- Flushing unused pharmaceuticals is not recommended by the FDA, EPA, or other organizations due to concerns about contaminating water supplies. Trace amounts of drugs have been found in streams, rivers, and drinking water. - The FDA only recommends flushing a small number of drugs that could cause harm if ingested. For most drugs, the recommended disposal method is to throw them in the trash mixed with an undesirable substance like kitty litter. - Take-back programs, drug collection sites, and hazardous waste facilities are better options than flushing or throwing drugs in the trash if available in your area. Proper disposal helps protect water quality and the environment.

1. Facts about Disposal in the USTo flush or not to flush, that is the question GreenPharmEdu.org

2. Fate of Unused Phamaceuticals What are Pharmacueticals Final Destination? Water Land Air

3. What We Do Know In terms of water, excretion is more responsible for APIs entering the environment then direct disposal Worth calculating, which ones in terms of Excretion clearance/ PBT/DDD

4. What We Do Know Drugs accumulate in peoples homes Healthcare facilities have pharmaceutical waste Reverse distribution Disposal

5. Primary Stakeholders Physcians Hospitals Primary Care Clinics and Health Centers Long-term Care Facilities Hospice Veterinarian hospitals and clinics Pharmacies

6. Secondary Stakeholders Government and Law Enforcement Third Party Payers Health Care Systems Waste Management Agencies Water quality agencies Public Utilities Public Health Organizations Environmental Health Organizations Professional Associations Consumers

7. Flush vs No Flush The White House Office of National Drug Control Policy (ONDCP) gives a synopsis of federal guidelines regarding proper drug disposal: http://www.whitehousedrugpolicy.gov/publications/pdf/prescrip_disposal.pdf The ONDCP website refers to the FDA website for drugs that are approved to be flushed in the toilet or sink.

8. Flush vs No Flush The FDA offers advice on which drugs are considered okay to flush and which drugs require alternative disposal methods. Per the FDA certain medicines may be especially harmful and, in some cases, fatal in a single dose if they are used by someone other than the person the medicine was prescribed for. For this reason, a few medicines have special disposal directions that indicate they should be flushed down the sink or toilet after the medicine is no longer needed.

9. MEDICINES RECOMMENDED FOR DISPOSAL BY FLUSHING

10. MEDICINES RECOMMENDED FOR DISPOSAL BY FLUSHING cont.

11. MEDICINES RECOMMENDED FOR DISPOSAL BY FLUSHING cont. *These medicines have generic versions available or are only available in generic formulations. List revised: March 2010

12. Concerns with flushing - FDA Disposal of these select, few medicines by flushing contributes only a small fraction of the total amount medicine found in the water. FDA believes that any potential risk to people and the environment from flushing this small, select list of medicines is outweighed by the real possibility of life-threatening risks from accidental ingestion of these medicines.

13. Concerns with flushing - EPA The EPA refers to the White House Office of National Drug Control Policy consumer guidance for the proper disposal of prescription drugs, released in February of 2007. EPA states that studies have shown that pharmaceuticals are present in some of our nation's waterbodies. Further research suggests that there may be some ecological harm when certain drugs are present. To date, no evidence has been found of human health effects from PPCPs in the environment. The EPA continues to advise that sewage systems are not equipped for PCPPs removal and that the risks from these low level contaminants on human and wildlife are unknown

14. Concerns with flushing – California Board of Pharmacy Advises against flushing. The website states several reasons why to use alternative methods of disposal: A recent study shows that 80 percent of US streams contain small amounts of human medicines. Sewage systems cannot remove these medicines from water that is released into lakes, rivers or oceans. Fish and other aquatic animals have shown adverse effects from medicines in the water. And, even very small amounts of medicine have been found in drinking water. The California Board of Pharmacy makes several suggestions on how to dispose of unwanted/unused medications in the home.

15. Concerns with flushing -Smarxt Disposal Advocates for responsible medication disposal and advises against flushing. Smarxt Disposal is a collaboration between the U.S. Fish and Wildlife Service, the American Pharmacists Association and the Pharmaceutical Research and Manufacturers of America to educate the public how to properly dispose of medication, keeping lives safe and protecting our natural resources. http://www.smarxtdisposal.net/

16. DISPOSAL ADVICE - FDA The FDA states that it is important to note that disposal by flushing is not recommended for the vast majority of medicines. Unused or expired medicines that do not have flushing directions in the label can be disposed of safely in the household trash by: Mixing them with something that will hide the medicine or make it unappealing, such as kitty litter or used coffee grounds. Placing the mixture in a container such as a sealed plastic bag. Throwing the container in your household trash. The FDA also mentions drug take-back programs and consulting with pharmacists regarding this issue. They also refer the public to a website DailyMed which allows anyone to find disposal instructions on any medication.

17. DISPOSAL ADVICE - EPA While discarded pharmaceuticals under the control of consumers are not regulated by RCRA, EPA encourages the public: To take advantage of pharmaceutical take-back programs or household hazardous waste collection programs that accept pharmaceuticals If there are no take-back programs near you: contact your state and local waste management authorities with questions about discarding unused pharmaceuticals, whether or not these materials meet the definition of hazardous waste Follow any specific disposal instructions that may be printed on the label or accompanying patient information

18. Chemo drugs and disposal The Occupational Safety and Health Administration (OSHA) provides a technical manual that outlines how to handle exposure to these antineoplastics and the contaminated waste associated with administration, preparation and casual contact. This technical manual also addresses how to decontaminate surfaces of items such as cups and plate wear and the potential exposure from excrement and urine of patients receiving chemotherapy. The manual also gives guidelines on how to handle soiled bedding of chemotherapy patients. This manual can be accessed at: http://www.osha.gov/dts/osta/otm/otm_vi/otm_vi_2.html

19. Chemo drugs and disposal cont. Alternatively, the University of Pittsburgh Medical Center Cancer Institute provides a brief information sheet specifically for patients and caregivers: http://www.upmc.com/HealthAtoZ/patienteducation/Documents/ChemotherapyWaste.pdf Another emerging issue is the trend towards dermal application of drugs increasing the probability of drugs being introduced into the environment from bathing to discarding the used delivery devices which contain very high levels of residues.

20. Other Methods of Disposal Drop off at local waste facilities: The EPA encourages the use of pharmaceutical take-back programs alternatively over drop-off at waste facilities. If take back programs are unavailable to the consumer the EPA has compiled a list of state and local waste management authorities by state. Please see: http://www.epa.gov/epawaste/wyl/stateprograms.htm Take back programs Pharmacy-based Community based Mail based

21. What is Most Important? A key insight into this challenge is that a wide spectrum of actions targeted at reducing the transfer of PPCPs to the environment holds the potential for reciprocally improving the quality and cost of healthcare C. Daughton

22. Integral Solutions Treating the environment and healthcare as an integral system could greatly clarify where and how to invest resources to achieve optimal outcomes. As improvements in either can lead to collateral in improvements in the other. C. Daughton