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Jun
13
Sandeep Singh Dhillon
3 most common mistakes when disposing unwanted medicines – MIMS Malaysia
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The appropriate handling and disposal of pharmaceutical wastes such as expired or unwanted medicines from households, are critical to mitigate many adverse effects these Active Pharmaceutical Ingredients (APIs) may have on the human body and the environment.

The Case of Malaysia
The Malaysian government categorized unwanted or expired medicines as scheduled wastes, which are governed under the Environmental Quality (Scheduled Wastes) Regulations, 2005[1]. A guideline was published by the Department of Environment, Ministry of Natural Resources & Environment, to guide various institutions in the disposal of related clinical and pharmaceutical wastes.

However, it was proven that such tasks were not an easy feat to accomplish, especially when it came to regulating waste disposal in the common household. In fact, several studies conducted to explore Malaysians’ awareness of proper pharmaceutical waste disposal showed disappointing results.

A study conducted among Malaysian patients showed that more than half of them disposed medicines by throwing them into the trash, followed by burning the medicines [2]. A second study conducted among Malaysian university students also indicated appalling results: 93% of the respondents did not know about the medicine return program, and the majority of them chose to dispose of medicines via flushing down the toilets or sinks[3].

Accumulated evidence revealed misconceptions surrounding the issue of safe disposal of household pharmaceutical wastes, and the following are the 3 most common misconceptions held:

1. It is safe to flush medicines down the toilets/sinks
Flushing medicines down toilets bowls or sinks may help households dispose of these unwanted medicines quickly, but this is potentially harmful to the environment. Wastewater treatment plants cannot sufficiently remove these APIs from the wastewater: the ability to remove APIs differ from one plant to another, depending on the availability of necessary treatment procedures. Inappropriate treatment or disposal practice may subsequently discharge high level of APIs back into our environment[4].

Many APIs will remain in the environment for a prolonged period of time; these include carbamazepine, fluoxetine, fluoroquinolones and tetracycline antibiotics. In addition, many degraded drug molecules may become more toxic or retain similar pharmaceutical activity as the parent drugs. Scientific evidence has pointed out that even sub-lethal concentrations could bring disproportionate levels of destruction upon the environment.

A good example is the “Asian Vulture Crisis”, in which exposure to diclofenac residue which was released into the environment decimated about 95% of vulture species in Asia, which led to the banning of diclofenac for veterinary use in India. Another dangerous outcome of unregulated disposal of antibiotics into our aquatic system is the development of antibiotic resistance among the exposed microorganisms[4].

2. Mixing dangerous drugs with unpalatable substances will prevent theft and abuse
Certain prescription medicines harbour significant risks to be misused or abused, and should be safely disposed of. These medicines include strong opioids such as morphine, oxycodone and fentanyl. Typically, these are prescribed for cancer patients to alleviate their pain. However, once these medicines expire, or are no longer in need – due to various reasons such as patient death, – their disposal becomes somewhat complicated.

Some patients or family members may mix these dangerous drugs with other unpalatable substances such as dirt, coffee grounds or cat litter to prevent accidental ingestion by children or pets, but this does not necessarily prevent illegal retrieval and abuse of these highly addictive drugs if they are disposed of into the trash after mixing.

In the U.S., abuse of and the sales of unused prescription drugs is a growing problem, as stated by the U.S. DEA[5] Due to this concern, the U.S. FDA recommended a list of medicines that should be disposed of through flushing[6].

In Malaysia however, pharmaceutical wastes are divided into three classes (I, II and III). Class I waste which poses no significant hazards can be safely disposed of together with other household wastes. However, for class II and III pharmaceutical wastes (APIs which pose significant hazards or contain heavy metals) must be disposed of at the appropriate waste management facility[1].

3. It is a good idea to crush medicines before disposal
It may seem logical to crush unwanted medicines before disposing them in order to prevent accidental ingestion by children who may mistake these as sweets. However, the act of crushing these medicines is in itself dangerous to the handler.

Many tablets or capsules are designed to hold the active ingredients and prevent unnecessary or premature exposure. Once the outer layer is crushed, the APIs are released as drug particles into the air. This is particularly dangerous when the crushed tablets/capsules are designed as extended release formulation, which may release a large dose when the formulation is compromised.

Subsequent absorption into the body may happen via the handler’s skin, or through accidental inhalation of the particles. This poses potentially harmful effects to children or women of childbearing age, especially when the crushed medicines are hormones or cytotoxic drugs.

In general, the safest method to dispose of unwanted medicines is to return them to the appropriate waste disposal facilities. The Malaysian Ministry of Health has implemented the Return Your Medicines Program in 2010, where these medicines can be returned to any pharmacy counters or medicine return box provided at all pharmacies of MOH hospitals and health clinics. MIMS

Reference:
1. Department of Environment. Guidelines on the handling and management of clinical waste in Malaysia. Ministry of Natural Resources & Environment. Putrajaya; 2009.
2. Al-Nagar RA, Adel A. Patients’ opinion and practice toward unused medication disposal in Malaysia: a qualitative study. Thai J Pharm Sci. 2010;34(3):117.
3. Azad MAK, Ansary MRH, Akhter MA, Al-Mamun SMM, Uddin M, Rahman MM. Disposal practice for unused medications among the students of the international islamic university Malaysia. J Appl Pharm Sci. 2012;2(7):101–6.
4. Kookana RS, Williams M, Boxall AB a, Larsson DGJ, Gaw S, Choi K, et al. Potential ecological footprints of active pharmaceutical ingredients: an examination of risk factors in low-, middle- and high-income countries. Philos Trans R Soc B Biol Sci. 2014;369(1656):20130586–20130586.
5. Take Back Your Meds. Medicine Disposal Myths and Facts [Internet]. Takebackyourmeds.org. 2010 [cited 2016 May 15]. Available from: http://www.takebackyourmeds.org/what-you-can-do/medicine-disposal-myths-and-facts
6. US FDA. Disposal of Unused Medicines: What You Should Know [Internet]. US FDA. 2016 [cited 2016 May 15]. Available from: http://www.fda.gov/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/EnsuringSafeUseofMedicine/SafeDisposalofMedicines/ucm186187.htm#Flush_List



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