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<div>Agreed! We have a big info hearing on sb 1014 the CA bill mirroring alameda ordinance. If you belong to national groups and can provide letters of support they are due to the committee tomorrow to get into the committee analysis . Go to
<a href="http://www.cpsc.org">www.cpsc.org</a> on the 2014 leg page for bill fact sheet, model letter of support and link to the bill itself. The bill got double referred to business and professions committee which is very conservative so med companies think
they have it killed there and we need to all fight hard to raise this as a national public heAlth issue.</div>
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<div>Heidi<br>
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Sent from my iPhone</div>
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On Mar 16, 2014, at 4:01 AM, "Catherine" <<a href="mailto:zenllc@usfamily.net">zenllc@usfamily.net</a>> wrote:<br>
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<p class="MsoNormal"><span style="font-size:12.0pt;font-family:"Times New Roman","serif";color:black">Hi Laurie and all,<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size:12.0pt;font-family:"Times New Roman","serif";color:black">I saw this article earlier, it is very insightful. It indicates 2 opportunities to reduce rx waste: healthcare purchasing dosage forms in which all the medication
will be used and pharma providing the dosage forms that are necessary. Both of these issues are frequently encountered with organizations trying to reduce waste. Manufacturers over-provide and make smaller quantities more expensive. It’s the paint paragdigm.
As most on this list already recognize, for rx waste, this is why the Almeda Co. extended producer responsibility law is so important.
<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size:12.0pt;font-family:"Times New Roman","serif";color:black"><o:p> </o:p></span></p>
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<p class="MsoNormal"><span style="color:black">Very truly yours,<o:p></o:p></span></p>
<p class="MsoNormal"><span style="color:black"><o:p> </o:p></span></p>
<p class="MsoNormal"><span style="color:black">Catherine Zimmer, MS, BSMT<o:p></o:p></span></p>
<p class="MsoNormal"><span style="color:black">Zimmer Environmental Improvement, LLC<o:p></o:p></span></p>
<p class="MsoNormal"><span style="color:black">St. Paul, MN <o:p></o:p></span></p>
<p class="MsoNormal"><span style="color:black">Ph: 651.645.7509<o:p></o:p></span></p>
<p class="MsoNormal"><span style="color:black"><a href="mailto:zenllc@usfamily.net"><span style="color:blue">zenllc@usfamily.net</span></a><o:p></o:p></span></p>
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<p class="MsoNormal"><span style="font-size:12.0pt;font-family:"Times New Roman","serif";color:black"><o:p> </o:p></span></p>
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<p class="MsoNormal"><b><span style="font-size:10.0pt;font-family:"Tahoma","sans-serif"">From:</span></b><span style="font-size:10.0pt;font-family:"Tahoma","sans-serif"">
<a href="mailto:pharmwaste-bounces@lists.dep.state.fl.us">pharmwaste-bounces@lists.dep.state.fl.us</a> [<a href="mailto:pharmwaste-bounces@lists.dep.state.fl.us">mailto:pharmwaste-bounces@lists.dep.state.fl.us</a>]
<b>On Behalf Of </b>Tenace, Laurie<br>
<b>Sent:</b> Wednesday, March 12, 2014 8:33 AM<br>
<b>To:</b> '<a href="mailto:pharmwaste@lists.dep.state.fl.us">pharmwaste@lists.dep.state.fl.us</a>'<br>
<b>Subject:</b> [Pharmwaste] article about hospital drug waste<o:p></o:p></span></p>
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<p class="MsoNormal"><o:p> </o:p></p>
<p class="MsoNormal"><o:p> </o:p></p>
<p class="MsoNormal"><a href="http://thegazette.com/2014/02/02/dealing-with-drug-waste-in-the-corridor/">http://thegazette.com/2014/02/02/dealing-with-drug-waste-in-the-corridor/</a><o:p></o:p></p>
<p class="MsoNormal">Go to the article to see two graphics detailing some specific drug waste costs and quantities.
<o:p></o:p></p>
<p class="MsoNormal"><o:p> </o:p></p>
<p style="background:white"><span style="color:black">IOWA CITY – When a patient emerges from anesthesia after surgery, his nurse wants to make sure he doesn’t feel pain.<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">She gets a 1 milliliter syringe of hydromorphone, a generic form of Dilaudid, from a secure drug cabinet. She plans to give her patient .2 milliliter. Even patients with open hysterectomies – some of the
most painful procedures – need just .4 milliliter.<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">She squirts the rest of the drug down the drain, where it can’t be abused by addicts but can pollute drinking water.<o:p></o:p></span></p>
<p class="wp-caption-text" style="background:white"><span style="color:black">Pharmacy technician Curt Balk of Solon, Iowa, stocks medications in the MedCarousel dispensing system at University of Iowa Hospitals and Clinics in Iowa City, Iowa. (Jim Slosiarek/The
Gazette-KCRG)<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">UI nurses disposed of an average 70 percent of each of 47,000 hydromorphone 1 milliliter syringes with waste in fiscal 2013.<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">Portions of nearly 250,000 doses of prescription medication were flushed down the drain or returned to the UI Hospitals and Clinics pharmacy to be wasted in the past two years, despite U.S. Environmental
Protection Agency guidelines against flushing drugs.<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">The UI Hospitals disposed of another 100,000 units of drugs worth nearly $1.5 million in the last two years because the drugs were expired, recalled or not stored properly.<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">But the UI doesn’t know how many drugs are wasted overall because records aren’t stored in one place, and some hospital units still use paper to track prescriptions.<o:p></o:p></span></p>
<p style="background:white"><strong><span style="color:black">Drug waste common, not benchmarked</span></strong><span style="color:black"><o:p></o:p></span></p>
<p style="background:white"><span style="color:black">Drug waste is inevitable at any hospital, especially one such as UI Hospitals, which dispenses 5 million doses of medication to inpatients each year and stocks 4,000 combinations of 1,200 drugs. The 700-bed
hospital deals with more unique ailments and more serious cases than any other hospital in the state.<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">Hospitals aren’t benchmarking drug waste, so it’s impossible to know how the UI Hospitals compares.<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">Some of the reasons for waste, such as pharmaceutical companies selling drugs in too-large containers, are out of the hospital’s hands.<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">But the drugs wasted at the UI Hospitals and across the nation create a disposal nightmare. Prescription drugs found in waterways can make animals and humans sick. Tossing life-saving drugs also adds to
the ballooning cost of American health care.<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">“There is a lot of opportunity to address the environmental concerns and identify opportunities for cost savings,” said Janet Howard, director of facility engagement for Practice Greenhealth, a not-for-profit
organization based in Virginia that helps hospitals seek environmental solutions. “The challenge is it takes time.”<o:p></o:p></span></p>
<p style="background:white"><strong><span style="color:black">Keeping drugs away from addicts</span></strong><span style="color:black"><o:p></o:p></span></p>
<p class="wp-caption-text" style="background:white"><span style="color:black">Medications hang above an IV drug compounding machine in the sterile, hood room at University of Iowa Hospitals and Clinics in Iowa City, Iowa. These areas are the only areas, because
they are sterile, where some drugs may be divided up for single-dose units. These smaller doses reduce waste.(Jim Slosiarek/The Gazette-KCRG)<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">Only about 5 percent of drugs prescribed in a hospital are controlled substances, which are governed by the U.S. Drug Enforcement Agency. A 1970 law requires drug manufacturers, distributors and dispensers
to track drugs from production to dispensing or destruction.<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">“It’s sort of like cradle to grave for drugs,” said Scott Collier, diversion program manager for the DEA’s St. Louis division.<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">The goal is to prevent diversion of drugs to addicts. But this doesn’t always work.<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">A Minnesota nurse was charged in 2011 with skimming drugs off a patient before he had surgery for kidney stones. The man claimed Sarah May Casareto told him he would need to “man up” because they couldn’t
give him much painkiller, according to the Minneapolis Star Tribune.<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">He was left writhing in pain because Casareto took his fentanyl, the newspaper reported. Casareto pleaded guilty to fifth-degree drug possession.<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">UI Hospitals tracks drugs from the moment they arrive at the loading dock to when they are dispensed or wasted. To avoid overstocking, pharmacists assign a value to each drug that indicates at which point
it should be reordered.<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">The hospitals’ precautions to avoid drug theft include witnesses verifying each drug transfer, fingerprint access to secure drug cabinets and even a drug vault with bullet-proof windows, a steel door and
reinforced walls.<o:p></o:p></span></p>
<p style="background:white"><strong><span style="color:black">UI drug data not centralized</span></strong><span style="color:black"><o:p></o:p></span></p>
<p style="background:white"><span style="color:black">Despite meticulous drug security, UI Hospitals does not have centralized records for drug tracking and does not examine drug waste as a whole.<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">The best data UI officials could provide to show drug waste came from EXP Pharmaceuticals, a California-based company that picks up wasted drugs every three weeks at UI Hospitals. EXP is a reverse distributor
also used by UnityPoint Health-St. Luke’s Hospital and Mercy Medical Center in Cedar Rapids.<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">A Gazette analysis of the UI’s EXP data from fiscal 2012 and fiscal 2013 shows:<o:p></o:p></span></p>
<ul type="disc">
<li class="MsoNormal" style="color:black;mso-margin-top-alt:auto;mso-margin-bottom-alt:auto;mso-list:l0 level1 lfo1;background:white">
EXP picked up 105,471 units of wasted drugs worth $1.47 million from UI Hospitals during that time. More than $800,000 worth of these drugs was eligible for return to manufacturers. EXP destroys the rest, likely by incineration.
<o:p></o:p></li><li class="MsoNormal" style="color:black;mso-margin-top-alt:auto;mso-margin-bottom-alt:auto;mso-list:l0 level1 lfo1;background:white">
About 20 percent of the drugs make up 80 percent of the waste. Painkillers, anesthetics and anti-anxiety medicines are high-use drugs, which equates to high waste.
<o:p></o:p></li><li class="MsoNormal" style="color:black;mso-margin-top-alt:auto;mso-margin-bottom-alt:auto;mso-list:l0 level1 lfo1;background:white">
Several of the UI’s high-waste drugs have been included on shortage lists by the Food and Drug Administration.
<o:p></o:p></li><li class="MsoNormal" style="color:black;mso-margin-top-alt:auto;mso-margin-bottom-alt:auto;mso-list:l0 level1 lfo1;background:white">
Although wasted in smaller quantities, some ultra-expensive drugs were tossed at UI Hospitals. These include two Gliadel wafers worth a total $38,000 used to implant in the brain to kill cancer cells, and four doses of snakebite antidote Crofab valued at a
combined $11,800.<o:p></o:p></li></ul>
<p style="background:white"><span style="color:black">Drugs wasted at the bedside, such as the hydromorphone washed down the drain, are tracked through AcuDose-Rx machines used throughout the hospital.<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">These secure medicine cabinets require nurses to scan their fingerprint and enter a password before gaining entry and then recording what is dispensed and how much is left. Another nurse must witness waste
going down the drain.<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">The problem with this data is that not all hospital units have AcuDose machines. The operating room, which handles about 75 surgeries a day, still uses paper slips to record each anesthetic or painkiller
prescribed for a procedure.<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">The UI Hospitals charged The Gazette $525 for two years’ worth of waste records from the AcuDose machines. Those records showed 248,246 drug transactions that resulted in waste.<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">Because the data did not include how much was prescribed or administered, it was difficult to tell how much was wasted.<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">The Gazette was able to determine that when UI employees wasted portions of 1 milliliter hydromorphone syringes in fiscal 2013 – which was 47,000 times – the average waste was .7 milliliters, or 70 percent
of each syringe.<o:p></o:p></span></p>
<p style="background:white"><strong><span style="color:black">Packaging contributes to waste</span></strong><span style="color:black"><o:p></o:p></span></p>
<p style="background:white"><span style="color:black">Pharmaceutical companies contribute to drug waste by packaging drugs in units that are too large for a single dose, UI officials said.<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">The 1 milliliter hydromorphone syringes contain more than twice as much medicine as most patients need in a single dose and the extra can’t be saved because of drug control laws.<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">Hospira, one of the world’s largest suppliers of generic drugs, also makes a .5 milliliter syringe of hydromorphone. But it is more expensive than the larger syringe and oddly shaped, so it’s hard to stock
in the AcuDose machines, said UI Pharmacy Manager Becky Triplett.<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">Another example is Acyclovir, an antiviral medication that can be used to treat infections in children. The one-gram vials available on the market are too large, even for adults, Triplett said.<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">“Why do they sell it that way?” she said. “I don’t know.”<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">And yet, UI pharmacy officials have not asked drug manufacturers make smaller containers, said Mike Brownlee, UI associate director and chief pharmacy officer.<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">“Because of drug shortages, we have been focused on just acquiring the drug let alone getting it in a different package size,” he said.<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">The UI Hospitals are part of the University HealthSystem Consortium, a Chicago-based alliance of 120 academic medical centers and 299 affiliated hospitals. Doug Smith, senior director of supply chain services
for the organization, has heard other hospital officials complain about drugs being packaged in oversized containers – particularly for children.<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">“Most of the manufacturers have created strengths and vial size based on adult doses,” Smith said. “If they want to make a product at a smaller dose, they must go to the FDA for approval.”<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">Despite the UHC’s size and clout, Smith doesn’t think the organization could convince pharmaceutical companies to change their ways. He recalled asking the industry in the 1980s to produce 12 new formulas
so that pharmacists wouldn’t have to dilute existing medications.<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">None of the changes were made.<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">“They have limited capacity in what they came make,” Smith said. “Adding another vial is another product line. Some of it is an economic decision they have to make.”<o:p></o:p></span></p>
<p style="background:white"><strong><span style="color:black">Drugs in the water</span></strong><span style="color:black"><o:p></o:p></span></p>
<p style="background:white"><span style="color:black">A 1999-2000 survey by the U.S. Geological Survey showed 80 percent of 139 streams across the nation had traces of prescription drugs, including antibiotics, antidepressants and hormones. Most of these drugs
enter the water supply from human consumption and excretion. But drugs flushed down hospital sinks contribute to the flow.<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">Even small amounts of prescription drugs in water can harm animals.<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">Estrogen in some lakes and streams in different parts of the country has caused fish to develop both male and female sex characteristics, according to USGS research.<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">In another study, male fathead minnows exposed to antidepressants at low levels showed decreased attention to females. The male fish, when exposed to higher levels of fluoxetine, the active ingredient in
Prozac, became aggressive to females, even killing them, said Rebecca Klaper, an associate professor at the University of Wisconsin-Milwaukee’s School of Freshwater Sciences.<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">Prescription drugs in water could also affect humans, but it’s harder to study.<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">“We still do not know if there are long-term problems, especially for sensitive populations like children,” said Dana Kolpin, an Iowa City-based USGS researcher who has studied the effects of prescription
drugs on white sucker fish in central Iowa.<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">Research such as this spurred the EPA to study drug disposal practices at U.S. hospitals. The agency visited 12 health care facilities, reviewed disposal records of 20 facilities and talked with about 700
people from hospitals, government agencies and drug-management companies to come up with best practices released in 2010.<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">“EPA’s goal is to keep pharmaceuticals out of U.S. waters,” the report said.<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">The EPA recommends hospitals track every drug dispensed for several weeks to discover waste patterns.<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">The UI Hospitals uses several of the EPA’s best practices, such as refusing drug samples, rotating stock and segregating waste, but officials have not done a waste inventory, Brownlee said.<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">“A deeper dive may reveal something, it may not,” Brownlee said.<o:p></o:p></span></p>
<p style="background:white"><strong><span style="color:black">Examining waste data</span></strong><span style="color:black"><o:p></o:p></span></p>
<p style="background:white"><span style="color:black">Researchers with the Albany, N.Y., Medical Center received a two-year EPA grant in 2007 to collect and sort pharmaceutical waste in some areas of the 630-bed academic medical center.<o:p></o:p></span></p>
<p class="wp-caption-text" style="background:white"><span style="color:black">Dr. Becky Triplett Pharmacy Manager at University of Iowa Hospitals and Clinics describes how pharmacy staff must divide a large bottle of medication into 15 mL, single-use bottles
because the manufacturer stopped producing the smaller units earlier this fall. This process requires staff time and the hospital also losees about a year off the expiration date of the larger bottle. (Jim Slosiarek/The Gazette-KCRG)<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">When the team sorted more than a year’s worth of waste from eight operating rooms, they found propofol, a common anesthetic, made up 45 percent.<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">“They were opening a bunch of bottles and wasting 90 percent of it,” said Russell Mankes, a retired associate professor in Albany’s Center for Neuropharmacology & Neuroscience.<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">As propofol doesn’t degrade in nature, accumulates in body fat and is toxic to aquatic life, the team looked for ways to reduce the waste, Mankes said.<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">By removing 50 milliliter and 100 milliliter vials of propofol from the pharmacy and keeping only the 20 milliliter vials, Albany practitioners wasted less, the study showed. The savings were estimated at
$100,000 a year.<o:p></o:p></span></p>
<p style="background:white"><span style="color:black"> <o:p></o:p></span></p>
<p style="background:white"><strong><span style="color:black">Opportunities</span></strong><span style="color:black"><o:p></o:p></span></p>
<p style="background:white"><span style="color:black">Many hospitals are struggling to do the right thing, said Howard, from Project Greenhealth. Some hospitals want to hire a reverse distributor, but they can’t afford it or there are no approved companies
nearby, she said.<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">Health care centers can’t donate pharmaceuticals because of the risk of liability if the drugs aren’t used properly or before expiration.<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">But examining waste data can lead to easy solutions, such as switching prescribing patterns or stocking a different strength of medicine, Mankes said.<o:p></o:p></span></p>
<p style="background:white"><span style="color:black">“You may have some real opportunities there to reduce waste, improve the bottom line and stop poisoning the fish and people around you,” he said.<o:p></o:p></span></p>
<p class="MsoNormal" style="background:white"><span style="color:black"><image001.gif><o:p></o:p></span></p>
<p class="MsoNormal"><o:p> </o:p></p>
<p class="MsoNormal">Laurie Tenace<o:p></o:p></p>
<p class="MsoNormal">Environmental Specialist<o:p></o:p></p>
<p class="MsoNormal">Waste Reduction Section<o:p></o:p></p>
<p class="MsoNormal">Florida Department of Environmental Protection<o:p></o:p></p>
<p class="MsoNormal">2600 Blair Stone Road, MS 4555<o:p></o:p></p>
<p class="MsoNormal">Tallahassee, FL 32399-2400<o:p></o:p></p>
<p class="MsoNormal">850.245.8759<o:p></o:p></p>
<p class="MsoNormal"><a href="mailto:Laurie.Tenace@dep.state.fl.us">Laurie.Tenace@dep.state.fl.us</a><o:p></o:p></p>
<p class="MsoNormal"><o:p> </o:p></p>
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