Towards Medicines Reuse: A Narrative Review of the Different Therapeutic Classes and Dosage Forms of Medication Waste in Different Countries

Medication reuse programs: a narrative review of the literature

A proportion of returned medications may potentially meet quality standards to be reused safely. In Australia, there is no regulatory guidance available to facilitate such medication reuse. This narrative review aimed to identify and review international literature describing medication reuse programs to provide insight into their implementation and potential barriers. Using the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) -based guidelines, a literature search was conducted in Medline, Scopus, and Embase using key words such as 'medication' and 'reuse' to identify relevant articles. Two reviewers ascertained eligibility for inclusion. Inclusion criteria included English language and publication after 2010. From the articles selected, identified international medication reuse programs and relevant regulatory aspects were summarized. Details, both regulatory and operational, for the specific medication reuse programs, described in the selected articles was further explored via a grey literature search. Of the 1973 identified articles, 84 were assessed for eligibility and 17 were included in this review. Of these, 14 described scenarios where medication reuse is prohibited, 2 studies described programs allowing the reuse of medication and 1 study did not discuss whether reuse was prohibited or not. From these primary articles, secondary citations were identified, with eight from gray literature. Barriers to medication reuse included exposure to environmental extremes during storage, physical appearance, evidence of tampering, safety, and efficacy concerns for the returned medication. Programs that exist globally have overcome these barriers. Several programs that provide safe and effective reuse of medications were i© The Author(s) 2024. Published by Oxford University Press on behalf of International Society for Quality in Health Care. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site-for further information please contact journals.permissions@oup.com.dentified and described. The findings described in this review should be used to inform frameworks for legislative, regulatory, and professional practice change for medication reuse. Measures implemented in the UK's pandemic response to safely reuse medications in the nursing home and hospice settings and European medication donation programs should be further investigated. The concept of medication reuse is not novel and should be considered for the Australian setting.

Economic Cost of the Waste of Anti-inflammatory and Analgesic Drugs in Mexico City

Anti-inflammatory and analgesic medications (AAMs) are widely used in Mexico and the rest of the world. Their excessive acquisition can lead to waste, representing an unnecessary expense for families and the public health system. The aim of this study was to estimate the economic cost of the waste of unused AAMs collected by the National System for the Collection of Residues of Containers and Medications (SINGREM, the acronym in Spanish) in Mexico City during 2019. Data from SINGREM on discarded AAMs in Mexico City were classified by the type and quantity of drug, pharmaceutical dosage form, origin, dose, and the complete or incomplete condition of the package. The unitary cost for each medication was based on public tenders of the Mexican Social Security Institute (IMSS) for the public sector and the prices in large drug store franchises for the private sector. A decision-making model was constructed to appraise the total cost of discarded AAMs. The economic cost of the 48924 units of discarded AAMs in SINGREM containers in Mexico City during 2019 was approx. USD$143500, of which over USD$127000 corresponded to the private health sector. The current findings evidence an enormous accumulation of unneeded or expired AAMs in Mexico City. According to the present data, the cost of such waste is substantial. The estimated cost was 8-fold higher for discarded medications originating from the private versus the public healthcare sector. It is important to implement measures to prevent this waste and increase awareness of the consequences of inadequate drug disposal.

Factors Influencing Public Willingness to Reuse the Unused Stored Medications in Jordan: A Cross-Sectional Study

The reissuing, redispensing, redistributing, or even recycling of the returned unused stored medicines is referred to as medicine reuse. A few studies have examined people's willingness to reuse unused stored medicines. This study aims primarily to explore the public's willingness to reuse unused stored medicines in the future and the factors affecting their decisions, and to assess the pharmacological types and formulations of the unused stored medicines by the public. A cross-sectional study was conducted using a convenient sampling technique over three weeks (February-March 2022) among Jordanian populations. Data were collected from 681 participants who agreed to fill out a questionnaire, which was distributed online. Participants showed a positive perception of reusing any of the unused stored medicines in the future; of those, 79.6% (n = 400) believed that reusing "unused medicines" has economic benefits and 50% (n = 251) believe there are environmental benefits. Moreover, more than half of the participants believed that reusing "unused medicines" is safe (n = 256, 51%), but provided that a pharmacist or a doctor evaluates their quality or that the unused medicines are stored well. Results from this study show that the public positively endorses the idea of reusing unused stored medicines if the quality and safety are assured. However, future studies are needed to evaluate the Jordanian healthcare professionals' perceptions towards medicine reuse and pharmaceutical companies' willingness to be a part or facilitator of medicine reuse.

Analysis of medicines returned to pharmacies for disposal and estimation of the cost due to medicine wasting

Background

Studies have shown that waste medicines generate a significant cost for the national health system (NHS) in many countries. No data are available on costs and therapeutic classes of unused medicines in Italy.Objective: Conduct a quantitative and qualitative analysis of unused medicines returned for disposal to selected pharmacies in Rome, Italy, as well as to estimate the related costs for the NHS.

Methods

Medicines returned to 4 pharmacies were collected for 8 months. Therapeutic class, number of remaining dosage units, remaining validity, and reimbursement by the NHS were analysed. The cost of reimbursed medicines was estimated on the prices provided by the Italian regulatory agency (AIFA).

Results

The study sample consisted of 3219 medicine packages containing remaining dosage units, of which 72.4% had expired while 27.6% had not. The average remaining validity of unexpired medicines was 13 months. Medicines reimbursed by the NHS accounted for 73% of the total. Cardiovascular drugs and anti-infectives were the main therapeutic classes (17.2% and 15.2% of total packages, respectively), followed by gastrointestinal drugs, central nervous system (CNS) drugs, non-steroidal anti-inflammatory drugs (NSAIDs), and corticosteroids. The average of remaining dosage units found in the examined packages was 68% of the initial number of units. In terms of cost, antibiotics were the most relevant therapeutic class, followed by cardiovascular drugs, analgesics, corticosteroids, and NSAIDs. The estimated cost for the Italian NHS was € 200,656,780 per year.

Conclusion

Waste medicines constitute a significant, but reducible cost for the NHS. The high prevalence of anti-infectives in the study sample appears to be a distinctive Italian characteristic and may be due to inappropriate prescribing. Policies aimed at reducing waste should improve prescriptive appropriateness and increase the variety of packaging size.

Issues on Powder Forms for Oral Solution and Suspension for Pediatric Patients in Japan: A Questionnaire-Based Observational Survey to Pediatric Pharmacists

BACKGROUND

Powders for oral solutions and suspensions (POS) are commonly used as pediatric oral medicines worldwide, except for Japan. Although global pediatric formulation development accelerates POS importation to Japan without any formulation change, oral solid multiparticulates remain to be the preferred pediatric forms in the country. This study aimed to evaluate the acceptance situation of four typical POS form products (mycophenolate mofetil, sildenafil citrate, valganciclovir hydrochloride, and voriconazole) that were recently approved in Japan.

METHODS

A questionnaire on four products was completed by pharmacists in 29 children's hospitals with more than 100 beds each, between November and December of 2019. The questionnaire has six items on (#1) type of institution, (#2) formulary status, (#3) dispensing practice, (#4) reasons why POS form(s) were not selected as hospital formulary, (#5) advantages and disadvantages of POS form, and (#6) opinions for POS form.

RESULTS

Of the 29 institutions, 7 (24%), 9 (31%), 4 (13%), and 10 (34%) institutions used POS of mycophenolate mofetil, sildenafil citrate, valganciclovir hydrochloride, and voriconazole, respectively. Reasons for not using these products were dispensed drug loss, formulation issues, and management issues in the pharmaceutical department and pediatric ward. Pharmacists preferred drug compounding such as tablet crushing and capsule opening to POS form use.

CONCLUSIONS

POS forms might be an unsuitable formulation for the current hospital settings in Japan. Thus, appropriate dosage forms that reflect the current clinical settings are necessary.

A systematic assessment of the epidemiologic literature regarding an association between acetaminophen exposure and cancer

Introduced in the 1950s, acetaminophen is one of the most widely used antipyretics and analgesics worldwide. In 1999, the International Agency for Research on Cancer (IARC) reviewed the epidemiologic studies of acetaminophen and the data were judged to be "inadequate" to conclude that it is carcinogenic. In 2019 the California Office of Environmental Health Hazard Assessment initiated a review process on the carcinogenic hazard potential of acetaminophen. To inform this review process, the authors performed a comprehensive literature search and identified 136 epidemiologic studies, which for most cancer types suggest no alteration in risk associated with acetaminophen use. For 3 cancer types, renal cell, liver, and some forms of lymphohematopoietic, some studies suggest an increased risk; however, multiple factors unique to acetaminophen need to be considered to determine if these results are real and clinically meaningful. The objective of this publication is to analyze the results of these epidemiologic studies using a framework that accounts for the inherent challenge of evaluating acetaminophen, including, broad population-wide use in multiple disease states, challenges with exposure measurement, protopathic bias, channeling bias, and recall bias. When evaluated using this framework, the data do not support a causal association between acetaminophen use and cancer.

The Effect of Quality Indicators on Beliefs about Medicines Reuse: An Experimental Study

Background: A number of studies have examined beliefs about medicines reuse. Although the practice is prohibited in UK community pharmacy, it does take place elsewhere in the world where it relies on visual checks of returned medicines as an indicator of their quality. One proposal is to integrate sensor technology onto medication packaging as a marker of their quality instead. Our aim was to gauge people’s beliefs about medicines reuse, in an experiment, with or without sensor technology and with or without the promise of visual checks completed by a pharmacist, as experimental conditions, should the practice be sanctioned in the UK in the future. Methods: A between participant study was designed with two independent factors testing the hypothesis that sensors and visual checks would increase pro-medicines-reuse beliefs. A questionnaire was used to measure medicines reuse beliefs and collect qualitative comments. Results: Eighty-one participants took part. Attitudes toward medication offered for reuse, participants’ perceived social pressure to accept the medication, and their intention to take part in medicines reuse all increased with the presence of sensors on packaging and with the promise of pharmacist visual checking, with the former causing a greater increase than the latter, and the combination of both making the greatest increase. People’s qualitative comments explained their concerns about medicines reuse, validating the findings. The use of sensors on medication packaging warrants further investigation if regulators are to consider approving medicines reuse in the UK.

The Validity of the Theory of Planned Behaviour for Understanding People's Beliefs and Intentions toward Reusing Medicines

Background: many factors can impact a person’s behaviour. When the behaviour is subject to prediction, these factors can include, for example, the perceived advantages and disadvantages of performing the behaviour, normative beliefs, and whether the behaviour is thought to be achievable. This paper examines intentions to engage in medicines reuse, i.e., to accept medicines that are returned unused to a pharmacy to be reused. The paper aims to outline the validity of the Theory of Planned Behaviour (TPB) for understanding people’s intentions to engage in medicines reuse by examining this against other long-standing health-related psychological theories of behavioural change. Thus, the Health Belief Model (HBM), Protection Motivation Theory (PMT), Trans-Theoretical Model of Health Behaviour Change (TTM/SoC), Theory of Reasoned Action (TRA), and TPB are examined for their application in the study of medicines reuse. Discussion: the HBM, PMT, TTM/SoC, TRA, and TPB were assessed for their relevance to examining medicines reuse as a behaviour. The validity of the TPB was justified for the development of a Medication Reuse Questionnaire (MRQ) to explore people’s beliefs and intention toward reusing medicines. Conclusion: TPB has been widely used inside and outside of health-related research and it was found to have more accurately defined constructs, making it helpful in studying medicines reuse behaviour.