By Darcy Hitchcock
Most households have a box somewhere filled with old, unused, perhaps outdated drugs: the pain pills the dentist prescribed that, thank heaven, you didn’t need for more than the first day, the muscle relaxant that left you comatose, the ointment for that embarrassing rash, antique bottles of aspirin, and perhaps even prescriptions from your now deceased parent. What are you to do with these? Until recently, most municipalities would tell you to flush the pills down the toilet. The Health Department has always been concerned about diversion of medications: child poisonings, medications given to relatives, and in the case of controlled substances, concern about the illegal drug trade. Flushing the pills seemed a way to keep drugs out of the wrong hands, but no one was concerned about the environmental impacts associated with this practice.
What happens when you flush medications? The wastewater treatment center isn’t set up to filter out these drugs, so they end up in our waterways. The USGS did a sampling of waterways across the country and found a disturbing number of drugs and other pollutants: steroids, non-prescription medications, hormones as well as other products such as plasticizers, fire retardants, insect repellant and detergents. Even caffeine, dispensed by your local Starbucks instead of the pharmacy, pollutes our streams.
While some argue that these pollutants aren’t harming human health (yet, anyway), there is emerging evidence that they are harming various aquatic organisms. Scientists are finding male fish growing eggs on their testes, but since the fish are also being laced with Valium, perhaps they don’t have to be depressed about their compromised sex organs. Furthermore, new research from the University of Wisconsin-Madison shows that minute concentrations of antibiotics and other drugs, in a variety of combinations, can kill, disrupt, alter and disfigure the bodies and reproductive abilities of Daphnia, a small invertebrate considered a keystone of freshwater food chains. Scientists are finding impacts at much lower concentrations that usually assumed.
If we wait for the scientists to study the effects of every pharmaceutical pollutant on snails, salamanders and salmon (and I’m just listing the S’s), we will never solve the problem. This seems a prudent place for the Precautionary Principle. Few would think it was a good idea to have anti-depressants, birth control pills, narcotics, and antibiotics in our rivers. Can’t we at least reduce the amount that is ending up in Nature?
There appear to be at least three major pathways for the drugs to end up in nature:
It is apparently technically feasible but expensive to remove drugs from the wastewater system. This will probably be the only way to deal with drugs passing through our bodies. However, this process is likely to result in sludge with concentrated amounts of drugs that then will also need to be disposed in a safe manner. So this is only a long-term and partial solution.
What can be done now? While may not be able to stop drugs from passing through our bodies and no one wants to go back to the pre-anesthetic, pre-antibiotic days, we certainly can shift our agricultural/ranching practices and stop flushing unused medications.
Regarding livestock drugs, many major buyers such as McDonald’s are establishing policies to limit antibiotic and hormone use. Denmark passed legislation to phase out antibiotics in livestock. The World Health Organization found that this reduced antibiotic use by 54% and significantly reduced antibiotic resistance in the animals, The growers discovered that practices such as raising a batch of chickens at the same time and then thoroughly cleaning the area reduced the need for these drugs without significantly affecting the growth rates.
In the US, the FDA recently outlawed the use of a Bayer antibiotic on livestock because of concern over antibiotic resistance. So what is needed here is more awareness and stronger pressure to change livestock practices.
Unused household and institutional medications are a much more complicated problem. First, the problem is getting worse. As the population ages, drug use increases. Since geriatric patients usually take more medications, they often also have more drug interaction problems that then lead to left-over supplies as they stop one and start another. Nursing homes and hospice centers end up with piles of pills when a patient dies. According to research, these long-term care facilities often do not know about existing regulations governing the disposal of their medications and instead have come up with creative methods. One facility had nurses injecting drugs into linen to prevent it from being diverted; but this of course, just ends up back in the wastewater. The situation is getting worse at home, too; most health plans now encourage the use of mail-order pharmacies that send you a three-month supply, whether you need it or not.
Then there is the problem of regulations. The Drug Enforcement Agency (DEA) requires that any controlled substances be tracked to the end-user and a DEA agent present to witness destruction when the substance is disposed. The Controlled Substances Act does not allow the end-user to return their unused drug to a pharmacy, only an exempt law official. This requires the public to know what is a controlled drug versus one that is not and severely limits what can be done with unused medications. Pharmacies already have a ‘reverse distribution chain’ where they send their overstock or out-of-date medications back to the manufacturer or a disposal site. But if a citizen brings them unused medications, it is now considered ‘waste,’ not ‘product’, and so requires a permitted hazardous waste vendor to manage it. If we could overcome this verbal slight-of-hand, the pharmaceutical companies would then be responsible for their own product from cradle-to-grave, or perhaps from cradle-to-cradle. It could potentially be cheaper to make new drugs out of old drugs using green chemistry techniques, but the FDA apparently approves not only the drugs but also the process to make them. So the pharmaceutical companies would need a huge incentive to jump through that approval process again. And anyway, technically it’s not legal to give anyone else your prescription drugs, even if for disposal.
Despite all these hurdles, some are still finding a way to make progress. British Columbia, which doesn’t have to adhere to our DEA restrictions, simply passed Product Stewardship legislation requiring that companies take back drugs, paints, pesticides and other products. Several other countries have done the same. Several communities on the East Coast, including in Maine and Massachusetts, have organized neighborhood drug disposal drives where a law enforcement agent could be present (but at least in some cases, the DEA didn’t want them to promote it because they didn’t want the bad guys to know about it.) Costco announced in a recent newsletter that their pharmacies would take back medications but a quick call confirmed that this was new news for the local pharmacist!
Europe is trying to nip the problem in the bud by proposing that eco-toxicity assessments be done early on in the testing of new drugs. It begins with an assessment of the probable aquatic concentration of the drug to rule out certain products like vitamins that are not as much of a concern.
In Portland, Oregon, Metro will accept medications as part of their household hazardous waste program and the DEA has allowed the program as long as the collection of controlled substances is minimal and incidental. Vancouver, Washington takes non-controlled substances through their household hazardous waste program but now requires controlled substances to go to the Sheriff’s office for disposal. (Vancouverites have to decide if their cough medicine is a controlled substance or not.) Both of these programs are inconvenient and not well advertised; they have collected only small quantities of unused drugs.
Two programs are worth watching. A coalition of government and non-profit groups is piloting a drug take-back program through a local pharmacy chain and a medical facility chain with the hope of creating a convenient take-back model. They are also looking at a program for nursing home chain as well. Arkansas recently passed legislation allowing the diversion of drugs to the poor. If managed well and with appropriate protections, this could potentially reduce Medicaid costs.
Once you collect unused medications, there is still the question of what to do with them. Arguments continue over what is the best disposal method. Many, including the Australian National Health and Medical Research Council, view incineration as the best option, but burning all those little brown plastic bottles can create other problems. It’s possible, of course, to separate those two waste streams. Pharmacists are not allowed to refill your prescription bottles, so without a change to the law, reuse isn’t yet an option. So down-cycling would be the only practical option outside of tossing them in landfills.
Some municipalities currently prefer dumping medications in a landfill, preferably one permitted and lined for hazardous waste. Michigan currently has a flier showing citizens how to obscure their bottles and dump them in with their household garbage.
To put it in a nutshell, we haven’t solved this problem. We still need a convenient, logical, and legal solution that protects both human health and the environment. It seems as if for every ‘logical’ solution, there is a regulation in the way. The only way to solve this is to make it a priority and bring together all the relevant parties to craft a solution.
The pharmaceutical companies are starting to become concerned about these issues. Drugs have become a targeted area for the Product Stewardship Institute, a group that represents many municipalities around the country. In Oregon, ACWA, the trade association of major wastewater facilities, is hoping to undertake an assessment of the problem. In Portland, Oregon, I’m working with a number of associates at the Zero Waste Alliance to investigate how our collective experience with multi-stakeholder dialogs and product stewardship could help uncover solutions for drugs and personal care products. If you want to learn more, please investigate the resources below.
For an excellent overview of the issue, see ‘Cradle-to-Cradle Stewardship of Drugs for Minimizing Their Environmental Disposition While Promoting Human Health. II. Drug Disposal, Waste Reduction, and Future Directions’ by Christian G. Daughton, Environmental Health Perspectives Volume 111, Number 5, May 2003
Pharmwaste listserve is a great place to share in the dialog. To get on, contact Laurie.Tenace@dep.state.fl.us.
For the Arkansas redistribution program for unwanted meds to the indigent, go to http://www.arkleg.state.ar.us/, click on “acts”, then “full text of acts”, then enter the number “162” to view this state’s initial approach at re-distributing medications that are un-used/un-expired and unwanted by the original buyer.
For the USGS study on pollutants in our streams, see ‘Pharmaceuticals, Hormones, and other Organic Wastewater Contaminant in US Streams, 1999-2000: A National Reconnaissance ’ which was published in Environmental Science & Technology 2002, 36, 1202-1211. (http://pubs.acs.org/hotartcl/est/es011055j_rev.html). You can also learn more about drugs and emerging contaminants at the USGS website (http://toxics.usgs.gov/regional/emc).
For an overview of the British Columbia product stewardship efforts on pharmaceuticals and other products, go to http://www.wlapwww.gov.bc.ca/epd/epdpa/ips/pdf/prodstew_plan.pdf
For information on Denmark’s phase-out of antibiotic use on livestock, see http://www.keepantibioticsworking.com/library/uploadedfiles/KAW_News_Release_on_WHO_Report.pdf