[health-vn] Feature: Getting At Pollution Due to Drug Disposal [USA]
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Fri May 8 00:12:01 EST 2009
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Subject: Feature: Getting At Pollution Due to Drug Disposal
Date: Thu, 7 May 2009 06:15:43 -0700
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*For Old Drugs, New Tricks
* Advice Veers Away From Flushing Unused Pills
By Susan Q. Stranahan
Special to The Washington Post
Tuesday, May 5, 2009
At the Leesburg Pharmacy, located in a Loudoun County strip mall, a big,
round fish tank sits atop the prescription counter. There are no fish
inside, not even any water: The tank is a repository for unused
medications. People can drop off the Vicodin that didn't get used once
the pain of a root canal subsided. Or the heart pills remaining after a
grandmother's death. Or an asthma inhaler that had passed its expiration
date. Or an antidepressant that turned out to have unpleasant side effects.
Once a week, the tank is emptied; the drugs are packed in cartons by
pharmacy personnel and ultimately incinerated by a commercial waste firm.
"Our customers are thrilled because they had no idea what else to do
with this stuff," said Cheri Garvin, chief executive of the
These are customers who are trying to do the responsible thing. Over the
years, Americans have been alerted to the dangers of a lot of
problematic waste materials -- paint thinner, batteries, air
conditioners. But leftover pills can seem so small, so easily
disposable, that many people routinely flush them down toilets, wash
them down sinks or throw them in trash that goes to a landfill.
And then they often end up in places where they shouldn't be, like the
public water supply.
The average American takes more than 12 prescription drugs annually,
with more than 3.8 billion prescriptions purchased each year, according
to the Kaiser Family Foundation. The most commonly cited estimates from
Environmental Protection Agency researchers say that about 19 million
tons of active pharmaceutical ingredients are dumped into the nation's
waste stream every year.
The EPA has identified small quantities of more than 100 pharmaceuticals
and personal-care products in samples of the nation's drinking water.
Among the drugs detected are antibiotics, steroids, hormones and
antidepressants. Last year, the Associated Press reported that trace
amounts of drugs had been found in the water supplies of 24 major
metropolitan areas; water piped to more than a milllion people in the
Washington area had tested positive for six pharmaceuticals.
The EPA does not require testing for drugs in drinking water and has not
set safety limits on allowable levels. While the minute quantities now
being detected appear not to pose an immediate health risk, according to
federal authorities, "there is still uncertainty about their potential
effects on public health and aquatic life" over the long term, the EPA's
water chief, Benjamin Grumbles, told a Senate committee last year. But
the impact of long-term exposure of drugs on humans as well as on other
species is less clear. Hormone-disrupting pharmaceuticals, for example,
are one possible cause of a high incidence of "intersex" fish in the
Potomac River basin: male smallmouth bass producing eggs, females
exhibiting male characteristics.
Until recently, federal guidelines recommended that surpluses of highly
toxic medications be flushed down the toilet; the same advice applied to
drugs with a high potential for abuse or "diversion" -- the industry's
word for what happens, for example, when kids help themselves to the
OxyContin or Percocet in their parents' medicine cabinet. For other
drugs, consumers have been directed to adulterate the medication by
mixing it with an unpalatable substance -- such as cat litter or coffee
grounds -- and put it out with the household trash.
But this spring, concerns about pharmaceuticals in the water supply led
the Office of National Drug Control Policy to amend its advisory,
telling consumers to avoid flushing unless the label or patient
information specifies that method of disposal. The new guidelines still
describe the cat-litter method of putting drugs in the trash, but they
also encourage consumers to make use of community drug take-back programs.
And that's the problem: In much of the country, including the Washington
area, drug take-back sites like the Leesburg Pharmacy are almost
impossible to find. An informal survey of the District and 10
surrounding jurisdictions turned up no city- or county-organized drug
"We are farther ahead with recycling our garbage than we are with
recycling drugs," said Babs Buchheister, the nursing director of Calvert
Fairfax and Prince William counties have prepared safe-disposal
information for residents, available on county Web sites. Their advice
echoes the new federal recommendations. "Like a lot of jurisdictions,
we're keeping an eye on chemicals and drugs that may be in our water,"
said Brian Worthy, a Fairfax County spokesman. "That's the reason we're
encouraging people not to flush their medications."
The Washington Metropolitan Council of Governments has studied a
regional drug take-back program, according to Steve Bieber, a staff
water resources manager. "It is a complicated issue, and there are a lot
of potential hurdles," Bieber said. "It's just not something that's
gotten to the point that we have any ideas ripe for regional consideration."
A major hurdle in any take-back program is what to do with controlled
substances -- for example, morphine -- which constitute about 10 percent
of all prescription medications in this country. Under Drug Enforcement
Administration rules, a third party -- beyond the patient and pharmacist
-- may not legally have possession of such drugs. Thus, a family member
or caregiver cannot return an unused portion of a controlled substance
to a take-back program on the patient's behalf. And any take-back
program must have a DEA-registered representative -- a pharmacist or a
law enforcement officer -- present to accept the drug.
The problem of disposal becomes especially acute for hospice providers,
who often are confronted with a medicine cabinet full of painkillers
after a patient dies or when a drug regimen is changed.
"There is a very delicate balance with an immediate need to avoid abuse
potential versus the long-term need to protect the environment," said
Catherine J. Woods of ExcelleRx, a Philadelphia medication management
company that serves 800 hospices nationally. "They are both legitimate
needs." Woods said hospice workers often feel forced to flush the drugs
simply because there is no other convenient alternative.
Clarifying the chain-of-custody rules is one of the key changes in the
Safe Drug Disposal Act, introduced in February by Rep. James P. Moran
Jr. (D-Va.). The bill, co-sponsored by Rep. Jay Inslee (D-Wash.), is
intended to foster state take-back programs. The bill would allow
caregivers as well as the patient to turn over regulated medications for
disposal in DEA-approved, government-run programs. The bill also would
bar pharmaceutical companies from independently recommending flushing as
a disposal method.
The goal of the bill is to eliminate obstacles to getting unwanted
medication out of circulation. The growing problem of drug diversion to
illicit users "makes the issue all the more compelling," said Julie
Simpson, an aide to Moran. The measure would require the DEA to create
five take-back models from which states may choose.
For now, instituting a take-back program requires determination and
persistence. When environmental concerns led Cheri Garvin of Leesburg
Pharmacy to see what she could set up, she found bureaucratic roadblocks
"The problem with this whole take-back issue, the minute you want to do
it, there are all these agencies telling you why you can't," Garvin
said. "I got indignant. I said I'd find a way."
Garvin struck a deal with a company known in the industry as a reverse
distributor, which already collected unsold and expired medications from
her drugstore and returned them to the manufacturer for credit. Under
the deal, the company would also collect medications returned by
customers (which, unlike unsold drugs, cannot be returned to the
manufacturer) and incinerate them at a waste-to-energy facility. (She
had to scramble to find a new reverse distributor after discovering that
a company she first used was putting the waste in a landfill.)
At least for now, the reverse distributor is making enough money from
the credit to cover the cost of incineration. But the cost of collection
and disposal is a commonly cited obstacle to setting up take-back
programs. In Washington state, pending legislation would have the costs
borne by the pharmaceutical industry. In Maine, which began a
groundbreaking mail-back program this year, the costs are borne by a
federal grant, supplemented with state funds.
Meanwhile, Garvin's fish tank stays on the counter, and customers fill
it up; she believes the chain-of-custody registry she maintains complies
with DEA regulations. She estimates that for every three cartons of
unsold medications from her pharmacy, there are 10 from customers, which
are hauled away every two months.
The program has been running for a year and a half. "People come in with
grocery bags full [of drugs]," Garvin said. "They've been saving them
for years, not knowing what to do. And to think, we're just a small
pharmacy in Northern Virginia."
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