[Pharmwaste] Prescription drug disposal

Bunnell, Ross Ross.Bunnell at po.state.ct.us
Wed Nov 7 12:44:25 EST 2007


Helen:

I would second the comments offered by Ann Pistell of the Maine DEP below, although I would add the following, from our state's perspective:

1.)  Solid Waste Disposal - Incineration.  While we here at the Connecticut DEP also have concerns about the unknowns of this option, we have been studying this possibility, and plan to continue to look into it as a potential disposal option for at least some pharmaceuticals.  Here in Connecticut, we already manage almost all of our municipal solid waste ("MSW") in "resource recovery" or "trash-to-energy" facilities, due to a lack of landfill capacity in our densely-populated state.  Under our operating permits issued to these facilities, they are required to have advanced emissions controls and operate at very high temperatures that, pending additional study, may be sufficient to destroy many pharmaceuticals without adversely affecting the air emissions from these facilities.  We also have the legal authority to screen and specifically approve or disapprove of the kinds of materials that may be disposed of at our incineration facilities that would provide us the means to ensure that only those pharmaceuticals that were appropriate for incineration were disposed of in this manner.

2.)  Consumer Collection Systems.  Here in Connecticut, we have thus far only engaged in a couple of "pilot" type consumer pharmaceutical collection events, and have relied upon Maine's experience to a great degree in setting them up.  There is a regional effort in the northeast states, with funding assistance from EPA, spearheaded by the Northeast Recycling Coalition (NERC), that has greatly helped to facilitate the development of these collections.  

This is just my personal opinion, but it seems to me that -- barring some major change of direction at the federal level -- consumer collection of pharmaceuticals is likely to head in the direction of household hazardous waste collection.  That is, I think we're likely to see collections as something that is encouraged by US EPA, but organized and implemented at the state and local level.  For example, here in Connecticut, we have spent 20 years putting together a system for the collection of household hazardous waste in all 169 towns in Connecticut.  Our system for this is not universally uniform throughout the state, but is instead a patchwork of mostly regional programs funded by municipalities, regional recycling authorities, or other organizations.  As a result, some parts of the state have fixed household hazardous waste collection centers that provide collection services 8 or so months out of the year, whereas other parts of the state rely on one-day collection events.

3.)  Information for Consumers.  It seems quite clear that you are aware of the federal guidelines.  However, many states have also published flyers or web pages for consumers, providing their own advice on consumer management of pharmaceutical wastes.  See, for example, Connecticut's flyer at http://www.ct.gov/dep/cwp/view.asp?a=2708&q=335480&depNav_GID=1763.  While states share technical information (e.g. through this list serve), the advice given may vary significantly from state to state depending on a variety of factors, including how they manage their solid waste (e.g. landfilling vs. incineration), concerns over inappropriate diversion of controlled substances, concerns over impacts on specific waterways, and many other factors.  I'm not sure you'll ever see national consistency on every aspect of such guidance, since these factors vary so much from state to state and locale to locale.

Good luck on your story, and please post a transcript of it when it is complete.

- - Ross Bunnell, CT DEP
Bureau of Materials Management and Compliance Assurance
Waste Engineering & Enforcement Division
79 Elm Street
Hartford, CT 06106-5127
Tel. (860) 424-3274  Fax (860) 424-4059

Disclaimer:  Any views expressed in this email represent only the sender's personal opinion based on his knowledge and experience with the DEP, and in no way should be considered a formal ruling by the Department.  It is always the obligation of a generator or other handler of waste to be familiar with and to comply with all applicable state and federal requirements.




-----Original Message-----
From: pharmwaste-bounces at lists.dep.state.fl.us [mailto:pharmwaste-bounces at lists.dep.state.fl.us] On Behalf Of Pistell, Ann E
Sent: Wednesday, November 07, 2007 9:20 AM
To: pharmwaste at lists.dep.state.fl.us
Subject: [Pharmwaste] Prescription drug disposal

To the NBC correspondent:

Most of us working actively on the prescription drug disposal issue just smile and nod at the new federal guidelines.  All of us, including the federal folks, know it is not the disposal silver bullet.  Right now, here are all the choices I can think of.
1. Flushing - a no-no for all drugs as far as most of us are concerned, basically because of the environmental impacts on ground and surface water and aquatic organisms.  Nobody knows the breakdown products, interactions and/or synergistic effects of the chemical soup created by flushing medications - either with other meds or any of the thousand other chemicals going down the drain.  The science just isn't there and may never be. Even for those drugs the feds listed. I believe they may have been looking at one drug not in interaction with other chemicals it may encounter in its journey down the pipes.

2. Solid waste disposal: landfilling - (the kitty litter option).  Plain and simple, landfilling is just delaying the medication or its breakdown products from entering the aquatic environment. Landfills produce leachate, which is in turn treated at a wastewater treatment plant and then discharged to a water body in most cases.  Treatment plants are not designed to remove pharmaceuticals.  Research is ongoing to evaluate the efficiencies of different wastewater treatment methodologies in removal, but improvements in that arena are way down the road.

3. Solid waste disposal: incineration - Again there are unknowns.  Incinerators vary in the technologies and capabilities and nobody is sure of what may go up and out the stack or into the ash (which may then be landfilled).  It is probably better than landfilling directly, but many drugs are hazardous by listing or characteristic and, at least in Maine, we are very concerned about this.  It gets into a whole discussion concerning RCRA which hasn't been updated since the 1970s.  So what's left? (We have determined that solid waste incineration is ok for most of the controlled drugs.)

4. Hazardous waste disposal - Maine DEP has made the determination that the vast majority of unwanted medications, when collected, need to be incinerated as hazardous waste. At the moment this is the most protective disposal option.  Maine and other states are experimenting with various collection models (one day events, mail-in and drop boxes in pharmacies and police stations) but I bet a poll of those of us on the front lines would show that most think hazardous waste incineration is the best option, logistics and cost aside.  Maine at least is following the precautionary principle.  We know that a lot more science needs to be done.

I wrote this in a hurry -hope it makes some sense.  There is a lot more that can be written.  
Ann Pistell
Me DEP
207-287-7703

-----Original Message-----
From: pharmwaste-bounces at lists.dep.state.fl.us [mailto:pharmwaste-bounces at lists.dep.state.fl.us] On Behalf Of pharmwaste-request at lists.dep.state.fl.us
Sent: Wednesday, November 07, 2007 6:54 AM
To: pharmwaste at lists.dep.state.fl.us
Subject: Pharmwaste Digest, Vol 25, Issue 3

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Today's Topics:

   1. RE: Mix Leftover Meds with Kitty Litter? (Miller, Fred L.)
   2. Prescription drug disposal clarification 
      (Chickering, Helen (NBC Universal))


----------------------------------------------------------------------

Message: 1
Date: Tue, 6 Nov 2007 22:50:46 -0800
From: "Miller, Fred L." <millerfl at wsu.edu>
Subject: RE: [Pharmwaste] Mix Leftover Meds with Kitty Litter?
To: "matthew mireles" <mirelesmc at earthlink.net>,	"Freeman, Kelly"
	<kfreeman at capcog.org>, <pharmwaste at lists.dep.state.fl.us>
Cc: Elizabeth Smith <smithce at flash.net>,	Cheenu Srinivasan
	<cheenu at earthlink.net>
Message-ID:
	<4A61D8080F10B7408DCE5E0EA7F55AF3195835 at EXCHANGEVS-03.ad.wsu.edu>
Content-Type: text/plain; charset="iso-8859-1"



This is some of the funniest advice I've seen lately.  If you want your drugs back from cat litter (used or not), it's a simple process involving commonly available solvents, acids, bases and paint/coffee filters.  It's less risky and less complicated than cooking meth so it's within the grasp of addicts.

It is also a well known method to drug traffickers.  As a former forensic drug chemist I can tell you there are a lot matrices to mix drugs with if you want them rendered "beyond recovery."  I used to spend my days recovering drugs from various media and cat litter is about as tough to get drugs out of as tablets and the recovery rate is nearly identical.

Fred

-----Original Message-----
From: pharmwaste-bounces at lists.dep.state.fl.us on behalf of matthew mireles
Sent: Tue 11/6/2007 9:17 AM
To: 'Freeman, Kelly'; pharmwaste at lists.dep.state.fl.us
Cc: 'Elizabeth Smith'; 'Cheenu Srinivasan'
Subject: RE: [Pharmwaste] Mix Leftover Meds with Kitty Litter?
 
We are involved with this project and the EPA-funded pilot study in Maine.
About 3 years ago, we started set up the national Unused and Expired Medicines Registry to collect data on unwanted meds.  The Registry is very rich with good info about type of drugs (prescript and OTC), quantity of returned drugs, cost, reason why people don't want them, and some environmental classification based on the JANUS pbt index (Sweden).  We now are receiving data from both coasts of the US.  

 

The Registry is the center of direct mail-back study in Maine to help evaluate the program and provide analyses of the collection.  The Registry is also part of our community campaign Get Rid of Unused Pharmaceuticals (GROUP).  For more info about the Maine study, go to www.noemaine.org <http://www.noemaine.org/> .  

If you want more info about the Registry or how to participate in this program, visit www.comofcom.com <http://www.comofcom.com/> .  We are based in the Houston area.

 

Matthew C. Mireles, PhD, MPH

President and CEO

Community Medical Foundation for Patient Safety

832-778-7777

 

  _____  

From: pharmwaste-bounces at lists.dep.state.fl.us
[mailto:pharmwaste-bounces at lists.dep.state.fl.us] On Behalf Of Freeman, Kelly
Sent: Tuesday, November 06, 2007 8:30 AM
To: pharmwaste at lists.dep.state.fl.us
Subject: [Pharmwaste] Mix Leftover Meds with Kitty Litter?

 

I just ran across this article and thought I'd pass it along.  Beware the ick factor.

 

Original can be found at http://www.msnbc.msn.com/id/21641396/

 

Thanks,

 

Kelly Freeman

Solid Waste Program Coordinator

Capital Area Council of Governments

512-916-6040 Phone

512-916-6001 Fax

kfreeman at capcog.org 

 

 


Don't flush leftover meds - mix with kitty litter


Experts say icky disposal method safer for kids and environment


WASHINGTON - It's time to pooper-scoop your leftover medicine.

Mixing  <http://www.msnbc.msn.com/id/21641396/##> cough syrup, Vicodin or Lipitor with cat litter is the new advice on getting rid of unused medications. Preferably used cat litter.

It's a compromise, better for the environment than flushing - and one that renders dangerous medicines too yucky to try if children, pets or drug abusers stumble through the trash.

A government experiment is about to send that advice straight to thousands of patients who use potent painkillers, sleeping pills and other controlled substances.

Why? Prescription drug abuse is on the rise, and research suggests more than half of people who misuse those drugs get them for free from a friend or relative. In other words, having leftovers in the medicine cabinet is a risky idea. Anyone visiting your house could swipe them.

So 6,300 pharmacies around the country have signed up for a pilot project with the Substance Abuse and Mental Health Services Administration. When patients fill prescriptions for a list of abuse-prone medicines, from Ambien to Vicodin, the pharmacist also will hand over a flyer urging them to take the cat-litter step if they don't wind up using all their pills.

Not a cat owner? Old coffee grounds work, or doggie doo, even sawdust. Just seal the meds and the, er, goop in a plastic bag before tossing in the trash.

"We don't want to assert that this is a panacea for the larger problem,"
says SAMHSA's Dr. H. Westley Clark. "It just provides them with a caveat that these are not things you can just lay around."

But the concern isn't only about controlled substances. How to best dispose of any medicine, whether prescription or over-the-counter, is a growing issue.

Unfortunately, "we don't have a silver bullet," says Joe Starinchak of the U.S. Fish and Wildlife Service.

No one knows just how many unused drugs Americans dump each year, or how many are hoarded because patients simply don't know what to do with them or that they should dispose of them.

No more flushing
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.

That's because antibiotics, hormones and other drugs are being found in waterways, raising worrisome questions about potential health and environmental effects. Already, studies have linked hormone exposure to fish abnormalities. Germs exposed to antibiotics in the environment may become more drug-resistant.

Some communities set aside "take-back" days to return leftover doses to pharmacies or other collection sites for hazardous-waste incineration. The <http://www.msnbc.msn.com/id/21641396/##> Environmental Protection Agency recently funded a novel pilot program by the University of Maine to see if consumers will mail back unused drugs - a program that local officials estimate could cull up to 1.5 tons of medications.

But it's not clear if incineration is better for the environment than the slow seepage from a landfill, cautions the Fish and Wildlife Service's Starinchak.

Plus, take-back programs require legal oversight to make sure what's collected isn't then diverted for illegal use.

Starinchak calls the yucky-bag disposal method interim advice - the top recommendation until more research can determine the best way to balance the human health, environmental and legal issues.

So early next year, Fish and Wildlife will team with the American Pharmacists Association for a larger campaign called SMARxT Disposal. The campaign will spread this latest advice through even more drugstores, to purchasers of all types of medicine.

"There is a $64,000 question here: Whether people really will get rid of it," says Carol J. Boyd, director of the <http://www.msnbc.msn.com/id/21641396/##> University of Michigan's Institute for Research on Women and Gender and a well-known specialist on drug diversion.

Say you're prescribed a week's worth of Vicodin for pain after a car crash, and you use only three days' worth. Most people would keep the rest, to avoid paying for more if they suffer serious pain for some other reason later. Boyd isn't sure how to counter that money issue.

But keeping the leftovers makes them accessible for misuse by children, other relatives or visitors. Stealing aside, Boyd's research uncovered that friends and family openly share these pills - "Use this, it helped me" - even with teens and college students, apparently not realizing there could be serious health consequences.

"The public needs to know this," Boyd says of the disposal advice. "What's not easy is, we don't know if it's working."

 

 


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Message: 2
Date: Wed, 7 Nov 2007 06:53:30 -0500
From: "Chickering, Helen (NBC Universal)"
	<Helen.Chickering at nbcuni.com>
Subject: [Pharmwaste] Prescription drug disposal clarification
To: <pharmwaste at lists.dep.state.fl.us>
Message-ID:
	<F4345C7070C8D847B73D14F2D91E34E74B27EA at RKFMLVEM05.e2k.ad.ge.com>
Content-Type: text/plain; charset="utf-8"

 
 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 âEUR" 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 âEUR¢ 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.
âEUR¢ Once a tray of patches has been opened, use or discard the patches within 2 months.
âEUR¢ Keep DaytranaTM and all medicines out of the reach of children. HOW TO REMOVE AND DISCARD DAYTRANATM âEUR¢ When you remove the patch, peel it off slowly.
âEUR¢ 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.
âEUR¢ Do not flush the pouches or the protective liners down the toilet. These items should be in a lidded container.
âEUR¢ If any sticky material (adhesive) remains on the childâEUR(tm)s skin after removing the patch, gently area with oil or lotion to remove the adhesive from the skin.
âEUR¢ Wash your hands after handling the patch.
âEUR¢ 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.
âEUR¢ Keep your medicine in a tightly closed container.
âEUR¢ 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
âEUR¢ Take your dose of TEQUIN once a day.
âEUR¢ Complete the course of medication (take all of the pills) even if you are feeling better.
âEUR¢ Do not use TEQUIN for another condition or give it to others.
âEUR¢ Store TEQUIN tablets at room temperature in a tightly sealed container.
âEUR¢ Throw away TEQUIN when it is outdated or no longer needed by flushing it down the toilet.
âEUR¢ 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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