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4 The highest levels detected were from nonprescription drugs.Managing Pharmaceutical Waste: A Discussion Guide for Health-System Pharmacists Overview and regulatory history The term “chemical pollutants” most often calls to mind pesticides and industrial sewage. and Firouzan ‘Fred’ Massoomi. ground. and behavior.S. and vancomycin. river tested in 1999. The study tested for 95 OWCs.1 Environmental Protection Agency (EPA) reports in recent years have cited multiple studies by analytical chemists on the problem of pharmaceutical waste. 80% contained one or more organic wastewater contaminants (OWCs). Massachusetts. Geological Survey study of Minnesota wastewater. ovaries. they have potential adverse consequences.6 In addition. and affect reproduction.S.3. and neurological disorders in children. respectively. endocrine disruption (which translates into problems with physical. is gratefully acknowledged. antibiotics. FASHP.6 In a 2000 study. The assistance of William W.. tetracycline.5 Endocrine disrupters found in U. Similarly. who served as content experts and reviewers of this document. The environmental and physical consequences of improper pharmaceutical waste management are serious. Most (82) of the OWCs were found in at least one stream sample. including water quality degradation. OWCs were found in 90% of the samples.S. all samples taken from the Ohio River contained Escherichia coli with some resistance to penicillin.. mimic hormones.S. Churchill. yet since the 1980s pharmaceuticals have increasingly been recognized as chemical pollutants of the environment. and drinking waters. development.2 In 2002. and negative public perception regarding water cleanliness. 3 ■ M A N A G I N G P H A R M A C E U T I C A L WA S T E . Nebraska Methodist Hospital.Ph. ampicillin-resistant bacteria were found in every U. waterways could have effects on future generations. Pharm. Omaha. antibiotic resistance is on the rise. genital defects. in a U. and sexual development). they interfere with normal functioning of the endocrine system (thyroid. mental. including pharmaceuticals. Human male sperm counts have dropped 50% on average since 1939. surface.. antibiotic resistance. adrenals. and there have been increases in infertility. cancers caused by hormones (breast and prostate). M. and 13% of the streams contained more than 20 OWCs. Department of Pharmacy Services. Brigham and Women’s Hospital in Boston. and prescription drugs. R. and testicles). Pharmacy Operations Coordinator. Many of the OWCs were pharmaceuticals from common prescription and nonprescription products.3 reported that of 139 streams sampled in 30 states across the country. Nebraska. Executive Director of Pharmacy Services.4 Although pharmaceutical contaminants have not been found at therapeutic levels.D.7 Samples containing the highest levels of antibiotics also contained bacteria with the greatest resistance. Kolpin et al.

By educating ourselves about this issue and the relevant regulations. The federal Resource Conservation and Recovery Act11 (RCRA) has been in place since 1976.v. a better management practice is to have nonhazardous pharmaceutical waste processed by a medical waste incinerator or a properly permitted municipal waste incinerator. Enforced by EPA. RCRA defines hazardous waste as chemicals or formulations so detrimental to the environment that they must be separated for special disposal and cannot be introduced into sewers or placed in landfills. store.”6 However. these must be considered in establishing waste streams. Outdated drugs being discarded may be also be included in this category. EPA and some states have begun stricter enforcement of RCRA and have levied significant corporate and personal fines for noncompliance and negligence. Recently. There is no statute of limitations on personal liability.14 However. pharmacists can help reduce the amount of pharmaceutical waste and potential OWCs entering the environment from hospitals and other health care organizations. this waste can be solidified and placed in a landfill. infectious waste 4 ■ placed in the “red bag” waste stream) and hazardous waste (RCRA waste stream). An exception to this is i. and dispose of hazardous waste.What can we do to prevent these products from entering our waterways and environment? Pharmaceutical waste from clinics. ampuls. In addition to RCRA requirements. hospitals. most sewage and water treatment facilities do not take pharmaceutical contaminants into consideration. setting forth strict rules for facilities that generate. many more pharmaceutical agents have RCRA-hazardous characteristics. so these wastes are left untreated to enter our surface. bags and tubing containing drugs. transport. Attempts to regulate the disposal of health care waste are not new. and health systems usually is thrown into the trash or dumped into a sink or toilet and thereby placed in the sewer waste stream. it regulates and tracks the disposal of solid waste.” “U list. and violations can involve prison sentences. or bottles. such as inhalers that use propellants. Disposal of devices used to administer nonhazardous medications. and Drug Enforcement Administration regulations. Nonhazardous pharmaceutical waste.v. unused or partially used i.9 If these drugs are not biodegraded or eliminated during sewage treatment. is another consideration. state. One reason for this is due to the fact that the RCRA hazardous pharmaceutical agent list (Appendix A) has not been updated as more agents have come to market. discontinued medications that are not suitable for reuse.12 Clearly defining pharmaceutical waste streams is the first step toward effective management. some states have regulations specific to the device and propellant used to deliver drugs. Hazardous pharmaceutical waste. for example. When permitted by both state regulations and RCRA.8 Which waste is hazardous? An environmentally sound approach to the complex issue of pharmaceutical waste management has been hampered by the distinction between medical waste (biohazardous.8. RCRA definitions must be considered. they eventually reach drinking water. In fact. any unused or partially used product is nonhazardous pharmaceutical waste. and tablets and capsules that have been dropped or spit out by a patient. solutions without drug additives.6 Discontinued medications that patients have brought from home and left are also considered pharmaceutical waste that should be disposed of in accordance with EPA. As a starting point for determining which pharmaceutical waste is hazardous.13 Examples include unused or partially used vials. ground. In Nebraska. and drinking water. these can be placed in sewer systems. Drugs deemed hazardous by federal EPA regulations are categorized as “P list.” or M A N A G I N G P H A R M A C E U T I C A L WA S T E .6 Approximately 5% of all pharmaceutical agents are considered “RCRA hazardous. Some have considered that once the manufacturer’s packaging is opened. hospitals are required to either segregate inhaler devices from the normal waste stream or puncture and triple rinse the container before disposal in the nonhazardous waste stream.10 Pharmaceutical waste can also contaminate the environment through improper incineration or landfill placement.6 The impact of these types of pharmaceutical waste on public health and the environment is unclear.

both the drug and the container that held the drug are considered hazardous and must be disposed of in an RCRA-approved container.g. vapors.6. paclitaxel). ■ Drugs meeting National Institute for Occupational Safety and Health (NIOSH) or Occupational Safety and Health Administration (OSHA) criteria. certain nitroglycerin formulations. epinephrine. Ignitability applies to an aqueous solution that contains 24% alcohol or more by volume and has a flash point less than 140 degrees F (e. selenium. and toxicity. in a commercial or compounded drug may be the culprit in regard to RCRA regulations. phenol. and no more than 1 kg/month of P-listed waste.. A large quantity generator (LQG) generates more than 1000 kg/month of hazardous waste or more than 1 kg/month of P-listed waste.. or fumes in a quantity sufficient to cause human and environmental harm (e. if a chemotherapy i.or U-listed drug. nitroglycerin. phentermine. However. and ■ Vitamins and mineral preparations with potential toxicity due to chromium. a facility must determine its “generator status. thimerosal). Some states may require a separate waste stream for infectious hazardous pharmaceutical waste. rather than the active ingredient. reactivity. it should be disposed of in a trace chemotherapy container as infectious chemotherapeutic waste. or cadmium. If chemotherapy residue cannot be removed safely from the i. bag has been hung but not completely used. lindane. although some may be considered exempt by individual states).”15 P-listed items are considered acutely toxic (e.16 A conditionally exempt small quantity generator (CESQG) generates no more than 100 kg/month of hazardous M A N A G I N G P H A R M A C E U T I C A L WA S T E . With the extra time and caution required. RCRA does not adequately regulate a number of hazardous drugs.14 Pharmaceutical waste is considered dangerous if it contains any of the following: ■ More than one P. ■ Drugs with LD50 (lethal dose in 50% of test animals) less than or equal to 50 mg/kg. such as glacial acetic acid and sodium hydroxide). benzoin. that react violently with water. choral hydrate.5 or higher (basic) (e. Even if not classified as hazardous. For example. it is the responsibility of each hospital to determine the appropriate waste stream for each new item. and selected antineoplastic waste).“chemical (D-list) characteristic.. Clearly. barium.g. As new drugs are added to formularies. Reactivity applies to waste with properties that are normally unstable and readily undergo violent changes without detonating. U-listed items are considered toxic (e. and if it can be separated from the patient-exposed sharp without exposure of the employee. physostigmine. some pharmaceutical wastes are dangerous to the environment.” RCRA defines a facility’s generator status and the associated regulations according to the amount and type of waste generated over time.16 A small quantity generator (SQG) generates less than 1000 kg/month but more than 100 kg/month of hazardous waste. Toxicity applies primarily to heavy metals that may be above maximum concentration or regulatory levels (e. ■ Chemotherapy agents. Corrosivity applies to an aqueous solution having a pH of 2 or lower (acidic) or of 12. bag.v. topical preps.g. and warfarin >3%). chemicals used for compounding.g. corrosivity. a double hazard exists.. Generator status and waste streams Before implementing a formal waste stream program. it should 5 ■ be removed and disposed of as RCRA hazardous waste. Determining the appropriate waste stream. ■ Immunosuppressants.v.. and accumulates less than 6000 kg of hazardous waste at any time.g. rubbing alcohol. selenium.. Items on the chemical characteristic list are pharmaceuticals that cause wastes with any of the following characteristics: ignitability. this may be one of the most expensive waste streams to manage. This waste must be separated for proper handling by a RCRA-permitted incinerator. nicotine. ■ Endocrine disrupters.g. not all pharmaceutical waste is considered hazardous according to RCRA definitions. or that when mixed with water generate toxic gases. When hazardous drug waste is infectious. cadmium. It is important to note that the diluent or preservative.

For example. Knowing the amount and type of waste generated. Compliance challenges Fully complying with RCRA regulations will present both operational and financial challenges for institutions. Direct care providers’ general lack of knowledge or misunderstanding of state and federal regulations is a potential contributor to noncompliance. health care organizations most likely will need to create additional waste streams. For proper handling of hazardous pharmaceutical waste. Whether or not an organization notifies EPA of its waste generation depends on the amount of hazardous waste it generates. return. Changes in prescribing practices may place additional financial burden on an institution due to additional wastes generated from these changes. the relevant state and federal regulations. and inappropriate use can have harmful outcomes. Operational challenges. In addition. Processes that require manual sorting of pharmaceutical waste are time consuming. administration. Landfills are the ultimate destination of both of these waste streams. For example.17 Pharmacies need uniform guidelines for the safe disposal of expired medications. The main waste streams that hospital pharmacists use to dispose of solid pharmaceutical waste are (1) municipal incineration of pharmaceutical packaging. RCRA hazardous waste. and infectious hazardous waste. Pharmacists’ lack of awareness or understanding of the cumulative effect of improperly disposed pharmaceutical waste on human health and the environment is an important challenge to be overcome. empty/partial vials. wastage. newer. and pharmacists should include this information in routine patient education. LQGs and SQGs must have an EPA identification number. a company that normally incinerates or autoclaves chemotherapy waste may not be set up to render RCRA waste EPA-safe. Each health care institution will need to make changes in its processes for drug dispensing. the facility can determine what improvements can be made and whether new waste streams are warranted. and disposal. Also. $4 to $8 per pound. A facility that is not in compliance with regulations for managing its listed waste could be fined $32. and (2) incineration of chemotherapy sharps and chemotherapy soft waste in a medical waste incinerator.17 All facilities must review their current policies and procedures to ensure compli- M A N A G I N G P H A R M A C E U T I C A L WA S T E .17 Educating health care professionals about the issue. Only 5% of the 100 pharmacies surveyed had consistent recommendations for their patients on drug disposal.500 per day. failure to institute guidelines for proper segregation of waste and to educate staff about them can be expensive. and so forth. Complying with RCRA regulations may place an additional financial burden on health systems. the regulations state that RCRA waste must be incinerated by a facility approved by EPA for managing this waste. institutions may face fines for noncompliance.18 A survey of consumers and pharmacies about medication disposal habits revealed 6 ■ Financial challenges. Potential solutions New waste streams. chemotherapy waste (yellow containers). Pharmacies had specific policies for expired or undispensed pharmaceuticals but lacked uniform guidelines on disposal. potentially dangerous to the sorter. $4 per pound. and labor intensive (for data entry and database management as well as the actual sorting). empty/partial glass and plastic bottles. Compliance with the regulations is a best management practice for hazardous pharmaceutical waste. RCRA regulates how these waste streams should be used. and the consequences of noncompliance will go a long way toward promoting more effective pharmaceutical waste management. ointments. Medical waste (red sharps containers) costs 18 cents to 35 cents per pound. $2 to $4 per pound. and they may not be in compliance with regulations. because processing costs vary significantly by type of waste. a variety of disposal methods.waste and no more than 1 kg/month of P-listed waste.19 It was apparent that the patients had not been properly educated about pharmaceutical waste disposal. more toxic pharmaceuticals may require more intensive waste management.

minimize amounts of unwanted or expired medications22 (original and repacked containers). Pharmacies can also minimize the amount of pharmaceutical waste by using reverse distribution. and disposed of by a specialized broker and a federally permitted RCRA incineration firm. Reverse distribution. The burden for proper disposal thus shifts to the reverse distributor. Facilities should contact their state EPA or regulatory body to learn what requirements apply. prepare patient-specific oral syringes instead of prepacks. infectious hazardous and compressed gas aerosols should be considered as separate waste streams. and bar-code scanning technology may be useful in the development of safe and effective pharmaceutical waste management streams. centralize disposal of physicians’ samples.16. use multidose vials. The team could serve as the facility’s liaison with the regional EPA office and possibly with the state environmental or sanitary office and outside consultants.g. and risk management alerts based on professional knowledge and experience. partially used nonhazardous items). the team could identify gaps in pharmaceutical waste stream management and work quickly to resolve them. State and county activity. empty medication vials that contained non-P-listed items. Online tools. in which unused but potentially usable pharmaceuticals are returned to the manufacturer for credit. Two will specifically address pharmaceuticals that cannot be disposed of in sewers.. Ignitable hazardous waste should be segregated. EPA has at least four current pharmaceutical waste initiatives. By evaluating current practices for compliance and potential harm. To help control the amount of hazardous pharmaceutical waste generated. An interdepartmental. EPA has determined that health care facilities do not have to consider returned pharmaceuticals as “discarded materials” and therefore do not have to treat them as hazardous waste. stored. transported. and D-listed wastes. chemotherapy spill clean-up materials.21 Health care facilities should rotate inventory and use the oldest stock first. and avoid unnecessary prescriptions (especially antibiotics). bulk and residue chemotherapy.ance with state and federal pharmaceutical waste management and environmental regulations. state regulation alerts where the state regulation is more stringent than the federal. Items that do not require special handling can go into the municipal trash or sewer system (e. and nonhazardous pharmaceutical waste. automation. Waste management team. Smith8 has used diagrams to illustrate current and potential waste streams. properly labeled. New pharmaceutical waste management streams would include P-. However.15 Pharmaceutical waste processed through reverse distribution does not count toward a facility’s hazardous waste generator status. 7 ■ Inventory management. U-. unit dose packaging for non-Plisted items. multidisciplinary team could be formed to be accountable for maintaining compliance with RCRA and state regulations. For example. Empty containers of nonhazardous items can also go in the trash. toxic hazardous waste.20 Computerization. Many states and some counties have specific regulations that are much more stringent than the federal RCRA regulations. more comprehensive tools must be developed to meet the needs of health care facilities across the nation. Waste management companies have made resources available on the Internet to assist pharmacies in cost-effective and compliant segregation of waste streams. Implementing a plan Organizations that implement a comprehensive pharmaceutical waste management plan can realize several benefits. minimum inventory levels should be maintained. In addition. Pharmaceuticals requiring special disposal can be identified through online databases that enable searches by NDC number and product or generic name. EPA initiatives. ignitable hazardous waste. the Joint M A N A G I N G P H A R M A C E U T I C A L WA S T E . which must comply with Return Industry Association (RIA) standards.15 To facilitate this process.8 Also available online are recommendations citing federal regulations and recommended waste streams.

Hazardous waste storage accumulation sites should be in the same locked area that houses mercury.) Monitoring compliance Some hospitals have posted a quick reference guide near disposal areas to help staff comply with pharmaceutical waste disposal practices. exposures. formaldehyde. such as ignitable and toxic. 5. may be mixed when waste profiling is used. as well as specific DOT training to ensure that proper shipping names are used. hospitals can provide their vendor with a list of all P.30 states. but they cannot be mixed in lab packs. The hazardous waste vendor can prepare this. For all of these services. U.” Key points for implementation are as follows: 1. “The organization manages its hazardous materials and waste risk” and “organizations must identify materials they use that need special handling and implement processes to minimize the risks of their unsafe use and improper disposal. The maximum storage time should be 90 or 180 days. Institutions should either contract with a hazardous waste broker or develop internal expertise in manifest preparation and land ban preparation (preparing those agents that cannot be disposed of in the landfill).10 states. “The organization analyzes identified environment of care issues and develops recommendations for resolving them.20 states. Nonhazardous drugs and municipal solid waste that can be disposed of in sewers should not be placed in any container that requires special incineration. storage.3.24 Standard EC. Nonhazardous drugs should be segregated into non-red and non-yellow containers that are labeled “Nonhazardous Pharmaceutical Waste—Incinerate Only” and are disposed of at a regular medical waste or municipal incinerator that is permitted to accept nonhazardous pharmaceutical waste. The hazardous waste manifest is a form that has both EPA and Department of Transportation (DOT) components. protects employees and patients. demonstrates responsible care in dealing with hazardous substances and hazardous wastes. Otherwise. “The organization improves the environment of care. 2. For the disposal of controlled substances. This document indicates what wastes are being disposed of and how they will be treated prior to application to the land. Mixing of hazard classes is dependent on the capabilities of your vendor. There are two approaches to manifesting 8 ■ hazardous waste: profiling and lab packing.” Standard EC.9. facilities have the option of contracting with a federally permitted RCRA hazardous waste incineration facility or TDSF (treatment. and brings the organization into compliance with several Joint Commission standards. and other laboratory chemicals. as determined by the facility’s waste generator status. more time-efficient approach. and other related incidents.10 states.Commission Environment of Care Performance Improvement Initiative23 reduces a facility’s EPA liability and risk exposure to a minimum. this is lab packing.9.9. the practice of two health care professionals witnessing the waste should continue unchanged. (Needles and empty syringes used to administer controlled substances are discarded in a sharps container.” Standard EC. 3. the nursing and pharmacy staffs need to document what is discarded in each container to be able to include all the appropriate waste codes on the manifest. and disposal facility). A Land Disposal Restrictions form must accompany the manifest. It is used to document tracking of hazardous waste from the generator through the transporter to the final disposer. This manifest also provides emergency response information for use if a spill occurs in transit. and chemical (D-list) waste codes being generated and the vendor can precertify the list and create a waste profile. it also ensures compliance with RCRA. Proper completion of a hazardous waste manifest requires knowledge of the contents of each container of waste. 4. xylene. Hazard classes. In most states.” Standard EC. “The organization monitors conditions in the environment of care” and “establish and implement processes for reporting hazardous materials and waste spills. All possible waste codes will be listed on the manifest for a particular waste stream. Logging each item placed in the hazardous waste container M A N A G I N G P H A R M A C E U T I C A L WA S T E . This is the simpler.

M A N A G I N G P H A R M A C E U T I C A L WA S T E . Centers for Medicare and Medicaid Services. Key points for monitoring compliance are as follows: 1. EPA is considering an initiative that will prevent the placement of certain drugs in sewers. or. 2. Document the entire process. 8. In the past. Perform periodic random audits to determine level of compliance. Track costs. 7. and the results of quality assurance audits. In addition. 4. and Florida have become more active. Organizations must then develop a comprehensive plan for full compliance through segregation of waste into the appropriate waste streams. the facility might choose to use a hazardous waste broker. Washington. Hazardous waste containers must be closed at all times except when waste is being added. Conclusion Regulatory involvement and environmental concerns are causing pharmacists to take a closer look at how their organizations are managing pharmaceutical waste. then the whole container becomes P or dual waste. 9 ■ 5. As problems are identified. It is the responsibility of each facility to monitor waste stream management compliance. Track quantities of waste generated by type and location. it is vitally important to ensure that all medications are disposed of in the proper waste stream. Be prepared. Check and verify staff knowledge of program details. in case EPA or the state agency makes an unannounced visit. 3. Flush nonhazardous liquid pharmaceuticals into the sewer system. and some states have regulations that are more stringent than those of EPA. bag and clamp the tubing. facilities should perform a gap analysis to understand and formally address each issue. Infectious hazardous waste must be separated from all other pharmaceutical waste. states such as California.also helps ensure compliance with EPA and other federal or state requirements. Free liquids: Avoid squirting free liquids into hazardous waste containers. for use during state and federal audits. and the Drug Enforcement Administration can alert EPA to violations. If P-listed waste or infectious hazardous waste is placed in the wrong container. Each organization should evaluate its current waste management practices in comparison with federal EPA and state regulatory guidelines. since it is the most expensive type of waste to dispose of. New interpretations or changes in existing regulations may arise as government surveyors and health care providers and administrators exchange information. health care institutions and practitioners were given a “pass” on enforcing rigorous disposal practices. Intravenous solutions: Leave the tubing attached to the i. send them to a medical waste incinerator or appropriately permitted municipal waste incinerator. 3. and the initials or name of the person disposing of the waste and person hauling it away. including all policies and procedures. Key points include the following: 1.v. state boards of pharmacy. 2. 7. Compressed-container medications (aerosols) must be separated for safety. Pharmacists can play a significant role in reducing medication waste and solving the pharmaceutical waste disposal problem. Promote waste minimization whenever possible. name of the product. Facilities should be aware that the Joint Commission. 4. That is no longer the case. 6. To get started and keep compliance on the right path. estimated amount deposited in the container. as best management. For full compliance with a pharmaceutical waste management program. 6. 5.25 States are allowed to enact regulations that are more stringent than federal regulations. the log should include the date. Enforcement EPA is in the midst of an initiative to enforce RCRA with regard to pharmaceuticals in the same manner that has always been used for chemical plants. Check waste containers to see if drugs are discarded appropriately. Minnesota. training and competency assessment efforts.

20(5):593–5. intelligence. 23.org (accessed 30 July 2007). LLC. 22.pca. com/quality-safety/tools-services/safety/topics/pharma-waste (accessed 2007 July 2). Bertino JS. U.html (accessed 2007 September 5). Vet Hum Toxicol. 1999–2000: a national reconnaissance. Daughton CG. Presence and distribution of organic wastewater compounds in wastewater. Saljoughian M.jointcommission. Pharm. Toxicological issues associated with PPCPs.wrppn. Colborn T.S.cfm (accessed 2007 July 3).mn. Kolpin DW. web. 14. Krenzelok EP.3% M A N A G I N G P H A R M A C E U T I C A L WA S T E EPA Code Regulated Agent D004 D005 D022 D007 D024 D013 D009 D101 D011 Arsenic (5 mg/L) Barium (100 mg/L) Chloroform (6 mg/L) Chromium (5 mg/L) M-cresol (200 mg/L) Lindane (0.com/safety/topics/pharma-waste/downloads/h2e-pharma-blueprint-04-15-06. Pharmaceutical waste: disposing of unwanted medications. www. 5.org/web/20030627025308/www. Introduction—Environmental stewardship of pharmaceuticals: the green pharmacy. www.umn. VA: U. 1997.htm (accessed 2007 July 14). 19. Smith CA.ca. Tri-Tac.keepantibioticsworking. h2e-online. Daughton C.2 mg/L) Selenium (1 mg/L) Silver (5 mg/L) .html. www. www. Drugs in the environment: emission of drugs. 10 ■ Chloral hydrate Chlorambucil Chloroform Cyclophosphamide Daunomycin Dichlorodifluoromethane Diethylstilbestrol Formaldehyde Lindane Melphalan D-LISTED U151 U010 U182 U188 U200 U201 U202 U205 U206 U237 U248 Mercury Mitomycin C Paraldehyde Phenol Reserpine Resorcinol Saccharine Selenium Streptozotocin Uracil mustard Warfarin <0. Kuspis DA.131(1–2):5–17. Geological Survey. Barber LB.com/new/resources_ library. Chemosphere. 2003. 9. and survival? A scientific detective story (with new epilogue by the authors). 2002.epa. streams. Sewer disposal of pharmaceutical waste. Dumanoski D.6:17–22. New York: Penguin Group. Drug disposal.mntap.C. Waste generation of drug product sample versus prescriptions obtained through pharmacy dispensing.dtsc.cfm?refID=37598 (accessed 2007 July 3). Minnesota 2000–02. Premier.4 mg/L) Mercury (0. Pharmacology Associates. 15.pdf (accessed 2007 July 14). Pharmaceutical waste: fish don’t need anti-depressants. U.jcrinc. Disposal of hazardous pharmaceutical waste. Green S. Environ Sci Technol.org/hazmat/pharma. JCAHO Environment of Care Performance Improvement Initiative.vestara. Pharmaceutical waste management issues and solutions. www. Heberer T.gov/region5/defs/html/rcra.state. www. s/s 6901 et seq (1976).us/oea/hhw/ pharmaceuticals. 2002. II. 21.com/images/Issues_Solutions. waste reduction.org/hospital/pdf/az/ 07%20Pharms%20Waste%20(AZ). Managing pharmaceutical waste: a 10-step blueprint for health care facilities in the United States.111(5):775–85. Section on Medication Management and Environmental Care. and drinking waters. 2004.45 (6–7):957–69. diagnostic aids and disinfectants into wastewater by hospitals in relation to other sources—a review. 2003–07. Minnesota Pollution Control Agency. Risk management of pharmaceuticals entering POTWs and municipal landfills from routine hospital waste management practices. 4. University of Minnesota. Sheehan E. Vestara. Reducing pharmaceutical waste from patient care settings.pdf (accessed 2007 July 3).edu/health/94-PharmWaste.pdf (accessed 2007 July 3). Kummerer K. 2.htm (accessed 2007 July 14). Furlong ET et al. Environmental Sciences. 2000. Meyer MY et al. 12. Cradle-to-cradle stewardship of drugs for minimizing their environmental disposition while promoting human health. 2004.org/cgi-bin/ jtextd?esthag/36/6/html/es011055j. What happens to expired medications? A survey of community medication disposal. Reston. 11.References 1.com/13519/ (accessed 23 July 2007). ground. Environmental Protection Agency. 18. Resource Conservation and Recovery Act 42 U. 20. Wooliever P. Pharmaceutical waste: why is it an issue now? Environmental Protection Agency.S. Appendix A Environmental Protection Agency (EPA) Resource and Conservation and Recovery Act11 Regulated Pharmaceutical Wastes and Corresponding EPA Code Typea P-LISTED U-LISTED EPA Code Regulated Agent EPA Code Regulated Agent P012 P042 P075 P081 P204 P188 P001 a Arsenic trioxide Epinephrine Nicotine Nitroglycerin Physostigmine Physostigmine salicylate Warfarin >0. http://pubs. Pharmacotherapy.archive. Smith CA.acs. Shafir W. The Joint Commission Standards. http://www. 2001. www. 13.epa.S.3% U034 U035 U044 U058 U059 U075 U089 U122 U129 U150 This list is not all inclusive.cfm (accessed 2007 July 15). Our stolen future: are we threatening our fertility. Managing pharmaceutical waste. Pharmaceuticals. items listed may be additives to primary formulations. fate.premierinc. Lee KE. Joint Commission. Environ Health Perspect. J Pharm Soc Wisc. Hospitals for a Healthy Environment. http://www. and other organic wastewater contaminants in U. 1996. Hospitals for a Healthy Environment.S. and future directions. Occurrence.gov/esd/ chemistry/ppcp/greenpharmacy-intro. Pai MP.6:HS-22-HS-24. National Exposure Research Laboratory. www. 16. Graci DM. 2002. 17.htm (accessed 2007 July 14). hormones. 10.premierinc. 3.38(1):48–9. Myers JP. 24.36(6):1202–11. 6. 8.goc/AssessingRisk/PPCP/PPCPTox. Furlong ET. surface. Minnesota Technical Assistance Program. 25. 7. Pharmaceutical waste in health care facilities. Toxicol Lett. http://www. and removal of pharmaceutical residues in the aquatic environment: a review of recent research data. Pharmaceutical waste management. Department of Toxic Substances Control.S.

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