Science of the Total Environment 478 (2014) 98–102
Contents lists available at ScienceDirect
Science of the Total Environment journal homepage: www.elsevier.com/locate/scitotenv
Public practice regarding disposal of unused medicines in Ireland Akke Vellinga a,⁎, Sarah Cormican a, Jacqueline Driscoll a, Michelle Furey a, Mai O'Sullivan a, Martin Cormican a,b a b
School of Medicine, National University of Galway, Ireland Department of Medical Microbiology, Galway University Hospitals, Galway, Ireland
H I G H L I G H T S • • • • •
Despite EU directives many countries lack appropriate unused medicines disposal systems. No information has been published on disposal of unused medicines in Ireland. Nearly 90% of respondents to a survey have unused medicines at home. Seventy five percent of respondents dispose of unused medicines appropriately if information is provided. Effective communication is likely to improve appropriate disposal.
a r t i c l e
i n f o
Article history: Received 21 November 2013 Received in revised form 23 January 2014 Accepted 23 January 2014 Available online 12 February 2014 Keywords: Questionnaire Disposal Household waste Drugs Medicine disposal Unused medicines
a b s t r a c t Background: Over recent years, a global increase in the use of pharmaceutical products has been observed. EU directives state that “Member states shall ensure that appropriate collection systems are in place for medicinal products that are unused or have expired” (Directive 2001/83/EC and Directive 2004/27/EC). Objectives: There is no published data on how people in Ireland dispose of unused medicines; therefore the purpose of this study is to establish baseline information on storage and disposal of medicines. Design: Data was collected over two 2-week periods a year apart. People in the streets of Galway and Cork were approached randomly and invited to participate by filling out a questionnaire. Results: The questionnaire was completed by 398 individuals (207 in Galway and 191 in Cork). Unused medicines were kept in the home by 88% of the respondents. The most cited reason for keeping unused medicines was “in case they are needed later” (68%). Of the respondents who had disposed of medicine in the past, 72% had done so inappropriately. Environmentally inappropriate disposal methods were through general waste disposal and via the sewage system. Interestingly, of the people who had received advice on disposal practices from a healthcare professional, 75% disposed of their medicine appropriately. Conclusions: There is little awareness among members of the public regarding appropriate ways to dispose of unused medicines. Our findings suggest that effective communication and established protocols will promote appropriate disposal practices. © 2014 Elsevier B.V. All rights reserved.
1. Introduction Over recent years, a global increase in the use of pharmaceutical products has been observed (Kaiser Family Foundation, 2010). This increase is related in part to an ageing population and significant burden of chronic disease, resulting in a higher proportion of the population taking medicines for longer periods of their lives (Moynihan et al., 2013). Increased use of pharmaceuticals in both human and animals may have effects beyond the immediate consumer as they may enter ⁎ Corresponding author at: School of Medicine, 1 Distillery Road, Galway, Ireland. Tel.: + 353 91 495194. E-mail addresses: [email protected] (A. Vellinga), [email protected] (M. Cormican). 0048-9697/$ – see front matter © 2014 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.scitotenv.2014.01.085
the environment (Daughton and Ruhoy, 2013). Much confusion exists about the proper way in which medicines should be disposed as many countries do not have standard medicines disposal protocols (Tong et al., 2011). The processes of absorption, metabolism and excretion of pharmaceuticals are variable; however for many agents significant quantities are excreted in urine and/or in faeces without alteration or in altered but biologically active form. In addition to excretion of administered pharmaceutical agents into the sewage system, pharmaceuticals may also enter the environment in unaltered form as a result of environmentally inappropriate disposal (Bound et al., 2006). Sewage treatment systems were not generally designed specifically to remove pharmaceuticals from effluent before discharge into receiving waters (Daughton and Ternes, 1999). Disposal of unused medicines into domestic waste may also lead to
A. Vellinga et al. / Science of the Total Environment 478 (2014) 98–102
landfill leachate and create environmental problems (Bound and Voulvoulis, 2005). Similar issues may arise with a variety of personal care products which frequently contain biologically active compounds. The situation is further complicated by substantial use of pharmaceuticals in agriculture through animal urine and faeces including land spreading of animal slurry. When pharmaceuticals enter the environment, complex biological and physical processes may result in degradation of compounds at variable rates, depending on environmental conditions (Fent et al., 2006). In some cases it is possible that pharmaceutical metabolites are reactivated by conventional sewage treatment processes before environmental discharge (Daughton and Ternes, 1999; Ruhoy and Daughton, 2008). Through sorption and biodegradation in the environment, pharmaceutical products may diffuse and transformed into by-products. These contaminant reservoirs may pose a higher or lower environmental risk (Crane et al., 2006; Fent et al., 2006). However, such risk assessment is difficult as it is generally assessed based on single compounds (Kümmerer, 2010). The human health and broader environmental impact of pharmaceutical agents in the environment are uncertain. Concentrations of individual compounds are generally well below the levels thought to cause acute harm to humans or readily detectable impacts on the wider environment (Bound et al., 2006). There is considerable uncertainty however regarding potential harm from chronic exposure to low levels of pharmaceuticals and the potential for health and environmental interactions from traces of multiple agents (Crane et al., 2006; Johnson et al., 2008). The latter issue arises because there are generally traces of multiple different pharmaceuticals agents in the environment (Carlsson et al., 2006). Environmental problems possibly associated with the use and disposal of pharmaceuticals have already been observed. Jobling reported the feminisation of fish and Oaks documented on the near extinction of the Asian vulture (Gyps bengalensis) from diclofenac (Jobling et al., 1998) (Oaks et al., 2004). In addition to the direct environmental effects of pharmaceuticals, the presence of antibiotics in wastewater has the potential to crease antibiotic resistant organisms and disrupt sewage treatment processes (Bound et al., 2006). Removing excreted pharmaceuticals from urine and faeces poses substantial technical challenges and there is debate as to the extent to which the evidence of harm justifies investment in upgrading treatment systems. The issue of appropriate medicines disposal should in principle be much easier to address. In fact there is an existing directive that places an obligation on EU member states to ensure that appropriate collection systems are in place for medicinal products that are unused or have expired (Directive 2001/83/EC and Directive 2004/27/EC). However this law is inconsistently applied and appears to be unenforced. Studies done in countries such as the UK, Sweden and New Zealand in recent years have shown that people frequently dispose of medicines inappropriately via routes which may be detrimental to the environment (Braund et al., 2009; Persson et al., 2009; Tong et al., 2011).These studies have also shown that if patients are aware of the impact of pharmaceuticals on the environment, they are more likely to return medicines for proper disposal and destruction (Tong et al., 2011). In Sweden, a national and frequently publicised system for disposal of unused medicine through pharmacies resulted in the participation of more than 50% of the population (Persson et al., 2009). This is consistent with a review regarding disposal methods around the world which stated that information is the key to appropriate disposal of unused medicines (Tong et al., 2011). A formal system and guidelines for disposal are particularly important in countries that offer free or subsidised medicines as there can be greater accumulation and hoarding of medicines (Braund et al., 2009). In Ireland where free and subsidised medicines are available to a section of the population either through the medical card or drugs payment scheme and where public expenditure on drugs in the community increased over six fold from 300 million euro in 1998 to 1.9 billion euro in 2008 (Barry et al., 2010), there is a clear need for a formalised system of disposal. The environmentally appropriate method to dispose of unused medicines is by returning them to the pharmacy. Currently, an ad hoc system
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is in place in Ireland whereby some pharmacies accept unused medicines for return and some do not (Health Service Executive Ireland (HSE), 2007–2012). The pharmacy regulator (Pharmaceutical Society of Ireland) advises its members to advise the public to return medicines to the pharmacy for safe disposal (Pharmaceutical Society of Ireland, 2011). There are however no obligations on the pharmacies to accept returns and the costs of disposal rest with the pharmacies. In two Irish counties, Cork and Kerry, efforts have been made to put a structured system in place for the safe disposal of unwanted and unused medicines. DUMP (Dispose of Unused Medications Properly) was organised by the Health Services Executive (HSE) in conjunction with community pharmacists in the region (Health Service Executive Ireland (HSE), 2007–2012). DUMP aimed to encourage members of the public to return unwanted or out of date medicines to pharmacies which would then be disposed of safely and properly and reduce the chance of accidental poisonings, overdose, inappropriate sharing of medicines and damage to the environment (Environmental Awareness Research Unit of Cork City Council, 2011). The scheme included both prescription and over the counter medicines. The campaign ran for 6-week periods at the start of each year from January 2007 to 2010. In a special report highlighting the outcomes of the DUMP campaign, the conclusion argued for more campaigns across the country and greater publicity but this has not happened (Kim and Aga, 2007; O'Driscoll et al., 2009). Against this background we conducted a study to assess knowledge and practice of Irish people regarding the disposal of unwanted pharmaceuticals. 2. Objectives The objective of this study was to establish baseline information on storage and disposal of medicines. The results combine two surveys in Ireland in Galway in 2010 and Cork in 2011. 3. Methods Interviews were held over 2-week periods, a year apart. People in the streets of the cities of Galway and Cork were approached randomly and invited to participate. People were approached at different times during the day, on weekdays as well as during the weekends. Participants could either complete the survey themselves or have their responses marked by the researchers. Participants had to be Irish residents, over 18 years of age with fluency in English. The questionnaire requested responses regarding medicine use, storage and disposal as well as socio-economic indicators (Table 1). A medical card provides free access to the general practitioner and other medical services and to medicine (subject to a small contribution). Medical card status is based on income thresholds and at the time of the survey in Ireland about 30% of the population were eligible for a medical card. People approached in Cork were asked two additional questions, namely, whether they had heard of the DUMP campaign, and if so, whether they had used the bins provided by the campaign to dispose of unused medicines. Data entry was done in Epidata (DK) and statistical analysis was performed using SPSS for windows (version 18.0). Dichotomous and ordered variables were analysed using the chi square test (for trend) and for continuous data, samples were compared with a t-test. A p-value of 0.05 was considered to be significant; however, due to the high number of comparisons, caution was observed in interpreting their practical significance. An overview of the questionnaire and possible answers is presented in Table 1. For questions where multiple responses were allowed, the percentages are based on the total number of answers provided. 4. Results A total sample size of 398 was obtained with 207 responders in Galway and 191 in Cork. Overall, 68% were female and 32% male. Most respondents were in the age group 26–65 years, 37% in the 26–45 years,
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Table 1 Questions and possible response options given to participants. Questions
Response options
Do you have medicines (tablets or syrups) in your home? Where in your home do you keep your medicines?
Yes or no Bedroom Bathroom Kitchen Other room Numerical answer given Yes, no or don't know Yes, no or don't know Yes, no or don't know Yes, no or don't know Yes, no or don't know In case needed later To give others if needed Unsure how to get rid of Do not want to waste them Yes, no or don't know Household waste Sink Toilet Burn Return to hospital or doctor Return to pharmacy Numerical answer given Numerical answer given Yes, no or don't know Side effects Change of medication Medicine labels were unclear/unclear instructions Medical condition improved or resolved/symptoms cleared Unsure why medicine was prescribed Too much prescribed Expiry date passed Inconvenience/difficulty following instructions Other Yes, no or no answer given
How many different types of medicine do you keep? Do you have any non-prescription (over the counter) medicines? Do you have any prescription medicines at home? Do you have any antibiotics at home? Do you have any prescription pain killers at home? Do you ever keep medicines after you have finished with your course? Those who answered yes, why do you keep unused medicines?
Have you ever disposed of leftover medicines (prescription or over the counter medication? If yes, how did you dispose of the medicines? If no, how would you dispose of the medicines? a) pills b) syrups c) both
How many visits have you made to a pharmacy to get prescription medication in the last three months? Have you ever been given advice by a healthcare professional on what to do with leftover medicine? If you had leftover medicines, was this because you discontinued the medication? If yes, why did you discontinue your medicines?
Have you ever shared leftover medicines with another person with similar symptoms? Respondents in Cork were asked Have you heard of the DUMP campaign? If yes, have you ever disposed of medicines using the bins provided by the campaign?
and 30% in the 46–65 years, 21% were under 25 years and 11% over 65 years. The respondents were mainly of Irish nationality (90%). They lived in cities (30%), towns or suburbs (37%) and in rural areas (33%). A medical card was held by 26% of the respondents. Educational levels were high, with nearly 60% of the respondents with a third level degree. Galway had a significantly higher percentage of respondents in the under 25 years age group (33% vs. 8%) but similar proportions in all age groups were interviewed if all respondents up to age 45 years were combined (58% vs. 60%). Relatively more people lived in cities and rural areas in Galway while more respondents lived in suburbs in the Cork sample. Significantly more respondents in Galway had a medical card compared to Cork (31% vs. 21%) but education levels were similar in both samples. Of all respondents, 88% kept medicine at home. Significantly more residents in Cork had medicine at home compared to the Galway respondents (94% vs. 83%) which was irrespective of age group. Most respondents stored their medicine in the kitchen (67%), followed by the bedroom (19%) and the bathroom (13%). No differences were observed according to gender or age group. Nearly 80% of the respondents have non-prescription medicines at home. Females were more likely to have over the counter medicine at home compared to males (84% vs. 66%) but there is little difference between age groups. Respondents without a medical card were significantly more likely to have over the counter (non-prescription) medicine at home compared to those with a medical card (82% vs. 68%). Overall, the majority of respondents had prescription medicines in their home (74%) of whom 33% had antibiotics and 40% prescription painkillers at home. No significant differences were observed for prescription drugs between males and females. Younger respondents were more likely to have antibiotics at home and this difference was similar but less
Yes, no or no answer given Yes, no or no answer given
pronounced for prescription painkillers. Respondents with a medical card generally had more prescription medicine at home, but this was not a significant difference (79% vs. 72%). When asked if unused medicine was kept, 52% (207) responded yes. Younger respondents were significantly more likely to keep unused medicine compared to older people (68% in under 25 years, 58% in 26–45 years, 46% in 46–65 years and 16% in over 65 years). Medical card holders were significantly less likely to keep unused medicine (39% vs. 56%). The reasons for keeping unused medicine were most often “in case they are needed later” (57%), “I don't want to waste them” (20%) and “I am not sure how to dispose of them” (17%) and 5% answered “To give to other people if they need them” (Fig. 1). However, when subsequently asked “have you ever shared leftover prescription medicines with another person with similar symptoms”, 16% (n = 63) answered yes. In comparison, the most answered reasons for
In case needed in the future
Don't want to waste
Not sure how to dispose of
To give others if needed Respondents (N=207) providing one or more reasons (N=223 answers).
Fig. 1. Overview of reasons respondents keep medicine.
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having unused medicines at all were that symptoms had improved (31%), side effects (13%) and a change of medicine (11%). Of the respondents, 72% (281) indicated that they had disposed of medicine. Of them, 72% (202) did this in an environmentally inappropriate manner. Answers indicated that unused medicine was disposed via household waste (51%), the sink (29%) or toilet (14%) (Fig. 2). No differences were observed between males and females. Older people and medical card holders are significantly more likely to appropriately dispose of unused medicine. If appropriately disposed, the method used most often is by return to pharmacy (96%). No differences in appropriate disposal methods were observed for gender or age but medical card holders are slightly less likely to use the pharmacy to dispose of their unused medicine (93% vs. 99%). The differences for those choosing an appropriate method of disposal between Galway and Cork were not statistically significant. Of those who received advice from a healthcare professional regarding disposal 75% chose an appropriate method (n = 141) compared to 25% of those that did not (Fig. 3). However, only 19% of the respondents indicated that they received this advice. There were no statistically significant differences for gender, age or medical card ownership between those that received the advice; neither was there any difference between Cork and Galway. In relation to the DUMP campaign, 23% of the respondents in Cork had heard of the campaign of whom 40% subsequently used the bins for disposal provided by the campaign. 5. Discussion Respondents to the survey have unused medicines for a variety of reasons, the most common ones being the termination of pharmacotherapy due to side effects or a change of medicine. The accumulation of unused medicine as a result of non-adherence to recommendations (often driven by an adverse drug reaction) is a shared responsibility between prescriber and consumer. Clear information at the point of prescribing (i.e. advice concerning side effects and medicine changes) and lower-dose prescribing can minimise adverse effects (Daughton and Ruhoy, 2013; Olsson and Pal, 2006). Respondents differed slightly in their behaviours depending on the city in which they were interviewed. The differences between the cities can mostly be explained by the difference in population demographics. Galway is a student city which is reflected in the high number of under 25 years. Ireland in general has a high educational achievement level and this is again reflected in the respondents' sample (Eurostat, September 2012). The relatively lower percentage of medical card holders in comparison with the general population reflects the selection procedures as well as the location. The main limitations to this study are its cross-sectional nature and the ‘hit and miss’ random approach of respondents. Both can result in a bias due to impaired recollection of ever receiving information or due to a higher participation of certain population groups. This method of enrolling participants favours certain population groups, due to researcher's selection of particular population groups as well as higher likelihood of female respondents (Bowling, 2005). However, none of these demographic factors seem to have an
Household waste Sink Toilet
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important and determining impact on the outcomes. A gap in information and awareness of the problem of disposal of medicine seems to be present in the population overall, regardless of demographic indicators. The environmental impact arising from the discharge of pharmaceuticals on human health and the wider environment is uncertain (Daughton and Ruhoy, 2013). However, there is sufficient reason for concern to take such precautionary measures, in particular, the appropriate disposal of unused medicines. Public awareness needs to be raised regarding the need for safe disposal and the routes of safe disposal. The high percentage of people choosing an environmentally inappropriate disposal method (74%) in our study is worrying in particular with the legal requirement set out by Directive 2001/83/EC and Directive 2004/27/EC stating that ‘Member states shall ensure that appropriate collection systems are in place for medicinal products that are unused or have expired’ (European Parliament, 2001; European Parliament, 2004). The current ad hoc system that is in place does not in practice appear to represent an ‘appropriate collection system’ as required by the European Directive while also failing to meet the needs of the public. The most influential factor determining whether someone disposes of their unused medicines appropriately in our study depends on whether this advice has been given. As only 19% of respondents recalled receiving advice on disposal of unused medicines, more effort needs to go into publicising the need for information on appropriate disposal. A similar pattern was shown in the United States where people who were informed of the proper methods to dispose of unused medicines were more likely to do so (Seehusen and Edwards, 2006). A key part of formulating and communicating a message to the public is to specify a clearly defined mechanism for disposal and an unequivocal obligation on a specified agent/agencies to accept medicines for disposal. It has been shown in Sweden, that if a formalised and sustained system for disposal of unused medicines is in place, 73% of people return their unused medicines to the pharmacy (Persson et al., 2009). In Ireland, programmes such as the DUMP are of value in providing information and supporting appropriate behaviour; these programmes are of limited impact because they are intermittent. Furthermore the absence of a clearly defined obligation with respect to accepting unused medicines for disposal makes it difficult for healthcare professionals to formulate a clear message to patients and their relatives regarding safe disposal. Media campaigns to inform the public are key to the safe disposal of unused medicines (Braund et al., 2009; Persson et al., 2009; Tong et al., 2011). Evidence suggests that concern of the environmental risk associated with improper disposal is the main motivation for returning unused medicines to the pharmacy (Tong et al., 2011). Therefore, public campaigns should focus on highlighting the environmental risk associated with inappropriately disposed medicines. An immediately practical solution is to place a clear obligation on those who retail medicines and personal care products to accept returns of the products they sell for safe disposal. A recent study in Texas showed that the public generally had favourable perceptions regarding medication take-back programmes and that having such a programme in place was an actual selling point for a pharmacy (Thach et al., 2013). Additionally, both prescriber and consumer can further contribute to safe disposal by limiting leftover medication through optimisation of medicine dosage (Daughton and Ruhoy, 2013). Notwithstanding the limitations of this study, we have shown that there is very little awareness among members of the Irish public in the disposal of their unused medicines. Our findings suggest that effective communication and clear (official) guidelines consistently implemented by authorities may facilitate appropriate disposal practices.
Other
Funding Respondents (N=202) indicating one or more ways of inapropriate disposal (N=202 answers).
Fig. 2. Overview of methods of environmentally inappropriate disposal.
This work was partly funded by the Health Research Board of Ireland and the Millennium Research Fund of the National University of Ireland, Galway through the summer student fellowship scheme.
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A. Vellinga et al. / Science of the Total Environment 478 (2014) 98–102 for those who disposed appropriately (N=75)
for thosewho received advice (N=141)
Received advice
Appropriate disposal
No advice
Inappropriate disposal
Fig. 3. Comparison of advice regarding environmentally appropriate disposal and disposal method.
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Contents lists available at ScienceDirect
Science of the Total Environment journal homepage: www.elsevier.com/locate/scitotenv
Public practice regarding disposal of unused medicines in Ireland Akke Vellinga a,⁎, Sarah Cormican a, Jacqueline Driscoll a, Michelle Furey a, Mai O'Sullivan a, Martin Cormican a,b a b
School of Medicine, National University of Galway, Ireland Department of Medical Microbiology, Galway University Hospitals, Galway, Ireland
H I G H L I G H T S • • • • •
Despite EU directives many countries lack appropriate unused medicines disposal systems. No information has been published on disposal of unused medicines in Ireland. Nearly 90% of respondents to a survey have unused medicines at home. Seventy five percent of respondents dispose of unused medicines appropriately if information is provided. Effective communication is likely to improve appropriate disposal.
a r t i c l e
i n f o
Article history: Received 21 November 2013 Received in revised form 23 January 2014 Accepted 23 January 2014 Available online 12 February 2014 Keywords: Questionnaire Disposal Household waste Drugs Medicine disposal Unused medicines
a b s t r a c t Background: Over recent years, a global increase in the use of pharmaceutical products has been observed. EU directives state that “Member states shall ensure that appropriate collection systems are in place for medicinal products that are unused or have expired” (Directive 2001/83/EC and Directive 2004/27/EC). Objectives: There is no published data on how people in Ireland dispose of unused medicines; therefore the purpose of this study is to establish baseline information on storage and disposal of medicines. Design: Data was collected over two 2-week periods a year apart. People in the streets of Galway and Cork were approached randomly and invited to participate by filling out a questionnaire. Results: The questionnaire was completed by 398 individuals (207 in Galway and 191 in Cork). Unused medicines were kept in the home by 88% of the respondents. The most cited reason for keeping unused medicines was “in case they are needed later” (68%). Of the respondents who had disposed of medicine in the past, 72% had done so inappropriately. Environmentally inappropriate disposal methods were through general waste disposal and via the sewage system. Interestingly, of the people who had received advice on disposal practices from a healthcare professional, 75% disposed of their medicine appropriately. Conclusions: There is little awareness among members of the public regarding appropriate ways to dispose of unused medicines. Our findings suggest that effective communication and established protocols will promote appropriate disposal practices. © 2014 Elsevier B.V. All rights reserved.
1. Introduction Over recent years, a global increase in the use of pharmaceutical products has been observed (Kaiser Family Foundation, 2010). This increase is related in part to an ageing population and significant burden of chronic disease, resulting in a higher proportion of the population taking medicines for longer periods of their lives (Moynihan et al., 2013). Increased use of pharmaceuticals in both human and animals may have effects beyond the immediate consumer as they may enter ⁎ Corresponding author at: School of Medicine, 1 Distillery Road, Galway, Ireland. Tel.: + 353 91 495194. E-mail addresses: [email protected] (A. Vellinga), [email protected] (M. Cormican). 0048-9697/$ – see front matter © 2014 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.scitotenv.2014.01.085
the environment (Daughton and Ruhoy, 2013). Much confusion exists about the proper way in which medicines should be disposed as many countries do not have standard medicines disposal protocols (Tong et al., 2011). The processes of absorption, metabolism and excretion of pharmaceuticals are variable; however for many agents significant quantities are excreted in urine and/or in faeces without alteration or in altered but biologically active form. In addition to excretion of administered pharmaceutical agents into the sewage system, pharmaceuticals may also enter the environment in unaltered form as a result of environmentally inappropriate disposal (Bound et al., 2006). Sewage treatment systems were not generally designed specifically to remove pharmaceuticals from effluent before discharge into receiving waters (Daughton and Ternes, 1999). Disposal of unused medicines into domestic waste may also lead to
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landfill leachate and create environmental problems (Bound and Voulvoulis, 2005). Similar issues may arise with a variety of personal care products which frequently contain biologically active compounds. The situation is further complicated by substantial use of pharmaceuticals in agriculture through animal urine and faeces including land spreading of animal slurry. When pharmaceuticals enter the environment, complex biological and physical processes may result in degradation of compounds at variable rates, depending on environmental conditions (Fent et al., 2006). In some cases it is possible that pharmaceutical metabolites are reactivated by conventional sewage treatment processes before environmental discharge (Daughton and Ternes, 1999; Ruhoy and Daughton, 2008). Through sorption and biodegradation in the environment, pharmaceutical products may diffuse and transformed into by-products. These contaminant reservoirs may pose a higher or lower environmental risk (Crane et al., 2006; Fent et al., 2006). However, such risk assessment is difficult as it is generally assessed based on single compounds (Kümmerer, 2010). The human health and broader environmental impact of pharmaceutical agents in the environment are uncertain. Concentrations of individual compounds are generally well below the levels thought to cause acute harm to humans or readily detectable impacts on the wider environment (Bound et al., 2006). There is considerable uncertainty however regarding potential harm from chronic exposure to low levels of pharmaceuticals and the potential for health and environmental interactions from traces of multiple agents (Crane et al., 2006; Johnson et al., 2008). The latter issue arises because there are generally traces of multiple different pharmaceuticals agents in the environment (Carlsson et al., 2006). Environmental problems possibly associated with the use and disposal of pharmaceuticals have already been observed. Jobling reported the feminisation of fish and Oaks documented on the near extinction of the Asian vulture (Gyps bengalensis) from diclofenac (Jobling et al., 1998) (Oaks et al., 2004). In addition to the direct environmental effects of pharmaceuticals, the presence of antibiotics in wastewater has the potential to crease antibiotic resistant organisms and disrupt sewage treatment processes (Bound et al., 2006). Removing excreted pharmaceuticals from urine and faeces poses substantial technical challenges and there is debate as to the extent to which the evidence of harm justifies investment in upgrading treatment systems. The issue of appropriate medicines disposal should in principle be much easier to address. In fact there is an existing directive that places an obligation on EU member states to ensure that appropriate collection systems are in place for medicinal products that are unused or have expired (Directive 2001/83/EC and Directive 2004/27/EC). However this law is inconsistently applied and appears to be unenforced. Studies done in countries such as the UK, Sweden and New Zealand in recent years have shown that people frequently dispose of medicines inappropriately via routes which may be detrimental to the environment (Braund et al., 2009; Persson et al., 2009; Tong et al., 2011).These studies have also shown that if patients are aware of the impact of pharmaceuticals on the environment, they are more likely to return medicines for proper disposal and destruction (Tong et al., 2011). In Sweden, a national and frequently publicised system for disposal of unused medicine through pharmacies resulted in the participation of more than 50% of the population (Persson et al., 2009). This is consistent with a review regarding disposal methods around the world which stated that information is the key to appropriate disposal of unused medicines (Tong et al., 2011). A formal system and guidelines for disposal are particularly important in countries that offer free or subsidised medicines as there can be greater accumulation and hoarding of medicines (Braund et al., 2009). In Ireland where free and subsidised medicines are available to a section of the population either through the medical card or drugs payment scheme and where public expenditure on drugs in the community increased over six fold from 300 million euro in 1998 to 1.9 billion euro in 2008 (Barry et al., 2010), there is a clear need for a formalised system of disposal. The environmentally appropriate method to dispose of unused medicines is by returning them to the pharmacy. Currently, an ad hoc system
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is in place in Ireland whereby some pharmacies accept unused medicines for return and some do not (Health Service Executive Ireland (HSE), 2007–2012). The pharmacy regulator (Pharmaceutical Society of Ireland) advises its members to advise the public to return medicines to the pharmacy for safe disposal (Pharmaceutical Society of Ireland, 2011). There are however no obligations on the pharmacies to accept returns and the costs of disposal rest with the pharmacies. In two Irish counties, Cork and Kerry, efforts have been made to put a structured system in place for the safe disposal of unwanted and unused medicines. DUMP (Dispose of Unused Medications Properly) was organised by the Health Services Executive (HSE) in conjunction with community pharmacists in the region (Health Service Executive Ireland (HSE), 2007–2012). DUMP aimed to encourage members of the public to return unwanted or out of date medicines to pharmacies which would then be disposed of safely and properly and reduce the chance of accidental poisonings, overdose, inappropriate sharing of medicines and damage to the environment (Environmental Awareness Research Unit of Cork City Council, 2011). The scheme included both prescription and over the counter medicines. The campaign ran for 6-week periods at the start of each year from January 2007 to 2010. In a special report highlighting the outcomes of the DUMP campaign, the conclusion argued for more campaigns across the country and greater publicity but this has not happened (Kim and Aga, 2007; O'Driscoll et al., 2009). Against this background we conducted a study to assess knowledge and practice of Irish people regarding the disposal of unwanted pharmaceuticals. 2. Objectives The objective of this study was to establish baseline information on storage and disposal of medicines. The results combine two surveys in Ireland in Galway in 2010 and Cork in 2011. 3. Methods Interviews were held over 2-week periods, a year apart. People in the streets of the cities of Galway and Cork were approached randomly and invited to participate. People were approached at different times during the day, on weekdays as well as during the weekends. Participants could either complete the survey themselves or have their responses marked by the researchers. Participants had to be Irish residents, over 18 years of age with fluency in English. The questionnaire requested responses regarding medicine use, storage and disposal as well as socio-economic indicators (Table 1). A medical card provides free access to the general practitioner and other medical services and to medicine (subject to a small contribution). Medical card status is based on income thresholds and at the time of the survey in Ireland about 30% of the population were eligible for a medical card. People approached in Cork were asked two additional questions, namely, whether they had heard of the DUMP campaign, and if so, whether they had used the bins provided by the campaign to dispose of unused medicines. Data entry was done in Epidata (DK) and statistical analysis was performed using SPSS for windows (version 18.0). Dichotomous and ordered variables were analysed using the chi square test (for trend) and for continuous data, samples were compared with a t-test. A p-value of 0.05 was considered to be significant; however, due to the high number of comparisons, caution was observed in interpreting their practical significance. An overview of the questionnaire and possible answers is presented in Table 1. For questions where multiple responses were allowed, the percentages are based on the total number of answers provided. 4. Results A total sample size of 398 was obtained with 207 responders in Galway and 191 in Cork. Overall, 68% were female and 32% male. Most respondents were in the age group 26–65 years, 37% in the 26–45 years,
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Table 1 Questions and possible response options given to participants. Questions
Response options
Do you have medicines (tablets or syrups) in your home? Where in your home do you keep your medicines?
Yes or no Bedroom Bathroom Kitchen Other room Numerical answer given Yes, no or don't know Yes, no or don't know Yes, no or don't know Yes, no or don't know Yes, no or don't know In case needed later To give others if needed Unsure how to get rid of Do not want to waste them Yes, no or don't know Household waste Sink Toilet Burn Return to hospital or doctor Return to pharmacy Numerical answer given Numerical answer given Yes, no or don't know Side effects Change of medication Medicine labels were unclear/unclear instructions Medical condition improved or resolved/symptoms cleared Unsure why medicine was prescribed Too much prescribed Expiry date passed Inconvenience/difficulty following instructions Other Yes, no or no answer given
How many different types of medicine do you keep? Do you have any non-prescription (over the counter) medicines? Do you have any prescription medicines at home? Do you have any antibiotics at home? Do you have any prescription pain killers at home? Do you ever keep medicines after you have finished with your course? Those who answered yes, why do you keep unused medicines?
Have you ever disposed of leftover medicines (prescription or over the counter medication? If yes, how did you dispose of the medicines? If no, how would you dispose of the medicines? a) pills b) syrups c) both
How many visits have you made to a pharmacy to get prescription medication in the last three months? Have you ever been given advice by a healthcare professional on what to do with leftover medicine? If you had leftover medicines, was this because you discontinued the medication? If yes, why did you discontinue your medicines?
Have you ever shared leftover medicines with another person with similar symptoms? Respondents in Cork were asked Have you heard of the DUMP campaign? If yes, have you ever disposed of medicines using the bins provided by the campaign?
and 30% in the 46–65 years, 21% were under 25 years and 11% over 65 years. The respondents were mainly of Irish nationality (90%). They lived in cities (30%), towns or suburbs (37%) and in rural areas (33%). A medical card was held by 26% of the respondents. Educational levels were high, with nearly 60% of the respondents with a third level degree. Galway had a significantly higher percentage of respondents in the under 25 years age group (33% vs. 8%) but similar proportions in all age groups were interviewed if all respondents up to age 45 years were combined (58% vs. 60%). Relatively more people lived in cities and rural areas in Galway while more respondents lived in suburbs in the Cork sample. Significantly more respondents in Galway had a medical card compared to Cork (31% vs. 21%) but education levels were similar in both samples. Of all respondents, 88% kept medicine at home. Significantly more residents in Cork had medicine at home compared to the Galway respondents (94% vs. 83%) which was irrespective of age group. Most respondents stored their medicine in the kitchen (67%), followed by the bedroom (19%) and the bathroom (13%). No differences were observed according to gender or age group. Nearly 80% of the respondents have non-prescription medicines at home. Females were more likely to have over the counter medicine at home compared to males (84% vs. 66%) but there is little difference between age groups. Respondents without a medical card were significantly more likely to have over the counter (non-prescription) medicine at home compared to those with a medical card (82% vs. 68%). Overall, the majority of respondents had prescription medicines in their home (74%) of whom 33% had antibiotics and 40% prescription painkillers at home. No significant differences were observed for prescription drugs between males and females. Younger respondents were more likely to have antibiotics at home and this difference was similar but less
Yes, no or no answer given Yes, no or no answer given
pronounced for prescription painkillers. Respondents with a medical card generally had more prescription medicine at home, but this was not a significant difference (79% vs. 72%). When asked if unused medicine was kept, 52% (207) responded yes. Younger respondents were significantly more likely to keep unused medicine compared to older people (68% in under 25 years, 58% in 26–45 years, 46% in 46–65 years and 16% in over 65 years). Medical card holders were significantly less likely to keep unused medicine (39% vs. 56%). The reasons for keeping unused medicine were most often “in case they are needed later” (57%), “I don't want to waste them” (20%) and “I am not sure how to dispose of them” (17%) and 5% answered “To give to other people if they need them” (Fig. 1). However, when subsequently asked “have you ever shared leftover prescription medicines with another person with similar symptoms”, 16% (n = 63) answered yes. In comparison, the most answered reasons for
In case needed in the future
Don't want to waste
Not sure how to dispose of
To give others if needed Respondents (N=207) providing one or more reasons (N=223 answers).
Fig. 1. Overview of reasons respondents keep medicine.
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having unused medicines at all were that symptoms had improved (31%), side effects (13%) and a change of medicine (11%). Of the respondents, 72% (281) indicated that they had disposed of medicine. Of them, 72% (202) did this in an environmentally inappropriate manner. Answers indicated that unused medicine was disposed via household waste (51%), the sink (29%) or toilet (14%) (Fig. 2). No differences were observed between males and females. Older people and medical card holders are significantly more likely to appropriately dispose of unused medicine. If appropriately disposed, the method used most often is by return to pharmacy (96%). No differences in appropriate disposal methods were observed for gender or age but medical card holders are slightly less likely to use the pharmacy to dispose of their unused medicine (93% vs. 99%). The differences for those choosing an appropriate method of disposal between Galway and Cork were not statistically significant. Of those who received advice from a healthcare professional regarding disposal 75% chose an appropriate method (n = 141) compared to 25% of those that did not (Fig. 3). However, only 19% of the respondents indicated that they received this advice. There were no statistically significant differences for gender, age or medical card ownership between those that received the advice; neither was there any difference between Cork and Galway. In relation to the DUMP campaign, 23% of the respondents in Cork had heard of the campaign of whom 40% subsequently used the bins for disposal provided by the campaign. 5. Discussion Respondents to the survey have unused medicines for a variety of reasons, the most common ones being the termination of pharmacotherapy due to side effects or a change of medicine. The accumulation of unused medicine as a result of non-adherence to recommendations (often driven by an adverse drug reaction) is a shared responsibility between prescriber and consumer. Clear information at the point of prescribing (i.e. advice concerning side effects and medicine changes) and lower-dose prescribing can minimise adverse effects (Daughton and Ruhoy, 2013; Olsson and Pal, 2006). Respondents differed slightly in their behaviours depending on the city in which they were interviewed. The differences between the cities can mostly be explained by the difference in population demographics. Galway is a student city which is reflected in the high number of under 25 years. Ireland in general has a high educational achievement level and this is again reflected in the respondents' sample (Eurostat, September 2012). The relatively lower percentage of medical card holders in comparison with the general population reflects the selection procedures as well as the location. The main limitations to this study are its cross-sectional nature and the ‘hit and miss’ random approach of respondents. Both can result in a bias due to impaired recollection of ever receiving information or due to a higher participation of certain population groups. This method of enrolling participants favours certain population groups, due to researcher's selection of particular population groups as well as higher likelihood of female respondents (Bowling, 2005). However, none of these demographic factors seem to have an
Household waste Sink Toilet
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important and determining impact on the outcomes. A gap in information and awareness of the problem of disposal of medicine seems to be present in the population overall, regardless of demographic indicators. The environmental impact arising from the discharge of pharmaceuticals on human health and the wider environment is uncertain (Daughton and Ruhoy, 2013). However, there is sufficient reason for concern to take such precautionary measures, in particular, the appropriate disposal of unused medicines. Public awareness needs to be raised regarding the need for safe disposal and the routes of safe disposal. The high percentage of people choosing an environmentally inappropriate disposal method (74%) in our study is worrying in particular with the legal requirement set out by Directive 2001/83/EC and Directive 2004/27/EC stating that ‘Member states shall ensure that appropriate collection systems are in place for medicinal products that are unused or have expired’ (European Parliament, 2001; European Parliament, 2004). The current ad hoc system that is in place does not in practice appear to represent an ‘appropriate collection system’ as required by the European Directive while also failing to meet the needs of the public. The most influential factor determining whether someone disposes of their unused medicines appropriately in our study depends on whether this advice has been given. As only 19% of respondents recalled receiving advice on disposal of unused medicines, more effort needs to go into publicising the need for information on appropriate disposal. A similar pattern was shown in the United States where people who were informed of the proper methods to dispose of unused medicines were more likely to do so (Seehusen and Edwards, 2006). A key part of formulating and communicating a message to the public is to specify a clearly defined mechanism for disposal and an unequivocal obligation on a specified agent/agencies to accept medicines for disposal. It has been shown in Sweden, that if a formalised and sustained system for disposal of unused medicines is in place, 73% of people return their unused medicines to the pharmacy (Persson et al., 2009). In Ireland, programmes such as the DUMP are of value in providing information and supporting appropriate behaviour; these programmes are of limited impact because they are intermittent. Furthermore the absence of a clearly defined obligation with respect to accepting unused medicines for disposal makes it difficult for healthcare professionals to formulate a clear message to patients and their relatives regarding safe disposal. Media campaigns to inform the public are key to the safe disposal of unused medicines (Braund et al., 2009; Persson et al., 2009; Tong et al., 2011). Evidence suggests that concern of the environmental risk associated with improper disposal is the main motivation for returning unused medicines to the pharmacy (Tong et al., 2011). Therefore, public campaigns should focus on highlighting the environmental risk associated with inappropriately disposed medicines. An immediately practical solution is to place a clear obligation on those who retail medicines and personal care products to accept returns of the products they sell for safe disposal. A recent study in Texas showed that the public generally had favourable perceptions regarding medication take-back programmes and that having such a programme in place was an actual selling point for a pharmacy (Thach et al., 2013). Additionally, both prescriber and consumer can further contribute to safe disposal by limiting leftover medication through optimisation of medicine dosage (Daughton and Ruhoy, 2013). Notwithstanding the limitations of this study, we have shown that there is very little awareness among members of the Irish public in the disposal of their unused medicines. Our findings suggest that effective communication and clear (official) guidelines consistently implemented by authorities may facilitate appropriate disposal practices.
Other
Funding Respondents (N=202) indicating one or more ways of inapropriate disposal (N=202 answers).
Fig. 2. Overview of methods of environmentally inappropriate disposal.
This work was partly funded by the Health Research Board of Ireland and the Millennium Research Fund of the National University of Ireland, Galway through the summer student fellowship scheme.
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for thosewho received advice (N=141)
Received advice
Appropriate disposal
No advice
Inappropriate disposal
Fig. 3. Comparison of advice regarding environmentally appropriate disposal and disposal method.
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