12 Pharmaceutical Waste: The Patient Role 191

Table 12.6 Distribution of unwanted and leftover drugs returned to pharmacies

Country Sample size, Sample size,

References patients packages Range Median Meana

UK
Linton (2003) 897 1,819a 1–34 1 2
McGovern et al. (2002) 100 256 1–17 2 3
Braybrook et al. (1999) 529 1,428 1–31 3
Cook (1996) 133 631 1–72 3 5
Hawksworth et al. (1996) 366 1,091 1–27 3
Spain
Coma et al. (2008) 227 1,176 1–121 5

Canada
Carter and Coppens 731 2,348 3
(1996)
Sweden
Ekedahl (2006) 1,577 8,795 1–140 3 6
Ekedahl (2003) 191 1,077 1–101 3 6
Bäckström and Olme 196 1,159a 3b –30 6
(1997)
Norway
Thormodsen et al. (1997a) 641 4,860 1–70 8
Wold and Hunskår (1992) 247 2,750 1–44 11
a Drugs instead of packages.
b Only drug returns ≥3 were included.

7920
Accumulated number of packs

7040

6160

5280

4400

3520

2640

1760

880

0
1 157 313 469 625 781 937 1093 1249 1405
Accumulated number of patients

Fig. 12.1 Lorenz diagram (n = 1,557 patients, 8,795 packs; Gini coefficient = 0.42). The solid
line represents the real accumulated number of returned packs in relation to accumulated number
of patients. The broken line is graphically illustrating a uniform return according to the statistical
mean (5.65) of returns per patient
192 S. Castensson and A. Ekedahl

Table 12.7 Proportion of patients aged over 60/65 returning unwanted and leftover drugs to phar-
macies and proportion of packages returned by these patients. Percentages are tagged 60+ for
patient age of 60 years and more and 65+ for 65 years and more

Country Sample size, Sample size,

References patients packages Patients (%) Packages (%)

UK
Langley et al. (2005) 114 340 6160+
Linton (2003) 897 1,819a 6560+
Braybrook et al. (1999) 529 1,428 6760+
Hawksworth et al. (1996) 360 1,091 6160+ 6860+
Canada
Grainger-Rousseau et al. (1999) 581 1,966 6365+
Carter and Coppens (1996) 731 2,348 42/4465+
Sweden
Ekedahl (2006) 1,577 9,077 6665+
Ekedahl (2003) 191 1,077 4965+ 6465+
Ekedahl et al. (2003) 20,171 6665+
Jonsson (2000) 299 1,554 5960+
Isacson and Olofsson (1999) 8,014 6365+
Bäckström and Olme (1997) 196 1,159a 4965+ 4765+
a Drugs instead of packages.

always take medications according to prescription and begins with the primary non-
adherence, which means that patients are not redeeming their prescriptions (Jones
and Britten 1998).
People have been surveyed as to why medicines they have obtained had not
been taken. This secondary non-adherence was focused in 20 studies based on
our inclusion criteria and the study results are summarised in Tables 12.8 and
12.9. The factors that contribute to secondary non-adherence include frequent
physician’s alterations in dosage of existing drugs and prescribing of new drugs,
patient improvement, adverse reactions and that the patient cannot detect whether
his/her condition is worsening or improving. In our review of the reasons reported,
we have tried to resolve the factors behind secondary non-adherence as seen in
Table 12.8. The table reflects primary factors related to the pharmacotherapy gen-
erating leftover and unwanted drugs. The non-adherence factor shown in the table
reflects the patient’s perspective not to take any more medications because of, e.g.
fear.
The patient’s death is a very obvious reason why leftover drugs are generated
because of discontinued drug use. However, the patient will also experience several
situations, which can be regarded as secondary factors in relation to the phar-
macotherapy that generate leftover and unwanted drugs. These are presented in
Table 12.9.
One way to reduce drug waste caused by an early change or discontinua-
tion of treatment is to limit systematically the quantity of medication that is