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KNOWLEDGE, ATTITUDE AND PRACTICE OF MEDICAL PROFESSIONALS

TOWARDS THE SAFE DISPOSAL OF UNUSED MEDICATIONS IN SOUTH INDIA

Article  in  WORLD JOURNAL OF PHARMACY AND PHARMACEUTICAL SCIENCES · April 2015

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 WORLD JOURNAL OWorld
Swaroop et al.
F PH A RMACY AND PHARMACEUTICAL SCIENCES
Journal of Pharmacy and Pharmaceutical Sciences
v SJIF Impact Factor 5.210

Volume 4, Issue 05, 1423-1430. Research Article ISSN 2278 – 4357

KNOWLEDGE, ATTITUDE AND PRACTICE OF MEDICAL

PROFESSIONALS TOWARDS THE SAFE DISPOSAL OF UNUSED
MEDICATIONS IN SOUTH INDIA

Swaroop HS*1, Ananya Chakraborty2 and Akash Virupakshaiah3

1
Postgraduate, 2Professor, 3Intern medical officer Department of Pharmacology, Vydehi
Institute of Medical Sciences and Research Centre 82 EPIP Area, Whitefield, Bangalore:
560037.

ABSTRACT
Article Received on
07 March 2015, Environmental contamination of medications is a serious threat that
Revised on 28 March 2015, has attained attention in recent years. The most environmental
Accepted on 19 April 2015
unfriendly means of disposition of leftover medication are reported to
be disposition of drugs into the sink, toilet, or into the dust bin. With
*Correspondence for
this background, the present study was conducted to assess the
Author
Knowledge, Attitude, and Practice (KAP) of medical professionals
Swaroop HS
Postgraduate, Department towards the safe disposal of medication. Twenty-eight percent of the
of Pharmacology, Vydehi participants were aware of the fact that medications excreted by human
of Medical Sciences and appear in sewage system and are detectable in the ecosystem. All the
Research Centre 82 EPIP
participants agreed that the government should make strict policies
Area, Whitefield,
regarding the drug disposal and 77% agreed that pharmaceutical
Bangalore: 560037.
companies should take back the expired drugs. Also, 65% respondents
agreed that they dispose unused medication in the garbage, and 9% disposes unused
medication in the toilet or sink. There is a strong requirement for increasing awareness about
safe disposition of medications.

KEYWORDS: Ecopharmacovigilance, disposal of medication, ecosystem.

INTRODUCTION
With the increased use of medicines both in human and veterinary practice, the extent of
environmental contamination is also high. [1] The potential routes of entry of medications into
the environment are through patient excretion into the sewage system, direct release through

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v

sewage from manufacturing units, or disposal of unused medication via trash or flushing.[2]
Few outcomes of such environmental contamination are a decline in number of vultures,
sterility in frogs, and feminization of male fishes.[3,4] Few studies have reported the alarming
decline in sperm count in men over the last few years and antibiotic resistance due to
environmental exposure of medications.[5]

This is a serious threat worldwide and has opened a new branch of science called
Ecopharmacovigilance (EPV). EPV is concerned with detection, assessment, understanding,
and prevention of adverse effects related to the presence of pharmaceuticals in the
environment, which affect human and other animal species.[6] The approaches of EPV include
green drug design, green chemistry in process development, development of biodegradable
products, minimization of manufacturing emissions, education over rational use of drugs,
improved prescribing practices, and safe disposal of unused drugs.[7, 8]

Medication disposal habits are influenced by environmental awareness, availability of

guidelines, dosage form, and social and cultural attitudes. The most environmental unfriendly
means of drug disposition are disposing drugs into the sink, toilet, or into the dust bin. In
India, the major reason for possession of unused, expired medicines is reported to be due to
purchase of over the counter (OTC) drugs for self-medication.[9] With this background, the
present study was conducted to assess the Knowledge, Attitude, and Practice (KAP) of
medical professionals towards the safe disposal of medication.

MATERIALS AND METHODS

Place of the study: The present study was carried out at Vydehi Institute of Medical Sciences
and Research Centre, Bangalore.

Study duration and permission: The study was conducted in the month of December' 2013.
It was approved by the Institutional Ethics Committee.

Design of the questionnaire: The questionnaire consisted of the demographic data, questions
on the type of unused/expired medications at home, reasons for stockpiling of leftover
medications, disposal techniques adopted to dispose solid, liquid and semi-solid medications
and questions exploring KAP about safe drug disposal methods. There were 5 questions
about knowledge, 5 on attitude (Likert scale), and 8 about the practice of disposition of
unused medications.

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Collection of responses: A structured validated questionnaire was prepared to assess the

KAP of medical professionals about the disposition of left over medications. The purpose of
the study was explained to the participants and their confidentiality was ensured. Informed
consent was obtained from them before filling the questionnaire.

Data analysis: The data collected was analyzed using descriptive statistics.

RESULTS
Response rate: A total of 200 questionnaires were distributed. Out of them, 163 were
returned giving a response rate of 81.5%.

Demographic details: The mean age of the participants was 27.98 years. Fifty-six percent of
the participants were males, and 44%; females. 23.53% participants gave history of chronic
diseases in the family. The most common chronic diseases cited were diabetes mellitus
(17.6%), hypertension (12.5%), and others (69.9%). One participant gave family history of
myasthenia gravis and psychosis. The medication that are usually kept at home were found to
be paracetamol, cough syrups, anti-diabetics, anti-hypertensives, aspirin, anti-histamines etc.
The list of medications is shown in Table 1.

Table 1: List of medications used and found to be stocked at home

Anti-diabetic drugs Metformin, Insulin, Vildagliptin
Anti-hypertensives Losartan, Amlodipine, Telmisartan
Antibiotics Amoxycillin and cloxacillin, Amoxicillin and
clavulinic acid. Ciprofloxacin, Erythromycin
Antipeptic ulcer drugs Aluminium hydroxide, Digene, Ranitidine
CNS drugs Olanzepine, Fluoxetine
Respiratory drugs Ambroxol
Non-steroidal anti- Aspirin, ibuprofen, paracetamol
inflammatory drugs
Hypolipedemics Atorvastatin

The KAP responses are enumerated as follows

Knowledge of medication disposal: 28% participants were knowledgeable of the fact that
medications excreted by human appear in sewage system and are detectable in the ecosystem.
And none of the participants could name the drug, fentanyl, that can be flushed through the
toilet. 43% participants were aware of the fact that unused medication should be disposed
after mixing with coffee grounds. Sixteen percent respondents opined that the presence of
pharmaceuticals in the environment can cause feminization of male fish. Only 5% of the

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v

participants were aware about the correct method of disposal of insulin syringes. The results
are shown in Figure 1.

Figure 1: Knowledge score (n= 163)

Attitude of medication disposal: All the participants agreed that the government should
make strict policies regarding the drug disposal. Seventy-seven percent, 9%, and 12%
participants agreed, disagreed or were not sure about whether pharmaceutical companies
should take back the expired medications. Eighty-five percent participants agreed that
purchasing medicines without prescription can add to the load of unused medicines at home.
Thirty-nine percent respondents mentioned that the pharmacy 'medication take back program'
can mean more work for pharmacies and is not possible in India, 26% opined that it is
possible and the remaining 35%; were not sure about that. Ninety-one percent respondents
agreed that proper education and guidance is strongly recommended for the safe drug
disposal of unused medications. The results are shown in Figure 2.

Figure 2: Attitude of disposition of left over medication (n=163)

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Swaroop et al. World Journal of Pharmacy and Pharmaceutical Sciences
v

Practice of medication disposal: Sixty-two percent participants mentioned that they use all
the prescribed medications. Sixty-two percent mentioned that they dispose unused
medication, 65% agreed that they dispose unused medication in the garbage, and 9% disposes
unused medication in the toilet or sink. When asked about whether unused medications are
used for another family member without prescription, only 20% respondents responded
positively. Sixty-two percent participants return unused medication to the pharmacy, and
83% of them empties liquid medications in the sink and gives the glass bottle for recycling.
The results are shown in Figure 3.

Figure 3: Practice of disposition of left over medication (n=163)

DISCUSSION
The global increase in the use of pharmaceuticals has lead to an increased international
awareness of the potential detrimental effects on the environment. Other than US Food and
Drugs Administration, many other countries have come up with guidelines on the proper
disposal of medication.[10, 11]
In India, the national formulary published in 2011, provides
guidelines on the same. Previous studies conducted in India and abroad mention that the
knowledge about environmental implications of unsafe medication disposal was
inadequate.[12]

In this study, the mean age of the participants was 27.98 years. Fifty-six percent of the
participants were males, and 44%; females. 23.53% participants gave history of chronic
diseases in the family. The most common chronic diseases were diabetes mellitus (17.6%),
hypertension (12.5%), and asthma (0.12%). These findings are in accordance to a previous
study that stated that diabetes and hypertension are the most common chronic diseases in

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v

India.[13] The medication that were found to be kept at home were paracetamol, cough syrups,
anti-diabetics, anti-hypertensives, aspirin, anti-histamines etc. which are similar to the
findings of a previous study conducted in dental students.[10]

Regarding knowledge of ecopharmacovigilance, only 28% participants were knowledgeable

of the fact that medications excreted by human appear in sewage system and are detectable in
the ecosystem. In a previous study conducted in South India, only 35% participants were
aware about the consequences of improper disposal of medications.[15] Regarding attitude,
100% participants agreed that the government should make strict policies regarding the drug
disposal. Previous studies also emphasized that in India, there is need to implement stringent
take-back programs and also to impart awareness to public regarding this serious
concern.[10,15] Regarding practice, 65% participants agreed that they dispense unused
medication in the garbage which is in accordance with previous studies. [10, 15, 16] In this study,
62% participants agreed that they return unused medication to the pharmacy, and 83% of
them empties liquid medications in the sink and gives the glass bottle for recycling. This is a
good trend as a previous study had reported that only 3.2% participants mentioned of
returning unused medication to the pharmacy.[15]

CONCLUSION
The study reflects that medical professionals do not use all the medications available at their
houses due to side effect, dosage changes, discontinuation of the drug, or due to expiration
date. Therefore, they expire. Expired or left out medications need clear guidance about safe
disposition into the environment. If medical professionals become aware and educated about
safe disposal of medication, or have the right attitude regarding the same, and agree to adhere
to practice guidelines, they can educate the patients and community about the same. Along
with regulatory and other interested bodies, they are the key persons who should work
together towards the goal to create a safe environment for future.

REFERENCES
1. Wang J, Hu X. Ecopharmacovigilance: Current state, challenges, and opportunities in
China. Indian J Pharmacol. 2014; 46: 13-7.
2. Srivastava B, Sinha AK, Gaur S, Gaur S, Palaria U. Ecopharmacovigilance: Its
importance and challenges. J Biomed and Pharmaceutical Res. 2014; 3: 81-7.

www.wjpps.com Vol 4, Issue 05, 2015. 1428

Swaroop et al. World Journal of Pharmacy and Pharmaceutical Sciences
v

3. Oaks JL, Gilbert M, Virani MZ, Watson RT, Meteyer CU, Rideout BA, Shivaprasad HL,
Ahmed S, Chaudhry MJI, Arshad M, Mahmood S, Ali A, Khan AA . Diclofenac residues
as the cause of vulture population decline in Pakistan. Nature. 2004; 427: 630–3.
4. Kvarnryda M, Grabicb R, Brandta I, Berg C. Early life progestin exposure causes arrested
oocyte development, oviductal agenesis and sterility in adult Xenopus tropicalis frogs.
Aquat Toxicol. 2011; 103: 18–24.
5. Carlsen E, Giwercman A, Keiding N, Skakkebaek NE. Evidence for decreasing quality of
semen during past 50 years. BMJ. 1992; 305: 609–13.
6. Medhi B and Sewal RK. Ecopharmacovigilance: An issue urgently to be addressed.
Indian J Pharmacol. 2012; 44(5): 547–549.
7. BIO Intelligence Service (2013). Study on the environmental risks of medicinal products,
Final Report prepared for Executive Agency for Health and Consumers. Available at:
ec.europa.eu/health/files/environment/study_environment.pdf, accessed on Oct 12, 2014.
8. Velo G and Moretti U. Ecopharmacovigilance for better health. Drug Saf. 2010; 33: 963-
8.
9. Holm G, Snape JR, Murray-Smith R, Talbot J, Taylor D, Sorme P. Implementing
ecopharmacovigilance in practice: Challenges and potential opportunities. Drug Saf.
2013; 36: 533-46.
10. Aditya S. Safe medication disposal: Need to sensitize undergraduate students. Int. J. of
Pharm. & Life Sci. (IJPLS) 2013; 4(3): 2475-2480.
11. FDA consumer information. How to dispose of unused medicines. Available at:
www.fda.gov/ForConsumers/ConsumerUpdates/ucm101653.htm. Accessed on Nov 5,
2013.
12. Guidelines for the Safe Disposal of Unwanted Pharmaceuticals in and after Emergencies,
13. Interagency Guidelines, 1999, 31 pages [E], WHO/EDM/PAR/99.2
14. Government of India, Ministry of Health and Family Welfare. National Formulary of
India. Available at:
www.researchgate.net/...Disposal...medicines...India.../00b7d51e7c4d1c758..., accessed
on Nov 10, 2013.
15. Patel V, Chatterjee S, Chishlom D, Ebrahim S, Gopalakrishna G, Mathers C, Mohan V,
Prabhakaran D, Ravindran RD, Reddy KS. Chronic diseases and injuries in India. Lancet
2011; 377: 413–28.
16. Lagishetty R, Nagarajan P and Vijayanandhan SS. Practice Towards Disposal of
Medicines (Left Out / Expired Drugs) Among The Patients Visiting Tertiary Care

www.wjpps.com Vol 4, Issue 05, 2015. 1429

 Swaroop et al. World Journal of Pharmacy and Pharmaceutical Sciences
v

Teaching Hospital and Primary Health Centre In South India. Asian J Biochem and
Pharmaceut Res. 2013; 1(4): 175-182.
17. Muragundi PM, Priyendu A, Janodia MD, Virendra SL, Udupa N, Anantha NN.
Knowledge, attitude and practice of date expired and unused drug disposal. Int J
Community Pharmacy. 2012; 5(2): 41-49.

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