Expand Prescription Drug Take-Back and Disposal Programs

Introductory Paragraph

Prescription drug take-back and disposal programs enhance safety, protect the environment, and decrease opportunities for drug diversion:

• Safety is is increased by limiting the risk of accidental exposure, such as childhood poisoning.
• Environmental benefits are linked to a decrease in flushing. Proper disposal ensures that medications do not get into drinking water and watersheds.
• Reducing drug diversion limits the ability of people to misuse these medications or give them to others who may misuse them. Prescription drugs involved in overdoses are almost all originally prescribed by physicians but are used by individuals other than the patient prescribed the drugs. A majority of abused prescription drugs are obtained from family and friends, including from the home medicine cabinet. SAMHSA’s National Survey on Drug Use and Health found that over 70 percent of people who used prescription pain relievers non-medically got them from friends or relatives, while approximately 5 percent got them from a drug dealer or from the Internet. Nearly 80 percent of heroin users reported using prescription opioids prior to heroin.

Most opioid abuse prevention strategies address proper disposal, and this is a step in the right direction. However, communities have significant opportunities to expand and enhance these efforts to reach more people. This article focuses on practical ways to make improvements to existing efforts and to add new options for communities.

Key Information

The worst disposal strategy is to throw drugs in the garbage, because they can accidentally be taken by kids or pets. The best options are detailed below, all of which can implementated in conjunction with each other:

• Increasing the Number of Drug Drop-Boxes in your Community. This is considered the best disposal option. So, it is important for communities to increase the number of drop boxes that are available and to promote awareness of them as a disposal option. In multiple cities and communities, drop boxes have resulted in increased safety and reduced the risk of opioid addiction. Boxes are often located in close proximity to law enforcement agencies, so the drugs are secure. Many pharmacies are now providing drop boxes as well.

• Education Campaigns - An information campaign enables a variety of sectors in the community to collaborate. For example, an awareness campaign could engage law enforcement in drug take-backs. When law enforcement hosts drop-off locations, it promotes the overall campaign. Health department staff could disseminate information. Schools could provide an avenue for reaching parents and informing them about the location of take-back events. Pharmacies and the businesses could be engaged in sponsoring the campaign. A few models of national campaigns are provided in the “Promising Practices” section below. Families are generally more receptive to tips for medication safety than they might be for information about other forms of prevention. Although statistics can be used in an education campaign, it may be more effective to provide basic ideas which can get people thinking about their own practices in a new way. For example, most people have not considered that it makes sense to keep a medication log or an inventory of all their medication types and amounts. Updating their inventory every six to twelve months keeps medication safety in their awareness. Likewise, people are ready to recall that the medicine cabinet in a bathroom is often not the best place to store prescriptions, since they should be stored in a cool, dry place. Humidity, heat, and the change in temperatures in the bathroom can alter the potency of some medications, and some storage devices can help protect medications from humidity, even if they are stored in bathrooms. This is a good lead-in to building a desire to obtain a lock-box. While community efforts should target everyone, there are three special populations which typically yield the highest return on educational investment:
  • Senior Citizens -- Senior citizens have a disproportionate number of medications in their homes. Helping seniors understand how to properly dispose of medications can make a big difference in the success of your program.
  • Nursing Homes. One study estimated the nation’s nursing homes discard anywhere from $73 million to $378 million worth of drugs a year. Some are incinerated, but many are flushed. Nursing homes could be provided with information and tools (or services) for more appropriate disposal options which are better for the environment and which minimize the likelihood of diversion of these medications.
  • Hospice Programs and Funeral Homes can help family members understand how to properly handle the medications they inherit when a loved one passes away. Funeral homes may distribute brochures to remind people to make sure that any prescription drugs which were being taken by a loved one are properly disposed. People in the late stages of life may have been getting prescription opioids to deal with pain, so hospice and funeral homes should be provided with disposal options.

• Proper Disposal — In addition to take-backs and promotion of drop-off locations, there are medication neutralization kits that are available. These provide an appealing way to engage people to take action in a one-off event that increases their readiness to take more routine medication safety actions. The U.S. Food & Drug Administration (FDA) provides guidance on the safest ways of disposing of medications at home. Some experts strongly recommend against flushing medications down the toilet. However, the FDA recommends that certain drugs be flushed immediately, such as Fentanyl patches, Oxycontin, and Percocet, and publishes a full list of pharmaceuticals that are safe to flush. While flushing is the last resort, flushing unused medications which are on the "flush list" is better than keeping them around. There are three optimal categories of in-home disposal — deactivation powders that are poured into prescription bottles, deactivation pouches into which prescriptions can be poured, and medication mail-back envelopes. Example of vendors which provide each of these are listed in the “Available Tools and Resources” section below. All three approaches have the benefit of being a low-cost solution to disposal. Powder packets offer a level of simplicity in distribution, because they can be easily attached to prescriptions by the pharmacist. All three in-home disposal approaches are useful as give-aways in campaigns to increase awareness of medication safety. All three methods support the environment and decrease the possibility of accidental exposure or intentional misuse.

• Safe Storage of prescription drugs within the home has been prioritized as a key strategy by many organizations and coalitions. It is essential that people who have prescription medications in their homes store them safely. If prescription drugs are safely stored, misuse can be stopped earlier, because people who have not yet developed a dependence on opioids usually do not go directly to illegal opioids like heroin or Fentanyl. Increasing awareness about the importance of safe storage often goes hand-in-hand with providing members of the community free or affordable storage options. A variety of vendors associated with both safe storage and disposal products are listed in the “Available Tools and Resources” section below. Failure to securely store prescription drugs contributes to the opioid epidemic and other health hazards in several ways:
  • Access to prescription drugs can lead to initial experimentation, especially by teens.
  • Easy access to unsecured opioids or other prescription drugs contributes to theft by people who sell them or give them away. This can occur with family, relatives, friends or from homes which they enter for other reasons such as work, open houses, or breaking and entering. Stealing prescription drugs, which is much easier when they are commonly available in unlocked medicine cabinets, is often a step toward more destructive misuse.
  • Children who access unsecured drugs sometimes take them, thinking they are candy.

It should be noted that the rise of synthetic Fentanyl on the street has led to conflicting viewpoints on disposal programs within the harm reduction community. It is safer for people to use prescribed opioids from a pharmacy, even if they have been prescribed for someone else. While not advocating stealing someone prescriptions, it is common knowledge that it is safer. This is a fine line, since prescription drugs are regulated and the illicit supply is not, and a person who regularly uses drugs is safer using drugs from a regulated supply over an unregulated supply. For someone who is in active use, destroying their safe supply - even though well intentioned - may put them at a higher risk of overdose if the result is that they turn to an unregulated (illicit) source instead. See SAFE Solutions article titled "Expand Drug Testing Options," for more information on Fentanyl, especially within the context of Fentanyl testing strips (FTS).

Relevant Research

This report highlights survey results that reveal the disconnect between parent knowledge and behavior regarding safe storage of medicine.

The Product Stewardship Institute documents successful cases of Extended Producer Responsibility (EPR). EPR, also known as product stewardship, describes a system where the life cycle costs of a product become part of the cost of manufacturing. EPR is a proven method to sustainably fund the recycling or disposal of a variety of products that have disposal concerns, such as paint and fluorescent lights. The following two cases show promise for a change in responsibility for pharmaceutical disposal:

• In France, the pharmaceutical EPR collects on average over 16,000 tons per year, at a cost of just $0.0022 per box. "In a recent survey, 77% of French residents claimed to have disposed of unwanted medication via these take-back sites, while 70% said they always dispose of pharmaceuticals in this way."
• In British Columbia the pharmaceutical industry has been funding the entire cost of their drug take-back program since 2004.

Staggering Statistics

• Only 2 in 10 who have dangerous medications—such as opioid pain pills, stimulants used to treat ADHD, and sedatives—lock them up.

• A recent study of adults living in households with children found that prescription opioids were stored in a locked or latched place in only 32.6% of households with young children and 11.7% with older children.

• More than 1,600 teens begin abusing prescription drugs each day.

• 1 in every 4 teens in America say they have misused or abused a prescription drug at least once.

• 60,000 kids under the age of 5 accidentally ingest these dangerous drugs every year and wind up in emergency rooms.

• 12-17 year olds abuse prescription drugs more than ecstasy, heroin, crack/cocaine and methamphetamines combined.

• In one study, only 8.6% of the respondents reported locking up their opioid medication and only 20.9% reported using a latched location.

• The National Drug Intelligence Center notes that older people are especially vulnerable to theft of prescription drugs. They also indicate that over half of teens, ages 12 and up, obtained prescription drugs from a friend or family member "for free."

Impactful Federal, State, and Local Policies

• Federal. According to the Government Accountability Office, only 2.5 percent of eligible organizations are participating in take-backs. The primary barrier is financial, because it costs money to maintain secure prescription drop-off container, to train staff to follow the relevant regulations, and to destroy the returned medication. A potential policy solution is to mandate opioid manufacturers to subsidize drop-off location operations and to pay patients for their returned bottles of pills.

• State Legislation Requiring Disposal Kits be Given with Prescriptions. In 2018 Kentucky passed a bill that amended KRS 218A.170 -- requiring "a practitioner or a pharmacist to sell or distribute a nontoxic composition, which permanently captures the controlled substance, for the sequestration or deactivation and disposal of unused, unwanted, or expired controlled substances anytime a controlled substance is sold or distributed." Kentucky was the first state to pass such a bill.

• Local Drug Take-Back Programs. San Francisco and several West Coast counties have issued legislation which require drug companies to fund drug take-back programs. At least a dozen other local governments around the country are considering similar legislation.

Available Tools and Resources

SAFE Project:

• "At-Home Drug Disposal" is a SAFE Project written article that discusses the importance of proper disposal for opioid/prescription medications at home and how to do so safely.
• See the wiki titled "Activate Your Community" for more detailed information on overcoming barriers to addressing drug misuse and building strategic partnerships for effective local initiatives.
• See the wiki titled "Reduce Criminal Diversion of Prescription Drugs" for more detailed information on the illegal distribution and misuse of prescription drugs, encompassing activities like selling medications, doctor shopping, and theft or forgery of prescriptions.

DEA National Prescription Drug Take-Back Day Initiative

This Initiative addresses a crucial public safety and public health issue by providing an opportunity for Americans to prevent drug addiction and overdose deaths. Since September 2010, the DEA has been promoting two national take-back days each year in April and October. An ongoing inventory of success cases is documented at the DEA website. Nationally, hundreds of tons are collected on each take-back day, and thousands of tons of prescription drugs have been collected. To support local Rx Take-Back Days, the DEA provides a toolkit featuring promotional materials for associated partners. DEA also has variety of on-line resources and ideas on how to implement a local take-back day.

State Level Drug Take-Back Programs

A sample of exemplary state efforts are referenced below:

• Arkansas
• Georgia
• Indiana
• Oregon
• Pennsylvania
• Washington

Medication Disposal Locators

The National Association of Drug Diversion Investigators (NADDI) provides an online resource to find locations of drop boxes, to buy boxes, apply for grants, and other information about drop boxes. The DEA disposal locator matches zip code to registered collectors which will pass unused medicine on to the DEA to disposed. Additional drug disposal locators are listed below:

• American Medicine Chest Challenge
• Dispose My Meds
• National Association of Boards of Pharmacy
• Rx Drop Box

The Product Stewardship Institute provides detailed guidance for expanding and improving a pharmacy-based collection program.

In-Home Disposal Products

• Deterra Drug Disposal System. Verde Technologies offers a product which deactivates prescription drugs. Each patented pouch contains a water-soluble inner pod containing activated carbon. Once the pharmaceuticals are placed in the pouch, warm water is then added, which dissolves the inner pod releasing the activated carbon. The warm water also dissolves prescription pills, patches, and liquids, allowing them to be absorbed by the carbon, rendering them inert and non-retrievable.
• DisposeRx is a powdered blend of solidifying materials that provides a solution for the safe disposal of unwanted or expired prescription drugs. Prescription drugs can be rendered safe for disposal (and impossible to misuse) by adding water and powder from the packet directly into the pill bottle and shaking the bottle.
• Stericycle has a program "Prescription Drug Seal & Send Pouches" which provides an option for unused prescription drugs to be mailed to Stericycle in an unmarked mailing pouch. The pills are then incinerated.

Here is a small sample of products which can either be distributed or advertised by community coalitions for families to purchase. Some of these are low-cost items, useful as give-ways at community events. Some of the items could have logos of local business sponsors or coalition branding added:

• IKeyp provides a safe that offers storage for personal items that need to be securely stored yet regularly accessed. It is linked to an app on a smart phone.
• Pack4U equips pharmacies with single-dose packaging. Using blister packs instead of having an entire bottle filled with prescription pills has been shown to help prevent accident poisonings in children.
• Safer Lock provides 4-digit combination lock boxes and locking caps.
• TimerCaps have a built-in LCD stopwatch timer which displays how long it has been since the cap was last replaced. Timer caps come in different sizes, and they can replace an existing medicine bottle cap (or you can get a cap and bottle combination). TimerCaps are easy to use and don't require a change in patient behavior. They are also useful to track the timing since the last dosage -- reducing accidental overdoses and emergency room visits.

Promising Practices

Many communities have engaged in education and awareness efforts to increase prescription drug disposal and safe storage. There is potential to reach significantly more people by reaching a more diverse group of cross-sector partners in a campaign. The CDC promotes two different national campaigns:

• The PROTECT Initiative is an innovative collaboration led by CDC. PROTECT unites public health agencies, private sector companies, professional organizations, consumer/patient advocates, and academic experts to keep children safe from unintended medication overdoses.
• Up and Away Campaign. "Put your medicines up and away and out of sight." This campaign is designed to remind families about the importance of safe medicine storage.

There are numerous examples of successful campaigns:

• Colorado. The Consortium for Prescription Drug Abuse Prevention has developed a successful program for reaching people age 65+
• Minnesota. The Mallinckrodt pharmaceutical company donated 30,000 disposal pouch systems to be distributed.
• New Jersey. The Inspira Health Network distributes the Deterra® pouch throughout their network.
• Pennsylvania has a goal of distributing Deterra® Drug Deactivation and Disposal pouches alongside 10% of all opioid prescriptions. In 2017, Attorney General Shapiro unveiled a plan to distribute 300,000 drug disposal pouches in 12 counties.
• Rhode Island has a partnership between the South Kingstown Partnership for Prevention and Rebels Inspiring Positive Lifestyles. Their medication safety campaign held community awareness events and garnered local news publicity for their cause and was able to raise funds to send youth leaders to CADCA training.
• Walmart provides DisposeRx powder packets with its pharmacy prescriptions.

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