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The Problem of Unwanted Medicines: (Source: Susan E. Boehme & Elizabeth H. Malloy, USEPA
- 1. Power Point Presentation: Overview of the Issue This presentation provides an overview of the issue, discussing the environmental and safety hazards related to unwanted medicines and describing the efforts that have been made to prevent unwanted medicines from being disposed of improperly. Speaker’s notes are provided on the CD for each slide for community organizers and officials who wish to use this presentation as the basis for their own outreach.
- 2. Susan Boehme, Ph.D. and Elizabeth Hinchey Malloy, Ph.D. Extension Specialists, Illinois-Indiana Sea Grant & Liaisons to the U.S. Environmental Protection Agency Great Lakes National Program Office The Problem of Unwanted Medicines: Environmental Impacts of Unwanted Medicines and Best Disposal Practices
- 3. Expired Medication Disposal HabitsExpired Medication Disposal Habits Kuspis and Krenzelok. 1996. “What happens to expired medications? A survey of community medication disposal.” Vet Hum Toxicol. 38(1):48-9 Returned to Pharmacy Did Not Dispose Flushed Trashed Used All Prior to Expiration 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
- 4. •Includes prescription and over-the-counter (OTC) medications, cleaning agents, cosmetics, nutritional supplements & skin care products •Produced and used in larger volumes yearly - 2006: over $274 billion was spent on over 3.7 million prescriptions - Consumption increased significantly in last 20 yrs - UN projects a 3-fold increase in next 25 years Pharmaceuticals and PersonalPharmaceuticals and Personal Care Products (PPCPs)Care Products (PPCPs)
- 5. In some cases, medicines are not entirely consumed due to: Change in prescription Patient’s health improves before finishing medicine Patient death Patient non-compliance Expiration date reached Bulk “economy size” containers of over-the-counter medicines contain more than is needed Disposal of Unwanted MedicinesDisposal of Unwanted Medicines
- 6. • Environmental impact - Accumulation in waterways potentially harmful effects on wildlife • Accidental ingestion (children & elderly) - In 2003, 78,000 children under were 5 treated for unintentional medication poisoning in U.S. • Illegal use or theft - Appropriation of pharmaceuticals by family and friends, workers in homes, open houses, and burglars • Unnecessary accumulation & waste of health care $$$ Main Risks of ImproperMain Risks of Improper Disposal PracticesDisposal Practices
- 8. U.S. Geological Survey monitoring studyU.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 Medicines in the EnvironmentMedicines in the Environment 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.
- 10. • 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 > 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) Effects on Aquatic Organisms:Effects on Aquatic Organisms: Cause for ConcernCause for Concern
- 11. Medicines in the EnvironmentMedicines in the Environment USGS/CDCP study of drinking water facilityUSGS/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 >10% 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. 329:99-113.
- 12. 2008 Associated Press Series • Antibiotics, anti-convulsants, mood stabilizers hormones - in the drinking water supplies of at least 46 million Americans • Detected in drinking water supplies of 24 major metropolitan areas • NJ drinking water plant (serving 850,000 people): metabolized angina meds & carbamazepine • Washington DC: 6 meds in drinking water IL has followed up with their own studies
- 13. Source: www.york.ac.uk/.../ gsp/esm/images/pharma1.jpg Entry Pathways of Medicines intoEntry Pathways of Medicines into the Environmentthe 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 systems
- 14. Pharmaceuticals and Personal CarePharmaceuticals and Personal Care Products (PPCPs)Products (PPCPs) • Degrade relatively rapidly in the environment • Show low bioaccumulation in biota • Do not “biomagnify” through food chains • Generally, are not acutely toxic BUT • May have biological effects at very low doses • May be “pseudo-persistent” contaminants
- 16. Communicating the issue Lack of conclusive research Safe disposal Controlled substances - DEA Funding for staff, disposal & publicity Privacy of medical information Misinformation Convenience Medicine Waste ManagementMedicine Waste Management Issues and BarriersIssues and Barriers
- 17. Challenges of Stewardship Programs • DEA prohibition on accepting narcotics unless law enforcement is present and all controlled substances are documented results in labor-intensive events • Funding • Developing partnerships across many public agencies & private sector law enforcement; pharmacies, water utilities, watershed orgs • Responsibility is taken off the manufacturer of the medicines
- 18. IL-IN Sea Grant Resource Kit:IL-IN Sea Grant Resource Kit: Disposal of Unwanted Medications A Resource for Action in Your Community http://www.iisgcp.org/unwantedmeds/ Purpose: Guide for communities who are looking for a solution for their drug disposal problem Use: Solid waste officials, county and state officials, community groups, environmental and community organizations, pharmacists, researchers Sucesses: Educated thousands of individuals on the issue, supported several outreach campaigns for communities holding events, created new networking groups
- 19. IL-IN Sea Grant Resource Kit:IL-IN Sea Grant Resource Kit: Disposal of Unwanted Medications A Resource for Action in Your Community http://www.iisgcp.org/unwantedmeds/ Content 1. Introduction to the issue 2. Case Studies of Take-Back Programs 3. How to Hold a Collection Event 4. Materials for Public Outreach and Education 5. Pharmaceutical Donation/Take-Back Legislation 6. International Policy on Medicine Donations 7. Bibliography on Pharmaceuticals, the Environment, and Human Health 8. PowerPoint Presentation
- 20. Illinois Counties Solid Waste Management Association (2007,08,09): Collection of Unwanted Medications: A Training Workshop for Illinois Communities Indiana Household Hazardous Waste Task Force, Inc. and Indiana DEM (2007 & 2009): A Workshop for the Collection of Unwanted Medications in Indiana Michigan DEQ, MI Sea Grant & IL-IN Sea Grant (2008): Unwanted Medicine Disposal: Doing it the Right Way Distributed ~500 toolkits plus 10,000’s online visits IISG Co-sponsored Workshops
- 21. Types of Stewardship Activities One-time consumer collection events Short-term collection campaigns Permanent collection locations On-going one-day events Collection boxes at pharmacies Police stations HHW facilities Mail-back programs Education
- 22. • Local take-back programs & pilots across the country • Pharmwaste http://lists.dep.state.fl.us/cgi-bin/mailman/listinfo/pharmwaste • Product Stewardship Institute www.pruductstewardship.us • Hospitals for a Healthy Environment: blueprint for hospital pharmaceutical waste management nationwide • Teleosis Institute (CA) data gathering and outreach Unwanted MedicationUnwanted Medication Collection InitiativesCollection Initiatives
- 23. Components of a Successful Collection • DEA goal Avoid diversion • Comply with State regs Board of Pharmacy Dept. of Health • Educate the public, health professionals, & pharmacists • Involve pharmacists/Police
- 24. What’s Happening in Indiana? Indiana DEM has created a brochure and website to advise residents on medicine disposal Numerous medicine collections have been organized locally by the TRIAD programs, partnerships between law enforcement and senior citizens’ organizations. http://www.in.gov/recycle/6141.htm
- 25. Marsh Pharmacy Store Collections (state-wide) Saturday, October 3, 2009 9AM - 5PM Sunday, October 4, 2009 11AM - 5PM http://www.marsh.net Partners: Indiana Department of Environmental Management, the Indiana Poison Center, CLS/Med-Turn & Statewide Medical Services
- 26. Go Greener ‘Med Drop’ West Lafayette, IN September 16, 2009 • 55 gals of unwanted medicines collected in 3.5 hrs! • Controlled substances accepted • Partners: • WL Go Greener • WLPD • Wildcat Creek Solid Waste Dept. • Purdue University
- 27. Chicago • 4 annual events, 25 Chicago sites, spearheaded by Chicago Police Dept. • Targeted older citizens; Since 2004: 6,000 lbs of medicines collected; now containers at 5 Chicago Police Stations What’s Happening in Illinois? • Annual HHW events ~50 barrels of meds diverted from waterways and landfills; properly disposed of by incineration Sangamon County (Springfield) • Will County (700,000 people) - pharmacies (non-controlled only) • Kendall County (100,000 people) - Yorkville police station • Many others (22 counties) through P2D2 Program • http://www.epa.state.il.us/medication-disposal/locations/index.html Other areas in Illinois
- 28. Solid Waste Agency of Northern Cook County (SWANCC) Illinois Pilot Program •Serving about 23 municipalities and 1 million northern Cook County Residents •Collecting meds and sharps at City Halls •Paid for by revenue from transfer station •Program costs expected to be about ~$100K for program ($0.10 per person)
- 29. Paul Ritter & Eric Bohm Pontiac Twp High School PP22 DD22 Prescription Pill &Prescription Pill & Drug Disposal ProgramDrug Disposal Program
- 31. IISG Education and Marketing Curriculum 4-H Service Learning Integration of “do not flush” message into displays, games brochures Newsletters, media, articles, etc.
- 32. New Sea Grant education resource provides background information for h.s. teachers and students, including sample community stewardship activities. Students who take part in activities will be equipped to help people make conscientious decisions when disposing of medications .
- 33. WISCONSINWISCONSIN Pharmaceutical Waste Working GroupPharmaceutical Waste Working Group • Formed in 2006 as one dayFormed in 2006 as one day consumer collection events wereconsumer collection events were beginningbeginning • Cross section of stakeholdersCross section of stakeholders • Focused on 3 areasFocused on 3 areas Supporting information and educationalSupporting information and educational outreachoutreach Improving data collectionImproving data collection Developing pilot program modelsDeveloping pilot program models
- 34. WI: Data CollectionWI: Data Collection • IdentifyingIdentifying new collectionnew collection programs andprograms and aggregatingaggregating resultsresults • Providing dataProviding data collection toolscollection tools • DevelopingDeveloping database ofdatabase of resultsresults
- 35. Fox Cities Case StudyFox Cities Case Study Upon arrival, participantsUpon arrival, participants completed a brief surveycompleted a brief survey providing their zip code,providing their zip code, how they heard abouthow they heard about program, and basicprogram, and basic reasons for not using thereasons for not using the medicationmedication
- 36. Fox Cities Case StudyFox Cities Case Study All meds received were sorted, categorized, identified, and recorded. This took a significant labor force.
- 37. Fox Cities Case StudyFox Cities Case Study # of participants and# of participants and medications collectedmedications collected AppletonAppleton ChiltonChilton LittleLittle ChuteChute OshkoshOshkosh WaupacaWaupaca TotalsTotals 177177 4343 5555 207207 108108 590590 participantsparticipants ControlledControlled SubstancesSubstances (# of pills)(# of pills) 1119411194 19801980 16771677 61156115 29752975 23,941 pills23,941 pills Non-Non- controlledcontrolled substancessubstances (pounds of(pounds of OTC andOTC and prescriptionprescription medicines)medicines) 396396 101101 9494 423423 225225 1,229 pounds1,229 pounds
- 39. Management ResultsManagement Results 3%1% 96% 0% federal control hazardous non-controlled state controlled
- 40. Wisconsin Initiatives: Collection Events 2006,07,08,09
- 42. Mail back programs • Maine - Disposal of Unwanted Medications Pilot Designed to meet Maine legislation Unique situation - State DEA accepting unwanted medicines (including controlled substances) Pharmacies to provide for mailer pick up and drop off Phase I – Spring 2008; 4 counties; no marketing Phase II – Fall 2008; statewide; marketing campaign • Wisconsin Pilot launched on Earth Day Includes Reverse distribution company Partnering with/direct contact with all pharmacies
- 43. Madison WI, WI color-coded bags pharmacy senior centers June collection event
- 44. Pennsylvania Initiatives: Keep Unwanted Medicine out of Lake Erie
- 45. Methods of Outreach •NIE full page articles •Surveys •Erie Green Campaign •News Coverage •Posters/Postcards •Pharmacy slips •Partner websites/newslett ers •Partner meetings and events •WQLN public service announcement •Press Event
- 47. Public Response and Perceptions Event Survey Participants requested more collection events 30% of participants had never heard about pharmaceuticals in the water before the event, and many didn’t realize it was affecting the lake.
- 48. Collection Results •87 participants •89% over the age of 46 •600 pounds of material (120 gallons) •5 of the 120 gallons controlled substances •3,839 controlled pills •69,232 non-controlled pills •384 personal care products
- 49. Unused Patient Medication Disposal Approximately 4 billion prescriptions are filled in the United States annually, and it has been estimated that as much as 35% of the dispensed medication goes unused, resulting in over 200 million pounds of pharmaceuticals which can adversely affect the environment if disposed of improperly.
- 50. • TakeAway™ Envelope • 10 Gallon TakeAway™ Community Environmental Return System
- 51. What is Still Needed?What is Still Needed? Research: •Excretion vs. disposal (Daughton study); veterinary and human-feedlots (CAFOs) •Humans, pets, livestock will always be taking meds, so solutions at the WWTP are needed for the long run •Impact of designer medications •Curb medicine waste and over-prescribing •Education and outreach •Provide simple solutions for individuals, MDs, pharmacies, hospitals (VA), hospices, rehab centers, schools, etc.
- 52. To Learn MoreTo Learn More Susan E. Boehme, boehme.susan@epa.gov Elizabeth Hinchey Malloy, hinchey.elizabeth@epa.gov www.iisgcp.org/unwantedmeds More info: http://www.epa.gov/ppcp/ Thank you to: U.S. EPA GLNPO for funding for this work and Shelley Cabrera for help with the toolkit, outreach and this workshop
Editor's Notes
- From this study, the predominance of disposal of pharmaceutical products in the trash and through the toilet is evident.
- Pharmaceutical products are everywhere in our lives. Scope of the unwanted medication Issue Thousands of distinct chemicals Broad (and increasing) usage Discharged from many small sources Many possess very high biological activity
- There are a number of reasons why pharmaceuticals may not be completely consumed and, therefore, remain (and may eventually reach their expiration date) in the hands of the public or health care facilities. These reasons include: With few exceptions, national, state, and local governments lack clear and consistent guidelines on how the general public can properly dispose of unwanted medicines.
- There are 4 main hazards associated with flushing, sharing, or trashing medications. First, pharmaceutical chemicals in waterways can harm wildlife. Sewage treatment plants are not designed to treat all the substances contained in medications. Therefore, when they are flushed down the toilet or sink, most of these chemicals pass through the wastewater treatment facility and accumulate in rivers, lakes, groundwater, and even in aquatic organisms such as fish and amphibians. Also, both nationally and internationally, medications are the most common poison exposure category, and unsecured storage or disposal to the trash remains a serious problem. Furthermore, as the biggest consumers of prescription medicines, it is a common but risky practice for senior citizens to self-prescribe medicines to treat new, undiagnosed symptoms. Leftover medicines in the home can provide an opportunity for theft and drug misuse or sale. And medicines that are not consumed represent wasted health care dollars. Studies identifying the types and quantities of drugs that go unused could lead to better-informed prescription practice and better advice to patients on how to take prescriptions.
- Numerous unregulated chemicals are ubiquitous trace contaminants in waters. Many result from consumer usage. The USGS study looked for 95 different contaminants, including many medicinal chemicals, but also others such as caffeine and detergents. They found: Note: Sample sites were targeted to streams susceptible to organic wastewater contamination (i.e. downstream of intense urbanization or livestock production).
- Much media interest resulted.
- The problem with pharmaceutical chemicals in the waterways is that some of them can have effects on aquatic animals. Researchers have found that some of the pharmaceutical chemicals in the water have similar structures and properties to estrogen, and can cause male fish and frogs to take on female characteristics, even producing eggs. And the active ingredient in Prozac has been linked to developmental delays in frogs in the laboratory. A major issue right now is the fact that a huge fraction of the medicine that people buy is getting into the water supply. The medicine that is consumed is hardly ever completely digested and so a significant portion of that goes directly to wastewater.
- This study was conducted by the US Geological Survey and the Center for Disease Control and Prevention Additionally, note that since a study can only find the substances it specifically tests for, PPCPs observed in U.S. surface, ground, and drinking waters probably represent just a fraction of all PPCPs that actually occur
- So how did these chemicals get into the environment? One source is direct outflow to water from wastewater treatment plants. Another possible source is from the sludge from wastewater treatment plants and the manure from medically treated domestic animals. This is typically applied to farmland as a soil amendment and might be a source of contamination of groundwater and runoff. Veterinary treatment on fish farms and direct runoff from livestock farms might be another source- it’s possible that veterinary medicine is an even bigger source to the environment than human medications, but we’ll need more research to determine the relative quantities. And old or poorly designed landfills may leak. Even non-leaking landfills represent a potential source, since the water from them must be pumped out and is usually treated by the municipal wastewater system.
- We each work in our own fields but all these issues have to be addressed for a solution to work on a long term basis A consumer awareness campaign has to be established to communicate the procedures that must be followed to safely manage unwanted medicines and to motivate people to participate in the program. While numerous studies have demonstrated the potential harm that pharmaceuticals pose for aquatic organisms, research is still needed to demonstrate the effects of such products on higher organisms and humans. Until more conclusive research, and funding for this research, is available, efforts to promote alternative disposal methods of pharmaceutical products will be hindered, unless a precautionary approach is taken and pharmaceuticals are kept out of the environment. Successful pharmaceutical waste management program must provide: -Safe disposal method. At present, all waste pharmaceuticals that are collected through proper disposal channels are incinerated. There is no legal alternative. -Secure handling and disposal of controlled medications to comply with Drug Enforcement Administration rules and to guard against misuse -Collection programs need to be easy to use if they are to compete with the toilet or the trash. The programs should be free to the public. -A funding source for take-back and disposal programs has to be established and maintained. There is currently no nationally established funding source for residential pharmaceutical waste management. -Privacy of patient medical information should be a priority.
- Illinois-Indiana Sea Grant, under a U.S. EPA GLNPO grant, has compiled a resource kit to help communities address this issue. We provide scientific background on the issue, Give examples of programs addressing the issue (we’ve got about 2 dozen case studies from across the US and from Canada, Australia, and Europe,) Step-by-step advice for organizing a collection program Sample outreach materials to publicize the issue, A listing of state laws related to medicine disposal, And a bibliography of news articles and scientific reports on the issue
- Illinois-Indiana Sea Grant, under a U.S. EPA GLNPO grant, has compiled a resource kit to help communities address this issue. We provide scientific background on the issue, Give examples of programs addressing the issue (we’ve got about 2 dozen case studies from across the US and from Canada, Australia, and Europe,) Step-by-step advice for organizing a collection program Sample outreach materials to publicize the issue, A listing of state laws related to medicine disposal, And a bibliography of news articles and scientific reports on the issue
- Some cities and counties have organized collection programs for their citizens to dispose of unneeded medicines. Usually these involve teamwork between police, a pharmacy, and hazardous waste contractors, and often others such as the municipal water department or solid waste department or environmental staff. These are usually single-day events where people can drop off their unneeded medicines at the pharmacy or some other location for safe disposal. Some areas have created more sustainable programs that provide year-round drop-off points, for example providing secure bins in police stations. It’s important to make sure such a program is sufficiently convenient for people to use on a regular basis and also providing security. On a slightly larger scale, a few states are working on legislation to deal with this issue. Maine passed a law several years ago establishing a mail-in program for consumers’ prescription medicines, but it was not funded and has not been implemented. This year (2007) their state legislature is considering a bill to fund that program with a one-time grant of $300,000. And several other states are considering programs that are similar: Additionally, in January 2005, Maine created the U.S. National Registry for Unused and Expired Medications to help unify and streamline national efforts. Other groups working on this issue include the pharmwaste email listserve Product Stewardship Institute, H2E Objectives: recommend how federal agencies can prioritize research and coordinate efforts. Goal: increase the safe and legal collection and disposal of unwanted pharmaceuticals nationwide through development of BMPs. U.S. EPA also has an internal work group meeting regularly to respond to the issue Some examples of interim medicine waste management programs in the Great Lakes region:
- Controlled substances not accepted
- Had support from the WL Police Department. Accepted controlled substances in addition to normal over the counter and prescription medications. Accepting ALL medications except liquid controlled substances (ie. cough syrup with codiene). Inhalers and non controlled liquid medications (in cat litter) were accepted by Wildcat Creek Solid Waste. All the rest were taken by the WLPD and incinerated.
- Since 2004, Chicago has collected more than three tons of old and unused medicine. Quantities collected: 2004 973 pounds 2005 3379 pounds 2006 1600 pounds Other IL activities: --Proposed state law would establish a mail-in program for patients to dispose of their unwanted medicines by mailing to a pharmaceutical reverse distributor or hazardous waste management company --Illinois EPA is supporting medicine disposal at HHW collections (piloting this in 10 counties in 2007) --Chicago’s HHW drop-off center accepts medicines --Kendall Co. medicine drop off pilot program at police stations (M-F 9-5).
- County breakdown Calumet 11% Waupaca 17% Outagamie 27% Winnebago 44%
- Need to add % numbers to each category Can we rearrange so that “misc” shows up at the end instead of in the middle??
- Milwaukee – Sept. 16, 2006 – another one planned June 9, 2007 125 cars 10,472 pills, bottles or patches (controlled substances) Fourteen 30-gallon drums non-controlled meds.
- The Maine Prudent Disposal of Unwanted Medications pilot will devise, implement and valuate a mail back plan to remove unused over the counter and prescription medications. A network of 75 distribution points located at pharmacies will provide for mailer pick up and drop offs to return unused medications. Informational materials for pharmacists, staff and individuals regarding the mailers will be developed and distributed. In addition, the pilot will test the effectiveness of an educational campaign about the hazards to life, health, and the environment posed by improper storage and disposal of unused mediations. Environmental Outcomes: The University of Maine Center on Aging estimate that approximately 1.5 tons of unwanted medications will be collected from households in Maine and disposed of in a prudent fashion. The project intends to understand the practicality and costs associated with a mail back medication return program. It also expects to provide information on the best methods to educate older adults concerning the hazards of unused medications and improper disposal and a reduction in the amount of medications available for improper disposal and diversion or poisonings and lead to a heightened awareness by the public-at-large and older adults that could lead to accidental deaths, human and animal poisonings, and suicides caused by unused medications.
- Using different colored bags to begin to track which route of communication about the event is most effective: at pharmacy (blue); via community centers (green) or at a previous collection event (red). Bags will be distributed at these different locales and residents asked to use them to return their meds.