Barrel Burning

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Medication Disposal Whats the Problem?Impacts
on Human and Environmental Health
Elizabeth Hinchey Malloy, Ph.D. and Susan Boehme,
Ph.D. Illinois-Indiana Sea Grant Jessica
Winter ORISE Intern, U.S. EPA Great Lakes
National Program Office
Presented at the Indiana Hazardous Waste Task
Force, Inc. workshop
A Workshop for the Collection of Unwanted
Medications in Indiana June 20, 2007
target audience solid waste managers, TRIAD
programs, waste water treatment plant operators,
health departments, household hazardous waste
contractors, and interested citizens
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Presentation Outline
Background on the issues - disposal of unwanted
medicine - medicines in the environment Collecti
on programs and initiatives Whats happening in
the Great Lakes? Tool kit overview
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Pharmaceuticals and Personal Care Products (PPCPs)

• Includes prescription and over-the-counter (OTC)
  medications, cleaning agents, cosmetics,
  nutritional supplements, skin care products
• Produced and used in larger volumes yearly
• Released via small quantity generators
• Biologically active

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Source U.S. Center for Disease Control and
Prevention. National Center for Health
Statistics. National Health and Nutrition
Examination Survey.
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Disposal of Unwanted Medicines

• In some cases, medicines are not entirely
  consumed due to
• Change in prescription
• Patients health improves before finishing
  medicine
• Patient death
• Patient non-compliance
• Bulk economy size containers
  of over-the-counter medicines
  contain more than is needed
  before expiration date

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Expired Medication Disposal Survey

• Survey of 100 pharmacies and 500 patients
• Pharmacy Policy
• 97 had established policies regarding the
  disposal of expired UNDISPENSED medication
• Pharmacy Advice
• Only 5 had consistent recommendations for
  patients on PRESCRIBED drug disposal
• 25 indicated that the issue of drug disposal was
  addressed only at the customers request

Boehringer, S Whats the Best Way to Dispose
of Medications? 2004. Pharmacists
Letter/Prescribers Letter 20 (200415)
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Expired Medication Disposal Habits

• 500 patients surveyed
• 54 disposed of medications in the trash
• 35.4 flushed drugs down the toilet or sink
• 7.2 did not dispose of medications
• 2 used all medication prior to expiration
• 1.4 returned medications to the pharmacy

Boehringer, S. Whats the Best Way to Dispose
of Medications? (2004)
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Main Risks of Improper Disposal Practices

• Environmental impact
• - Accumulation in waterways ? potentially harmful
  effects on wildlife
• Accidental ingestion (children elderly)
• - 78,000 children/year under 5 treated for
  unintentional medication poisoning in U.S.
• Illegal use or theft
• - Appropriation of pharmaceuticals by family and
  friends, workers in homes, and burglars
• Unnecessary accumulation waste of health care
  

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Medicines in the Environment

• U.S. Geological Survey monitoring study
• 139 streams analyzed in 30 states
• Contaminants identified in 80 of these streams
• 82 contaminants identified (many were
  pharmaceuticals)
• Co-occurrence common average 7 distinct
  contaminants identified per stream

Kolpin, D.W. et al. 2002. Pharmaceuticals,
hormones, other organic wastewater contaminants
in U.S. streams, 1999-2000 A national
reconnaissance. Environmental Science
Technology. 36(6)1202-1211.
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Medicines in the Environment

• USGS/CDCP study of drinking water facility
• Analyzed for 106 contaminants in 24 water samples
  from locations within a drinking-water- treatment
  facility and the 2 streams serving the facility
• 40 contaminants detected in 1 or more samples of
  stream water or raw-water supplies in the plant
• 34 contaminants detected in gt10 of these samples
• Some prescription and non-prescription drugs and
  their metabolites were detected in finished water

Stackleberg, P.E. et al. 2004. Persistence of
pharmaceutical compounds and other organic
wastewater contaminants in a conventional
drinking-water-treatment plant. Science of the
Total Environment. 32999-113.
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Effects on Aquatic Organisms Cause for Concern

• Aquatic exposure chemicals in the aquatic
  environment can result in continuous,
  multigeneration exposure.
• Feminization of fish - link to estrogen exposure?
• Ex Boulder Creek, CO female white suckers
  outnumber males by gt 5 to 1 50 of males have
  female sex tissue (David Norris, Univ. of
  Colorado at Boulder)
• Effects of antidepressants on fish and frog
  development?
• Ex Lab studies show low levels of common
  anti-depressants, including Prozac, Zoloft, Paxil
  and Celexa, cause development problems in fish,
  and metamorphosis delays in frogs
  (Marsha Black, Univ. of Georgia)

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Entry Pathways of Medicines into the Environment

• Outflow from wastewater treatment plants
• Surface application of manure and biosolids
• Commercial animal feeding operations and
  aquaculture
• Landfill leachate sent to wastewater treatment
  plants
• Septic tanks

Source www.york.ac.uk/.../ gsp/esm/images/pharma1
.jpg
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Medicine Waste Management Issues and Barriers

• Communicating the issue to the public
• Lack of conclusive research
• A waste management program for medicines needs to
  provide
• Safe disposal method (typically hazardous waste
  incineration)
• Identification of controlled substances in order
  to comply with Drug Enforcement Administration
  requirements for handling
• Convenience to participants
• Funding for disposal publicity
• Privacy of medical information

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What Can Be Done?

• Education and awareness
• Extended producer responsibility
• Pollution prevention
• Legislation (regional and national)
• Creative thinking on collection
• Collections
• - One-day drop-off events
• - Long-term take-back programs for consumers
  unneeded medicines
• (both need collaboration with reverse
  distributors, pharmacies and/or local police
  departments)

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Other Countries Initiatives

• Australia
• Community pharmacies collect unwanted/expired
  medications
• Paid for by Commonwealth with pharmaceutical
  industry support
• Canada-British Columbia
• Return program established voluntarily by
  pharmaceutical industry
• 75 of all pharmacies in British Columbia accept
  unused/expired medications
• European Union
• 11 nations have take-back programs
• Pharmacies accept unwanted pharmaceuticals
• More than half operated by pharmaceutical
  industry/ pharmacies - remainder paid for by
  municipalities

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The new (2/21/07) federal prescription drug
disposal guidelines advise Americans to

• If alternative methods of disposal are not
  available,
• Take unused, unneeded, or expired prescription
  drugs out of their original containers
• Mix with an undesirable substance
• Put in sturdy, opaque, non-descript containers
• Throw these containers in the trash
• Flush prescription drugs down the toilet only if
  the label specifically instructs doing so.
• Dispose of unused prescription drugs through
  pharmaceutical take-back programs if available.

The White House Office of National Drug Control
Policy (ONDCP), Health and Human Services (HHS),
U.S. EPA
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The American Pharmacists Association and the U.S.
Fish and Wildlife Service jointly recommend the
following (2/14/07)

• DO NOT FLUSH unused medications
• When tossing unused medications, protect
  children and pets from the potentially negative
  effects 
• crush or dissolve solid medications
• mix with kitty litter or a solid kitchen
  substance
• place in a sealed plastic bag to reduce the
  poisoning risk
• remove and destroy ALL identifying personal
  information
• check for approved state and local collection
  programs or with area hazardous waste facilities
• Talk To Your Pharmacist

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Unwanted Medication Collection Initiatives

• Local take-back programs pilots in CA, FL, IN,
  IL, IA, OH, WI, WA, MI and the Northeast
• Legislation in Maine established a mail-in
  program IL, MA, WI and CA considering similar
  legislation
• Pharmwaste email listserve national group of
  health care professionals, waste management
  officials, government http//lists.dep.state.fl.u
  s/cgi-bin/mailman/listinfo/pharmwaste
• Product Stewardship Institute www.pruductstewardsh
  ip.us
• Hospitals for a Healthy Environment organization
  developing a blueprint for hospital
  pharmaceutical waste management nationwide

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Whats Happening in Illinois?

• Chicago Collection for Household Unwanted
  Medicine May 2006
• 3rd annual event, 25 Chicago sites
• Spearheaded by Chicago Police, U.S. EPA Region 5,
  IL-IN Sea Grant
• Targeted older citizens
• One-day event 1,330 citizens
• turned in 1,600 lbs of
• prescription and OTC
• medications

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Whats Happening In Wisconsin?

• Collection Events
• Outreach Guidance, FAQs
• Law Enforcement Survey
• Statewide Working Group
• Possible Pilot Program

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Wisconsin Initiatives Collection Events 2006

• Brown Co. June 27 28
• 175 participanjts
• Approx. 3,500 pill containers (109,000 pills)
• Est. 230,000 worth of medicine (conservative,
  based on pharmacists estimates of shelf price)
• 10 controlled substances
• Winnebago Co. Oct. 3 and 4
• 114 participants
• 5 x 30-gal. non-controlled (184 lbs.)
• 3,426 pills/caps controlled, assorted liquids
• Cost 1,325.91
• Rock Co. Nov. 11
• Four hours
• 132 cars
• 261 pounds of prescription/outdated drugs
• 37 pounds controlled substances

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WI DNR Guidance for Collecting Unwanted Household
Pharmaceuticals
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Wisconsin Initiatives Collection Events
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Wisconsin Initiatives Collection Events
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125 cars 3 walk ups 128
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Milwaukee collected fourteen 30-gallon drums of
non-controlled substances
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Cool Facts
Controlled substances 10,472 pills
Oldest medication 1925
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Wisconsin Initiatives Collection Events
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Key Issues in WI Right Now

• Need disposal options for households where
  collections have not occurred
• Need disposal options for assisted living or
  long-term care facilities
• Need to engage coroners and law
  enforcement
• Need to establish a funding source

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Whats Happening in Michigan?

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Whats Happening in Indiana?
Indiana DEM has created a brochure to advise
residents on medicine disposal (excerpt below).
Numerous medicine collections have been organized
locally by the TRIAD programs, partnerships
between law enforcement and senior citizens
organizations.
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IL-IN Sea Grant Resource Kit Disposal of
Unwanted Medications A Resource for Action in
Your Community

• Includes
• Background
• What are the substances of concern?
• What are the risks of improper disposal?
• How do these substances enter the environment?
• Take-back program case studies - models of
  success
• Guidance for organizing medicine collections for
  households
• Legislation on disposal and donation of unneeded
  medication
• Materials for public education and outreach
• Bibliography of news articles and scientific
  reports

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Disposal of Unwanted MedicationsA Resource for
Action in Your Community

• Reviewed and revised by scientists, doctors,
  nurses, pharmacists, drug enforcement, waste
  management professionals, and community
  organizers
• Kit requested by county water treatment/ solid
  waste officials, environmental groups, other EPA
  regions and state agencies
• Holding workshop/training with solid waste
  managers in Illinois, Indiana
• Now on-line www.iisgcp.org/unwantedmeds

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Resource Kit ImpactsShort- and Long-Term

• Short-Term
• Form advisory group for review of resource kitv
• Give presentations on topic widely v
• Long-Term
• 1 year ? wider distribution of educational
  materials (clearer, more direct, more
  accessible) educate the educator (e.g.
  ILCSWMA)
• 2 years ? public able to 1-stop shop for info
  re mgmt. of household pharmaceutical waste
  disposal
• 2 years ? change disposal habits of public
  shift away from flushing, disposing in trash,
  etc.
• 5 years ? sustainable collection program
  established in Great Lakes city
• 10 years ? measurable decrease of
  pharmaceuticals in local water supplies/watershed
  s

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What is Still Needed?

• Research
• Humans, pets, livestock will always be taking
  medications, so solutions at the WWTP are needed
  for the long run
• Research on designer medications
• Determine the relative importance of the
  different sources excretion vs. disposal
  veterinary vs. human medicine
• Curb medicine waste and over- prescribing
• Education and outreach

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To Learn More
Elizabeth Hinchey Malloy, IL-IN Sea
Grant hinchey.elizabeth_at_epa.gov Jessica Winter,
U.S. EPA GLNPO winter.jessica_at_epa.gov
www.iisgcp.org/unwantedmeds
Additional materials and links to ongoing work
relevant to this issue are available at the U.S.
EPAs PPCPs web site
www.epa.gov/nerlesd1/chemistry/pharma
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Acknowledgments

• U.S. EPA Great Lakes National Program Office
• Scott Morgan, Indiana Household Hazardous Waste
  Task Force, Inc.
• Joanie Burns, Wisconsin Department of Natural
  Resources
• Bart Hagston, Illinois Counties Solid Waste
  Management Association
• Sgt. Jeff Hoffmann, Chicago Police Department
• Lara Polansky, UC Santa Barbara NOAA Hollings
  Scholar Program