Leftover drug disposal: Customer behavior, pharmacist recommendations, and obstacles to drug take-back box implementation

Could pharmacy technicians play a role in supporting the appropriate and safe use of traditional and complementary medicines?

Across the world traditional and complementary medicine (T&CM) product use is prevalent with some countries reporting greater than 50% of the population using these products. T&CM products are primarily self-selected through retail outlets including pharmacies. Pharmacists across the world generally agree they should play a role in ensuring the appropriate and safe use of T&CM products but report being time and resource poor to do so. In this commentary, it is proposed that pharmacy technicians as members of the pharmacy workforce, who with adequate education, and supportive technologies could support pharmacists in providing guidance to consumers and patients about the appropriate and safe use of T&CM products. Pharmacy technicians play a crucial role in the pharmacy workforce, serving as integral members of healthcare teams fulfilling a wide array of tasks essential for the efficient functioning of pharmacies and ensuring the safe dispensation of medications. They have been described by pharmacists as the "the face of the pharmacy" in the community setting and relied on not only for mitigating and triaging problems, but also be primarily responsible for developing rapport, eliciting trust and even loyalty from pharmacy patrons. As such, there is a momentous opportunity for pharmacy technicians to play a role in providing T&CM advice and triaging the need for pharmacists' intervention where harm, or risk of is identified.

Elucidating determinants of medication disposal programs at retail pharmacies in North Carolina

BACKGROUND

Pharmacy-based medication disposal programs is one approach to prevent diversion of unused prescription opioids.

OBJECTIVE(S)

The objective of this study was to assess the extent to which disposal programs have been implemented by retail pharmacies and identify determinants of implementation using the Consolidated Framework for Implementation Research.

METHODS

A sequential mixed-method design was used to examine implementation of medication disposal programs at pharmacies in Pitt County, NC. We conducted environmental scans of all retail pharmacies that served community members (N = 31) to assess the extent to which disposal programs had been implemented. Then, we conducted interviews with pharmacists (n = 15; 48.4%) to identify determinants of implementation. The following pharmacy types were represented in the completed interviews: corporate chain (n = 10), small chain (n = 1), independently owned and operated (n = 1), medical (n = 2), and government (n = 1).

RESULTS

We found that 32.3% of pharmacies (n = 10) had a medication disposal box and 12.9% (n = 4) had posted a flyer on medication disposal. Pharmacists perceived that patients benefit from disposal boxes and medication disposal is in their purview. Determinants of implementation included the cost of sustaining the intervention, polices of corporate and regional management, variable local control in the decision-making process to implement a disposal box, and experience with having a medication disposal box.

CONCLUSION

Our findings highlight one way in which pharmacists can have a vital role in preventing diversion of opioid analgesics and associated consequences. There is a need to expand disposal boxes at pharmacies to increase community member accessibility and use. Future research is needed to determine the cost-effectiveness of expanding the scale of disposal box implementation in community pharmacies.

Anti-cancer drug waste disposal practices and wastewater management in hospitals: A Lebanese survey

INTRODUCTION

To achieve continuous environmental sustainability and protect the population's health, healthcare waste (in liquid or solid form) needs appropriate management and suitable treatment strategies before its final disposal in the environment in order to reduce its adverse impacts. This study aims to identify disparities in the waste management of anti-cancer drugs and the wastewater generated in Lebanese hospitals.

METHODS

Three questionnaires were designed to evaluate the level of knowledge, awareness and experience of hospital personnel regardless of their job levels. Data was collected in December 2019 from three departments of each participating hospital: pharmacy, oncology and maintenance departments. A descriptive analysis was conducted to summarise the survey results.

RESULTS

The results revealed a lack of transparency and awareness of the participants, with a high frequency of 'prefer not to say' responses when asked about the disposal methods of anti-cancer drugs and with only 5.7% of the participants in the pharmacy department sharing their disposal procedures. The same perception was deduced regarding hospitals' wastewater treatment, where responses were often contradicting, preventing making assumptions about the fate of hospital wastewater.

CONCLUSION

The results of this survey support the need to establish a more comprehensive waste management programme in Lebanon that would be maintained through regular training and supervision.

PPCPs in coastal wastewater treatment plant effluent and uptake by Pacific oysters (Crassostrea gigas): Findings from a laboratory experiment

Municipal wastewater treatment plant (WWTP) effluent is a primary source of pharmaceuticals and personal care products (PPCPs) to the marine environment, as most of these compounds are not fully removed during the treatment process. Continual discharge from WWTPs into coastal areas may act as a stressor by continually exposing organisms to a suite of PPCPs. To quantify organismal exposure to PPCP mixtures, we conducted a 12-week lab experiment that exposed Pacific oysters to effluent from two Oregon coastal WWTPs of different discharge capacities (permitted as <1 million gallons/day and >1 million gallons/day; or < or >3.785 million liters/day) at a dilution of 25 %. Composite samples of weekly collected effluent and a subset of freeze-dried oysters from experiment week 12 were analyzed for PPCPs. Though challenges with food availability inhibited our ability to confidently identify effects of the contaminants on growth and fitness, the experiment allowed us to examine uptake of contaminants from effluent into an estuarine bivalve of commercial importance. We detected 30 PPCPs and three alkylphenols in effluent and 13 PPCPs and four alkylphenols in oyster tissue, indicating high rates of release from secondary treatment and significant potential for marine organism exposure to and uptake of PPCPs in rural coastal areas.

Ecopharmacology: Knowledge, Attitude, and Medication Disposal Practice Among Pharmacy Students

Background

Ecopharmacology, as a form of drug management for the environment, focuses on the impact of drugs on the environment. Pharmacists, and by extension pharmacy students, are expected to play an important role in ecopharmacology. Therefore, this study was conducted to determine the knowledge and attitude towards ecopharmacology and the practice of disposal of leftover or expired medicines among pharmacy students.

Methods

This was a descriptive cross-sectional study among pharmacy students in Northwestern Ethiopia. The study took place from May 1 to June 15, 2023. A self-administered questionnaire was used for data collection.

Results

Four hundred and forty-five students were included in the study. Only 91 (20%) of the students were aware of the term ecopharmacology, 27% knew that excretion from the human or animal body is the major route by which pharmaceutical agents enter the environment, and 42% were aware of the risk of increased antimicrobial resistance due to antibiotic residues in the environment. In addition, only 27% of respondents reported receiving information about the disposal of pharmaceuticals. The most common method of disposing of medications was throwing them away in household trash (61.8%).

Conclusion

Our results suggest that while most pharmacy students in Ethiopia have a positive attitude toward ecopharmacology, they do not know enough about ecopharmacology and dispose of their medicines poorly. More uniform education in ecopharmacology and pharmaceutical pollution might be warranted in the pharmacy curriculum.

Promoting Disposal of Left-Over Opioids After Surgery in Rural Communities: A Qualitative Description Study

BACKGROUND

Patients rarely dispose of left-over opioids after surgery. Disposal serves as a primary prevention against misuse, overdose, and diversion. However, current interventions promoting disposal have mixed efficacy. Increasing disposal in rural communities could prevent or reduce the harms caused by prescription opioids.

AIMS

Identify barriers and facilitators to disposal in the rural communities of the United States Mountain West region.

METHODS

We conducted a qualitative description study with 30 participants from Arizona, Idaho, Montana, Nevada, Oregon, Utah, and Wyoming. We used a phronetic iterative approach combining inductive content and thematic analysis with deductive interpretation through the Precaution Adoption Process Model (PAPM).

RESULTS

We identified four broad themes: (a) awareness, engagement, and education; (b) low perceived risk associated with nondisposal; (c) deciding to keep left-over opioids for future use; and (d) converting decisions into action. Most participants were aware of the importance of disposal but perceived the risks of nondisposal as low. Participants kept opioids for future use due to uncertainty about their recovery and future treatments, breakdowns in the patient-provider relationship, chronic illness or pain, or potential future injury. The rural context, particularly convenience, cost, and environmental contamination, contributes to decisional burden.

CONCLUSIONS

We identified PAPM stage-specific barriers to disposal of left-over opioids. Future interventions should account for where patients are along the spectrum of deciding to dispose or not dispose as well as promoting harm-reduction strategies for those who choose not to dispose.

A Current Review of Water Pollutants in American Continent: Trends and Perspectives in Detection, Health Risks, and Treatment Technologies

Currently, water pollution represents a serious environmental threat, causing an impact not only to fauna and flora but also to human health. Among these pollutants, inorganic and organic pollutants are predominantly important representing high toxicity and persistence and being difficult to treat using current methodologies. For this reason, several research groups are searching for strategies to detect and remedy contaminated water bodies and effluents. Due to the above, a current review of the state of the situation has been carried out. The results obtained show that in the American continent a high diversity of contaminants is present in the water bodies affecting several aspects, in which in some cases, there exists alternatives to realize the remediation of contaminated water. It is concluded that the actual challenge is to establish sanitation measures at the local level based on the specific needs of the geographical area of interest. Therefore, water treatment plants must be designed according to the contaminants present in the water of the region and tailored to the needs of the population of interest.

Closing the loop: Establishing reverse logistics for a circular economy, a systematic review

Reverse Logistics (RL) of end-of-use/end-of-life products has become a vital part of circular economy practices for manufacturers. However, significant quantities of resources are still landfilled instead of being recovered. With mounting pressure on businesses to address the sustainability crises (resources, climate change, waste, toxicity) on account of the take-make-dispose-based linear economy, companies today realise the importance of RL but face several barriers to implementing it, including a lack of knowledge. Although several studies have investigated different aspects of RL in various industries in different country settings, less attention has been devoted to developing a systematic and holistic approach for designing and implementing RL. To address these gaps, this paper reviews 116 scholarly articles published between 2011 and 2021 to identify attributes related to the design and implementation of RL systems. Based on a systematic literature review, a conceptual framework is presented covering the key activities, drivers and barriers, stakeholder engagement and performance management in RL. Such a framework can support companies evaluate different approaches and strategies, as well as the opportunities and challenges of designing and implementing RL and transitioning towards a Circular Economy.

Exploring antibiotic consumption between urban and sub-urban catchments using both parent drugs and related metabolites in wastewater-based epidemiology

Consumption of antibiotics leads to the dissemination of antimicrobial resistance worldwide. Better knowledge of temporal and spatial consumption of antibiotics helps public health authorities to control their usage and combat antimicrobial resistance. However, measuring antibiotic consumption with population surveys, sales data, and production statistics remains challenging due to the complexity of prescription preference, patient compliance, and direct disposal of unused drugs. With the approach of wastewater-based epidemiology (WBE), this study aims to evaluate the consumption of eight commonly-used antibiotics between developed urban and developing sub-urban catchments in China and to characterise the ratios of parent drugs to metabolites in studying the consumption. Seven parent antibiotics were detected in all the wastewater samples (n = 56), whereas some metabolites were detected sporadically. The ratios of parent chemicals to metabolites varied among locations and were often higher than the ratios in pharmacokinetic studies. Estimated consumption of antibiotics ranged from 3.2 ± 2.0 mg/day/1000 inhabitants for trimethoprim to 28,400 ± 7800 mg/day/1000 inhabitants for roxithromycin in the studied catchments. Higher consumption of sulfapyridine, sulfadiazine and roxithromycin was observed in urban than suburban catchments, while consumption of sulfamethoxazole, norfloxacin, and trimethoprim was higher in suburban than in urban catchments. Using the literature data, we found more than 95% reduction of antibiotic use in an urban catchment. Our study revealed the geographical pattern in antibiotic use across different urban and suburban catchments via WBE, and the potential of monitoring parent-to-metabolite ratios for WBE in estimating antibiotic use. These results provide a basis for health authorities to plan different drug-specific control policies between urban and suburban catchments, and for future WBE studies to be aware of other sources, such as animal husbandry and disposals of unused drugs, that can influence the estimated consumption.

Effectiveness of environmental health and loss framing on household pharmaceutical take-back schemes

Pharmaceutical pollution poses an emerging environmental and public health problem. Together with increasing medicine use and pharmaceutical manufacturing effluents, improper disposal of household pharmaceutical waste significantly adds to this issue, despite pharmaceutical take-back schemes having been established in many countries. Even where take-back schemes are available return rates remain low. Previous studies have used only survey and interview methodologies and therefore merely described the situation. This study goes further, exploring not only the effects of the availability of information on pharmaceutical take-back schemes but also the effects of the framing of information provided to individuals on their intentions and reported behaviours to collect unused and/or expired household pharmaceuticals and return them to a pharmacy. The data were collected throughout three preregistered, randomised experiments with representative samples (N = 3754). The results show that tapping into individuals' pre-existing conception of the problem and psychological biases through the delivery of environmental health, loss framing information highly increased the odds of returning household pharmaceutical waste. This result is long-lasting (Studies 2 and 3), is found in various European countries (Study 1), and remains robust in all studies. Based on the results, we suggest that, in the context of household pharmaceutical waste management, psychologically informed, proactive approaches combined with targeted local action and services can reduce the psychological and practical barriers to pro-health and pro-environmental behaviour. The findings are used to support a policy recommendation that is cost-efficient, easy to use, and effective.

Management of pharmaceutical micropollutants discharged in urban waters: 30 years of systematic review looking at opportunities for developing countries

Pharmaceutical micropollutants' contamination of urban waters has been studied globally for decades, but the concentration of innovations in management initiatives is still in developed economies. The gap between the locus of innovations in pharmaceuticals and the relative stagnation in less developed economies to manage waste originating in this activity seems fruitful for investigations on innovation in integrated micropollutant management strategies. These tensions allow for advances in current knowledge for environmental management and, particularly, finding solutions for the contamination by pharmaceutical micropollutants of urban water bodies in developing countries. We aim to list the main strategies for managing pharmaceutical micropollutants discussed to point out opportunities for developing countries to advance in this direction. Methodologically, we conducted a systematic literature review from 1990 to 2020, covering 3027 documents on "pharmaceutical micropollutants management." The framework formed by the macro-approach to integrated management operationalized by the dimensional micro-approaches: technical, organizational, community, and governmental allowed us to understand that (1) the management of pharmaceutical micropollutants tends to occur through a technical approach centered on the removal of aquatic matrices, green chemistry, and urine diversion; (2) management with an organizational approach has enabled removing drugs from water bodies by drug take-back program, collaborative projects, drug use reduction, and better organizational practices; (3) the community approach have helped minimize this type of pollution by reducing the consumption of medicines and the proper destination for medicines that are no longer in use. Finally, the government management approach emerges as a source of legal, economic, and informational instruments to reduce pollution by pharmaceutical micropollutants. Furthermore, these management approaches allowed us to identify 15 opportunities for possible adjustments for developing societies. These opportunities can be promising for practices and research and, in the medium term, contribute to minimizing pollution by pharmaceutical micropollutants in urban waters.

Opioid-Involved Overdose Vulnerability in Wyoming: Measuring Risk in a Rural Environment

BACKGROUND

Between 2009 and 2019 opioid-involved fatal overdose rates increased by 45% and the average opioid dispensing rate in Wyoming was higher than the national average. The opioid crisis is shaped by a complex set of socioeconomic, geopolitical, and health-related variables. We conducted a vulnerability assessment to identify Wyoming counties at higher risk of opioid-related harm, factors associated with this risk, and areas in need of overdose treatment access to inform priority responses.

METHODS

We compiled 2016 to 2018 county-level aggregated and de-identified data. We created risk maps and ran spatial analyses in a geographic information system to depict the spatial distribution of overdose-related measures. We used addresses of opioid treatment programs and buprenorphine providers to develop drive-time maps and ran 2-step floating catchment area analyses to measure accessibility to treatment. We used a straightforward and replicable weighted ranks approach to calculate final county vulnerability scores and rankings from most to least vulnerable.

FINDINGS

We found Hot Springs, Carbon, Natrona, Fremont, and Sweetwater Counties to be most vulnerable to opioid-involved overdose fatalities. Opioid prescribing rates were highest in Hot Springs County (97 per 100 persons), almost two times the national average (51 per 100 persons). Statewide, there were over 90 buprenorphine-waivered providers, however accessibility to these clinicians was limited to urban centers. Most individuals lived further than a four-hour round-trip drive to the nearest methadone treatment program.

CONCLUSIONS

Identifying Wyoming counties with high opioid overdose vulnerabilities and limited access to overdose treatment can inform public health and harm reduction responses.

Pharmaceutical pollution sources and solutions: Survey of human and veterinary medication purchasing, use, and disposal

Human and veterinary pharmaceuticals offer many benefits, but they also pose risks to both the environment and public health. Life-cycle stewardship of medications offers multiple strategies for minimizing the risks posed by pharmaceuticals, and further insight is required for developing best practices for pharmaceutical management. The goal of this study was to clarify points of intervention for minimizing environmental and public health risks associated with pharmaceuticals. Specifically, our objectives were to provide insight on purchasing, use, and disposal behaviors associated with human and veterinary medications. This study used a state-wide representative sample of Vermont adults (n = 421) to survey both human and veterinary pharmaceuticals as potential sources of the unintended consequences of prescribed and over-the-counter (OTC) medications. The majority (93%) of respondents had purchased some form of medication within the past twelve months, including OTC (85%), prescription (74%), and veterinary (41%) drugs. Leftover drugs of any kind were reported by 59% of respondents. While 56% of people were aware of drug take-back programs, the majority reported never being told what to do with leftover medications by their physician (78%), pharmacist (76%), or veterinarian (53%). Among all respondents, take-back programs were the most common disposal method (22%), followed by trash (19%), and flushing (9%), while 26% of respondents reported keeping unused drugs. Awareness of pharmaceutical pollution in the environment and having received information about proper disposal were both significantly associated with participation in take-back programs. These findings indicate that a large volume of drugs are going unused annually, and that only a portion of leftover medications are returned to take-back programs where they can be appropriately disposed. Our results warrant further investigation of clinical interventions that support lower dose prescribing and dispensing practices in order to reduce the unintended environmental and public health consequences of pharmaceuticals within the consumer sphere. In addition, our findings suggest that directed efforts to raise awareness of proper disposal may be more effective than broad awareness campaigns, and we recommend research on the efficacy of providing disposal instructions on drug packaging.