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. and 'medication disposal' in Medicines wastage the PubMed TM. . . . . . . . . . Much research has also been undertaken on the levels of pharma- 1 Tel. . . . . . . 'unused medicines'.3. . . . . . . . . . . 2010). . . . . .1. . . . .2 a School of Pharmacy and Chemistry Department. . . . .ac. .ac. Rhiannon Braund c. Patients with knowledge about the impact of pharmaceuticals in the environment were more likely to return medications for proper disposal and destruction. . . . . . Braund). . . . .. . . New Zealand a r t i c l e i n f o a b s t r a c t Article history: Pharmaceuticals have been detected throughout the environment where at least in some cases. . . 293 3. Author's personal copy Environment International 37 (2011) 292–298 Contents lists available at ScienceDirect Environment International j o u r n a l h o m e p a g e : w w w. .2. . .envint. . . . . 2006). . .1. . . . 2008. .C. Furthermore. . . . . . . . toilet or sink. .otago. . . . . . . . . such as the sink. . . 2006. .. . 0160-4120/$ – see front matter © 2010 Elsevier Ltd. . . . . PO Box 56 Dunedin 9054. . . . . . . 297 Acknowledgements . . . . . . . . . . Medline TM. . . . . . . . Lienert et al. . . . . . .braund@otago. . . . . . . . . . . . . . . . 'medicines wastage'. . . . . . . . . . . .: + 64 3 479 7927. some pharmacies around the world refused to accept unused medications or discouraged the practice. . . . . . © 2010 Elsevier Ltd. . 2008. . . Snyder. . . .: + 64 3 479 7240. . This review surveys the current peer- reviewed literature on attitudes and practices to medicine disposal methods as reported by patients and the Keywords: various medication disposal and destruction systems around the world. .10. . . . . . . . . . . . . . . . . . . . . . . . . . 297 References . . Methodology . . . . . . . . . . . . . . . . . Dunedin 9054. . . . . . pounds and their metabolites in the environment (Kasprzyk-Hordern and even though the concentrations detected are of the order of nanograms to micrograms per liter (Moldovan et al. . . . .: +64 3 479 5285. . . . . Results and discussion . . . . . . . The availability of formalized protocols for medicines disposal . . . . Tong a. . . . .1016/j. . . pose a chronic threat to human or animal health (Zuccato et al. . . . . 293 4. . . . . New Zealand b Chemistry Department. . . . . . . . . rhiannon. . . . . . . . 2009) and drinking (Benotti et al. bpeake@chemistry. . . . . quences (Pomati et al. . . . . All rights reserved. University of Otago. . . . 296 4. . . . . . . Snyder and Benotti. 2009) water. . . . 298 1. . . . . . It is concluded that it is of paramount importance that a formalized protocol for patient disposal and destruction of pharmaceuticals be implemented around the world. .. . . . . .⁎. . .. e l s ev i e r. 293 4. .ac. . . .2010. . . . . . . . . . . . . 296 5. . Contents 1. . . . . . . . . . . . . . 2009. Conclusion . . .nz (R. . . . 293 4. . . . . . . . . . . . . . . . .. . . . .nz (A. . . . . . . . . Twelve peer-reviewed articles with specified sample sizes were selected. . ceuticals in waste water and their possible environmental conse- 2 Tel.tong@otago. . . . . Kummerer. . . A literature search was carried out Medicines disposal Unused medicines using the keywords 'medicines disposal'. . Peake b. . . . PO Box 56. . . . Dunedin 9054. . . . . University of Otago. c o m / l o c a t e / e n v i n t Review Disposal practices for unused medications around the world Alfred Y. . toilet or rubbish bin. . . Search strategy . Barrie M. New Zealand c School of Pharmacy. . . .. . . . . . 2007. . . . . . . . . . . . . Peake). . Scopus TM and International Medication disposal Pharmaceuticals Abstracts TM up to the end of May 2010. . . . . . Pharmaceutical compounds have been detected in surface There have been many recent reports of pharmaceutical com. . . . . . . . . . 2007) there remains an uncertainty about whether compounds at these levels ⁎ Corresponding author. . . . . . Introduction . Introduction et al. Liquid medications were more likely to be rinsed down the sink. . . . . .nz (B. . . . . . . . . . . . . (Bartlett-Hunt et al. . . . . . . . .. . . Tong). . . . . . . . . . . . . . . Many result from improper patient disposal of unused pharmaceuticals via Accepted 2 October 2010 environmentally-unfriendly routes. . . . . . . . . . . . . . . they have been Received 18 July 2010 shown to have a detrimental effect. . . . . Methods of medication disposal . . . . . . University of Otago. . doi:10. E-mail addresses: alfred. . . . . . . . . .C. . . . . PO Box 56. . . . . . . . . . . . . 292 2. . . Influence of environmental awareness on medication disposal methods . Tel. ISI Web of Knowledge TM.Y. . . . . . . . . . . . . . . . . . . . .M. . .002 . . . as opposed to solid tablets and capsules which were more likely deposited in the rubbish bin. Google Scholar TM. The most popular methods for medication disposal were in the garbage. . . . . Much confusion exists about the 'proper' way of medication disposal as many countries do not have standard medication disposal protocols. . . Schmitt-Jansen et al. . . . . All rights reserved.. . . .

interview with participants and mailed questionnaire). 3. 2004). it is possible to infer whether such disposal practices are affected by 4. Zorita et al.. Ridout have on the environment. (Ridout et al. tionnaires (2). 2007) had a university education.. 2006. 66% environmental impact of pharmaceuticals is to be reduced then we of the participants involved in the Kuwait study (Abahussain et al. Author's personal copy A. and ‘medication disposal’ were used in searches Voulvoulis. telephone surveys (4). Only five studies between 1999 and 2009 in the US alone (Kaiser Family Foundation.. ‘ unused medicines’. 2007). 2007. Excessive prescribing by doctors (Ekedahl. Rosal et al. ticals are disposed of in the garbage. If unwanted pharmaceu. 2006) were males. 2007). Only peer-reviewed literature were considered but not medication was also a common means of disposal in Lithuania with restricted to just being written in English. al. 2007). 2009. One study employed both interview and increase from 2 billion to 3. medication and their extent of usage are summarized in Table 2.. Information environment.. The demographics of participants varied between studies. One study did not state a sample size for the participants effluent before discharge into waterways (Nakada et al. the methods for disposal of unused country).C. it is necessary to establish what are the et al. 2009. Methodology Processes employed in sewage treatment plants are often ineffective in removing all improperly disposed pharmaceuticals and therapeutic Fourteen studies were identified in the primary peer-reviewed medication excreted in unchanged or metabolized forms from literature. 2007) and another surveyed participants from town... ‘medi. 2007). is there a need for a another study only considered responses from participants if they formalized protocol for disposal and destruction of unused and were actively involved in the disposal of household medication expired medications worldwide in order to minimize their potential (Gotz and Keil. Aziz and Ibrahim. 2010). 2009). no one reported on the use of the toilet or sink as a . 2007). One study limited their current methods employed by individuals to dispose of unused and study population to middle and upper class households (Abahussain expired pharmaceuticals? Is their choice of disposal methods and Ball. Tong et al. 2009) involved randomized poor compliance to certain medicines (Lindberg et al. pharmaceuticals were necessary in their country (or if one was Pharmaceuticals may enter the environment through improper already established.. Results and discussion peoples' demographics and their knowledge of environmental issues concerning pharmaceuticals in the natural environment. Abahussain and Ball. The most common method for disposal of pharmaceuticals by 2. involving the PubMed TM.. 1996. and the impact such methods may Southampton studies in England (Sullivan and George. Sullivan and George.. 2006) may also increase the volume of unused medication. 1996). 1986) where most of the participants were skilled manual reported practices and attitudes to medicines disposal. must address the issues related to improper disposal practices. they eventually end up in The range of methods used to deliver the questionnaire to landfills with the potential to be discharged into the environment as participants included: postal surveys (3). the remaining 13 peer-reviewed studies are summarized in Table 1.. If the likely Although most studies had a majority of female participants. 2009) and thus pharmaceuticals can The methodologies used and the target populations investigated in potentially be discharged into waterways. whether they were inclined to use it). By obtaining workers.. Comeau et al. 1996. 2008). online or computerized surveys The use of pharmaceuticals is on the rise. sewage system as a means for disposal of unwanted medications (due Data obtained from the studies included the study population to the unavailability of working sewage systems in many parts of the demographics of the participants. 2010). and participants' attitudes to the disposal of However much less is known about the factors that lead to the medications when stated. The age profile of the participants also varied in all Some of the questions pertaining to the disposal of unused the studies and it was not possible to generalize the demographics as pharmaceuticals by households and individuals include: what are the such data was missing from some studies. It is also interesting to employing various types of survey instruments (such as telephone note that no one surveyed in the Lithuanian countryside utilized the questioning. Gotz and Keil. Search strategy individuals or households is disposal in the garbage and is by far the predominant method of disposal reported in Kuwait (Abahussain et The keywords ‘medicines disposal’. Scopus TM and International Pharmaceuticals medications (55%) and return of medications to pharmacies (45%) Abstracts TM databases to retrieve references published up to the were the predominant ‘disposal’ methods in a Swedish survey in 2007 end of May 2010. 2009). self-administered ques- leachate (Barnes et al. 1999.. with an estimated (3) and interviews (2). suburb influenced by any prior knowledge of environmental issues associated and rural settlements (Krupiene and Dvarioniene. and Daughton. 2007. Kim who responded and so was excluded from the review. The studies that were included contained occurrence of these pharmaceuticals in all these different parts of the information regarding the sample size of participants. ISI Web of Knowledge TM.. The bibliographies of retrieved references were also (Persson et al. Google Scholar particularly in towns and suburban areas. 2009. Unused and expired medicines often are the result of patients' Kotchen et al. and whether 2002) but another significant factor is the human disposal of participants felt a proper disposal system for unused and expired unwanted medication.. United Kingdom (Bound and cines wastage’. The educational status of participants was impact on the global environment? varied. Similarly.. 2007. 2008) resulting selection of participants via various methods such as the use of an in many cases is in not taking or finishing courses as directed by the electoral register (Ridout et al. and expired medication. Sullivan and George. compared to the early by the public around the world. 2005). disposal of unused and expired pharmaceutical dosage forms in the toilet or sink (Ruhoy and Daughton. 2006. Parolini et al. Clearly a major factor is the human excretion of these was also noted regarding participants' awareness of environmental pharmaceuticals and their metabolites into sewage (Heberer et al. Studies involving both this method being utilized by 50% of the respondents living in the random and convenience samplings were included as well as studies countryside (Krupiene and Dvarioniene.. / Environment International 37 (2011) 292–298 293 2007. Home backyard burning of expired and unused searched. 2008). Li and Randak. and Aga. issues surrounding pharmaceuticals in the environment. 1997.9 billion prescription numbers yearly telephone survey techniques (Blom et al. This review 4. Medline TM. Yet with pharmaceuticals? Most importantly.. however storage of unused TM.Y.. Ruhoy through the telephone directory (Kotchen et al. Persson et al. 1986. this information from the peer-reviewed literature studies.1. but 62% of the participants in the Kuwait study (Abahussain In order to evaluate current and past medicine disposal methods and Ball. and Lithuania (Krupiene and Dvarioniene. Methods of medication disposal will also include data on the availability of formalized disposal systems as reported in various countries around the world and deduce The methods used by respondents to dispose of their unused their impact on peoples' medication disposal habits. 1996) or prescriber (Thormodsen et al. 1986.

only 19% reported toilet as the method of disposal. one address was used as the starting point for another five addresses. Washington State) computerized kiosks. 67% outliers. Mean age system. 100 rural and urban pharmacies (46 hospital-based and your expired medications”. 2009 Persson et al. between 30 and 44 years. awareness of selected households. from the electoral register. 1996 Blom et al. / Environment International 37 (2011) 292–298 Table 1 Studies and their methodologies found in the peer-reviewed literature. Gender California) medicines in the environment and chosen by generating random was evenly split. Centre. Apartments not households. 2006) many used the sink or disposal of ointments and creams into the sewage.000 (48%) person households. 1994. randomly Participant was person who disposal and whether medicine chosen from Swedish-speaking answered the phone provided disposal habits correlated with their residents in Sweden. medicines disposal. 53% female. whilst only 10% surveyed. 2009) reported that the majority of survey interview was “How do you dispose of particular classes of participants in an online questionnaire involving medicines disposal. sex and education. household medication disposal and included. instituted by the National Poisons anonymous website visitors age. 55% of non-responders after 1 month. England (Southampton) Postal questionnaire with follow-up A 1:200 random sampling drawn Participants 18 years and over. 49. Kuwait Self-administered questionnaire on Outpatients from hospital Mean age of respondents 37. prescriptions at five large hospitals..8% female.9% and 32. most (37%) skilled manual workers. the type of medication may also influence consumer The method of disposal of medication was also influenced by the disposal according to a nationwide Dutch survey in the 1990s (Blom dosage form of the medication. or returned their unwanted to have disposed of tablets and capsules in the sink or toilet and only medications to a healthcare provider or the pharmacy. it 24% of the respondents disposed of liquid formulations in the garbage. university degree. 1996 Sullivan and England (Southampton) Postal questionnaire with follow-up A 1:200 random sampling drawn Participants 16 years and over. 2009 Kotchen et al. system 2007 Gotz and Keil Germany Bias-controlled ‘interview’ Random selection of participants. Author's personal copy 294 A. 27% the rubbish bin was the preferred method for disposal of tablets/ would dispose cough medications in the garbage or toilet and 26% in capsules (51%) and semi-solid dosage forms such as ointments and the sewage system. is important to note that this study was carried out in a US Army Furthermore.9 years.9% of the sample respectively). unused medication to pharmacies. Netherlands Interviews and phone surveys Samples drawn from communities Most (35%) were 35–49 years in 2–3 (latter 10% of samples) by the Dutch with a population N 100. Convenience sample of participants' Participants from variable social- Dvarioniene with two open-ended questions towns. Edwards Tacoma. ‘usually’ or ‘sometimes’ in the toilet or sink. New Zealand Closed-question online survey Convenience sampling from Variable social-economic groups. he/she was 15 years or older.Y. the German study (Gotz and Keil. cities. 2009 Braund et al. 2006 Abahussain et al. painkillers. in a hospital waiting room. female. disposal methods and types of pharmacies collecting filled 66% male. most George of non-responders after 1 month. disposed of their medications in the rubbish. Indeed a disposal study in New et al. thus it was unknown how many participants would have of solid dosage forms were disposed of in the toilet or sink. 62% had a university medications disposed. Moreover. Year of Author(s) Locality Research instrument Sampling method and Demographics of respondents study population investigated 1986 Ridout et al. 54 private community pharmacies). Anonymous survey on Convenience sample of outpatients 52% of participants were female. less than 1% of the respondents reported 2006 US study (Seehusen and Edwards.. and skin ointment of used the sink or toilet as the preferred method for disposal of liquid antibiotics?” Whilst 52% and 42% of the participants said antibiotics dosage forms such as suspensions (55% of the survey sample) whereas and painkillers should be returned to the pharmacy respectively. In contrast. By contrast. 1996). suburbs and settlements and economic groups. Tong et al. United States (Ventura and Closed questions regarding Telephone survey of randomly Person answering telephone was Santa Barbara Counties. most (40%) were skilled manual workers. participants varied. The social-economic Voulvoulis Southeastern UK) Asked about disposal methods and representative mix of participants in status and age ranges of the types of medications disposed.6% had a willingness to pay for a disposal telephone numbers. in a creams (80%). pharmacists. 1996 Kuspis and United States Callers and pharmacists were asked Callers to a poisons information Varied callers. degree. education. One of the questions asked of the participants during the Zealand (Braund et al. Institute of Public Opinion. 2005 Bound and England (cities/towns in Close-ended questions: interview. Final sample chosen after over responsible for household adjustment for demographic disposal of pharmaceuticals. towns and villages. 2006 Seehusen and United States (Madigan. randomly selected Krenzelok the question “What do you do with centre. Sweden Closed questions on medicines Telephone questionnaire.. attitudes. However. means for disposal in Sweden (Persson et al. inhabitants. sex. Interviewees drawn from a 54. 2007) reported that Medical Centre and only methods which directly discharge pharma. 32% of the participants disposed of their unused liquid formulations ceuticals into the aquatic environment (via the sewage system) were ‘always’. Multiple entries from a similar visitor was eliminated by data checks. from the electoral register. views on a proper disposal. Only 27% of participants would return cough . age. participants chosen if 18 years or over. 42.5 years. mostly young (18–39 years) and old (N 60 years) (28. medication. female. 2007 Krupiene and Lithuania Close-ended postal questionnaire.C. 2007 Abahussain Kuwait Self-administered questionnaire Convenience sample of 250 Middle or high social-economics and Ball that asked participant opinion on households. such as cough medicine. 2009). German speakers aged 14 years and delivered on multimedia pen pads. and regarding whether they returned the countryside.

/ Environment International 37 (2011) 292–298 4% (unspecified method) 2009 Persson et al. 14%a 23% a (recycled alongside cardboard 29%a(always) 11%a(usually) and 1306 medications) 7% (sometimes) and 6% (rarely) (sometimes) and 13%a (rarely) and plastics) and 15%a(toxic waste bins) 15% a(sometimes) 11%a(rarely) 2007 Gotz and Keil Germany (liquid 10% (always).2% (sink) – 14% (returned to healthcare provider) 22. 6% 1005 12% (store at home) and A.Y. Sweden (2004 survey) – 3% 54% (kept medicines) 42% 1000 2009 Persson et al.4% 500 2% (finished medications) 1996 Sullivan and George United Kingdom 27% 15% 15% (kept medicines) 34% 400 2005 Bound and Voulvoulis United Kingdom 11. Tong et al.4% (give away or burn) 13% 452 (ointments and creams) Author's personal copy 2009 Kotchen et al. b Total number of participants from towns. Netherlands 3% 9% 16% (chemical waste) and 58% 2154 6% (kept medicines) 1996 Kuspis and Krenzelok United States 35.C.2% 76. United Kingdom 46% 14% 15% (kept medicines) 17% 443 1996 Blom et al.5% (give to friend) 11. 2% (usually).0% 97% 0. Sweden (2001 survey) – 7% 48% (kept medicines) 41% 1000 2% (recycling station) 1% (health centre) 2009 Persson et al.4% 54% 7.5% (burning unused medications) – 2007 Krupiene and Dvarioniene Lithuania (countryside) – 50% 50% (burning unused medications) – 2009 Braund et al.2 (kept medicines) and 1. Kuwait 11. Method of disposal Year of study and author(s) Locality (with Toilet or sink Garbage Other (stated) Return to pharmacy Sample formulations or setting) size (n) 1986 Ridout et al. Sweden (2007 survey) – 3% 55% (kept medicines) 43% 1000 a No differentiation between dosage forms in disposal routes other than toilet/sink.4% (give away or burn) 24% 452 and capsules) 2009 Braund et al. 13% medications) (sometimes) and 12% (rarely) 2007 Krupiene and Dvarioniene Lithuania (towns) 8% 89% 2% (burning unused medications) 3% 200b 2007 Krupiene and Dvarioniene Lithuania (towns) 6% 87% 12.9% 301 2007 Abahussain et al.5% (give to friend) – 200 2007 Gotz and Keil Germany (solid 1% (always). New Zealand (liquid 55% 24% 0.5% (waste sites or other disposal 21.5% 8. 8% (usually).7% (give away or burn) 17% 452 medicines) 2009 Braund et al. 295 .8% (toilet) 35.5% 63.2% 3. suburbs/settlements and countryside. Kuwait 2.9% 300 2006 Seehusen and Edwards United States 53. 7%a (always). 9%a(usually). United States 28% 45% 5% (hazardous waste centre).Table 2 Methods used to dispose of unused medication as reported by the peer-reviewed literature. New Zealand (tablets 19% 51% 2.8% 392 facility) 2006 Abahussain et al. New Zealand b1% 80% 2.

1986. However this study was undertaken in a asked why they did so. This may be due to proper disposal of medication campaigns solid medications should be crushed with an unpalatable substance. Conversely. and residues from the inciner- 2009) asked participants whether they were aware that pharmaceu. ation site may still be discharged into the environment albeit in ticals have been detected in the environment. in fact. 2009). Many may have failed to return environmental issues surrounding medicines disposal only partially medications to pharmacies because many felt stigmatized or stupid accounts for peoples' medicine disposal habits. the long term consequences associated with the exposure of the disposal set by the Food Drug and Administration (FDA).3. 1990s which advocated that patients should return any unused. For all other medications the FDA has recommended 1996 compared to 1986 (Ridout et al.. 2009) there was no reported prevalence of any who were from lower social-economic groups. Furthermore. However. a recent study in the United States (Kotchen et al. From this data. Tong et al.aware participants in this US study (38. which suggests that awareness of unwanted medication to pharmacies. reported that only 3% of the respondents residing in towns returned and 23.. No official methods guidelines for disposal of unwanted medications exist in Kuwait (Abahussain and Ball. to deal with waste medicines compared to the situation for middle or participants that returned unused medication to the pharmacy were upper class participants.7% in trash. 2007). promoted by the Royal Pharmaceutical Society of Great Britain in the such as cat litter. there were no official guidelines for pharmaceutical 2009). improper disposal of medication. diverted (Vivian. state environment to such pharmaceuticals from the sewage or landfill is at . and disposed in the garbage in a leakproof. In addition 40% of the responding participants suggested that has been reported as recently as 2006 that 35% and 21% of the public knowledge of how unused medications should be disposed of participants in a US study (Seehusen and Edwards. when seen carrying medications back into the pharmacy. 2009). participants in Kuwait (Abahussain and Ball. As many as It is apparent that environmental awareness may not be associated 73% of the study sample did not think pharmacies were able to take with educational status. In 2007. However. Pharmacies in Lithuania are poorly utilized as to pharmacies).. Therefore. Author's personal copy 296 A. 42% of the participants said they were hospital and so there is always the likelihood that patients were worried about environmental pollution by medications compared providing answers that they thought were ‘correct’ and establishing a with only 26% giving the same response in 2001. sink or garbage at that time. complete combustion of the Furthermore. 2009). 2007). The current FDA recommendations. sealed container (Glassmeyer et al. It (15%). Sullivan and George..e. reduce the likelihood of poisonings and diversion (Inciardi et al. that. where the natural environment is in were more likely to dispose of medications in a manner that reduces closer proximity to burn sites and hence the products of combustion potential environmental pollution (i. mixed.Y. no medications were collected in that it was appropriate to flush medications down the sink or toilet 2007 when a pilot collection scheme was trialed with survey respectively. 2007). Even in a Dutch study proper medicines disposal system and returning medication to from the 1990s 72% and 80% of the participants who stated they pharmacies for disposal are seemingly appropriate answers even to returned unused medication to a pharmacy or to a chemical waste participants unaware of proper disposal methods. 2006). Controlled medications are a major hurdle in the US for the establishment of a convenient. and most opted to store their unused medication or medicines disposal and may have been more dependent on the state return the medications to the pharmacy for disposal.. 2009) and this adds extra running medication is a major influence on how people dispose of unused costs to the system. This may be a particular consideration participants stated they were aware of this fact and these participants for people in the countryside. Whilst unused medication predominantly via the sewage or the garbage did backyard burning of pharmaceuticals may render pharmaceuticals to so because it was convenient. the US in the 1990s (Kuspis and Krenzelok.. 2007) 62% of back unwanted medication. tions. 1996) and this situation may have led people in the US to dispose of pharmaceuticals 4. improper disposal was still prevalent in drug collection depots (Krupiene and Dvarioniene.C. In a Swedish randomized telephone 2006) surveyed hospital patients in a Kuwaiti government hospital survey (Persson et al. Some state laws in the United States actually prevent pharmacies medicine disposal habits are clearly influenced by environmental from accepting unwanted medications (Seehusen and Edwards.. it was acceptable for pharmacists in the boxes should be available to the public. 2009). Influence of environmental awareness on medication disposal conveniently in the toilet.2. 1996). Whilst such practices may excess and/or expired medications to pharmacies for proper disposal. many pharmacies may have the study sample were university graduates or had some form of actively refused to accept returned medications and thus added tertiary education but 97% of the study participants stated they would confusion to the ‘proper’ method for disposal of unwanted medica- dispose of their unwanted medications in the garbage. many people United States to advise patients to dispose of unused medications in thought it was appropriate that medicines should be disposed of in the their own sink. if a ‘take-back’ or ‘mail-back’ program is unavailable then unused 1996). 1996). The availability of formalized protocols for medicines disposal nationwide disposal protocol — such substances have to be invento- ried by law enforcement even in many small pilot collection programs The availability of official state guidelines for disposal of unwanted me in the US (Glassmeyer et al.2% in toilet or sink). facility respectively. be inactive (Peake and Braund. From the results of two UK studies (Table 2) it can be ‘dangerous’ medications which should be flushed down the toilet seen that more people returned unused medication to pharmacies in (Mitka. cost-effective 4. return unwanted medications arising from burning. It could be that these participant flushing unused medication down the toilet or sink in the patients may not have been able to afford expensive methods of 2007 survey. In addition. whereas the previous 2006 study (Abahussain et al. toilet or garbage if they did not or could not return secure bins in shopping malls (21%) and home collection schemes their medications to the pharmacy (Kuspis and Krenzelok. It was environmentally.. 2006) awareness. / Environment International 37 (2011) 292–298 medications to the pharmacy. 2006) thought it was medicines disposal is seemingly a recent concept even to health appropriate that the option of returning medicines in pharmacy drop- professionals. thought was lacking in Kuwait. Forty-three percent of partially or fully oxidized forms. it is likely people return pharmacy boards. list 26 pharmaceuticals. pharmaceuticals is never guaranteed. but this is not the sole factor which will determine how particularly controlled substances as these medications may be patients discard their unused medications. did so because they were concerned about the In Lithuania most people dispose of unwanted medications in the environment (Blom et al. whilst the participants who disposed garbage or burn them (Krupiene and Dvarioniene. Nevertheless Some studies reported in the literature have also asked whether this latter study surveyed participants from middle to high social- participants knew of the environmental risks associated with economic groups. 2007) and 54% of the responding participants in The association between environmental pollution and improper an earlier Kuwaiti study (Abahussain et al. In Kuwait (Abahussain and Ball.. or the Environmental Protection Agency (EPA) in unused medications considered to be more harmful to pharmacies. Indeed. In the 1990s.

The most popular medicine disposal methods disposal which may have added to confusion (Erickson. The need for of the world. it is clear from this review that the few studies that have Ultimately. different for unused medication disposal. however. Author's personal copy A. and guidelines for disposal of dosage forms are disposal systems that are cost-effective. 2010). Some prescribed and actually employing methods which completely degrade unwant- medicines have disposal instructions on the packaging. it has been reported that laziness may also be a contributing alternative solution which has not been reviewed at all in this paper is factor for a lack of medication returns to pharmacies in Sweden for physicians to minimize their prescribing of excessive and (Persson et al. and currently. and safe means for their ultimate disposal. observed in many of the studies still have the potential to People who visit pharmacies and healthcare centers on a regular detrimentally pollute the environment. or the actual frequency of disposal via the various methods hence their potential environmental impact. there is an increased risk of accumulation and hoarding of unused Germany is another country that is reported as having no state-run medication. all only starting to become aware of the various methods employed but if the same system was transferred to another country. However. the cost of setting up a nationwide medicines disposal been undertaken on disposal practices have involved only a small system accessible by the public may be substantial. In addition.Y. proper disposal of unused medications may include public education on disposal of pharmaceuticals is further empha. For a more comprehensive and accurate picture prevalence of improper disposal methods as reported in Sweden of the global situation. and the residual deposited in dispose of pharmaceuticals may depend on cultural and social specified landfills. system may. It can be said factors may impact on medication disposal habits. which is another area that requires Medicines returned to pharmacies are ultimately destined for further investigation. data were not recorded in this study. particularly those with large human populations and attitudes and knowledge of medicine disposal practices. only apply to Sweden. Conclusion Acknowledgements The current evidence collated from a relatively small number of studies undertaken in different countries suggests that patients still Dr. but also the hence where pharmaceutical disposal practices may have a significant availability of a well-run disposal system. such a practice would drastically reduce type and quantity of medications that were disposed of in the German the medicines needing to be disposed of in used or unused forms and study.. easily accessible to the public different between regions (Gotz and Keil. the pharmaceuticals can then be for medicinally rich leachate to be discharged from a landfill is completely destroyed by high-temperature incineration. It has been confusion about the ‘correct’ way to dispose of medications. and the most effective convenient to continue to dispose of pharmaceuticals at home. it collated evidence suggests there is a pressing need for increasing has to be used by the public. Furthermore it has been reported that the White unused medication and how improper disposal methods may affect House and FDA have offered conflicting information on medication the environment. further research needs to be undertaken in (Persson et al. one other Indeed. but the low number of countries. how people incineration at high temperatures. rather than discourage and nearly one-quarter of the participants surveyed stated they kept embarrass patients for doing so. this ed pharmaceuticals is of paramount importance as this avoids does not apply to all pharmaceuticals in Germany. 2009) where unused medication to a pharmacy. Finally. 2006). scientists. suggest. 2009) is clearly influenced not only by the people's other countries. as this review has shown. and establish an official unused medications to pharmacies and healthcare providers were guideline that is relevant to their particular country. Overall. the lack of pharmacy access to countryside dwellers in disposal of unused medications.. It has been estimated that 73% of Swedish people differences. Confusion exists in different basis may be more educated about returning medication to countries as many countries lack adequate guidelines for the ‘proper’ pharmacies. A typical recommended that standardized and legally binding protocols for collection and disposal system may be set up to 1) collect unwanted drug disposal are set up in this country but many of the participants medicines that have been returned to pharmacies or 2) collect the stated that they were unwilling to pay for the institution of an official medicines directly from patients. Public services around the world. Eike Breitbarth (Chemistry Department. All solid wastes in garbage are subjected the willingness of patients to use the suggested system. as this would have required a knowledge have a role to play in ensuring that patients take all of their prescribed of whether patients are taking their medications and such compliance medications. . 2009). 5. it would be mandatory in Germany. Future directions for research in this area may ing that many people may know that it is appropriate to return include further evaluation of user-friendly and cost-effective means of unused medications to pharmacies but instead they found it more returning unused medications to pharmacies. health professionals and government officials are that Swedish people appear to be very compliant with state protocols. / Environment International 37 (2011) 292–298 297 present unknown. Of course. University of Otago) very much lack the knowledge as to the proper disposal of their for assistance in translating some of the literature written in German. In turn. depending on cost constraints and medications disposal system. Subsequently much environmental pollution will result ashes deposited in leakproof containers bound for specialized landfills entirely from the medicines that are disposed of in the sewage system dealing in pharmaceutical waste. schemes that allow patients to conveniently and discreetly return sized by a recent New Zealand study (Braund et al. The effectiveness of the Swedish disposal public awareness on the issue of medication disposal. there has been little established reverse distribution system run by a major pharmacy analysis of pharmacists' attitudes and methods for disposal of unused wholesaler in conjunction with the state pharmaceutical association. need to be more proactive country did not return medication to pharmacies. this could be the fact patients.C. To minimize to high temperature incineration in Germany and thus the likelihood discharge into the environment. At least 55% of the participants remarked that they that consumers are willing to pay for the institution and running costs sometimes returned their unused medication to pharmacies. Since 1971 Sweden has an impact on the global environment. of course. 2007). and this opens avenues for future studies on how these eventually return unused medications to pharmacies. For certain parts more likely to do so (Seehusen and Edwards. know what to do with them. This may be particularly important unwanted medicines around the household because they did not in countries which offer free or subsidized medications and thus. and how these may impact on the social attitudes to state protocols may render the system ineffective. Finally. Tong et al. pharmacists also reported by the participants. and the unlikely. the limited that in order for a ‘disposal and destruction’ system to be successful. Of course. medication from pharmacies.. The establishment of formalized state-run collection and disposal system. of such a system. environment. In the United States. about educating patients on how to use and dispose of medication in a it was shown that patients who were counseled to properly return more environmentally acceptable manner. it was not possible to ascertain the unnecessary medication. Lithuania may also be another reason why these people living in this including government and health sectors.

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