[Pharmwaste] Prescription drug disposal clarification

[Chickering, Helen (NBC Universal)]

 Hello, I'm a medical correspondent with NBC News Channel. 
 
 I've been working on a story about Prescription Drug Disposal and came across your list serv during a simple term search.  The information I found there was by far the most helpful and most insightful.  It helped change the focus of my story.  
 
I want to say thank you and to share the clarification stumbling blocks I'm working on as I try to get this piece on the air. Below is the note to media contacts at the EPA, White House, and FDA.   I also forwarded a link to the list serv thread that highlights the confusion to some of those contacts.  Please know I am not publishing or quoting any of the thread - just used it as a resource for my research.
 
Here's the latest note.  I'd love to get your feedback and any updates on efforts to get the list updated.
 
Kind regards,
Helen
Helen Chickering
Medical Correspondent
NBC News Channel
    
 We've delayed this piece for a noon release tomorrow.  A few more questions/clarification issues with an ASAP deadline. 
 I'm sending this message to all parties.  Please answer areas that apply.  Thank you!
 
 
Story angle:  As scientists continue to study pharmaceuticals and the water supply - (science that has uncovered trace amounts - parts per trillion, suggests an impact on environment/aquatic life - no impact so far on people)  The public is becoming aware of drug disposal concerns - specifically - flushing isn't environmentally friendly.  While we wait for science to uncover a greener way to dispose of drugs  - what's the consensus about the best way for consumers to dispose of prescription drugs?
 
Right now my story is focusing more on the confusion by different messages a person might find - depending on where they go first.   Jennifer DeVallance with ONDCP - has this comment about the different guidelines the public may encounter in their search for green disposal information.
 
" Regardless of the approach - federal state and local entities are all interested safeguarding legitimate access to prescription medications, while preventing diversion, abuse and protecting the environment.  All encourage people to monitor and safeguard prescription drugs and dispose of them when they are expired or no longer needed. "



1. Consumer Prescription Drug Disposal Programs - While I appreciate the information about past pilot projects, my question is Where are we now?   Are the EPA and other organizations in a research and development phase  - gathering stats, etc. from various pilot projects in an effort to come up with recommendations or some sort of national standard?   Is there any formal effort to find a reasonable/environmentally friendly drug disposal option for consumers?  IF so what is the plan and deadline?  If not - what is the purpose of these pilot programs - is there any unified goal - or are they just a collection of efforts by different organizations?  
 
 Is this more recent project through the the Substance Abuse and Mental Health Services Administration - which seems to be an education effort - an effort to take/study a different angle to this problem - or just another groups effort to tackle the drug disposal-environment-abuse issue?
 
2. Where can consumers go - now - for the most accurate information on prescription drug disposal? Is the issue of how drugs are disposed - kitty litter v. flushing - a real risk factor  when it comes to drug abuse/addiction?  How do you know -  Is there scientific or other evidence that proves or suggests this? Or is it a drug storage issue?   



3 The FDA list of drugs consumers should flush.  Questions - Where did this list come from?  What is the reasoning behind the list?  Specific questions - Oxycodone and other opiates - obviously the abuse issue here. But where is Hydrocodone?  Drug patches are on the list too - are they meant to be flushed? Daytrana drug info on FDA site recommends not flushing.   Xyrem is a rarely used drug - a narcolepsy drug - Why is this on the list?   Antibiotics -Gatifloxacin/  Fluoroquinolones are antibiotics - why are they on the list - especially when even patients who take the drug send concentrated amounts into the system. 
Baraclude Tablets (entecavir), Reyataz Capsules (atazanavir sulfate),Zerit for Oral Solution (stavudine) are all anti-HIV meds.  Why are they on the list?
      
 
More FDA flushing list questions. The White House website - (and today's AP article note - Once, patients were told to flush old drugs down the toilet. No more — do not flush unless you have one of the few prescriptions that the Food and Drug Administration specifically labels for flushing....).

I researched the list - and that is not the case for every drug - at least not from what I could find on the FDA website - patient and/or label info.  In addition, most  of the disposal information is buried  - not sure how patients would even see it.

      The FDA advises that the following drugs be flushed down the
      toilet instead of thrown in the trash: 
            Actiq (fentanyl citrate) -  - narc pain med - lollipop - rinse down drain - toss the sticks
            Daytrana Transdermal Patch (methylphenidate) -  - this is an adhd patch - Says Do Not Flush
            Duragesic Transdermal System (fentanyl) - pain patch - do flush
            OxyContin Tablets (oxycodone) - narcoctic pain med - flush
            Avinza Capsules (morphine sulfate)  narcotic pain - flush
            Baraclude Tablets (entecavir) hep b medicine - flush or down sink
            Reyataz Capsules (atazanavir sulfate) hiv med - flush or down sink
            Tequin Tablets (gatifloxacin) - antibiotic - flush
            Zerit for Oral Solution (stavudine) - HIV - oral kids drug - first rec says throw away, bottom notes flush
            Meperidine HCl Tablets - narcotic flush
            Percocet (Oxycodone and Acetaminophen) - narcotic flush
            Xyrem (Sodium Oxybate) - narcolepsy drug/controlled - flush
            Fentora (fentanyl buccal tablet) - narc/pain for cancer patients - flush
 
Details from website search: 
FDA consumer drug disposal information from FDA website: - no flush - but rinse down drain or trhow away
1. How should I dispose of Actiq after use?
Partially used Actiq units may contain enough medicine to be harmful or fatal to a child or other adults
who have not been prescribed Actiq. You must properly dispose of the Actiq handle right away
after use even if there is little or no medicine left on it. Please follow these directions to dispose of
the handle:
1. Once you have finished the Actiq unit and the medicine is totally gone, throw the handle away
in a place that is out of the reach of children.
2. If any medicine remains on the handle after you have finished, place the handle under hot
running water until the medicine is gone, and then throw the handle away out of the reach of
children and pets.
3. NDA 20-747/S-023
Page 54
3. If you did not finish the entire Actiq unit and you cannot dissolve the medicine under hot
running water right away, put the Actiq in the temporary storage bottle that you received in the
Actiq Welcome Kit for safe keeping. Push the Actiq unit into the opening on the top until it falls
completely into the bottle. Never leave unused or partially used Actiq units where children
or pets can get to them.
4. Dispose of the handles in the temporary storage bottle as soon as you can by following the
directions in steps 1 and 2. You must dispose of all handles in the temporary storage bottle at
least once a day.
Do not flush entire unused Actiq units, Actiq handles, or blister packages down the toilet.

2. How should I store DaytranaTM? - no flush
• Store DaytranaTM in a safe place at room temperature, 59 to 86° F (15 to 30° C). Keep DaytranaTM patches in
their unopened pouches until ready to use.
• Once a tray of patches has been opened, use or discard the patches within 2 months.
• Keep DaytranaTM and all medicines out of the reach of children. HOW TO REMOVE AND DISCARD DAYTRANATM
• When you remove the patch, peel it off slowly.
• Fold the used DaytranaTM patch in half and press firmly so that the sticky side sticks to
the used patch down the toilet or dispose of it in a lidded container right away.
• Do not flush the pouches or the protective liners down the toilet. These items should be
in a lidded container.
• If any sticky material (adhesive) remains on the child’s skin after removing the patch, gently
area with oil or lotion to remove the adhesive from the skin.
• Wash your hands after handling the patch.
• After the patch is removed and disposed of, record this time on the administration chart.

3. Duragesic Transdermal System (fentanyl) - yes flush After you have stopped using a patch, be sure to fold the sticky sides of the patch together and flush it down the toilet. Do not put used fentanyl skin patches in a garbage c

*	If your healthcare professional tells you to stop using the fentanyl skin patch, throw away the unused packages. Open the unused packages and fold the sticky sides of the patchtogether, and flush them down the toilet. 

*	

 
4. Oxycontin - yes flush
11. Patients should be instructed to keep OxyContin in a secure place out of the reach of
children. When OxyContin is no longer needed, the unused tablets should be destroyed
by flushing down the toilet.
you have been taking it for more than a few days.
After you stop taking OxyContin, flush the unused tablets down the toilet.
What Should I Avoid While Taking OxyContin®?
 
4. Avinza - Narcotic - yes - Flush
 Patients should be instructed to keep AVINZA in a secure place out of the reach
of children. When AVINZA is no longer needed, the unused capsules should be
destroyed by flushing down the toilet.
 
5. Baraclude is a prescription medicine used for chronic infection with hepatitis B virus (HBV) in adults who also have active liver damage.  - No disposal info on patient info sheet. Lactic Acidosis/Liver problems side effects.  - Found flushing info on more detailed label section:
 
Storage
616 BARCLUDE Tablets should be stored in a tightly closed container at 25° C (77° F);
617 excursions permitted between 15-30° C (59-86° F) (see USP Controlled Room
61 8 Temperature).
619 BARCLUDE Oral Solution should be stored in the outer carton at 25° C (77° F);
620 excursions permitted between 15-30° C (59-86° F) (see USP Controlled Room
621 Temperature). Protect from light. After opening, the oral solution can be used up to the
622 expiration date on the botte. The bottle and its contents should be discarded after the
623 expiration date.
624
 
side effects.
771 How should i store BARACLUDE?
772 · Store BARCLUDE Tablets or Oral Solution at room temperature, 59° to 86° F (15°
773 to 30° C). They do not require refrigeration. Do not store BARCLUDE Tablets in a
77 4 damp place such as a bathroom medicine cabinet or near the kitchen sink.
775 . Keep the container tightly closed. BARCLUDE Oral Solution should be stored in
776 the original carton and protected from light.
777 . Throwaway BARCLUDE when it is outdated or no longer needed by flushing
778 tablets down the toilet or pouring the oral solution down the sink.
779 . Keep BARACLUDE and all medicines out of the reach of children and pets.

 
6. Reyataz is a prescription medicine used with other anti-HIV medicines to treat people who are infected with the human immunodeficiency virus (HIV). Reyataz is a type of anti-HIV medicine called a protease inhibitor. Reyataz helps to block HIV protease, an enzyme that is 
FLush - yes 
Store REYATAZ Capsules at room temperature, 59° to 86° F (15° to 30° C). Do not store this
medicine in a damp place such as a bathroom medicine cabinet or near the kitchen sink.
• Keep your medicine in a tightly closed container.
• Throw away REYATAZ when it is outdated or no longer needed by flushing it down the toilet or
pouring it down the sink.
General information about REYATAZ
 
7. Tequin - flushing yes - Tequin is an antibiotic used to treat adults with lung, sinus, or urinary tract infections and also to treat certain sexually transmitted diseases caused by germs called bacteria.  The sexually transmitted disease called gonorrhea is treated by Tequin. Other sexually transmitted diseases including syphilis and non-gonococcal diseases are not treated by Tequin. 
Remember
• Take your dose of TEQUIN once a day.
• Complete the course of medication (take all of the pills) even if you are feeling better.
• Do not use TEQUIN for another condition or give it to others.
• Store TEQUIN tablets at room temperature in a tightly sealed container.
• Throw away TEQUIN when it is outdated or no longer needed by flushing it down the
toilet.
• Keep this and all medications out of reach of children.

*	

8. Zerit - ZERIT oral solution - "throw away - then at very bottom - Flush" (pronounced ZAIR it) is a prescription medicine used in combination with other
drugs to treat adults and childen who are infected with HIV (the human
immunodeficiency virus), the virus that causes AIDS. ZERIT belongs to a class of drugs
called nucleoside reverse transcriptase inhibitors (NRTIs). By reducing the growth of
HIV, ZERIT helps your body maintain its supply of CD4 cells, which are important for
fighting HIV and other infections.
Oral solution (for children): ZERIT for Oral Solution is taken twice a day (every 12
hours). If your child will be taking ZERIT, the doctor should give you written
instructions on how to give this medicine. Before measuring each dose, shake the
bottle well. Store ZERIT for Oral Solution in a tightly closed container in a
refrigerator and throw away any unused portion after 30 days.
*	

This medicine was prescribed for your particular condition. Do not use ZERIT for another
condition or give it to others. Keep ZERIT and all other medicines out of the reach of children.
Throw away ZERIT when it is outdated or no longer needed by flushing it down the toilet or
pouring it down the sink.

*	

9.    Meperidine HCl Tablets - morphine like substance  - for pain relief

1.	
Patients should be advised that if they have been receiving treatment with meperidine for more than a few weeks and cessation of therapy is indicated, it may be appropriate to taper the meperidine dose, rather than abruptly discontinue it, due to the risk of precipitating withdrawal symptoms. Their physician can provide a dose schedule to accomplish a gradual discontinuation of the medication.

2.	
Patients should be instructed to keep meperidine in a secure place out of the reach of children. When meperidine is no longer needed, the unused tablets should be destroyed by flushing down the toilet. 

10. percocet -      Percocet (Oxycodone and Acetaminophen) narcotic pain relief - flush

*	
When PERCOCET tablets are no longer needed, the unused tablets should be destroyed by
flushing down the toilet.
4. Patients should be advised

11. Xyrem - Xyremâ (sodium oxybate) is a central nervous system depressant with anti-cataplectic activity in
patients with narcolepsy
Your doctor has determined that you may benefit
from taking Xyrem. Xyrem has been shown to
reduce excessive daytime sleepiness and
cataplexy in patients with narcolepsy.
 When you can no longer draw medication
out of the bottle with the measuring device,
it is time to throw the bottle away. Use a
marker or pen to deface the bottle label
so someone else cannot use it for illicit
purposes. Pour any unused Xyrem®
down the drain. Place the empty bottle
in the trash so it is not used for illegal
purposes.

12. Fentora -  Flush Yes - FENTORA is a prescription medicine that contains the medicine fentanyl.

 Patients and caregivers should be advised that if they have been receiving treatment
with FENTORA and the medicine is no longer needed they should flush any
remaining product down the toilet, and if they then need further assistance, contact
Cephalon at 1-800-896-5855.
Disposal of Unopened FENTORA Blister Packages When No Longer Needed
Patients and members of their household must be advised to dispose of any unopened
blister packages remaining from a prescription as soon as they are no longer needed.
To dispose of unused FENTORA, remove FENTORA tablets from blister packages and
flush down the toilet. Do not flush the FENTORA blister packages or cartons down the
toilet. (See SAFETY AND HANDLING.)
Detailed instructions for the proper storage, administration, disposal, and important
instructions for managing an overdose of FENTORA are provided in the FENTORA
Medication Guide. Patients should be encouraged to read this information in its entirety
and be given an opportunity to have their questions answered.
In the event that a caregiver requires additional assistance in disposing of excess unusable
tablets that remain in the home after a patient has expired, they should be instructed to
call the Cephalon toll-free number (1-800-896-5855) or seek assistance
 

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