Risks associated with the environmental release of pharmaceuticals on the U.S. Food and Drug Administration "flush list"

Acute exposure to environmentally relevant concentrations of pharmaceutical pollutants induces neurobehavioral toxicity in zebrafish (Danio rerio)

Pharmaceutical waste from point and non-point sources enters, persists, or disseminates in the environment and is known as environmentally persistent pharmaceutical pollutants. Understanding the impacts of pharmaceutical pollutants on the environment and health is essential. This study investigates the behavioral impacts of pharmaceutical pollutants on aquatic organisms and delineates the possible nexus of oxidative stress. The male zebrafish were exposed to four major representative pharmaceutical pollutants, viz., acetaminophen, carbamazepine, metformin, and trimethoprim at environmentally relevant concentrations individually as well as in a mixture for seven days. Substantial alterations in social interaction, aggressive nature, novel tank exploration, and light and dark zone preferences were recorded and the degree varied to different pharmaceutical pollutants. The activity of oxidative stress markers, superoxide dismutase, glutathione-S-transferase, and catalase, was found to be suppressed to 66-20%, 42-25%, and 59-20% respectively with the elevated malondialdehyde generation (180-260%) compared to control. The activity level of acetylcholine esterase was found to be increased to 200-500% across all treatment groups. Despite the synergistic impacts of pharmaceutical pollutants on the whole system that could not be ascertained, this comprehensive study highlights their toxicity nature to induce neurobehavioral toxicity in zebrafish through oxidative stress mechanisms and altered cholinergic systems.

Perceptions of disposal options for unused opioid analgesics among people who have been prescribed an opioid analgesic in North Carolina

Background: Medication disposal programs have been promoted as one solution to the opioid crisis, but uptake by community members has been minimal.Objectives: To clarify perceptions of medication disposal options among people who have been prescribed an opioid analgesic in North Carolina to inform interventions that can facilitate the disposal of unused opioids.Methods: In 2022, we conducted focus groups with participants who received an opioid medication in the past year to gain information to develop an intervention related to the disposal of unused opioid medication (12 focus group discussions (FGDs); total N = 37; 30 identified as female, 6 as male, and 1 as another gender). Participants were shown a slide with the Food and Drug Administration's recommended disposal options and asked about their perceptions of each option. Themes were derived using an inductive, thematic, qualitative approach.Results: Seven themes about perceptions of medication disposal programs emerged from the data. Four of the themes reflect potential barriers to medication disposal: failed disposal attempts, lack of sufficient education on proper disposal, unclear meaning of specific disposal language, and concerns about existing disposal options. Three of the themes provide insight on potential facilitators of medication disposal: preference of low-cost disposal options, ease and accessibility among disposal methods, and preferred disposal methods.Conclusion: Patients should be provided clear and consistent guidance from prescribers and dispensing pharmacists on when and how to dispose of unused medications and opportunities to dispose of medications at no cost to the patient.

Occurrence, environmental impact and fate of pharmaceuticals in groundwater and surface water: a critical review

In many nations and locations, groundwater serves as the population's primary drinking water supply. However, pharmaceuticals found in groundwater and surface waters may affect aquatic ecosystems and public health. As a result, their existence in natural raw waters are now more widely acknowledged as a concern. This review summarises the evidence of research on pharmaceuticals' occurrence, impact and fate, considering results from different water bodies. Also, various analytical techniques were reviewed to compare different pharmaceuticals' detection frequencies in water bodies. These include liquid chromatography-mass spectrometry (LC-MS), high-performance liquid chromatography (HPLC), ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS), and gas chromatography-mass spectrometry (GC-MS). However, owing to LC-MS's high sensitivity and specification, it is the most reported instrument used for analysis. The PRISMA reviewing methodology was adopted based on relevant literature in order to focus on aim of the review. Among other pharmaceuticals reviewed, sulfamethoxazole was found to be the most frequently detected drug in wastewater (up to 100% detection frequency). The most reported pharmaceutical group in this review is antibiotics, with sulfamethoxazole having the highest concentration among the analysed pharmaceuticals in groundwater and freshwater (up to 5600 ng/L). Despite extensive study and analysis on the occurrence and fate of pharmaceuticals in the environment, appropriate wastewater management and disposal of pharmaceuticals in the water environment are not still monitored regularly. Therefore, there is a need for mainstream studies tailored to the surveillance of pharmaceuticals in water bodies to limit environmental risks to human and aquatic habitats in both mid and low-income nations.

Using Hepatic Gene Expression Assays in English Sole (Parophrys vetulus) to Investigate the Effects of Metro Vancouver Wastewater Effluents

The present study has investigated the effects of Metro Vancouver's wastewater treatment plant (WWTP) effluents on English sole (Parophrys vetulus) hepatic gene expression using novel targeted gene expression assays to complement the 2017 Burrard Inlet Ambient Monitoring Program conducted by Metro Vancouver. Seven locations of varying distance to the WWTPs were included. Twelve genes involved in xenobiotic defense (CYP1A, HSP70), thyroid function (DIO1), lipid and glucose metabolism (FABP1, FASN, GLUT2, PPARδ, PPARγ), protein synthesis (18S rRNA, RPS4X), and reproduction (ERα, VTG) revealed several differences between these impacted sites. A key finding of the present study was that males exhibited VTG transcript levels either equivalent or exceeding female levels of this gene at all sites investigated, indicating widespread exposure of estrogenic contaminants throughout Burrard Inlet. Furthermore, the induction of hepatic CYP1A was observed due to possible downstream sites being subjected to a larger influx of certain planar halogenated and non-halogenated hydrocarbons from multiple industrial contributors. This study also revealed significant differences between the sites examined and in genes involved in transcriptional regulation and synthesis of proteins, lipids and glucose metabolism, and thyroid hormone metabolism. Collectively, this study demonstrates the potential of molecular biomarkers of urban contaminant exposure in wild caught English sole for use in diagnosing a broader range of adverse health effects when combined with conventional whole organism health indicators.

Expired medications and disposal practices in Arab households

OBJECTIVES

Over the past few decades, the accumulation of expired and unused medications in households has become a concern. Most people are unaware of how to properly dispose of unused and/or expired medicines. Our objective was to inspect the extent of expired medications within Arab households in United Arab Emirates (UAE), to determine which therapeutic groups yield greater amounts of unused medications, and evaluate drugs' disposal practices.

METHODS

This descriptive study was written in accordance with the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) checklist for cross-sectional studies. It was conducted among Arab households in UAE (n = 503) using an online questionnaire between November 2020 and January 2021. Questions were related to participants' socio-demographics, the prevalence of expired medications in households and their disposal.

KEY FINDINGS

Around 58% of the respondents had expired medications in their houses and 74% had drugs that were never used. The most common medicines left unused were analgesics (34%) followed by cosmetics (27%) and antibiotics (26%). More than 42% of expired medications were in solid dosage forms, 28% were semisolid and 24% were liquid dosage forms. The predominant disposal method among the surveyed participants was throwing medications into the garbage (86%).

CONCLUSIONS

Large quantities of expired medications in Arab households exist with a high prevalence of analgesics, antibiotics and cosmetics. Arab households are unaware of the proper drug disposal procedures. Therefore, community pharmacists are recommended to offer training on proper medication disposal practices and to encourage the public to return medications to pharmacies.

Perioperative opioid management for minimally invasive hysterectomy

Given the high volume of hysterectomies performed, the contribution of gynecologists to the opioid crisis is potentially significant. Following a hysterectomy, most patients are over-prescribed opioids, are vulnerable to developing new persistent opioid use, and can be the source of misuse, diversion, or accidental exposure. People who misuse opioids are at risk of an overdose related death, which is now one of the leading causes of death in the United States and is rising in other countries. It is the physician's responsibility to reduce opioid use by making impactful practice changes, such as 1) using pre-emptive opioid sparing strategies, 2) optimizing multimodal nonopioid pain management, 3) restricting postoperative opioid prescribing, and 4) educating patients on proper disposal of unused opioids. These changes can be implemented with an enhanced recovery after surgery protocol, shared decision-making, and patient education strategies related to opioids.

An assessment of the current practice of community pharmacists for the disposal of medication waste in the United Arab Emirates: A deep analysis at a glance

Objective

The study aimed to identify the current practice carried out by community pharmacists to dispose of expired medications in their workplace and assess any practical steps utilized to reduce medication waste.

Method

A cross-sectional study was conducted among community pharmacists in the United Arab Emirates (UAE). The participants were asked about their routine practice in disposing of different expired medications and the current actions taken to reduce the number of disposed medicines.

Results

The study included (n = 418) community pharmacists. More than a third of expired liquid, solid, and semi-solid dosage forms were collected by licensed contractors. In addition, more than a third of the pharmacists disposed of different dosage forms via unauthorized methods (general garbage, sink and toilet). Most expired drugs were skin and hair products, antibiotics and analgesics. The majority of pharmacists (68.4 %, n = 286) agreed that expired pharmaceutical and non-pharmaceutical products, other than those disposed of via contractor, should be done through a specialized centre. This opinion was found to be strongly associated with years of practice as community pharmacists (P < 0.05).

Conclusion

Part of the existing disposal practices for expired pharmaceutical products in the UAE is carried out by contractors licensed by health authorities. However, concern remains regarding some pharmaceutical and non-pharmaceutical products that have not been disposed of correctly. Additionally, there is a need for a specialized center for medication disposal (p < 0.05). A stock limitation is the best practice for managing medication quantities in stock (p < 0.05).

Factors Associated With Safe Prescription Opioid Disposal After Surgery in Adolescents

INTRODUCTION

Unused prescription opioids contribute to diversion, unintended exposure, and poisonings in adolescents. Factors associated with safe prescription opioid disposal for adolescents undergoing surgery are unknown.

METHODS

Parents of adolescents (13-20 y) undergoing surgery associated with an opioid prescription were enrolled preoperatively. Parents completed a baseline survey measuring sociodemographics and family history of substance abuse and two postoperative surveys capturing opioid use and disposal at 30 and 90 d. Safe disposal was defined as returning opioids to a healthcare facility, pharmacy, take-back event, or a police station. Factors associated with safe opioid disposal were assessed using bivariate analysis.

RESULTS

Of 119 parent-adolescent dyads, 90 (76%) reported unused opioids after surgery. The majority of parents reporting unused opioids completed the surveys in English (80%), although many (44%) spoke another language at home. Most reported income levels <$60,000 (54%), did not attend college (69%), and had adequate health literacy (66%). Most parents (78%) did not report safe opioid disposal. Safe opioid disposal was associated with younger patient age, (median 14 y, IQR 13-16.5 versus median 15.5 y, IQR 14-17, P = 0.031), fewer days taking opioids (median 5, IQR 2-6 versus median 7, IQR 4-14, P = 0.048), and more leftover pills (median 20, IQR 10-35 versus median 10, IQR 5-22, P = 0.008).

CONCLUSIONS

Most parents fail to safely dispose of unused opioids after their adolescent's surgery. Younger patient age, shorter duration of opioid use, and higher number of unused pills were associated with safe disposal. Interventions to optimize prescribing and educate parents about safe opioid disposal are warranted.

Palliative Farming

Billions of animals live and die under deplorable conditions in factory farms. Despite significant efforts to reduce human consumption of animal products and to encourage more humane farming practices, the number of factory-farmed animals is nevertheless on an upward trajectory. In this paper, we suggest that the high levels of suffering combined with short life-expectancies make the situation of many factory-farmed animals relevantly similar to that of palliative patients. Building on this, we discuss the radical option of seeking to reduce the suffering of factory-farmed animals through the use of drugs that alleviate pain and distress, administered under a regimen where experiential wellbeing is prioritized over the aim of avoiding drug-dependence.

Postoperative Opioid Prescribing, Use, and Disposal in Children

This article provides an overview of postoperative opioid prescribing, use, and disposal patterns in children and also identifies gaps in knowledge and areas for improvement. We present evidence that there is a need to tailor prescriptions to specific procedures to reduce the number of excess, unused prescription opioid pills in the home. We also explain the need to provide culturally competent care when managing a child's pain after surgery. Finally, we discuss the need for widespread provider and caregiver education about safe prescription opioid use, storage, and disposal.

Review and assessment of drug disposal state statutes in the United States, 2022

BACKGROUND

Ensuring opportunities exist to dispose of unused or unwanted drugs that are appropriate, accessible, and affordable is critical to avoid misuse and lasting harm to the environment.

OBJECTIVE

The objectives of this study were to identify state statutes promulgated in all 50 states and the District of Columbia (DC) facilitating disposal of unused or unwanted drugs in the community setting and assess their characteristics.

METHODS

A retrospective review of state statutes in all 50 U.S. states and DC between October 2020 and May 2022 was conducted. Statutes using terms "drug and disposal or collection" and that were intended to facilitate disposal of unused or unwanted drugs were included. Drug donation programs or repositories, drug returns to the pharmacy, charitable clinics, and others not intended to dispose or unused or unwanted drugs were excluded. Publicly available resources and Westlaw, a legal resource, were used to identify state statutes. Descriptive statistics were used to describe the findings.

RESULTS

Of the 50 U.S. states and DC, we found that most states enacted a statute pertaining to drug disposal (63%; n = 32) as of May 2022. Of states with a drug disposal statute, few had funding mechanisms or required pharmacy participation. Most statutes specified the type of product that may be accepted for disposal, what site may accept them, and who may dispose of the product. Few states specified which health care provider or other individual may accept the product(s) for disposal.

CONCLUSION

Most states have enacted statutes facilitating drug disposal, but their characteristics varied widely. Opportunities may exist at the state level to further incentivize proper drug disposal, and further research is needed to measure possible effects of these state statutes.

Disposal of Unused and Expired Medicines within the Sunyani Municipality of Ghana: A Cross-Sectional Survey

The occurrence of pharmaceuticals in the environment is a global challenge. Pharmaceuticals such as antibiotics and analgesics have been reported in various environmental matrices at varying concentrations. The major disposal route for unused and expired pharmaceuticals in Ghana is throwing them into dustbins. Although there are laws on the proper disposal patterns of drugs, these laws are poorly implemented. Sunyani is a fast-growing community with several health facilities that dispense medications daily. The purchase and use of medications among households are also high. However, no data exist on the disposal patterns of pharmaceuticals within the Sunyani Municipality. This study aims to identify the disposal patterns for unused and expired medications by households and pharmacies within the Sunyani Municipality, Ghana. A descriptive cross-sectional study was conducted among 400 persons in homes and 35 persons from randomly selected pharmacies and over-the-counter medication shops (OTCMs) within the Sunyani Municipality. A face-to-face interview approach using structured questionnaires for each respondent was employed. Household respondents disposed of unused and expired medications mainly through dumping in garbage cans (70.8%), incineration (11.5%), and flushing down the sink (9%). Pharmaceutical shop respondents also disposed of unused and expired medications into dump cans, by incineration, through the Food and Drugs Authority of Ghana, and took back to pharmaceutical wholesalers. Disposal practices observed in this study by households and pharmacy respondents were largely inappropriate. This could be due to the lack of education on the proper disposal patterns available to these respondents. It is recommended that guidelines on safe disposal be put in place, and a structured procedure for collecting unused and expired pharmaceuticals should be introduced.

Disposal practices for unused and expired medications: pilot data from three cities in three countries

Objective: To collect pilot data on medication disposal practices of unused and expired medications from three cities in three countries. Methods: A cross-sectional survey was conducted in Pittsburgh, United States (US); Turin, Italy; and Kobe, Japan. A convenience sampling was utilized through drug take-back programs in Pittsburgh, US; pharmacy customers in Turin, Italy; and pharmacy students and family members in Kobe, Japan. Descriptive analysis was conducted to assess medications disposal practices including attitudes and beliefs of respondents. Results: The sample included 342 respondents [99 (Pittsburgh, US); 168 (Turin, Italy); and 75 (Kobe, Japan)]. The mean unused and expired medications per patient for Pittsburgh, US was (1.60±2.30 and 0.51±1.54); Turin, Italy (1.69±1.86 and 0.49±1.22) and Kobe, Japan (6.69±8.78 and 0.84±2.26). The major reason for unused medications in Pittsburgh, US (31.3%) was "Medication was as needed"; in Turin, Italy (28.0%) "No longer suffer from the condition"; and in Kobe, Japan (54.7%) "No longer suffer from the condition". The most common reason for expired medications was "No longer suffer from the condition" (Pittsburgh, US 17.2%; Turin, Italy 15.5%; Kobe, Japan 12.0%). The disposal method in Pittsburgh, US was disposing in the toilet (35.4%); returned to the pharmacy in Turin, Italy (51.2%); and disposed the original container in the trash in Kobe, Japan (82.7%). Conclusions: There is a need for counseling protocols regarding proper disposal, which can lead to better adherence, reduction of prescription drug abuse, and less environmental hazards due to improper disposal of prescription medications.

Opioids and Public Health: The Prescription Opioid Ecosystem and Need for Improved Management

While U.S. opioid prescribing has decreased 38% in the past decade, opioid deaths have increased 300%. This opioid paradox is poorly recognized. Current approaches to opioid management are not working, and new approaches are needed. This article reviews the outcomes and shortcomings of recent U.S. opioid policies and strategies that focus primarily or exclusively on reducing or eliminating opioid prescribing. It introduces concepts of a prescription opioid ecosystem and opioid pool, and it discusses how the pool can be influenced by supply-side, demand-side, and opioid returns factors. It illuminates pressing policy needs for an opioid ecosystem that enables proper opioid stewardship, identifies associated responsibilities, and emphasizes the necessity of making opioid returns as easy and common as opioid prescribing, in order to minimize the size of the opioid pool available for potential diversion, misuse, overdose, and death. Approaches are applicable to opioid prescribing in general, and to opioid prescribing after surgery.

Barcoding drug information to recycle unwanted household pharmaceuticals: a review

Huge quantities of unwanted pharmaceuticals are left in households, notably as a consequence of the rising drug demand caused by improved healthcare and the aging population. Unwanted pharmaceuticals may thus easily end up polluting ecosystems upon disposal. This pharmaceutical waste issue has been aggravated during the coronavirus disease pandemic (COVID-19) by excess prescription and panic buying. Unwanted household pharmaceuticals are normally collected by owners and volunteers, then incinerated in centralized facilities, yet with low efficiency during the COVID-19 lockdowns. Most pharmaceuticals could be recycled because they are rather stable, however there is actually no sustainable strategy to manage unwanted pharmaceuticals in a pandemic. Here I review the management of unwanted pharmaceuticals in households during the pandemic, with emphasis on drug take-back programs, waste minimization and recycling efforts. Reducing pharamaceutical waste could be done by informing people on what to do with unwanted pharmaceutical products; using machine-readable codes for automatic sorting; and applying existing techniques for recovery of active pharmaceutical ingredients for reuse. I propose a new strategy where owners sort their unwanted pharmaceuticals and submit information online. This will generate coded mailing labels that allow the owner to separate pharmaceuticals into categories such as opened, unused, expired, and non-expired. Once collected by recycling facilities and manufacturers, active ingredients will be extracted to create new pharmaceuticals which will be recycled to other patients.

Using an Environmentally Friendly Disposal Bag to Discard Leftover Opioids After Gynecologic Surgery

OBJECTIVE

To evaluate the effects of an environmentally friendly drug deactivation bag on opioid disposal among patients undergoing gynecologic surgery.

METHODS

This prospective cohort study included patients undergoing gynecologic procedures requiring an opioid prescription from March 2020 to December 2020. Patients were managed on a restrictive opioid prescribing algorithm and given an opioid disposal bag. The carbon drug deactivation bag neutralizes the opioid medication and can be discarded safely in the trash. Patients were educated about pain management goals and the disposal bag. Patients were surveyed at their postoperative visit to evaluate satisfaction, number of leftover pills, and disposal methods. Statistical analysis was performed using SPSS Statistics 26.

RESULTS

Two hundred patients were asked to complete the survey, with a response rate of 78%. The most common procedures were exploratory laparotomy (50%) and minimally invasive hysterectomy (41%). Most patients (91%, 95% CI 91-97) filled their opioid prescription and 64 (41%, 95% CI 34-48) had leftover opioid pills. Most patients with leftover opioid pills (73%, 95% CI 67-79) discarded them; 78%, 95% CI 69-80 used the disposal bag. Patients undergoing an exploratory laparotomy most commonly used the disposal bag. All patients who used the disposal bag stated they would use it again.

CONCLUSION

Despite a restrictive opioid prescribing algorithm, 41% of gynecologic surgical patients had leftover opioid pills. This study demonstrated that leftover opioid pills were safely discarded 73% of the time when patients were provided an opioid disposal bag and preoperative education.

Postoperative Opioid Prescribing After Female Pelvic Medicine and Reconstructive Surgery

OBJECTIVE

This study aimed to provide female pelvic medicine and reconstructive surgery (FPMRS) providers with evidence-based guidance on opioid prescribing following surgery.

METHODS

A literature search of English language publications between January 1, 2000, and March 31, 2021, was conducted. Search terms identified reports on opioid prescribing, perioperative opioid use, and postoperative pain after FPMRS procedures. Publications were screened, those meeting inclusion criteria were reviewed, and data were abstracted. Data regarding the primary objective included the oral morphine milligram equivalents of opioid prescribed and used after discharge. Information meeting criteria for the secondary objectives was collected, and qualitative data synthesis was performed to generate evidence-based practice guidelines for prescription of opioids after FPMRS procedures.

RESULTS

A total of 6,028 unique abstracts were identified, 452 were screened, and 198 full-text articles were assessed for eligibility. Fifteen articles informed the primary outcome, and 32 informed secondary outcomes.

CONCLUSIONS

For opioid-naive patients undergoing pelvic reconstructive surgery, we strongly recommend surgeons to provide no more than 15 tablets of opioids (roughly 112.5 morphine milligram equivalents) on hospital discharge. In cases where patients use no or little opioids in the hospital, patients may be safely discharged without postoperative opioids. Second, patient and surgical factors that may have an impact on opioid use should be assessed before surgery. Third, enhanced recovery pathways should be used to improve perioperative care, optimize pain control, and minimize opioid use. Fourth, systemic issues that lead to opioid overprescribing should be addressed. Female pelvic medicine and reconstructive surgery surgeons must aim to balance adequate postoperative pain control with individual and societal risks associated with excess opioid prescribing.

Assessment on chronic and transgenerational toxicity of methamphetamine to Caenorhabditis elegans and associated aquatic risk through toxicity indicator sensitivity distribution (TISD) analysis

Evidence about the adverse effects of methamphetamine (METH) on invertebrates is scarce. Hence, C. elegans, a representative invertebrate model, was exposed to METH at environmental levels to estimate chronic and transgenerational toxicity. The results of chronic exposure were integrated into an underlying toxicity framework of METH in invertebrates (e.g., benthos) at environmentally relevant concentrations. The induction of cellular oxidative damage-induced apoptosis and fluctuation of ecologically important traits (i.e., feeding and locomotion) might be attributed by the activation of the longevity regulating pathway regulated by DAF-16/FOXO, and detoxification by CYP family enzymes. The adverse effects to the organism level included impaired viability and decreased fecundity. The results from transgenerational exposure elucidated the cumulative METH-induced damage in invertebrates. Finally, a new risk assessment method named toxicity indicator sensitivity distribution (TISD) analysis was proposed by combining multiple toxicity indicator test data (EC_x) to derive the hazardous concentration for 10% indicators (C₁₀) of one species. The risk quotient (RQ) values calculated by measured environmental concentrations and C₁₀ in southern China, southeastern Australia, and the western US crossed the alarm line (RQ = 5), suggesting a need for long-term monitoring.

Pharmaceutical Pollution and Disposal of Expired, Unused, and Unwanted Medicines in the Brazilian Context

The occurrence of pharmaceuticals in the environment is an everyday recognized concern worldwide, and drugs as environmental contaminants have been detected in water and soil systems, posing risks to humans and wildlife. The presence of drugs in wastewater, groundwater, and even drinking water occurs in several countries, including Brazil, where the pharmaceutical market is expanding over the years. The adverse, harmful effects of pharmaceuticals in the environment range from the spreading of antimicrobial resistance and species survival to the interference with reproduction and increased cancer incidence in humans. Therefore, it is demanding to count on proper legislation to prevent these pollutants from entering the distinct environment compartments. In some developed countries, laws, directives, programs, and initiatives regarding drug disposal reach a mature status. In Brazil, federal laws dealing with drug residues' management are recent, with flaws that might facilitate non-compliance with drug pollution issues. Besides, pharmacies and drugstores are not obligated to collect unneeded household medicines, while particular State laws aim to ordinate the disposal of drug residues regionally. In this review, we consider the current knowledge about pharmaceutical (drug) pollution, the recommendation and regulations on the disposal of useless medicines in some countries, and in the context of the expanding pharmaceutical market in Brazil. The awareness of emerging contaminants in the environment, besides the joint effort of authorities, consumers, and the general public nationwide, will be required to avoid pharmaceutical/drug pollution and achieve an eco-friendly environment and a sustainable society.

Opioid use in children's surgery: Awareness, current state, and advocacy

In response to the ongoing opioid epidemic, many surgeons who care for children have reflected upon current practices and the history of our own prescribing. In this editorial review, we provide a brief summary of the origins of opioid use in medicine and surgery, we describe how the ongoing opioid epidemic specifically impacts children and adolescents, and we explore contemporary efforts underway to facilitate evidence-based opioid prescribing. Resources for pediatric surgeons including national guidelines related to safe opioid prescribing and web-based toolkits that may be used to implement change locally are highlighted. The goal of the present manuscript is to introduce opioid stewardship as a guiding principle in pediatric surgery. LEVEL OF EVIDENCE: LEVEL V (Expert opinion).

Adolescents' awareness about prescription opioid misuse and preferences for educational interventions

OBJECTIVES

This study explored adolescents' awareness about prescription opioid misuse, sources of medication information, and educational preferences.

DESIGN

An online survey explored adolescents' understanding and perceptions of prescription opioids and opioid misuse and safety, medication information sources, and educational preferences.

SETTING AND PARTICIPANTS

Eligible participants included students from 3 Wisconsin high schools who could speak and understand English. Participants were recruited through "backpack mail" and completed surveys online at school.

OUTCOME MEASURS

Survey responses were compared across demographic information of the study participants. Binary response items were compared across demographic strata by Fisher exact tests, and Likert responses were analyzed by Kruskal-Wallis tests.

RESULTS

A total of 190 students (53% female, 53% white, 32% Hispanic) were surveyed. Most (83.5%) considered using someone else's opioid medication to be misuse, 85.2% identified using opioids at a higher dose or frequency than prescribed as misuse, and 67.6% considered using an opioid prescription after its expiration date to be misuse. Approximately 90% of students perceived that opioid misuse causes some, quite a bit, or a great deal of harm to a person's physical and mental health and school ability. Many students were able to correctly identify examples and consequences of misuse, however 24.7% believed that flushing opioids down the drain was dangerous. The most common source for finding information about opioids was Google or other search engines (67.6%), followed by talking with parents (56.7%), talking with a doctor or nurse (54.9%), and online videos (42.3%).

CONCLUSION

Adolescents have some opioid safety knowledge, but there is a clear opportunity to increase knowledge and understanding of risks. Adolescents could benefit from opioid safety education, particularly on safe storage and disposal, harms of misuse, and strategies for discouraging peer opioid misuse.

Communication of Recommendations for the Disposal of Unused Prescription Opioid Medications by Stakeholders in the News Media

OBJECTIVE

The opioid epidemic is a national public health emergency that requires a comprehensive approach to reduce opioid-related deaths. Proper and timely disposal of unused prescription opioids is one method to deter improper use of these medications and prevent overdose. The objective of this study was to understand how recommendations for disposing of unused prescription opioids, including both take-back programs and toilet disposal, are communicated to the public.

METHODS

Two hundred sixty-three US newspaper articles published between January 1, 2014, and June 30, 2017, containing information on opioids and take-back programs were found using LexisNexis. Using content analysis, articles were coded for the presentation of and recommendation for opioid disposal practices, beliefs about environmental harm from toilet disposal, and additional strategies to reduce opioid supply. The entity responsible for the statement was also captured.

RESULTS

Take-back programs were presented as a recommended disposal strategy for unused prescription opioids in 88.6% of coded articles. Toilet disposal was presented as a recommended disposal strategy for unused prescription opioids in 3.4% of articles and as harmful to the environment in 16.0% of articles. Individuals from health care, government, and law enforcement were primarily involved in discussing opioid disposal practices.

CONCLUSIONS

Although toilet disposal is recommended by the US Food and Drug Administration (FDA) for disposal of unused prescription opioids when a take-back program is not readily available, it was infrequently presented or recommended in news media articles. These results highlight the importance of improving communication of FDA guidelines for opioid disposal in the media, particularly by health care providers, government employees, and law enforcement officials.

What Happens to Unused Opioids After Total Joint Arthroplasty? An Evaluation of Unused Postoperative Opioid Disposal Practices

BACKGROUND

This study evaluates the fate of unused opioids after total hip arthroplasty (THA) and total knee arthroplasty (TKA) at our facility.

METHODS

Medication disposal after primary elective THA and TKA was classified as appropriate (in accordance with United States Food and Drug Administration guidelines) or inappropriate for all patients undergoing these procedures during the second half of the fiscal year 2015.

RESULTS

In total, 199 THAs and 144 TKAs met inclusion criteria. Total pills prescribed were 55,635. Approximately 8925 (16%) of pills were unused. About 39.9% of patients disposed of unused opioids appropriately, while 60.1% of patients reported still having (18.5%), not knowing where they were (8.2%), or other (33.4%). There was no significant association with the type of opioid prescribed.

CONCLUSION

A large volume of unused opioids were improperly disposed of after total joint arthroplasty.

Nootropic drugs: Methylphenidate, modafinil and piracetam - Population use trends, occurrence in the environment, ecotoxicity and removal methods - A review

Pharmaceuticals which originally were designed to treat people with neurological and psychiatric conditions, e.g. Alzheimer's disease or attention deficit hyperactivity disorder (ADHD), are nowadays often misused by students as a 'brain doping' substances. These substances are known as nootropic drugs, smart drugs or cognitive enhancers, as they increase memory, attention and concentration of healthy individuals. Since they are easily available illicitly, their consumption is observed to be growing. Currently, these pharmaceuticals started gaining researchers' attention, especially since they have been recently detected in wastewater, surface water and even drinking water. This review summarises the current state of knowledge on nootropic drugs in terms of their population use trends and ethics, occurrence in the environment and detection techniques, toxicity and removal methods, in example of methylphenidate, modafinil and piracetam - three most popular nootropics. It points out that the main sources of knowledge on cognitive enhancers illicit use are often inconsistent questionnaires, which are not supported by wastewater analysis to become more veracious. Simultaneously, the studies concerning toxicity and removal methods of nootropic drugs are still limited and in many cases environmentally irrelevant. Although the prescription rules has been subjected to more strict control in developed countries, regulatory frameworks with regard to their ecosystem occurrence are still lacking and should be introduced. Moreover, the use of environmentally relevant concentrations in toxicity studies should be a standard, leading to proper ecotoxicity risk assessment. Based on this review, it is recommended to routinely monitor nootropics and their metabolites in waste- and surface waters.

Estimating the eco-toxicological risk of estrogens in China's rivers using a high-resolution contaminant fate model

The contamination of freshwater systems arises in many river basins due to industrialization and population growth, posing risks to ecosystems and human health. Despite these concerns, the fate and potential impact of many emerging pollutants are currently unknown, especially when the compounds are released into surface waters from populations distributed across large spatial scales. In order to address this shortcoming, a spatially-explicit contaminant fate model was developed as an extension of the global, vector-based river routing model HydroROUT. HydroROUT operates at very high spatial resolution (∼500 m), simulates river and stream chemical transport with in-stream removal, and contains links to a set of lakes and reservoirs, which act as a partial sink during the transport. The chemical fate model was applied to China and includes a consumption and release module based on county-level population demographics, considers point-source contributions from 2547 wastewater treatment plants, and accumulates contributions of rural and urban populations not connected to sewage treatment plants. As a case study, the sources and fates of the estrogens estrone (E₁), 17β-estradiol (E₂), estriol (E₃), as well as the synthetic estrogenic steroid hormone 17α-ethinylestradiol (EE₂) were modelled in Chinese surface water bodies. Preliminary validation of the results showed predictions to be within the ranges of concentrations reported in literature, with exception of EE₂. The total estrogenic mass in the entire river and lake system amounted to 370 tonnes of estrogens, with about 1.3 tonnes per year discharged to the ocean, neighboring countries or to inland sinks. Under a selected baseline scenario, eco-toxicological risk-i.e., contaminant concentrations in excess of the predicted no effect concentration (PNEC)-is found in 23.6% of all analyzed rivers of China with an average flow > 0.1 m³/s. Out of these, about 4% of rivers showed a high level of risk of 10 times or more above PNEC. Medium-to-large rivers are disproportionally affected; for example, 23.6%, 37.3%, 29.0% and 21.6% of river length are at risk in rivers of 1-10, 10-100, 100-1,000, and 1,000-10,000 m³/s of discharge, respectively, whereas no risk was predicted in the largest rivers (i.e., >10,000 m³/s) of China. Wastewater treatment plants process 22.5% of the total hormone load and thus play an important role in water quality control by reducing the risk in substantial portions of the river network, which would otherwise show elevated risk. Releases from untreated population dominate by far the overall contribution to risk.

Reverse Logistics of Postconsumer Medicines: The Roles and Knowledge of Pharmacists in the Municipality of São Paulo, Brazil

Environmental contamination due to the disposal of expired or obsolete drugs is a concern, since there is no specific Brazilian legislation, regarding disposal by the final consumer, thus reflecting the need for reverse logistics of medicines, after their consumption. The objective of this study was to survey the knowledge of pharmacists regarding their role in the reverse logistics of medicines and to understand the contribution of reverse logistics, aimed at the appropriate disposal of Group B waste, on a voluntary basis, by the population, in the municipality of São Paulo. A survey conducted through interviews with a hundred and sixty-one pharmacists demonstrated that 35% have partial knowledge of the postconsumer reverse logistics of their place of work and 16.8% have complete knowledge of the environmental harm resulting from the contamination of medicinal waste. The pharmacists also reported (10%) that there should be an educational plan for clients, and 50% of them agreed that incentives and disclosure, regarding the importance of reverse logistics for medicines, should be provided to consumers.

Number of Unused Medications at the Time of Last Admission: A Prospective Observational Study in a Single Palliative Care Unit

BACKGROUND:

Unused medications (UM) are an important issue, with the waste associated with UM a burden to the health-care system. The aims of this study were to clarify the amount and costs of UM in patients with advanced cancer at the time of their last admission to a palliative care unit and to explore the factors contributing to the cost of UM and how patients dealt with UM.

METHODS:

A prospective observational study was conducted in single palliative care unit. Unused medications were classified into 6 categories and the number and cost of UM by category calculated per patient. Patients were classified into 2 cost groups (high and low) based on the total cost of UM, and the number and cost of UM by category were compared between these 2 groups.

RESULTS:

Of 194 consecutive hospitalized patients, data were analyzed for 90. The mean number and cost of UM per patient was 440 and US$301, respectively. Opioids accounted for 47% of the cost of UM. Comparing costs by UM category, the proportion of opioids (51% vs 21%; P < .0001) and oral anticancer drugs (14% vs 3%; P = .02) was higher in the high- than in the low-cost group.

CONCLUSION:

Based on the results of the present study, the estimated annual waste cost of UM for patients with cancer who died in Japan was approximately US$110 million. Interventions to educate patients regarding UM and to eliminate barriers to opioid use may help reduce the cost of UM, particularly opioids and anticancer drugs.

Empowering Post-Surgical Patients to Improve Opioid Disposal: A Before and After Quality Improvement Study

BACKGROUND

Our country is in the midst of an opioid epidemic. Although the problem is multifactorial, one issue is the presence of excess prescription opioid medications circulating in our communities. Our objective was to determine whether dissemination of an educational brochure would improve the disposal of unused opioids after surgery.

STUDY DESIGN

Eligible surgery patients from an upper extremity/peripheral nerve clinic were enrolled into this prospective before and after study between February 2017 and September 2017. Patients who reported opioid use preoperatively were excluded from this study. The same survey was administered to the group of patients who did not receive the intervention and to those who did receive the intervention. Our primary endpoint was the proportion of patients who disposed of unused opioid medications.

RESULTS

A total of 334 patients were studied: 164 who did not receive the brochure and 170 who received the brochure. Seventy-six patients were excluded for preoperative opioid use. After dissemination of the brochure, there was a significant increase in the proportion of patients who disposed of their unused opioids (11% vs 22%, p = 0.02). Of those who disposed of their opioids, there was no significant difference in the proportion of patients from each group who disposed in a manner that was recommended by the brochure (43% vs 64%, p = 0.19).

CONCLUSIONS

Dissemination of the educational brochure improved disposal of unused opioids after surgery. This low-cost, easily implemented intervention can improve disposal of unused opioids and ultimately, decrease the amount of excess opioids circulating in our communities.