[Pharmwaste] Flushed drugs pollute water

[DeBiasi,Deborah]

http://www.madison.com/wsj/mad/top/index.php?ntid=110588&ntpid=1

  
 
Flushed drugs pollute water

RON SEELY
608-252-6131
December 10, 2006

Nurse Lorilee Olmsted has heard the same order too many times when it
comes to disposing of unused drugs in the many nursing homes and
hospitals where she has worked.

"'Flush them,' that's what they tell me," Olmsted said. "It happens so
frequently. . . . It is greatly disturbing to me."

Olmsted is disturbed because she knows those drugs don't just go down
the drain. They go into the sewer system and eventually contaminate our
lakes, streams and drinking water.

And she is frustrated because for Wisconsin residents there are few safe
ways to get rid of expired or unused drugs.

For hospitals and other health-care institutions the disposal of drugs
is a confusing and expensive process.

"The problem is that the regulatory environment isn't set up in the
right way to allow people to do the right thing environmentally. It's an
infuriating bureaucratic quagmire," said Mark Borchardt, a Marshfield
Clinic water researcher.

Health-care workers and environmental advocates say:

Drugs flushed down the toilet or thrown into a landfill can end up in
our groundwater.

Laws for health-care institutions on how to dispose of drugs are
confusing and outdated. Enforcement of these laws is nearly nonexistent.

No laws regulate household disposal of drugs.

It's estimated that as many as 80 percent of the state's hospitals and
nursing homes do not have adequate pharmaceutical disposal programs in
place.

And because of federal Drug Enforcement Administration rules, any
collection of narcotics for disposal requires that a law enforcement
officer be present at every step of the process. This makes it very
difficult for communities to hold household pharmaceutical collection
events and impossible to set up permanent drug disposal sites.

The restrictive DEA rules are why some hospitals - such as UW Hospital
and Meriter in Madison - find it easier to just flush narcotics down the
toilet.

For residents and others trying to sift through it all, good advice is
difficult to come by - even from pharmacies and government agencies.

On its Web site, for example, Walgreen Drug Stores still advises people
to dispose of drugs by flushing them.

Even regulatory agencies such as the state Department of Natural
Resources are perplexed by how to control improper disposal of unused
pharmaceuticals by individuals and institutions because there often
isn't a single, simple answer, according to Joanie Burns, section chief
for the agency's hazardous waste prevention and management unit.

"It's a really, really difficult issue for us," Burns said, "because we
don't have an ideal solution."

But the issue is beginning to get more attention, according to Burns,
and the agency has recently held three workshops for state hospitals on
how to implement the difficult disposal rules.* 

Impact of drugs uncertain

 Researchers don't know all of the impacts of these drugs in the water
but they know they're present.

An extensive nationwide study by the U.S. Geologic Survey has found
evidence of pharmaceuticals including antibiotics and hormonal drugs,
such as birth control pills, in surface waters throughout the nation.

In Dane County, Ken Bradbury, with the Wisconsin Geological and Natural
History Survey, found acetaminophen and two hormones in water coming
from septic systems at a new Sun Prairie subdivision.

And Bill Sonzogni, a researcher with the state Laboratory of Hygiene,
discovered accumulations of endocrine disrupting chemicals, found in
drugs such as birth control pills that mimic natural hormones, in water
entering and leaving Madison's sewage treatment plant.

In Canada, a study by the National Water Research Institute for Health
and Environment Canada found nine different drugs in water samples taken
near 20 drinking water treatment plants across southern Ontario. The
drugs included the painkillers ibuprofen and naproxen as well as
gemifibrozil, a cholesterol-lowering medication.

Whether the presence of drugs in water translates into human health
impacts is still being studied.

But research has shown that drugs containing hormones such as estrogen
are causing changes and deformities in fish and other aquatic creatures.

The World Health Organization indicates that human risk assessments have
shown low concentrations of pharmaceuticals in drinking water have a
negligible health risk. But WHO points out that long-term exposures have
not been evaluated, especially in populations with other illnesses or
with compromised immune systems.

Also, according to the WHO, antibiotics in water supplies are a
potential concern because the most frequently used antibiotics are
becoming less effective as the infections they are designed to combat
become resistant. That resistance increases with heightened exposure to
the drugs.* 

Disposal is complicated

 So why isn't more being done to prevent these drugs from being flushed
away and into our groundwater?

Enough agencies certainly are involved. They include the federal
Environmental Protection Agency and Drug Enforcement Administration, the
state Department of Health and Family Services, and the state Department
of Natural Resources.

But even a health-care giant such as UW Hospital has faced confusion and
little oversight when it tries to deal with the problem.

In the last couple of years, the hospital has put in place its own
sophisticated system for sorting and disposing of pharmaceutical wastes
that is based on the Environmental Protection Agency's Resource
Conservation and Recovery Act, or RCRA.

Getting such systems up and running has not been easy, according to
David Musa, assistant director of drug distribution for UW Hospital, and
officials at other hospitals. At UW Hospital, the system involves
various disposal containers - black, red or white depending on the waste
being disposed - and a separation process that takes considerable
educating of staff.

A similar disposal system is being developed at Meriter Hospital
although it remains a pilot program and will not be used hospitalwide
for several months, according to Steve Almeida, pharmacy operations
supervisor for the hospital.

At St. Mary's Hospital, Russ Jensen, director of pharmaceutical
services, said many of the hospital's unused drugs are returned to a
reverse distributor, a company that takes back drugs and provides the
hospital a credit, while other hazardous drugs are incinerated.

Even with extensive disposal programs in place, Meriter and UW Hospital
still flush many narcotics down the drain because they would need law
enforcement officers present if they were to dispose of the painkillers
in a more environmentally friendly way.

Also, UW Hospital's Musa added, research so far hasn't shown narcotics
in the water supply to be as big a problem as other drugs, such as
antibiotics.* 

Federal rules outdated

One of many problems is that RCRA, the main set of federal rules
governing disposal of pharmaceutical wastes, is not only confusing but
outdated, according to Charlotte Smith, the owner of PharmEcology, a
Milwaukee company that provides consultation on drug and medical waste
disposal to hospitals and other health care institutions.

One issue is that the list of drugs that should be considered hazardous
and, therefore, regulated has not been substantially updated since the
rules went into effect in 1976, Smith said.

An example, Smith said, is the list of highly toxic chemotherapy drugs;
even though about 100 chemotherapy agents of similar toxicity are now
used, only eight such drugs are on the EPA list.

And, Smith added, while the rules create a way to divert disposed drugs
to hazardous waste incinerators and away from landfills or flushing,
exemptions weaken the law.

Hospitals and other health-care institutions are permitted to flush up
to 33 pounds of certain pharmaceuticals a month under the law.
Households are completely exempt.

Enforcement is another issue. Smith said EPA regions in other parts of
the country have in the last two or three years started toughening up
their oversight.

On the East Coast, for example, audits of hospitals resulted in several
citations, including fines against prestigious organizations such as
Memorial Sloan-Kettering Cancer Center.

But here in Wisconsin, and elsewhere in the Midwest, hospitals have been
pretty much left to their own devices, according to UW Hospital's Musa.

That's partly why, he added, the hospital went ahead and put in place
its own system for separating and disposing of pharmaceutical waste,
most of which now ends up at a hazardous waste incinerator. He added
that the hospital has not been visited by federal regulators.

Musa said establishing the program was difficult, partly because of the
confusing laws but also because of the volume of drugs handled by the
hospital.

"The laws really were developed for industry and not for health care,"
Musa said. "We've tried hard to make it simple but getting our staff to
think about and understand RCRA has been a daunting challenge."

If establishing such a program is difficult for an enormous hospital
such as UW Madison, it is even harder for rural hospitals and nursing
homes.

In fact, Smith estimates that as many as 80 percent of the state's
hospitals do not have adequate pharmaceutical disposal programs in
place. And many, she added, still simply flush unused drugs down the
toilet.

Olmsted, the Wisconsin nurse who works with a nurse staffing agency,
said she has seen it firsthand. She said many of the nursing homes where
she has worked are probably the worst offenders.

"Most of them," Olmsted said, "just don't think about it. Or they don't
want to pay to ship the drugs."


Buckets of pills

The DEA forbids transfer of narcotics, even those that are being thrown
away, without the presence of law enforcement officials at each point
where the drugs change possession.

Moving narcotics through the waste stream simply becomes too complicated
in the face of these and other regulations, Musa and others said.

Those same DEA laws are one of the biggest stumbling blocks when it
comes to establishing a reasonable way for individuals to properly
dispose of unwanted pharmaceuticals.

These discarded drugs, piling up in medicine cabinets in homes
everywhere, are probably the biggest source of pharmaceuticals going
down the drain and into our lakes, streams and aquifers, according to
experts.

"We're just denting the surface here," Musa said. "Most of the drugs are
consumed in peoples' homes."

Some indication of the volume of drugs awaiting disposal - or simply
being flushed down the toilet - is to be found in the buckets of pills
that have been turned in at the few drug collection events that have
been held around the state.

In Marshfield, at a day-long event organized by a group called
Groundwater Guardians, homeowners turned in 418 pounds of uncontrolled
pharmaceuticals and three, 3-gallon containers of controlled drugs such
as painkillers. Many times during the day, as many as 10 cars were
waiting in line to dispose of drugs.

At a similar event held in Milwaukee, people turned in enough
uncontrolled drugs to fill 14 30-gallon drums.

But even holding these collection events is nearly impossible in the
face of existing laws, such as those of the DEA governing transfer of
controlled substances.

Borchardt, the Marshfield Clinic researcher who is active with
Groundwater Guardians in central Wisconsin, said setting up the single
event in his community was exhausting and required dealing with numerous
agencies, many of which were not cooperative.

"We spent a year trying to get it organized," Borchardt said. "It seemed
so simple. But my letters to the regional DEA office went unanswered. We
were completely stonewalled. . . . Yet, there is a huge need for these,
even in our little town."

In Madison, organizing a collection has proven such a thorny task that
the city has yet to host such an event.

Several people active on the issue have struggled to organize a
collection, according to Dave Radisewitz, hazardous waste manager for
the Madison-Dane County Health Department.

Radisewitz said Madison organizers, who have faced the same issues
organizers in Marshfield and elsewhere struggled with, hope to have a
collection in the spring.

The same problems being encountered in organizing the single collection
event make it impossible to have a regular drop-off point for drugs,
similar to the Clean Sweep hazardous waste collection site, Radisewitz
added.

In the meantime, it pains Radisewitz to tell people they have few
options for properly disposing of their drugs.

"I just tell them to please wait until the date of our collection,"
Radisewitz said. "The only other answer I can give them is the toilet or
the trash, but it's frustrating that that's the only answer."
 
 



Deborah L. DeBiasi
Email:   dldebiasi at deq.virginia.gov
WEB site address:  www.deq.virginia.gov
Virginia Department of Environmental Quality
Office of Water Permit Programs
Industrial Pretreatment/Toxics Management Program
Mail:          P.O. Box 1105, Richmond, VA  23218 (NEW!)
Location:  629 E. Main Street, Richmond, VA  23219
PH:         804-698-4028
FAX:      804-698-4032