[Pharmwaste] Old meds? Many get conflicting disposal advice

Tue Sep 16 12:12:01 EDT 2008

http://www.msnbc.msn.com/id/26724228/

Old meds? Many get conflicting disposal advice

Federal agencies offer opposite guidance on flushing unused medications

The Associated Press

updated 3:43 p.m. ET, Mon., Sept. 15, 2008

American consumers know not to toss old car batteries in the trash or
pour motor oil down the drain, but those who want to get rid of unused
drugs face a barrage of conflicting guidance: flush, DON'T flush, toss
in the trash, DON'T toss in the trash.

Often, there's no information at all.

The most likely source of guidance should be the instructions packaged
with prescription drugs, or advice dispensed by a pharmacist or doctor.

But an Associated Press examination of hundreds of instructions provided
with prescription medications found that Americans are almost never told
how to safely dispose of unwanted drugs, despite mounting evidence that
medications flushed down the toilet damage the environment and
eventually reach drinking water supplies.

The AP reviewed information accompanying the 50 most-dispensed
prescription drugs in the U.S., ranging from sheets that patients get
when they pick up a prescription to detailed technical literature aimed
at doctors and pharmacists.

Prescriptions for those 50 drugs were filled 1.1 billion times last
year, representing 28 percent of the national market, according to the
health care information company IMS Health. The AP also contacted
working pharmacists around the country to find out what they tell
customers.

None of the literature included federal drug disposal guidelines,
published more than a year ago, nor any other step-by-step directions
about how to get rid of medicines - even though much of the literature
is produced or reviewed by the Food and Drug Administration, which
helped develop the guidelines. The most common reason given: Space is
very limited on drug instructions and people often don't read them
carefully, so side effects and other risks are more important to detail
than disposal.

The issue of disposal was mentioned in 118 out of 282 pieces of material
that AP reviewed, but the typical advice given was to ask a doctor,
pharmacist or waste disposal expert how to discard medication. At best,
paperwork produced by a private publisher and given patients at some
pharmacies warns them not to flush medicines down the toilet unless
instructed, though it doesn't say what they should do instead.

46 million in U.S. drinking water tainted with meds
The AP's findings were part of its ongoing investigation into the
presence of pharmaceutical residues in the nation's drinking water
supplies. The news agency has reported that at least 46 million
Americans are drinking water from supplies tainted with minute
concentrations of a vast array of pharmaceuticals.

Government and private scientists and researchers believe that most
pharmaceutical contamination comes from unmetabolized drugs excreted by
consumers, then flushed down toilets.

The AP has reported on an important secondary problem - that U.S.
hospitals and long-term care facilities throw away an estimated 250
million pounds of drugs and contaminated packaging annually, flushing
much of the unused pharmaceuticals down drains, toward drinking water
supplies.

But there's another source - consumers who throw away unwanted, expired
or unneeded prescriptions.

It doesn't help that they're often left confused about how to properly
dispose of their discards.

"I've read about proper disposal of batteries, but I don't ever recall
reading proper disposal of drugs," says Lisa Morris, of Hillsboro, N.D.,
who has worked in nursing homes in Minnesota and Montana.

More than half the 301 patients surveyed at a military base pharmacy in
2006 said they had flushed medications down a toilet; fewer than 20
percent said they had ever been given advice about proper disposal by a
health care provider.

"It's one of those things providers and patients just don't know about,"
said Dr. Dean Seehusen, a family physician at the Eisenhower Army
Medical Center at Fort Gordon, Ga., who conducted and published the
survey. "I was never told what do with unused medication, not in medical
school, not in residency, not in fellowship. I've taught family medicine
for eight years now at three institutions and this is never part of the
regular curriculum."

"Do not flush" represents part of the federal government's widely
ignored and unenforceable guidelines. The guidelines suggest mixing most
unwanted medicines with coffee grounds or kitty litter, then tossing the
mess into the trash. There are 13 medicines - mostly strong narcotics -
that the federal government explicitly says should be flushed so junkies
won't get them.

Mixed messages
But federal agencies don't have a consistent message. For example, the
Fish and Wildlife Service says "DO NOT FLUSH unused medications" while
the White House - backed by the FDA and Environmental Protection Agency
- says "Flush prescription drugs down the toilet" if they are on the
list in the special guidelines. Meanwhile, the Drug Enforcement
Administration says there is no "safe, secure and reliable disposal
system" for some narcotics.

The FDA even seems confused about whether it is pondering issuing
disposal guidelines. Ilisa Bernstein, the FDA's director of pharmacy
affairs, first said the agency was considering requiring guidelines on
the materials it regulates. A spokesman later said that was not the
case, and Bernstein added that no one at the agency has discussed a
mandate in the year-plus she's worked on disposal issues.

A spokeswoman for the Environmental Protection Agency said that even
unused pharmaceuticals considered hazardous waste at hospitals aren't
regulated at home.

"Regulation of hazardous waste generated by the millions of households
across the country - and usually in very small amounts - was deemed to
be impractical by Congress and EPA," spokeswoman Roxanne Smith said.

Private programs to take back meds
There have been scattered public and private programs around the U.S. to
take back unwanted medicines. Smith said the EPA encourages people to
bring unused drugs to such local programs "to reduce the potential for
harm posed by this waste." But officials who run such programs say
effectiveness is limited by convoluted regulations or financial
challenges.

Plus, it's tough to break habits.

Elephant Pharmacy, based in Berkeley, Calif., has a takeback program,
but director Peter Koshland said, "I still think people are flushing
their medication. That's what they've known to do, back from whenever."

Theoretically, health care professionals could guide consumers on
disposal.

But pharmacists at leading chains Walgreens and CVS in a dozen major
U.S. cities repeatedly told an AP reporter they had no advice about what
to do with unwanted medications.

Spokesmen at the headquarters of Walgreens and CVS said company
pharmacists are supposed to inform consumers never to flush medications
- that without exception, medications should be tossed into the trash.
This advice contradicts the instructions for the federally listed
medications that are supposed to be flushed.

The federal government's showcase public service outreach has been the
SMARxT Disposal partnership, a collaboration between the U.S. Fish and
Wildlife Service and two associations representing pharmaceutical
manufacturers and pharmacists.

The SMARxT program has printed about 25,000 bookmarks and 8,000 magnets
with a "do-not-flush" message to be distributed at conferences and
events. Earlier this year, SMARxT ran a booth at a fly fishing event
next to the Potomac River in Washington, D.C. The Potomac is one source
of drinking water that is contaminated with pharmaceuticals and is home
to male fish that have developed eggs inside their sex organs.

The SMARxT Web site's message doesn't fully track the federal
guidelines, either: "DO NOT FLUSH unused medications and DO NOT POUR
them down a sink or drain." Leaving out the federally listed exceptions
was intentional, according to the trade group Pharmaceutical Research
and Manufacturers of America, which along with the American Pharmacists
Association joined the wildlife service in the campaign.

The goal was "a clear message that applies to the vast majority of
drugs," said Marjorie E. Powell, senior assistant general counsel for
the pharmaceutical trade group.

There are other examples of mixed messages. The AP repeatedly found
advice that is conflicting, confusing or simply missing.

For example: The commonly prescribed painkiller Percocet (generically
known as oxycodone/acetaminophen) is supposed to be flushed down the
toilet, according to the federal guidelines. But paperwork accompanying
the top-selling version, a generic, states: "Do not flush medications
down the toilet or pour them into a drain unless instructed to do so."

The cancer pain drug Actiq also is on the federal flush list. But
patients who read the FDA-produced guide for the lollipop-like
medication find far more opaque advice.

"Do not flush entire unused Actiq units, Actiq handles, or blister
packages down the toilet," the medication guide reads. That language
appears immediately after step-by-step instructions on how to dispose of
unwanted medication, which specifies snipping the medication from the
handle with wire cutters and letting it fall into the toilet.

"It may be a little bit confusing and maybe it's something that we can
look at," the FDA's Bernstein said of the language.

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
PPCPs, EDCs, and Microconstituents
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