When Not to Flush

Drugs were not designed to be spewed into streams and lakes, spread atop crop fields as part of a sludge-based soil amendment or buried in dirt (to ultimately be washed into groundwater). Yet huge quantities of these and related personal-care products (such as cough medicines, soaps, mouth washes, and aspirin) unwittingly end up in the environment.

A talk yesterday by Ilene Ruhoy, a physician and researcher with EPA in Las Vegas, focused on the source of the problem: us.

Everyone who’s ever been prescribed a drug has contributed to the problem. Take the medicine and some share of it will be excreted and end up in the sewer. Don’t finish the supply of medicine and you’ve now got a disposal problem.

For instance, what happens if you are given a prescription that says “for pain as needed.” After knee surgery I was prescribed a whole bottle or narcotic tablets to deal with the anticipated pain. In the end, I took two tablets and never needed a third. What was I to do with the rest?

I’m not supposed to share them with a family member in pain. I’m not supposed to self medicate for a subsequent injury. It goes without saying that I can’t sell them. Indeed, Ruhoy explained yesterday, the Controlled Substances Act — or CSA — of 1970 even prohibits my returning them to a pharmacy for disposal.

I’ve written about the occasional ad-hoc “take-back” programs that some pharmacists have privately undertaken as a public service in recent years. They’d announce a day when people could empty their medicine cabinets of out-dated or no-longer-needed drugs. One or more pharmacists would then accept the meds and send them off for incineration with other expired drugs from their own inventories. But such programs have been drying up, Ruhoy says, as the feds have pointed out that such “green” acts could constitute a felony.

So what would Ruhoy (and her EPA coauthor Christian Daughton) recommend?

First, physicians should consider ordering trial prescriptions. Perhap a scrip for two to five pills, not 18 to 24. If people need more, they can get more. Of course, I can see one consumer complaint here. Most insurance companies charge us by the prescription refill, not the number of pills provided. Hence, multiple trips to the pharmacy risks greatly upping the consumer costs for meds that aren’t taken on a chronic basis.

Drug companies should also stop offering doctors sample packs of meds, Ruhoy said. If all of those pills don’t used, these small, overly packaged samples will end up going into the trash.

At the other end of the dispensing continuum,are those big-box discount stores that sell over-the-counter medicines in bulk. No one needs to buy 500 ibuprofen tablets at once, Ruhoy argues. Their expiration date will pass long before most will have been consumed, she says. If, in some rare instance, so many are needed, she says that should probably be one neon light signaling that another trip to the doctor is warranted to understand how better to cope with or end chronic pain.

Ruhoy maintains that her medical colleagues share some responsibility for the unused-pills problem. They should pay more attention to tracking whether their patients actually use all of the pills they have been prescribed. This could make for more effective medicine, Ruhoy notes, and largely eliminate pharmaceutical waste. The “ultimate objective,” she says, should be “no leftover drugs.”

How big a deal are those leftovers? Well, data are iffy, but Ruhoy stumbled onto one indirect measure. She asked the Clark County, Nevada, Coroner’s Office how many drugs it had confiscated over a 13-month period beginning in January 2005. These were meds that had been in the homes of 1,623 people who died. The pharmaceuticals were initially reviewed as clues to potential influences behind the individuals’ deaths.

Roughly a third of the drugs turned up by home searches were for GI-tract problems, like ulcer and gastric-reflux pills. Another 30 percent were “nervous system” meds. Think antidepressants, tranquilizers, dementia drugs, and pills to manage hyperactivity disorder. Roughly twelve percent were pharmaceuticals used to treat heart ails, and another 10.4 percent were antibiotics and other agents for combating infections.

After the coroner’s investigations were completed, some 325,000 pills, tablets and capsules were sent into the sewer system, Ruhoy learned. We’re talking about more than 100 kilograms of meds that were literally flushed into the environment.

And this was from fewer than one-in-1,000 households in the local metro area. Imagine how many other drugs were out there, potentially awaiting disposal.

I know first hand how many that can be. When my mother-in-law recently died, I turned up some 18 bottles of medicines that she had squirreled away in drawers, boxes, and a suitcase pocket. This amounted to literally hundreds of pills — many mixed and unlabeled in a small bag or container. Why so many? Some were prescriptions that the doctors found didn’t work, so they substituted newer alternates. Some she simply forgot she had. Others were purchased in bulk from mail-order services and had not been used up.

Ruhoy and Daughton recommend that physicians look to personalize their prescribing policies more to an individual’s age, gender, and — one day — genetics. Drugs that work better are more likely to be used. Doctors should also routinely scout for drug interactions among their patients, because these may explain why some people stop taking prescribed meds or why they come back to their doc requesting yet another therapy to manage what turned out to be a side effect.

“The very fact that excess drugs accumulate and need disposal points to problems in the way health care is administered,” Ruhoy says. Indeed, health-care policy should lead to “the design of prescribing/dispensing practices that do not lead to the accumulation of leftover drugs.” Keep in mind, she points out, those leftovers “represent wasted medical care,” wasted health-care costs, and people who aren’t receiving all of the therapeutic benefits they deserve.

Finally, Ruhoy and Daughton ask: Isn’t there some way a legal take-back program can be developed? Perhaps via federal agencies charged with environmental protection or drug policy?

I second that. Meanwhile, what am I supposed to do with all of my mother-in-law’s old meds?