Old meds? Many get conflicting disposal advice

updated 3:43 p.m. ET Sept. 15, 2008

American consumers know not to toss old car batteries in the trash or pour motor oil down the drain, but those who want to get rid of unused drugs face a barrage of conflicting guidance: flush, DON'T flush, toss in the trash, DON'T toss in the trash.

Often, there's no information at all.

The most likely source of guidance should be the instructions packaged with prescription drugs, or advice dispensed by a pharmacist or doctor.

But an Associated Press examination of hundreds of instructions provided with prescription medications found that Americans are almost never told how to safely dispose of unwanted drugs, despite mounting evidence that medications flushed down the toilet damage the environment and eventually reach drinking water supplies.

The AP reviewed information accompanying the 50 most-dispensed prescription drugs in the U.S., ranging from sheets that patients get when they pick up a prescription to detailed technical literature aimed at doctors and pharmacists.

Prescriptions for those 50 drugs were filled 1.1 billion times last year, representing 28 percent of the national market, according to the health care information company IMS Health. The AP also contacted working pharmacists around the country to find out what they tell customers.

None of the literature included federal drug disposal guidelines, published more than a year ago, nor any other step-by-step directions about how to get rid of medicines — even though much of the literature is produced or reviewed by the Food and Drug Administration, which helped develop the guidelines. The most common reason given: Space is very limited on drug instructions and people often don't read them carefully, so side effects and other risks are more important to detail than disposal.

The issue of disposal was mentioned in 118 out of 282 pieces of material that AP reviewed, but the typical advice given was to ask a doctor, pharmacist or waste disposal expert how to discard medication. At best, paperwork produced by a private publisher and given patients at some pharmacies warns them not to flush medicines down the toilet unless instructed, though it doesn't say what they should do instead.

46 million in U.S. drinking water tainted with meds
The AP's findings were part of its ongoing investigation into the presence of pharmaceutical residues in the nation's drinking water supplies. The news agency has reported that at least 46 million Americans are drinking water from supplies tainted with minute concentrations of a vast array of pharmaceuticals.

Government and private scientists and researchers believe that most pharmaceutical contamination comes from unmetabolized drugs excreted by consumers, then flushed down toilets.

The AP has reported on an important secondary problem — that U.S. hospitals and long-term care facilities throw away an estimated 250 million pounds of drugs and contaminated packaging annually, flushing much of the unused pharmaceuticals down drains, toward drinking water supplies.

But there's another source — consumers who throw away unwanted, expired or unneeded prescriptions.

It doesn't help that they're often left confused about how to properly dispose of their discards.

"I've read about proper disposal of batteries, but I don't ever recall reading proper disposal of drugs," says Lisa Morris, of Hillsboro, N.D., who has worked in nursing homes in Minnesota and Montana.

More than half the 301 patients surveyed at a military base pharmacy in 2006 said they had flushed medications down a toilet; fewer than 20 percent said they had ever been given advice about proper disposal by a health care provider.

Guidelines for prescription drug disposal Here are the federal guidelines for proper disposal of prescription drugs: — Take unused, unneeded or expired prescription drugs out of their original containers. Throw the packaging in the trash. — Mix prescription drugs with an undesirable substance, such as used coffee grounds or kitty litter, and put them in impermeable, non-descript containers, such as empty cans or sealable bags. This will further ensure the drugs are not diverted. — Flush prescription drugs down the toilet only if the label or accompanying patient information specifically instructs doing so. — Take advantage of community pharmaceutical takeback programs that allow the public to bring unused drugs to a central location for proper disposal. Some communities have pharmaceutical takeback programs or community solid-waste programs that allow the public to bring unused drugs to a central location for proper disposal. Where these exist, these programs are a good way to dispose of unused pharmaceuticals. The FDA advises that the following 13 drugs be flushed down the toilet instead of thrown in the trash: — Actiq (fentanyl citrate) — Daytrana transdermal patch (methylphenidate) — Duragesic transdermal system (fentanyl) — OxyContin tablets (oxycodone) — Avinza capsules (morphine sulfate) — Baraclude tablets (entecavir) — Reyataz capsules (atazanavir sulfate) — Tequin tablets (gatifloxacin) — Zerit for oral solution (stavudine) — Meperidine HCl tablets — Percocet (Oxycodone and Acetaminophen) — Xyrem (Sodium Oxybate) — Fentora (fentanyl buccal tablet) Note: Patients should always refer to printed material accompanying their medication for specific instructions.

"It's one of those things providers and patients just don't know about," said Dr. Dean Seehusen, a family physician at the Eisenhower Army Medical Center at Fort Gordon, Ga., who conducted and published the survey. "I was never told what do with unused medication, not in medical school, not in residency, not in fellowship. I've taught family medicine for eight years now at three institutions and this is never part of the regular curriculum."

"Do not flush" represents part of the federal government's widely ignored and unenforceable guidelines. The guidelines suggest mixing most unwanted medicines with coffee grounds or kitty litter, then tossing the mess into the trash. There are 13 medicines — mostly strong narcotics — that the federal government explicitly says should be flushed so junkies won't get them.

Mixed messages
But federal agencies don't have a consistent message. For example, the Fish and Wildlife Service says "DO NOT FLUSH unused medications" while the White House — backed by the FDA and Environmental Protection Agency — says "Flush prescription drugs down the toilet" if they are on the list in the special guidelines. Meanwhile, the Drug Enforcement Administration says there is no "safe, secure and reliable disposal system" for some narcotics.

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The FDA even seems confused about whether it is pondering issuing disposal guidelines. Ilisa Bernstein, the FDA's director of pharmacy affairs, first said the agency was considering requiring guidelines on the materials it regulates. A spokesman later said that was not the case, and Bernstein added that no one at the agency has discussed a mandate in the year-plus she's worked on disposal issues.

A spokeswoman for the Environmental Protection Agency said that even unused pharmaceuticals considered hazardous waste at hospitals aren't regulated at home.

"Regulation of hazardous waste generated by the millions of households across the country — and usually in very small amounts — was deemed to be impractical by Congress and EPA," spokeswoman Roxanne Smith said.

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