Wednesday, May 9, 2012

What’s in your medicine cabinet?

If yours is like those in most households, you may have medicines that expired in the previous millennium, with pills, poultices, elixirs, solutions, snake oil, and other antiquarian finds that would be more appropriate to a medical museum than a medical cabinet. With the increased availability of cheap over-the-counter drugs, along with what is called the most expensive instrument in the field of medicine—i.e., the prescription pad—the rising tide of unused and expired medications threatens to overwhelm us. And in this case, “tide” has a double meaning, with a significant portion of medicines ending up in our water supply—and, eventually, in the food chain. This could have downstream effects on human health and has already been shown to impact fish and other wildlife. A related concern is diversion of unused drugs into the wrong hands. Many youths no longer need to find a dealer of drugs—they can just open the medicine cabinet in their own house. Aside from abuse, misuse of meds is a concern as well. Well-meaning parents may “prescribe” some unused antibiotics from a previous bout with the flu to their teen, unaware of the possible side effects and interactions that may occur. Finally, small children or pets may gain access to and become poisoned by drugs that are not stored securely. Breaking this cycle of medication mayhem requires thinking (and acting) both locally and globally. Medical assistants and other health professionals can play a key role by educating patients about proper drug disposal. They should also underscore proper use of drugs (for example, finishing all pills in a course of antibiotics) as well as the hazards of “repurposing” one’s prescriptions among friends and family. Further, they can work on the front end to limit overprescribing and thereby reduce the nation’s unwanted cornucopia of medications. Overkill, or overpill? The scope of the problem A few facts underscore the extent of the drug disposal problem the nation faces. From 1970 to 2010, spending on prescription drugs in the United States increased from $5.5 billion to nearly $260 billion. This translates into more than four billion prescriptions filled in the U.S. each year, says Philip P. Burgess, RPh, DPh, MBA, chair of the Illinois State Board of Pharmacy. “It has been estimated that as much as 35 percent of the dispensed medication goes unused,” Burgess adds. “This results in over 200 million pounds of pharmaceuticals, which can adversely affect the environment if disposed of improperly.” A 2008 investigation by the Associated Press found a veritable witch’s brew of pharmaceuticals in the nation’s drinking water, including “antibiotics, anti-convulsants, mood stabilizers and sex hormones.” “Pharmaceuticals and endocrine disruptors are being detected in drinking water supplies in minute amounts—parts per billion and parts per trillion—amounts too small to be removed at wastewater treatments plants. While detection does not equal risk, some studies are beginning to show detrimental effects on aquatic life,” says Debra Shore, Commissioner of the Metropolitan Water Reclamation District in Chicago, one of the world’s largest wastewater treatment agencies. For example, researchers have found that drugs in our waterways are causing the development of “intersex” fish, which exhibit both male and female characteristics. Scientists have also charted “changes in behavior, reproduction, and growth in frogs, mussels, shrimp, and other aquatic animals,” leading to concerns of “the decline of entire populations through decreased reproduction and increased predation,” says Laura Kammin, Pollution Prevention Program Specialist at Illinois-Indiana Sea Grant, located in the University of Illinois in Chicago. At the same time, while it is true that pharmaceuticals in the environment could lead to “grave consequences” for wildlife, “comparing environmental impacts to those caused by misuse or abuse would be comparing apples to oranges,” Kammin says. “Misuse and abuse directly impacts human health and safety. There is an immediate concern in those cases because of the danger of overdose and also the risk of addiction and all the health and societal problems that can cause. The environmental damage is not seen immediately.” Indeed, one immediate danger is to young children and pets, who can be the victims of nondisposal or inadequate disposal of medications. Between 2001 and 2008, for example, more than 430,000 children five years or younger were seen in emergency departments due to self-ingestion of prescription and OTC medications; this led to 41,000 admissions, 18,000 injuries, and 66 deaths. And earlier this year, the American Society for the Prevention of Cruelty to Animals (ASPCA) Animal Poison Control Center reported that, for the fourth straight year, human prescription medications topped their list of pet toxins, with OTC human medications ranked third. The other direct impacts on human health are drug misuse and diversion for illicit purposes (e.g., abuse). In fact, according to data from the U.S. Substance Abuse & Mental Health Services Administration (SAMHSA), prescription drugs are the second most abused drugs in the U.S., trailing only marijuana and far ahead of cocaine, heroin, LSD and other equally notorious substances. In addition, SAMSHA data show that treatment admissions for prescription drug abuse increased 430 percent in 10 years, and the Centers for Disease Control and Prevention reports that “the death toll from overdoses of prescription painkillers has more than tripled in the past decade.” Opioids (including Vicodin and OxyContin) and benzodiazepines (such as Vanax and Valium) are particularly seductive and are highly addictive, and are contributing in large part to the rise in unintentional overdose deaths. In short, “Generation Rx” is taking advantage of the easy access of prescription drugs in the home. “‘Pharm parties’ are an alarming and growing phenomenon among teens,” Burgess says. “After raiding their parents’ or grandparents’ medicine cabinets, the kids will pop random pills along with consuming alcohol.” Many teens are also under the mistaken impression that prescription drugs are somehow “safer” than street drugs. It’s not just the nation’s youth that are at risk, however: “Senior citizens’ homes are notorious for the sharing of medications among the residents,” adds Burgess. “This results in significant increases in drug interactions and negative side effects for these patients.” And the death earlier this year of singer Whitney Houston has brought renewed attention to the vulnerability of women to prescription drug abuse. Abuse is a daunting concern—and misuse is a serious issue as well. “People sometimes share their medications with friends or relatives, not realizing what a dangerous practice that can be,” Kammin says. “A doctor prescribes medication to a patient based on their medical history, calculating the proper dosage based on factors such as age and weight. Medications should never be shared. The potential for adverse reactions, or even death, is too great a risk.” Disposing of the problem: One man’s story So it’s readily apparent that the nation has a drug problem. But how do we solve it? And what role can proper disposal of unused medications play in the solution? Paul Ritter is a high school science teacher in Pontiac, Ill—not coincidentally, home of the second largest landfill in the U.S. One day in 2007, his wife asked how she should dispose of some old medications in their home. Unsure of the answer, Ritter posed it to the students in his ecology class, and the rest is history. The students investigated the issue and, alarmed at their findings, began to develop a grassroots media and advocacy campaign to draw attention to the problem. Their work led Illinois, in 2011, to become the first state to pass legislation to pay for pharmaceutical disposal through a $20 fine for specified drug-related offenses. Ritter is seeking to expand this work to other states, in his role as director of the National Prescription Pill and Drug Disposal Program, or “P2D2,” as it’s known. This collaborative effort between communities, pharmacies, police departments, hospitals, city officials, and students is intended to raise awareness of the dangers of inadequate drug disposal, including misuse and abuse as well as the environmental impacts. Ritter is a passionate advocate of the cause of proper pharmaceutical disposal. Although he is recipient of the 2011-2012 National Environmental Science Teacher of the Year, he is quick to give credit to his students for their work with P2D2. “It’s one of the greatest and humbling things I’ve ever been a part of,” he says. “When you inspire students to be agents of change, you can’t hold them back.” Further, his initial interest in this issue has expanded beyond a strictly environmental perspective. During an out-of-town school field trip to an aquarium, one of his students abused opioids and became severely impaired. That unfortunate incident “solidified what we were doing,” he says. “We need to really make sure that we take care of this. “This is our moral obligation to do so,” adds Ritter. “So I don’t have another parent who calls me to say that their child is dead. I look into the eyes of my children and my students, and I think that I have to do everything humanly possible to solve this.” “There oughta be a law” (or is there?) “We need to make it simple and easy for people to dispose of medicines safely and right now we don’t.” – Debra Shore. Currently, 18 other states have developed P2D2 programs, and Colorado, Florida, and Mississippi have pending legislation similar to that enacted in Illinois. This begs the question—what about a nationwide solution (e.g., from the feds)? In 2010, President Obama signed into law the Secure and Responsible Drug Disposal Act, to allow consumers to dispose of controlled substances more easily and help limit drug diversion. The Drug Enforcement Administration (DEA) will soon be issuing guidelines to implement this act, notes Burgess. The law is intended to “[address] a longstanding issue where patients were not allowed to return drugs to a DEA registrant because such a return would be outside the ‘closed chain of distribution’ established by the Controlled Substances Act.” More recently, the Pharmaceutical Stewardship Act of 2011, introduced to the Congress in last September by Rep. Louise Slaughter (D-NY), “would set up a nonprofit corporation financed by pharmaceutical producers who would be responsible for establishing comprehensive drug take-back programs in every state.” Currently in committee in the House, the proposed legislation has received backing from such organizations as the American Medical Association, American Rivers, and Natural Resources Defense Council. The popularity of (and the need for) drug take-back programs is indeed growing—but is take-back a keeper? A recent study of 148 such programs in 21 states and several countries found limited data to suggest that the programs help prevent prescription drug abuse. Only those programs that collect controlled substances have any impact on substance abuse prevention, the study notes. (It is important to add that the report does not analyze the potential environmental benefits of take-back programs.) Some take-back programs operate via mail-back envelopes, which can be especially convenient for people living in remote locations. For example, 100 tons of unwanted medications have been incinerated in an environmentally conscious manner through a nationwide mail-back program of Sharps Compliance, says Burgess. Meanwhile, Maine has a successful EPA-funded pilot program using free mailers, notes Kammin; it is the only mail-back program in the nation that can legally accept controlled substances. The 3 Rs of drug disposal As the recycling part of the equation, take-back programs are vital to any long-term solution, but a better approach might be to start with the first of the three Rs of the environment—“reduce.” Ritter believes this is critical. “We have responsibility to not overprescribe,” he says. “We need to be wary of the amounts put forward [into the system]”—a significant challenge given the prevalence of “tele-docs,” doctor-shopping, and pill mills. Whatever the source, a significant amount of prescribed medications are not being finished by patients. A study in New Zealand found that the majority of medications returned to community pharmacies had 75 percent of the original dispensed amount. One key is to change health professions education to ensure that students and practitioners are cognizant of the systemic side effects of overprescribing, and to look beyond an individual patient to see the larger population health consequences. “Some states have looked at mandating this type of educational program as part of a continuing education requirement for physicians and dentists in order to renew their licenses,” notes Burgess. “Prescribing excess quantities of medications is definitely contributing to the seriousness of this problem and has an easy resolution.” Adds Kammin, “Physicians should be mindful of the quantity of medication prescribed. Try a sample first to see if it will work for the patient. Do not unnecessarily push samples provided by pharmaceutical reps. Be aware of the consequences of having pharmaceuticals present in the environment. And educate patients on how they can responsibly dispose of any unused medications.” Stephanie Bell, CMA, medical assisting instructor/program manager at Illinois School of Health Careers in Chicago, believes that today’s medical providers are “very active in educating their patients” through preventive care, health awareness screenings, weight loss and pain management programs, and other interventions, thereby lessening the need for writing prescriptions. For the second R, “reuse,” many unexpired, perfectly good medications often go to waste. Taking advantage of this possibility poses some logistical challenges, to be sure. Burgess says that reuse is possible “only if the medication has been kept in a totally controlled environment to ensure no contamination or improper storage.” An analysis from England found that medications returned to pharmacies did not expire for another 17 months and that one-quarter of the medications could be reused. As for the third R—“recycle”—Ritter believes that “rethink” might be a better term. “Medication is a quality of life thing, and vital to health of so many, so I’m not a pharma basher by any means. But we need to be mindful not only of what we do with it but how we dispose of it. Then we can make good choices.” Disposal 101: What to tell patients Here are some guidelines to share with patients seeking advice on how to handle and dispose of expired medications, according to the Food and Drug Administration (FDA). The safest and most effective way to dispose of old medications is through a take-back program, which may be offered through household garbage or recycling services, local pharmacies, or police departments. If no such program is available, people should: • Mix medicines (do not crush tablets or capsules) with an unpalatable substance such as kitty litter or used coffee grounds • Place the mixture in a container such as a sealed plastic bag; and • Throw the container in your household trash Flushing? If, and only if . . . Once considered the best method of disposal, flushing unused drugs down the toilet “should be absolutely discouraged,” says Burgess. “Unfortunately, because the public has become much more aware of not flushing drugs down the toilet, it has exacerbated the problem by drugs staying in the medicine chests for years making them readily available for pilferage.” For a certain select list of medications, however, the FDA recommends disposal via flushing if they cannot be disposed of via a take-back program. These drugs “may be especially harmful and, in some cases, fatal in a single dose if they are used by someone other than the person the medicine was prescribed for,” says Shelly Burgess, Public Affairs Specialist at the FDA. “Any potential risk to people and the environment from flushing this small, select group of medicines is outweighed by the real possibility of life-threatening risks from accidental ingestion.” A list of these medications is available at http://1.usa.gov/192HN0. What is your role? Medical assistants can help address drug disposal in many different ways. “In the office setting, it is the responsibility of the medical assistant to monitor the sample closet for expired medications and also to dispose of them according to the office policy,” says Bell. This can help reduce the chances of drug diversion. When working with patients, “medical assistants could help by directing people to local medicine collection programs or providing tips on disposal via the trash if collection programs are not available in their area. They could also help educate people on the dangers of sharing medications . . . [and] make doctors aware of this issue.” Also critical are patient education and follow up on proper use of drugs and adherence to prescribed regimens. At a larger, community-wide level, says Ritter, “medical assistants can play a vital role to get patients to set up community [take-back] programs of their own, and [by] working with students to help them be the leaders of change.” Sidebar: Links for more information Safe Medicine Disposal for Maine Program http://www.safemeddisposal.com http://www.disposemymeds.org/ National Community Pharmacists Association National Prescription Pill and Drug Disposal Program, or “P2D2,” (www.p2d2program.org Take Back Your Meds http://www.takebackyourmeds.org Disposal of Unwanted Medicines toolkit http://www.iisgcp.org/gros/meddisposal.html Environmental Protection Agency (EPA): Pharmaceuticals and Personal Care Products as Pollutants (PPCPs) http://www.epa.gov/ppcp/

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