Old Medications Are a Public Health Threat. How Can Texas Physicians Help Keep Them From Being Misused?
Tex Med. 2017;113(12):49–54.
By Sean Price
Jeanie Jaramillo-Stametz, PharmD, had just recently finished pharmacy school in 2003 when she went to work at Amarillo's Texas Panhandle Poison Center. She quickly noticed the center received a lot of inquiries about problems with legal medications.
"We were getting calls every single day about kids who were being poisoned [by medications they found at home] ― in addition to overdose calls," said Dr. Jaramillo-Stametz, who is now an assistant professor of pharmacy practice at Texas Tech University Health Sciences Center in Amarillo. "Just knowing that there were children getting into medications within the home every day, and the fact that these preventable poisonings were occurring so frequently was alarming."
Dr. Jaramillo-Stametz began researching programs that help people safely dispose of unwanted medications with the goal of creating one in Amarillo. She found some on the East Coast but relatively few in Texas. She also found conflicting regulations on disposing of medications among a host of state and federal agencies, including the U.S. Drug Enforcement Administration (DEA) and the Texas Commission on Environmental Quality.
Finally, in 2009, Dr. Jaramillo-Stametz cleared all the hurdles, obtained funding, and started holding twice-a-year Medication Cleanout days, one in the spring and the other in the fall. The program started in Amarillo and has since expanded to Lubbock and Abilene. Through 52 total events, the programs combined have taken in more than 40,000 pounds of medicines, roughly the same weight as a blue whale.
Special Agent Elaine Cesare in the DEA's Dallas office says concern about the increasing abuse of opioids ― and other narcotic prescription drugs ― has been a driving force in the effort to get rid of old meds.
"There are addicts who will contact a real estate agent and say, 'Hey, can I see a home?' and while they're in there, they're going through people's cabinets getting drugs out," she said. "It just feels good to get the curiosity out of your cabinet."
But she and other experts point out that the problem of unused and unwanted medications is just part of a much larger, more complex problem. When physicians prescribe medications, their first duty is to get their patients what they need, says Sunny Wong, MD, a Laredo gastroenterologist who has worked with the Texas Medical Association on effective ways to dispose of unused medicines. However, many health insurance policies force patients to buy more medications than they need by requiring them to buy in bulk.
"The cost of health care is going up," Dr. Wong said. "And one of the problems is the amount of drugs being given out ― whether they are used or not."
Dealing With Leftovers
Patients who hold on to leftover medications often don't understand the risk they pose for poisonings or misuse. Especially dangerous are narcotic painkillers. One study found that 39 percent of the 41,502 drug poisoning/overdose deaths in 2012 involved opioids. Meanwhile, the 2013 National Survey on Drug Use and Health found that 53 percent of people obtained opioids for nonmedical use from a friend or relative, 10.6 percent bought them from a friend or relative, and 4 percent stole them from someone they knew.
"Our medicine cabinets are the No. 1 source of medications for teens to experiment [with] or abuse," Dr. Jaramillo-Stametz said. "And there's a misperception by teens that it's better and safer to abuse a prescription medication than it is illicit drugs ― marijuana, heroin, cocaine ― when really these can be just as dangerous. Even regular non-narcotic prescriptions and over-the-counter medications can be abused and cause harm."
But those who want to get rid of old medications also have a problem: People traditionally either threw old medicines in the trash or ― to keep kids from retrieving them ― washed them down the sink or toilet. In some cases, flushing is still advised. For instance, the Food and Drug Administration (FDA) says that opioids like fentanyl should be flushed because they depress breathing in children who accidentally touch them.
But recent studies have shown that flushed medications end up in waterways and hurt wildlife. For instance, they have been blamed for the growth of antibiotic-resistant bacteria among fish species. Most of the pharmaceuticals that end up in waterways come from normal bodily excretion, not the dumping of old medicines, Dr. Jaramillo-Stametz says. However, dumping is a problem, and it doesn't just occur by flushing drugs down the toilet or sink.
"In theory, our landfills are lined so well that these medications would never leach out into our water system," she said. "But in West Texas, landfills tend to be old, and leaching can occur. So medications are getting out of the landfills and leaking through the ground into our water system as well."
For that reason, DEA, FDA, and other government agencies recommend disposing of medications at drop-off sites. But, currently, there is no all-inclusive program at the state or national level that allows people to dispose of old medications at their convenience. The Texas Legislature approved a pilot program in 2015 but provided no funding for it. At the national level, DEA coordinates two take-back days each year, one each in the spring and fall. While DEA funds the disposal of collected medications, it is up to local law enforcement to provide staff and other resources for the events.
Texas does have some local drop-off programs. (See "Where to Get Rid of Unwanted Meds.") Also, Walgreens has established some stores as drop-off sites. But many Texans ― especially in rural areas ― have no options for safe disposal other than programs like the ones run by Dr. Jaramillo-Stametz.
Earlier this year, the TMA House of Delegates adopted new policy encouraging the safe and effective disposal of medications. (See "TMA Policy on Disposing of Unused Medications.") Among other things, it calls for greater education on the topic and more study about effective and creative ways to dispose of old medications. Dr. Wong, who was instrumental in passing the resolution, says the goal is to make disposing of old medications as easy as dropping mail in the mailbox.
"The ideal situation for practices and patients is to [follow] the concept of a toner cartridge being shipped back to the manufacturer at no cost to the consumer," he said.
Beyond the Band-Aid
Dr. Jaramillo-Stametz agrees that medication drop-offs need to be simpler and easier. However, she says all drop-off programs ultimately are a "Band-Aid approach." The best solution, she says, is for physicians to prescribe less, especially for first-time prescriptions. But in many cases, the physician's hands are tied by the economics of health insurance, she says.
"A lot of this is driven by the insurance industry," she said. "The physicians are doing what they can, and they're trying to provide their patient with the appropriate medication at the best rate that the patient would like. [The patients] want the $10 copay for a 90-day supply; they don't want the $10 copay for a 30-day supply. ... It's very difficult for [physicians] to manage all that and find a compromise where the patient will be happy without creating the problem of over-dispensing and accumulation."
Physicians need to look for ways to minimize prescriptions, especially those ― like opioids ― that are frequently abused, Dr. Wong says. But it's also important for physicians to provide practical information, such as the addresses of drop-off sites, he says. Even with these efforts, Dr. Wong says, the situation is unlikely to improve without help from state and national lawmakers.
"Nothing is going to change unless there is a legislative policy passed on this issue," he said. "Pharmaceutical companies and/or the pharmacy benefit managers should be responsible for cleaning up the amount of unused meds that is floating out there in the public domain."
Dr. Jaramillo-Stametz says that some modest reforms are taking place already. For instance, CVS Caremark, one of the country's biggest prescription benefit managers, has started limiting the number of doses in first-time opioid prescriptions. But much bigger changes are needed. She says Texas ― unlike many other states ― also has no mechanism for recycling unused medications, so huge numbers of expensive prescriptions are simply being incinerated.
"We do get many meds that come into to the take-back events that are still factory sealed or sealed in blister cards," she said. "And if we had a mechanism to donate those to people who would have nothing otherwise, that's something we would like to push for as well."
But Dr. Jaramillo-Stametz says the best thing physicians can do now is educate themselves on ways to minimize the problem. She says most of the volunteers at her Medication Cleanout events are future health care workers ― medical, nursing, and pharmacy students ― who are witnessing first-hand just how many medications are wasted today.
"They get to see the true impact of all these things going to disposal because patients aren't taking their medications," she said. "It gives them a new perspective, and they realize this is a much bigger problem than they would have ever dreamed. And they carry that through to their careers."
Sean Price can be reached by phone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.
Where to Get Rid of Unwanted Meds
These three locator tools can help patients find the nearest medication disposal site:
Also, some local governments provide locations where people can dispose of unwanted medicines. Check your city or county website.
TMA Policy on Disposing of Unused Medications
In 2017, TMA adopted the following resolution on "Promoting Safe and Effective Disposal of Unused Medications."
(1) Work to educate physicians, other health professionals, patients, family members, and the public about the safe and effective disposal of nonprescription/prescription medications;
(2) Assist local county medical societies with identifying, developing, and promoting safe drop-off and drug disposal services;
(3) Develop a model bill that requires written disposal information be provided at the point of purchase or delivery of a prescription; and
(4) Convene a conference to include pharmaceutical companies and trade association representatives to evaluate programs and mechanisms for safe disposal and funding of these services.
And in 2011, the TMA House of Delegates adopted a policy stating TMA "supports state and federal legislation to allow charity, county, and other gap clinics, as well as other physicians who receive pharmaceuticals that are not controlled substances or insulin from patient assistance programs, to dispense these drugs, free of charge, with proper documentation to their own patients who are in need of such assistance."
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Disposal for Physicians
Violating safety guidelines on the disposal of unused medications can mean big headaches for physicians. See "Don't Get Waste-Deep" in the October 2017 issue of Texas Medicine.
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