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

Pharmacists perspectives on challenges and facilitators in initiating medications take-back program in Indonesia: A qualitative study

Objective

The establishment of a medication take-back program is an important intervention to prevent the improper disposal of expired or unused household medications. However, such a program has not been established in Indonesia. A significant step in establishing the program is to gain a better understanding of pharmacists' perspectives on the associated challenges and facilitators. Therefore, this study aimed to explore pharmacists' perspectives on the associated challenges and facilitators in initiating medications take-back program in Indonesia.

Methods

This qualitative study was conducted through Key Informant Interviews with a purposive sample of nine pharmacists working in community health centers (CHC) in Bandung City, Indonesia. The discussions were transcribed, coded, and analyzed using Atlas.ti9 software.

Results

Pharmacists' perspectives on initiating medications take-back program were categorized into two main themes, including challenges and facilitators. The identified challenges comprised a lack of personnel, financial constraints, geographical constraints, lack of facilities, and inadequate knowledge. Meanwhile, the facilitators included the good responsibility of pharmacists, incentives, and convenient locations.

Conclusion

The identified challenges and facilitators should be considered when initiating medication take-back programs in Indonesia.

Unused medicine take-back programmes: a systematic review

Background

Improper disposal of unused medicine can impact the environment causing significant healthcare and financial burdens. While the medicine take-back programme is an effective management strategy, its effectiveness differs across countries. This study aimed to systematically review the take-back programmes in various countries and to identify areas needing improvement for programme enhancement.

Methods

We conducted searches in Medline, EMBASE, CINAHL, Web of Science, Scopus, and Google Scholar, from database inception to June 2023.

Results

The review included 27 studies spanning 15 countries' medicine take-back programmes. While some programmes, mostly observed in the USA, were conducted at the local level with non-health-associated facilities, others were done at the national level within healthcare facilities. The cost of collected medicines ranged from US$7,416 to US$1,118,020, primarily involving medicines related to the nervous system, cardiovascular system, alimentary tract, and metabolism. Legislations pertaining to these programmes were available in the USA, most European countries, and Mexico, but unavailable in Spain, Austria, Australia, and New Zealand. However, despite this, the government or the industry in these countries managed the programmes.

Conclusion

Well-structured take-back programmes featuring easily accessible collection points, regular collection schedules, clear programme ownership, with legislation defining financial responsibilities, showed positive outcomes.

Evaluating a health system-wide opioid disposal intervention distributing home-disposal bags

OBJECTIVE

To evaluate a health system-wide intervention distributing free home-disposal bags to surgery patients prescribed opioids.

DATA SOURCES AND STUDY SETTING

We collected patient surveys and electronic medical record data at an academic health system.

STUDY DESIGN

We conducted a prospective observational study. The bags were primarily distributed at pharmacies, though pharmacists delivered bags to some patients. The primary outcome was disposal of leftover opioids (effectiveness). Secondary outcomes were patient willingness to dispose and factors associated with disposal (effectiveness), recalling receipt of the bag (reach), and recalling receipt of bags and disposal over time (maintenance). We used a modified Poisson regression to evaluate the relative risk of disposal. Inverse probability of treatment weighting, based on propensity scores, was used to account for differences between survey responders and non-responders and reduce nonresponse bias.

DATA COLLECTION/EXTRACTION METHODS

From August 2020 to May 2021, we surveyed patients 2 weeks after discharge (allowing for home opioid use). Eligibility criteria were age ≥18, English being primary language, valid email address, hospitalization ≤30 days, discharge home, and an opioid prescription sent to a system pharmacy.

PRINCIPAL FINDINGS

We identified 5134 patients with 2174 completing the survey (response rate 42.3%). Among respondents, 1375 (63.8%) recalled receiving the disposal bag. Among 1075 respondents with leftover opioids, 284 (26.4%) disposed, 552 (51.3%) planned to dispose, 79 (7.4%) did not plan to dispose, 69 (6.4%) had undecided, and 91 (8.5%) had not considered disposal. Recalling receipt of the bag (incidence rate ratio [IRR] 1.25, 95% confidence interval [CI] 1.13-1.37) was positively associated with disposal. Patients who used opioids in the last year were less likely to dispose (IRR 0.82, 95% CI 0.73-0.93). Disposal rates remained stable over the study period while recalling receipt of bags trended up.

CONCLUSIONS

A pragmatic implementation of a disposal intervention resulted in lower disposal rates than prior trials.

Patient Willingness to Dispose of Leftover Opioids After Surgery: A Mixed Methods Study

We examined how convenience and financial incentives influence patient willingness to dispose of leftover prescription opioids after surgery. We also identified additional barriers and facilitators to disposal.

Background

In the United States, up to 70% of surgical patients are prescribed opioids and up to 92% will have leftover tablets. Most do not dispose of leftover opioids, increasing the risk for opioid-related harm. Current interventions promoting opioid disposal have shown mixed success.

Methods

We conducted a mixed methods study using a standard gamble survey and semi-structured interviews. Participants estimated willingness to dispose in 16 scenarios with varying convenience (time requirements of <5, 15, 30, and 60 minutes) and financial incentives ($0, $5, $25, $50). We estimated the likelihood of disposal using a multivariable mixed effects modified Poisson regression model. Semi-structured interviews explored how convenience, financial incentives, and other barriers and facilitators influenced decisions to dispose.

Results

Fifty-five participants were surveyed and 42 were interviewed. Most were willing to dispose when the time required was <15 minutes. Few were willing to dispose if the process required 60 minutes, although a $50 financial incentive increased rates from 9% to 36%. Anxiety about future pain, opioid scarcity, recreational use, family safety, moral beliefs, addiction, theft, and environmental harm also influenced decision-making.

Conclusions

Interventions promoting opioid disposal should focus on convenience, but the selective use of financial incentives can be effective. Tailoring interventions to individual barriers and facilitators could also increase disposal rates.

Primary prevention of prescription opioid diversion: a systematic review of medication disposal interventions

Background: In the U.S., 50-75% of nonmedical users of prescription opioids obtain their pills through diversion by friends or relatives. Increasing disposal of unused opioid prescriptions is a fundamental primary prevention strategy in combatting the opioid epidemic.Objectives: To identify interventions for disposal of unused opioid pills and assess the evidence of their effectiveness on disposal-related outcomes.Methods: A search of four electronic databases was conducted (October 2019). We included all empirical studies, systematic literature reviews, and meta-analyses about study medication disposal interventions in the U.S. Studies of disposal interventions that did not include opioids were excluded. We abstracted data for the selected articles to describe the study design, and outcomes. Further, we assessed the quality of each study using the NIH Study Quality Assessment Tools.Results: We identified 25 articles that met our inclusion criteria. None of the 13 studies on drug take-back events or the two studies on donation boxes could draw conclusions about their effectiveness. Although studies on educational interventions found positive effects on knowledge acquisition, they did not find differences in disposal rates. Two randomized controlled trials on drug disposal bags found higher opioid disposal rates in their intervention arms compared to the control arms (57.1% vs 28.6% and 33.3%, p = .01; and 85.7% vs 64.9%, p = .03).Conclusions: Peer-reviewed publications on opioid disposal interventions are limited and either do not address effectiveness or have conflicting findings. Future research should address these limitations and further evaluate implementation and cost-effectiveness.

Unused and Expired Medications Disposal Practices among the General Public in Selangor, Malaysia

The appropriate disposal practice of unused and expired medications has become a global challenge that has caught the attention of health policymakers, pharmaceutical organizations, healthcare professionals, and the wider community. The current study aimed to evaluate the awareness, attitudes, and behaviors relating to the disposal practice of unused and expired medications and medication wastage issues among the general public in Selangor, Malaysia. The quantitative, cross-sectional study was conducted using a pre-validated structured survey form. Among the approached individuals, 426 showed their willingness to participate in the study. More than 80% of the study population reported being aware of the medication wastage issue and its impact on patients and the economy. The respondents with a higher level of education (OR = 1.85; 95% CI = 1.18–2.52; p < 0.003) were more likely to be cognizant of the detrimental consequences of inappropriate waste disposal. The female respondents were more likely to report comprehending that the availability of free healthcare resources is contributing to medication waste (OR = 1.33, 95% CI = 1.015–2.34; p < 0.005). The majority of respondents reported throwing away unused medications (202; 47.4%) and expired medications (362; 84.9%) in the garbage. The respondents believed that the provision of appropriate directions by healthcare professionals (312; 73.2%) and prescribing/dispensing medications in quantities for the duration that ensures patient adherence (114; 26.7%) could minimize medication wastage. The Ministry of Health (258; 60.5%), pharmaceutical organizations (212; 49.7%), and pharmacists (193; 45.3%) were the respondents’ perceived responsible sources of information. The current findings reported that respondents were familiar that inappropriate practices of medication wastage might have harmful consequences. However, a gap exists between their awareness and practice, and the disposal approaches practiced by the respondents were generally not appropriate.

Applying Contemporary Management Principles to Implementing and Evaluating Value-Added Pharmacist Services

Value-added pharmacy services encompass traditional and emerging services provided by pharmacists to individual and entire populations of persons increasingly under the auspices of a public health mandate. The success of value-added pharmacy services is enhanced when they are carried out and assessed using appropriate theory-based paradigms. Many of the more important management theories for pharmacy services consider the “servicescape” of these services recognizing the uniqueness of each patient and service encounter that vary based upon health needs and myriad other factors. In addition, implementation science principles help ensure the financial viability and sustainability of these services. This commentary reviews some of the foundational management theories and provides a number of examples of these theories that have been applied successfully resulting in a greater prevalence and scope of value-added services being offered.

Prescription Opioid Analgesics Commonly Unused After Surgery: A Systematic Review

Importance

Prescription opioid analgesics play an important role in the treatment of postoperative pain; however, unused opioids may be diverted for nonmedical use and contribute to opioid-related injuries and deaths.

Objective

To quantify how commonly postoperative prescription opioids are unused, why they remain unused, and what practices are followed regarding their storage and disposal.

Evidence Review

MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials were searched from database inception to October 18, 2016, for studies describing opioid oversupply for adults after a surgical procedure. The primary outcome-opioid oversupply-was defined as the number of patients with either filled but unused opioid prescriptions or unfilled opioid prescriptions. Two reviewers independently screened studies for inclusion, extracted data, and assessed the study quality.

Findings

Six eligible studies reported on a total of 810 unique patients (range, 30-250 patients) who underwent 7 different types of surgical procedures. Across the 6 studies, 67% to 92% of patients reported unused opioids. Of all the opioid tablets obtained by surgical patients, 42% to 71% went unused. Most patients stopped or used no opioids owing to adequate pain control, and 16% to 29% of patients reported opioid-induced adverse effects. In 2 studies examining storage safety, 73% to 77% of patients reported that their prescription opioids were not stored in locked containers. All studies reported low rates of anticipated or actual disposal, but no study reported US Food and Drug Administration-recommended disposal methods in more than 9% of patients.

Conclusions and Relevance

Postoperative prescription opioids often go unused, unlocked, and undisposed, suggesting an important reservoir of opioids contributing to nonmedical use of these products, which could cause injuries or even deaths.

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.

Prescription Disposal Practices: A 2-Year Ecological Study of Drug Drop Box Donations in Appalachia

OBJECTIVES

We quantified controlled substance donations via permanent drug donation boxes over 2 years in a region with high prescription abuse, assessing medication characteristics, time between dispensing and donation, and weight of medications donated per capita.

METHODS

In partnership with Drug Enforcement Administration and local law enforcement, we analyzed permanent drug donation box collections in 8 Northeast Tennessee locations from June 2012 to April 2014. We recorded controlled substance dosage units along with the product dispensing date.

RESULTS

We collected 4841 pounds of pharmaceutical waste, 4.9% (238.5 pounds) of which were controlled substances, totaling 106,464 controlled substance doses. Analysis of dispensing dates for controlled substances indicated a median of 34 months lapsed from dispensing to donation (range = 1-484 months). The mean controlled substance donation rate was 1.39 pounds per 1000 residents. Communities with fewer than 10,000 residents had a statistically higher controlled substance donation rate (P = .002) compared with communities with 10,000 or more residents.

CONCLUSIONS

Permanent drug donation boxes can be an effective mechanism to remove controlled substances from community settings. Rural and urban community residents should be provided convenient and timely access to drug disposal options.

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.