Proper drug disposal programs

Proper drug disposal programs are a suggested strategy to reduce illicit drug use and unintentional poisoning (Schafer 2021, McElyea 2022, TFAH-Levi 2013, Simons 2010, US FDA-Unused medicines), reduce pharmaceutical contamination of fresh water, and improve water quality (Karim-Nejad 2022, Ehrhart 2020, Amin Dar 2019, Kinrys 2018, Lubick 2010, Glassmeyer 2009, Ruhoy 2008, Becker 2010, US EPA-PPCPs). Available evidence suggests that drug disposal programs increase collection and proper disposal of unused prescription drugs (Schafer 2021, Fleming 2016, Gray 2015, Yang 2015a, Stewart 2015, Perry 2014a, Welham 2015) and reduce pharmaceuticals in the environment (Stoddard 2015). However, additional evidence is needed to confirm effects on drug use and water quality.

Prescription drugs collected. Available evidence from hundreds of drug take-back events and drop-boxes suggests these efforts successfully collect prescription drugs, which reduces their availability for misuse at least by the amounts collected (Schafer 2021). Additional evidence is needed to establish effects on overall proper drug disposal rates and amounts of unused opioids that are disposed of compared to amounts that remain in homes (Schafer 2021). More information is needed about the outreach efforts of drug take-back campaigns and events, including how and which populations are reached within a community (Schafer 2021). A Michigan-based case study suggests take-back events can reduce excess opioids in a community and remove prescription opioids from many homes with youth or children (Moustarah 2020). A Kentucky-based study suggests increasing parent awareness of drug take-back programs and parents’ perceptions of availability of prescription drugs for adolescent nonmedical use can increase proper drug disposal (Egan 2020a). A prescription drug take-back program designed to monitor opioid prescriptions for surgery patients successfully reclaimed excess opioid drugs from patients at post-surgery follow-up visits and reduced the amount of opioids participating surgeons prescribed to subsequent patients (Lewis 2023). Drug take-back events may be more inclusive and accessible if organizers are aware that law enforcement participation can reduce participation among many populations that fear police interactions; disposal boxes provide an acceptable alternative to take-back events (Schafer 2021).

Drug use effects. Ongoing statewide drug disposal programs with permanent collection receptacles may more effectively prevent drug abuse and accidental poisoning than temporary, one day take-back events (Ruhoy 2008, Simons 2010). A Denton, Texas-based study associates drug take-back events with reduced unintentional poisonings and prescription drug misuse (Stoddard 2017). Surveys suggest that community campaigns to raise awareness about drug take-back events increase use of disposal programs and conversations with children about the dangers of prescription drug abuse (Yanovitzky 2016). Patient education about safe opioid handling practices and proper disposal appears to increase knowledge and use of proper opioid disposal methods (McElyea 2022). Proper opioid disposal is more likely through take-back programs or drop-boxes that accept any unused drugs and can be incentivized with compensation (Buffington 2019). Partially filling prescriptions of opioids initially may also reduce the amount of unused drugs that need disposal (Buffington 2019).

Water quality effects. Many federal agencies and experts suggest that individual households, hospitals, and health care facilities avoid flushing any pharmaceuticals to preserve water quality and protect aquatic life and ecosystems (Amin Dar 2019, Mankes 2013, US EPA-Medicine disposal). Active pharmaceutical ingredients (APIs) released into the environment via improper disposal (e.g., flushing or landfill leaching) can adversely affect aquatic life, contaminate freshwater resources, and promote drug resistance in bacteria (Kessler 2010, Pal 2010, US EPA-PPCPs). Flushing unused pharmaceuticals can cause spikes in APIs in the environment (Ruhoy 2008); flushed pharmaceuticals may also break down into compounds that have different toxicity levels than the original drug (Lubick 2010). Over 80% of sampled U.S. streams have evidence of pharmaceuticals in the water (Becker 2010, USGS-Emerging contaminants).

Best practices. Patient and pharmacist education may be needed to reduce improper drug disposal and increase use of proper disposal programs (Ehrhart 2020, Kinrys 2018, Seehusen 2006, Jarvis 2009). Pharmacists can help reduce pharmaceutical waste and educate patients about available proper medication disposal methods and the negative effects of improper medication disposal on the environment and society (Ehrhart 2020, Afanasjeva 2019). A North Carolina-based study suggests pharmacists working in a pharmacy where a medication drop-box is available are more likely to consistently recommend proper drug disposal methods (Egan 2024). Experts suggest pharmaceutical companies have a shared ethical responsibility for implementing proper medication disposal programs, including providing education, raising awareness, and managing services, with collaboration needed between companies, government agencies, health care providers, and patients to successfully implement programs (Karim-Nejad 2022). Healthcare providers simply handing out information about proper drug disposal without instruction or discussion does not appear to influence proper drug disposal practices; more active interventions such as personalized teaching about drug disposal kits, discussions about drug take-back opportunities, and reviewing storage and disposal instructions before dispensing medication and/or drug disposal kits are more likely to increase proper drug disposal practices (Bicket 2021). Available evidence suggests patients prefer mail-in drug disposal resources provided with prescriptions or traditional drop-off drug take-back programs that have minimal time costs and no monetary costs for patients (Varisco 2023). Increased wastewater testing is suggested as a low cost way for communities to quickly monitor changes in drug use along with current testing for pharmaceuticals, pathogens, and pollutants (RAND-Pardo 2020).

Costs. Benefit cost analysis suggests that establishing a proper drug disposal program would yield positive net social benefits (Kotchen 2009). Permanent secure drop-box or bin-based programs appear to be more cost-effective than mail-in programs or one day events (Carnevale-Drug takeback 2012).

It is unclear what impact proper drug disposal programs have on prescription drug misuse rates.

Available evidence suggests that safe storage and disposal of prescription opioids is rare, however, data suggest Black patients have a higher likelihood of locking prescription opioids (Broman 2021). Information and resources for safe storage and proper disposal of drugs is needed for people from all racial and ethnic backgrounds, of all ages, and with diverse education levels (Broman 2021). Data suggests that prior to the 1980s, people who were older, living in urban areas, and people of color had a higher risk for opioid use; available evidence suggests that higher risk for opioid use, especially prescription drug misuse, has shifted to people who are younger, living in suburban areas, and white people (Kearney 2019). Inequalities by race, geographic location, and economic status persist in overdose deaths (CDC-Disparities widen, Zhang 2018c). Most people who overdose are non-Hispanic whites, about 10% are non-Hispanic Blacks, and 8% are Hispanic (Salmond 2019). Experts attribute this demographic breakdown to the unconscious bias and prejudices of health care providers, who are more cautious prescribing opioids to patients of color based on the prejudiced assumption that patients of color are more likely to abuse or sell opioid prescription drugs (Salmond 2019). Individuals who exhibit mental health conditions are also more likely to use opioids (Salmond 2019).

The diversion and misuse of prescription drugs, especially of opioids, is an epidemic in rural, suburban, and urban communities across the U.S. (Kearney 2019). Drug take-back programs are one primary prevention method to reduce the supply of diverted prescription drugs (Kearney 2019). Tailoring outreach messages for non-English speakers, providing culturally sensitive, multi-lingual communication, establishing programs led by people of color, and addressing fear of law enforcement can remove barriers to participation in proper drug disposal programs (Kearney 2019, Broman 2021). Disposal drop-boxes, mail-back programs, and options that allow participation without requiring interaction with law enforcement are more accessible, inclusive, and encourage broader community engagement (Broman 2021, Kearney 2019). A North Carolina-based study suggests the number of drug disposal boxes are increasing and that drug disposal boxes are more likely to be placed in neighborhoods with lower incomes and higher rates of opioid overdose deaths. Experts suggest that continuing to expand permanent, secure drop-box locations could increase proper drug disposal and reduce prescription opioid diversion and misuse (Egan 2022).

Opioid overdose deaths have been increasing since 1999 (Freeman 2018). The rise in opioid overdose deaths began in the 1990s with a substantial increase in the prescription of both natural and semi-synthetic opioids because they were effective at managing chronic pain and falsely marketed to health care providers as non-addictive (CDC-Understanding the epidemic, Bennett 2021, Haffajee 2020, Volkow 2016). Prescription opioid sales increased fourfold between 1999 and 2008 (Judd 2023). Many patients who became addicted to prescribed opioids turned to non-prescribed forms of opioids, such as heroin, which lead to a second wave of opioid overdoses in 2010. In 2013, a third wave began when synthetic opioids, such as fentanyl, that are much more potent than other forms of opioids, were combined with other drugs or counterfeit prescription pills, often unknown to the purchaser (CDC-Understanding the epidemic). In 2013, the U.S. Department of Health and Human Services declared the misuse of prescription opioids an epidemic. Four years later, in 2017 the opioid epidemic was declared a national public health emergency (Salmond 2019). Between 2020 and 2021, the opioid overdose death rate increased by over 15% and the synthetic opioid overdose death rate increased by over 22% (CDC-Understanding the epidemic).

The dramatic increase in opioid sales was the result of pharmaceutical companies that overproduced and oversupplied opioid drugs for huge profits, pharmacies that filled the prescriptions, and health care providers who overprescribed the medications (Judd 2023). In rural areas many physicians overprescribed opioids to patients who travel long distances for treatment, do not have the ability to attend frequent appointments, and do not have alternative pain management interventions in their area (Judd 2023). Large quantities of prescription opioids exacerbate the opioid epidemic in the U.S. as 50-75% of non-medical opioid users have diverted drugs from friends or relatives with a prescription (Schafer 2021). According to the 2019 National Survey on Drug Use and Health, over 10 million people use prescription opioids for non-medical reasons annually (Schafer 2021). Diverted prescription opioids were involved in over 40% of opioid overdose deaths in 2016 (Schafer 2021). In most cases, medical schools do not provide enough training about pain management, especially the relationships between tolerance, physical dependence, and addiction with opioids, best practices for opioid prescriptions, and other pain treatment strategies (Volkow 2016).

It was not legal for pharmacies and health care facilities in the U.S. to accept unused prescription drugs for disposal until the Controlled Substances Act was amended with the Secure and Responsible Drug Disposal Act of 2010 (Kinrys 2018, US Congress 111-273). The Secure and Responsible Drug Disposal Act of 2010 gives the Drug Enforcement Administration (DEA) authority to create, regulate, and propose new opportunities for proper drug disposal such as take-back programs, mail-back programs, and permanent, secure drop-boxes (Kinrys 2018). This federal legislation addressed proper medication disposal practices in response to increasing prescription medication misuse, especially among teenagers using prescription opioids, and unintentional overdose deaths (Kinrys 2018). In October 2014, the DEA implemented Final Rule 9 allowing pharmacies and health care locations to register as designated sites for proper drug disposal programs and as of February 2016, there are 882 locations registered as collectors with the DEA (Kinrys 2018).

Research studies have detected pharmaceutical drugs in streams across the U.S., including antidepressants, antibiotics, antihypertensives that treat high blood pressure, analgesics or painkillers, and endocrine-disrupting drugs that alter hormones (Karim-Nejad 2022). Concentrations of pharmaceuticals have been found above detection limits in surface, drinking, and groundwater in many countries in Australia, Africa, Asia, Europe, North America, and South America (Karim-Nejad 2022, NCCID-Qadar 2021). Globally, efforts to improve environmental sustainability in health care are growing and proper drug disposal programs are needed to preserve water and soil quality and to maintain ecological systems (Karim-Nejad 2022). The U.S. Environmental Protection Agency has labeled many pharmaceuticals and personal care products, especially compounds that change normal hormonal function, as contaminants of emerging concern because of potential effects on aquatic life (US EPA-PPCPs).

• What proper drug disposal opportunities are available in your community? How are your local proper drug disposal programs addressing barriers to participation, including fear of law enforcement, time and cost constraints, and lack of awareness?
• What educational opportunities are available for pharmacists and health care providers to learn about the need for and availability of proper drug disposal methods?
• What outreach and educational efforts exist in your community to improve public use and awareness of proper drug disposal opportunities?

Several states have legislation that authorizes and guides proper drug disposal programs for consumers, such as Maine (ME Statutes 22 604), Ohio (OH HB 93), and Washington (WA HB 2600). Some states have legislation that prohibits health care institutions from flushing unused medications into public wastewater, as in Illinois (IL-SB 1919). Other states provide public guidelines and educational materials about proper drug disposal, such as Connecticut (CT-Medicine disposal), Florida (FL-Unwanted medications), New York (NY-Proper drug disposal), and New Jersey (NJ DEP-Medication disposal). Some states also offer maps for residents to find nearby take-back locations, as in Michigan (MI EGLE-Drug disposal). As of 2023, 44 states and Washington, D.C. have laws establishing prescription drug repository programs, which allow unused medications to be donated instead of discarded and avoids improper disposal methods; donated drugs can be used to increase access to affordable medication (NCSL-Drug repository).

The DEA has two drug take-back events each year; since 2010, the DEA has collected 4.8 million pounds of prescription drugs on only 9 days (US DEA Public affairs 2014). In 2016, the DEA set a record, collecting about 447 tons at almost 5,400 sites in all 50 states (US DEA Public affairs 2016). Sheriff's offices also host regularly scheduled drug take-back programs for the public. Operation Medicine Cabinet in Broward County, Florida is one example (Broward Sheriff-OMC).

October 22nd is National Prescription Drug Take-Back Day; in 2016, more than 5,000 collection sites nationwide participated. Private organizations have also established permanent drug disposal receptacles. For example, Walgreen’s pharmacy has over 500 collection kiosks at pharmacies in 35 states and Washington, D.C. (White House-Botticelli 2016).

AMCC-Rx drop - The American Medicine Chest Challenge (AMCC). Use the search tool to find the drop off location closest to you!

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* Journal subscription may be required for access.

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