Often while admitting patients, and on subsequent visits during medication management, I have run into a familiar scenario. The time comes to assess the medication regimen, and like Sherlock Holmes, I begin asking questions. Once it is established that I want to see the patient’s medications in their bottles, the patient or caregiver directs me to a cabinet in the kitchen or bathroom, or offers a large box or basket of medication bottles and my quest begins. Which mediations are current? Which ones are discontinued, what is expired, and what is for use as needed? What do I do with all the medications that are in bottles with fill dates and expiration dates that are long passed?

Having noted that many of our senior patients have suffered through financial hardships in their lives, quite often they are reluctant to throw away medications that are expired or that have been discontinued. They feel that this is wasteful, or that the physician may decide to put them back on the medications in the future. I have also often noted that many patients do not check expiration dates on medications, both prescription and over the counter, as they should. Needless to say, we often provide teaching about throwing away medications that are expired as we identify this. Quite often, the dilemma becomes what to do with these expired and non-used medications.

The public has varying ideas of how to properly dispose of medications. According to a study by Pittsburgh Poison Center, 500 people were surveyed about how they disposed of medications. “Of the 500 people polled, 1.4% returned medications to the pharmacy, 54% disposed of medications in the garbage, 35.4% flushed medications down the toilet or sink, 7.2% did not dispose of medications, and 2% stated that they used all medications before expiration.”[1]

Another study by the Eisenhower Army Medical Center in Evans GA showed that there is a lack of clear guidance for how patients should dispose of unused and expired medications. “More than half (of 301 patients surveyed at an outpatient pharmacy) reported storing unused and expired medications in their homes, and more than half had flushed them down a toilet. Only 22.9% reported returning medication to a pharmacy for disposal. Less than 20% had ever been given advice about medication disposal by a health care provider.”[2]

Obviously, there is needed education in the community regarding proper disposal of unused and expired medications. Without this education, patients may improperly dispose of medications which can lead to contamination of groundwater, surface water, and drinking water. In 2002, the U.S. Geological Survey sampled streams in 30 states. Of the 139 streams tested, 80% had measurable concentrations of prescription and nonprescription drugs, steroids, and reproductive hormones.[3]

Patients may also continue to hoard old medications, or throw them in the trash where children or pets may find them and ingest them. This can cause serious injury including death. So what should we teach our patients to do with expired and unused medications?

The FDA gives the following guidelines:

1. Follow any specific disposal instructions on the drug label or patient information that accompanies the medication. Do not flush prescription medications down the toilet unless specifically instructed to do so.
2. Check with your local city or county government, household trash and recycling program, and/or DEA about drug take back programs. These programs allow you to bring unused medications to a central location for proper disposal.
3. If no specific disposal instructions are available, and no drug take back program is available in your area, throw the drugs in the household trash after doing the following:
   1. Take them out of the original container and mix them with cat litter, coffee grounds, or the like. This will make the medications less desirable if found by children or pets.
   2. Put them in a sealable bag, empty can, or like container to prevent them from leaking or breaking out of a garbage bag. Dispose with household trash.
4. Before throwing out a medication container, remove all identifying information from the label to protect the identity and privacy of personal health information
5. Do not give medications to your friends.
6. When in doubt on how to dispose of a medication, call your pharmacy.[4]

Some medications, such as powerful pain medications, can be toxic or deadly if ingested by someone other than for whom they are prescribed. In certain cases, these medications SHOULD be flushed for safety reasons. These drugs include Fentanyl , Demerol, Diazepam, Methadone, And Oxycontin, for example. For a complete list of medications that the FDA recommends being flushed, go to www.fda.gov/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/EnsuringSafeUseofMedicine/SafeDisposalofMedicines/ucm186187.htm#MEDICINES.

Medications in patch form, such as Fentanyl patch, should be folded in half so the sticky sides are together and flushed down the toilet. This will prevent children and pets from getting the remaining drug from the patch once removed from the skin and causing harm.[5]

Other options available for home care and hospice use include reusable disposal systems such as “Drug Buster”.[6] These instant drug disposal systems come in reusable containers, which instantly break down medications in a solution, and prevent re-ingestion. These systems allow the visiting staff to place unused or expired medications in a container, shake the solution, and dispose of the medications in the trash. The added medications in such systems are dissolved are less likely to leach into the water system if exposed.

As part of a responsible medication management system, health care professionals should assist in identification of what medications should be discarded. Education to the patient and family on how to properly dispose of medications is a vital piece of patient education that can impact the safety of the patient as well as the environment.

[1] www.ncbi.nlm.nih.gov/pubmed “What Happens to Expired Medications? A Survey of Community Medication Disposal.” Kuspis DA, Krenzelok EP. Pittsburgh Poison Center, Children’s Hospital of Pittsburgh, PA, 15213, USA

[2] www.ncbi.nlm.nih.gov/pubmed/17090787 “Patient Practices and Beliefs Concerning Disposal of Medications.” Seehusen DA, Edwards J. Eisenhower Army Medical Center, Evans, GA, USA

[3] www.calrecycle.ca.gov/HomeHazWaste/Medications

[4] “How to Dispose of Unused Medicines”, FDA Consumer Health Information/U.S. Food and Drug Administration, April 2011, www.fda.gov/consumer.

[5] Nursing 2013, May issue, Volume 43, No.5, Patient Education Series  “Medicine disposal”, p.35.

[6] www.drug-buster.com