Strategic communication, design, writing, editing, Web development

Durham, North Carolina

home > portfolio > writing > medication disposal

An Advocate for Safe Medication Disposal

In the summer of 2008, a preceptor at Bryan Pharmacy in Carrboro, North Carolina, showed PharmD student Sherry Yang an article about medication disposal and asked her to develop a handout on the subject for the pharmacy’s patients. It was the first time the issue had come to Yang’s attention.

Less than two years later, Yang, now in her fourth year at the UNC Eshelman School of Pharmacy, has become a passionate advocate for more attention and action on the issue. She has studied the problem, published papers, made presentations, helped with medication-return programs, and even successfully lobbied for curriculum changes.

“I’ll probably become known as the person who won’t shut up about medication disposal,” she says.

Getting SMARxT about Medication Disposal

Pharmacies try to avoid overstocking medicine, and when they do have unused medications, most are able to send them back to the manufacturers for credit. That option, however, is not available for patients with leftover medicines. Under Drug Enforcement Administration regulations, controlled substances — including many prescription medications — can only be transferred among DEA registrants, which include everyone in the drug-distribution chain from manufacturers to pharmacists. Patients, however, are not DEA registrants. Therefore health-care professionals are not allowed to take back controlled prescription drugs from patients.

“Patients might pass away or they might get changed to different medications, and they don’t know what to do with their leftover medicines,” says Kelly Scolaro, PharmD, a clinical assistant professor at the School. “When they come to the pharmacy, they ask, ‘Can you take this back? Can you throw this away for me?’ It’s a lot of confusion on the consumers’ part and the pharmacists’ part, and nobody knows what to do.

“It is a problem, especially with controlled substances because the way the laws are written and the way we are obligated to obey those laws. You can try to help someone but then you might put your license in jeopardy even though you are trying to do the right thing.”

To add to the problem, unless patients specifically ask about it, they almost never get information about medication disposal when they pick up their prescriptions, says Stefanie Ferreri, PharmD, a clinical associate professor at the School who also practices at Kerr Drug.

“There is a huge need for education about proper medication disposal for this very reason,” Ferreri says.

Flushing had traditionally been a recommended way for patients to dispose of unused medication on their own because it’s easy and it keeps the drugs out of the wrong hands. However, medications that are flushed or poured down the drain can end up in the water system. In 2002, the U.S. Geological Survey published a study that reported low concentrations of chemicals, including hormones, steroids, and other human and veterinary drugs, in 80 percent of the 139 streams studied.

The article that Yang got from her preceptor at Bryan Pharmacy discussed an alternative — SMARxT Disposal, a campaign to discourage people from flushing their medicines. SMARxT guidelines recommend crushing most medications; mixing them with kitty litter, sawdust, or coffee grounds; sealing them in a plastic bag; and putting them in the trash.

Developing the handout about SMARxT piqued Yang’s interest in the issue, so she went online to see if there were any medication-disposal programs in North Carolina. She found nothing.

“That’s how I started to know about medication disposal being an issue,” she says.

Part of the reason Yang had never heard about medication disposal being a problem before was because it wasn’t covered in class. The topic has traditionally received little attention in the classroom, says Scolaro, who directs the School’s Pharmaceutical Care Lab, where students acquire skills through hands-on activities and interactions.

“Ten years ago, when I was in school, we never talked about it, and I think it was because we didn’t really think of it as a problem,” Scolaro says. “People were just flushing their meds down the toilet if they didn’t want them. There were so many other things we had to learn about in the curriculum, and medication disposal just wasn’t considered important enough to make time in the curriculum for it.”

That has begun to change at the School, thanks in large part to Yang’s advocacy. She made a presentation about the issue at a faculty meeting in the summer of 2008, which caught the attention of Scolaro and fellow faculty member Lisa Dinkins, PharmD, both of whom have been advising Yang on her work since.

“Lisa and I have been helping Sherry with her publications, but she made us both say, ‘Wait a minute, we need to teach this,’ ” Scolaro says.

Since fall 2008, Dinkins and Scolaro have adjusted their Pharmaceutical Care Lab courses for first-year PharmD students to add more emphasis on medication disposal. For instance, during role-play exercises, students playing the part of the pharmacist are now expected to tell the patients what to do with leftover medication. Also, Scolaro and Dinkins are pointing students to online resources, such as the SMARxT guidelines, which they can reference when they are out in practice.

“Lisa and I are both very committed now that Sherry has opened our eyes,” Scolaro says. “Really, Sherry was the impetus for this.”

Take-Back Programs Slowly Moving Forward

The fall after Yang’s stint at Bryan Pharmacy, one of her instructors pointed her to the Maine Benzodiazepine Study Group. Yang attended the group’s International Symposium on Pharmaceuticals in the Home and Environment in November 2008 and was the only person from the Southeast who attended the track focusing on drug return and disposal.

“I learned a lot when I was there, hearing what the other states are doing and learning what kind of campaign effort has been done nationwide on medication disposal,” Yang says. “I felt like if other states can do it, why can’t we do it? And we always pride ourselves on being a pharmacy-progressive state. We are very progressive on a lot of pharmacy issues, but somehow, I feel, medication disposal is an issue that we’ve lagged on in the state.”

When she got back from the conference, Yang began talking to more people and doing more research. She published an article in the winter 2009 issue of North Carolina Pharmacist, explaining the issue of medication disposal, examining local and national efforts to solve the problem, and making suggestions on what can be done in North Carolina. She has another paper, titled “Raising Awareness of Medication Disposal in Professional Schools,” slated for publication in the March/April 2010 issue of the Journal of the American Pharmacists Association. In addition, Yang will present a poster of her work at the American Pharmacists Association Annual Meeting and Exposition in March.

There is no statewide medication-return program in North Carolina, and a 2008 white paper by Avalere Health found only thirty-some permanent and one-day medication take-back programs in the United States, along with a couple of mail-back programs. Part of the challenge is finding sustainable funding, but one of the biggest hurdles is the DEA regulations that prohibit health-care professionals from taking back medications from patients.

Yang says the DEA recognizes this problem and is working to tweak the policy, though she expects changes to be slow in coming. In the mean time, many of the take-back programs get around the problem by getting law-enforcement officers and local DEA branches involved in their events.

“It’s a little different in every state even though the DEA is a federal agency,” Yang says. “Right now there is not a guideline on how to run a medication-disposal program, so every state has to figure out a way that will be legal and follow the DEA regulations.

“I think that’s one of the reasons why a lot of states aren’t focusing on this issue. Because there’s no guideline or policy, if you want to do that, you are kind of on your own, and some states would rather not touch it and just wait till the federal government has something firmer and clearer.”

In the absence of a statewide program, local one-day take-back events have popped up around North Carolina in the last couple years, and Yang has been an active participant. In October and November of 2009, she volunteered at take-back events in Chapel Hill, Charlotte, Mars Hill, and Wilmington. The events allowed people to bring their unused medications to a designated site, where organizers collected them and took them to an incinerator to be destroyed.

“Whenever someone came in, they usually had a big bag or a box,” Yang says. “They are always very grateful to have that kind of place to get rid of their medication. So there’s definitely a need.”

Some of these events also gathered data on the medication they receive. Yang is hoping such information will help shed more light on why people have significant amounts of leftover medication in the first place.

“I feel that right now, what we are seeing on medication disposal is just the tip of an iceberg,” she says. “There’s a whole issue hiding behind it: Why do we even have that much medication left? Because we don’t have that data, we don’t really know where exactly these medications are from and why they are left over.”

While doing rotations in different parts of the state during her PY4 year, Yang has discovered more take-back programs, but they are all one-day events and very localized, which she says limits the amount of coordination and information exchange among the organizers.

“I would like to see not a bigger but a more connected effort and take what we are doing in the state and bring to it a nationwide perspective,” Yang says. “Other states are doing other things, and it would be great if we can learn from them and they can learn from us.”

Growing Awareness

Reports about pharmaceuticals in the water have generated a lot of buzz in the last couple years as the focus shifted from rivers and streams to drinking water. In 2008, the Associated Press reported that the drinking water of at least 41 million Americans contained minute concentrations of an array of antibiotics, sedatives, sex hormones, and dozens of other drugs.

Those findings spurred government action in 2009. The Environmental Protection Agency listed 13 pharmaceuticals — mostly sex hormones — as candidates for regulation in drinking water. The agency also began a survey to check for 200 contaminants — including 125 pharmaceuticals or related chemicals — at water-treatment plants around the country. The National Toxicology Program is also conducting research on the human health effects of drugs at low levels in the environment.

As the spotlight shines on the quality of drinking water, the issue of medication disposal has received greater attention as well. The Food and Drug Administration has updated its list of waste drugs that should be flushed and has stated that it wants to work toward the return of all unused medications. The White House Office of National Drug Control Policy also revised its guidelines to put more emphasis on medication disposal.

“Instead of one line about medication-return programs, it has a paragraph,” Yang says of the ONDCP guidelines. “They are working their way up a little bit at a time. It’s actually a big breakthrough on the regulation part. The federal government is seeing a lot of states doing their small, localized medication-disposal programs, and now they’ve actually started recognizing that as a way for safe disposal. So even though it’s just one paragraph in the regulations, it’s a big step.”

While the environmental concerns are making headlines, Yang sees them as only a secondary issue when it comes to medication disposal. For one thing, flushed medications are hardly the only source of pharmaceuticals in the water. The AP reported in 2009 that U.S. manufacturers, including major drugmakers, have legally released at least 271 million pounds of pharmaceuticals into waterways in the last twenty years, and Yang says it is difficult to tell which portion of the pharmaceuticals in the water came from which sources. Also, even alternative disposal methods such as SMARxT could result in pharmaceuticals eventually seeping through landfills and into the water supply.

The way Yang sees it, even though SMARxT is an imperfect solution, it is better than flushing and it accomplishes one important goal — getting unused medications out of the house and reducing the chances that they will end up in the wrong hands. For her, that should be the main focus of medication disposal.

“When I first started learning about medication disposal, my whole perspective was from the environmental perspective,” Yang says. “But now I feel like medication disposal in the community has two parts. There’s the environmental part — you do not want pharmaceuticals getting into the water — and there’s also the part about medication safety. And if you really look at medication disposal itself, I really feel like it’s more about medication safety than environmental. There are environmental implications in there, but I think the bigger part is about medication safety — about not accumulating medication in your house.”

Yang, who has applied for hospital residencies, says she has developed an interest in medication safety and would like to pursue that topic in her career. And of course, she will continue working to raise awareness about medication disposal.

“When I started looking at medication disposal, it was just a one-page handout, and now it’s become a much bigger project. I see it almost as a career,” she says. “I think somebody should do it. It’s a problem, and we have to deal with it.

“When I go to those medication-disposal events, I ask the police officers and the people there why they do it. There are a lot of reasons — it’s a good public service, it’s a good opportunity to talk to the people — but when you boil everything down, it’s just the right thing to do. It’s like ‘Why do we turn off the lights when we leave the room? Because it’s the right thing to do.’ I feel that this is the right thing to do.”