forms, results showed that a high percentage were solid dosage forms (73.39 %), of the total unused/expired medications, most of them were prescription drugs (91 %) which were purchased at private pharmacies. Expiration date of medications ranges from 1995 to 2016, being 2011 the outstanding year (36.66 %).

CONCLUSION

Addressing the aspect of unused drug disposition constitutes a challenge for Mexican government, due to health implications related to inadequate disposition. No matter how efficient the programs of collection and disposal of expired drugs are, none of them can collect all unused or expired drugs, that is the reason why the best approach might be to prevent this need.

Can older people remember medication reminders presented using synthetic speech?

Reminders are often part of interventions to help older people adhere to complicated medication regimes. Computer-generated (synthetic) speech is ideal for tailoring reminders to different medication regimes. Since synthetic speech may be less intelligible than human speech, in particular under difficult listening conditions, we assessed how well older people can recall synthetic speech reminders for medications. 44 participants aged 50-80 with no cognitive impairment recalled reminders for one or four medications after a short distraction. We varied background noise, speech quality, and message design. Reminders were presented using a human voice and two synthetic voices. Data were analyzed using generalized linear mixed models. Reminder recall was satisfactory if reminders were restricted to one familiar medication, regardless of the voice used. Repeating medication names supported recall of lists of medications. We conclude that spoken reminders should build on familiar information and be integrated with other adherence support measures.

Medicines discarded in household garbage: analysis of a pharmaceutical waste sample in Vienna

Objectives

To analyze a sample of pharmaceutical waste drawn from household garbage in Vienna, with the aim to learn whether and which medicines end up unused in normal household waste.

Methods

We obtained a pharmaceutical waste sample from the Vienna Municipal Waste Department. This was drawn by their staff in a representative search in October and November 2009. We did a manual investigation of the sample which contained packs and loose blisters, excluded medical devices and traced loose blisters back to medicines packs. We reported information on the prescription status, origin, therapeutic group, dose form, contents and expiry date. We performed descriptive statistics for the total data set and for sub-groups (e.g. items still containing some of original content).

Results

In total, 152 packs were identified, of which the majority was prescription-only medicines (74%). Cardiovascular medicines accounted for the highest share (24%). 87% of the packs were in oral form. 95% of the packs had not expired. 14.5% of the total data set contained contents but the range of content left in the packs varied. Results on the packs with contents differed from the total: the shares of Over-the Counter medicines (36%), of medicines of the respiratory system (18%) and of the musculo-skeletal system (18%), for dermal use (23%) and of expired medicines (19%) were higher compared to the full data set.

Conclusions

The study showed that some medicines end up unused or partially used in normal household garbage in Vienna. Our results did not confirm speculations about a high percentage of unused medicines improperly discarded. There is room for improved patient information and counseling to enhance medication adherence and a proper discharge of medicines.