1. PROPER DISPOSAL OF UNWANTED MEDICATIONS “THE DISPOSAL PROPOSAL” Patti Darbishire, PharmD Clinical Associate Professor, Pharmacy Practice

2. OBJECTIVES Describe the entities that have an interest in proper medication disposal and reasons why List options for proper medication disposal Discuss research results

3. ABUSE VS. MISUSE For purposes of this presentation: Abuse: Intentionally using medications for an unintended purpose or for recreational use Misuse: Unintentional, but improper and/or unsafe medication use Abuse or Misuse = Harm or Death

4. Who has a vested interest in proper disposal of medications? Law Enforcement Healthcare system Environmentalists All of us!

5. DRUG ABUSE STATISTICS In the US (2010), ~9 million people abused prescription medications. The most abused prescription drug categories: 1. Painkillers, 2. Sedative-Hypnotics, 3. Stimulants 1 70% of abused pain relievers were not prescribed for the abuser Obtained from a friend or relative (knowingly or unknowingly) 2 62% of teens get the prescription drugs from their family’s medicine cabinet 1

6. MISUSE STATISTICS 90% of U.S. poisoning deaths due to prescription drugs Most opioid pain meds, antidepressants and cardiovascular drugs 6 77% of prescription, OTC, and illicit drug overdose deaths in Indiana are unintentional 3 12%

7. OUR CHILDREN AND PETS Over a 10 year period 2.5 million children in the US <6 years old were poisoned by unintentional ingestion of medications, personal care products, and/or vitamins 6,7 In 2012, the American Society for the Prevention of Cruelty to Animals received more than 25,000 calls related to pets consuming human prescription medication 8 http://animals.howstuffworks.co m/pets/pet-travel/pet-meds-for- traveling.htm http://www.poison.org/stats/

8. HC PROFESSIONALS’ INTEREST Expired medications can be dangerous because some chemicals become: more potent less potent degrade into other chemicals Retaining discontinued medications can cause: confusion in correct therapy duplication in therapy HC professionals are interested in improving adherence to prescribed therapies, e.g. antibiotics, pain medications

9. MEDICATION OVERLOAD http://takemedsseriously.org/safe-disposal/disposal-options/http://takemedsseriously.org/safe-disposal/disposal-options/ and http://www.disposemymeds.org Annual number of prescriptions per capita 23 : 12 for people ages of 19 - 64 28 for people age 65 or older

10. WHY DOES THIS HAPPEN? Prescribing: Many patients won’t leave the office without a Rx “Just in case” prescriptions Full prescription vs. trial dose for new medications Prescription Filling: Insurance companies encourage large quantities through cost incentives and mail-order Pharmacy Auto Refill option leads to stockpiling medications

11. POSSIBLE SOURCES OF DRUG WASTE 2. https://www.arhp.org/publications-and-resources/contraception-journal/august-2011

12. DRINKING WATER The problem: Wastewater treatment plants are not designed to eliminate medication from drinking water Inability to eliminate drug waste through the sewer or septic systems Medication from landfill runoff goes straight into the streams and rivers

13. MEDICATIONS IN THE ENVIRONMENT Many medications can be found in rivers, lakes, groundwater and drinking water About 80% of water sources contain low levels of medications 10 Includes: antibiotics anti-depressants, steroids/hormones painkillers cancer treatments many others 11 http://toxics.usgs.gov/regional/emc/environmental_occurrence.html

14. PERSONAL CARE PRODUCTS AND THE ENVIRONMENT Personal care products are not regulated by the FDA Many harm the environment Safety to humans has not been evaluated http://www.amurie.com/learn.html The goodguide.com reviews best environmental products http://www.huffingtonpost.com/2013/10/3 0/great-lakes-microbeads_n_4178363.html Microbeads non degradable plastic bead absorb and retain toxins ingested by fish

15. MEDICATION TAKE BACK OPTIONS Drop boxes and collection bins Public take-back events E.g. Purdue College of Pharmacy Pre-paid mailers (purchase at some pharmacies or online) Pharmacies Police departments Drug manufacturers (pre-paid mailers) http://thedailynews.cc/2012/0 9/25/montcalm-county-now-home-to-5-med-drop-off-boxes/

16. PURDUE UNIVERSITY RESEARCH Student pharmacists hosted 15 community medication take-back events between 2012 – 2015 Categorized ~5000 prescription, OTCs, and personal care products (for both humans and animals) - about 1/3 of what was collected Recorded the drug name, drug class, controlled status, and expiration date Student and faculty researchers developed and administered a survey to 478 participants who brought medications to the events Collected participant demographics and information on participants’ disposal practices and opinions Each survey was linked to the recorded medication data but no identifiable patient information was recorded Students talked to participants about proper disposal methods and educational brochures on safe disposal methods were distributed to participants

17. WHAT HAPPENS TO MEDICATIONS COLLECTED? The EPA considers medication collected at take-back sites to be household waste and recommends incineration 20,21 Medications were taken by police officers to Covanta Energy – incineration facility utilizing specialized air filters to prevent toxins from entering the air Controlled Air Incinerator http://www.epa.gov/ttnchi e1/ap42/ch02/final/c02s03. pdf

18. WHAT WE FOUND The average number of medications returned per person was 10, and the average number of years the product was expired was 5. 58% of medications returned were prescribed, 40% were purchased over-the-counter and 2% were veterinary medications. The top 3 drug categories collected were analgesics (26%), cough and cold products (16%), and anti-infectives (11%). 24% of analgesics returned were schedule II narcotics, with the most commonly returned medication being the controlled substance hydrocodone/acetaminophen. Upon analysis of antibiotic prescriptions, it was determined that, on average, only 37% of antibiotic therapy is consumed by the patient. 98% of participants recognized that improper medication disposal is harmful to the environment, but only 64% knew where to take medications for proper disposal. 32% of participants continue to throw medication in the trash, 28% report never having previously disposed of medications, and 25% continue to flush medications down the toilet. A slight majority (54.4%) of participants were not willing to pay for medication disposal services. *References available upon request