Medicosnext
Words by Dr. Binaya Shrestha and Sanjaya Mani Dixit
The expansion of the pharmaceutical industry and improved availability of medications collectively contribute to an increase in drug utilization and the accumulation of pharmaceuticals in households globally. With the increased availability of the medicines, we also notice the problem of increased expiry of medicine.
Expired medicines are the finished products that have passed their expiration date, as indicated on the label or packaging. Expired medications may potentially lose their effectiveness or even become harmful. Expired drugs imply financial losses because they should no longer be distributed and must be discarded. Common expired medicines include but not limited to NSAIDs, antibiotics, antidiabetics and antihypertensive products.
The increased availability of medicines is accompanied by a concerning rise in medicine expiry. Expired drugs not only imply financial losses but may also pose potential harm as they lose effectiveness or even become harmful.
In Nepal, during Gorkha earthquake 2072 a large volume of medicines and medical devices were donated by various countries. A big portion was expired and occupied space in inventory shelves. Donated medicines during disaster conditions might end up as expired products due to high influx, improper management, and unwanted products. It has been noted as a global phenomenon that following a turmoil situation, various countries and pharmaceutical industries try to send in supplies not only to help people in the difficult situation but also to rid themselves of the near expired lots of medicines.
An average of around 4% of medicines in supply chain system accounts for expired medicines. Considering 60 billion NPR market volume of medicines, about 2 billion NPR is wasted as expired medicines. (USAID data)
The Ripple Effect on Medicine Disposal
In clinical practice, 50 percent of the medicines are prescribed irrationally that further results in the redundant storage in of the medicines causing further harm to the patient and the environment. WHO also revealed that patients often do not finish off their course of medicines and the remaining medicines are distributed to the friends and relatives without proper consultations. Due to lack of proper guidelines and its enforcement in developing countries like Nepal, people usually dispose the medication waste in whatever ways they think is the best.
In the aftermath of disasters, including the Gorkha earthquake in 2072, a global phenomenon unfolds where donated medicines, often near expiry, flood affected areas. This inadvertently contributes to the predicament of expired products due to high influx, improper management, and unwanted items.
Self- medication in a way can be seen as the by-product of improper disposal practices as well as the cause of it. Self-medication among general population is another reason in increasing the burden of medication waste in the society. Over the counter drugs and even the prescription only medicines are easily made available at the local pharmacies from where people can purchase them without proper consultation.
Improper disposal of medications can lead to various consequences, including childhood poisoning, environmental pollution, adverse effects on wildlife, and the development of antibiotic resistance. The effectiveness of the healthcare system is often assessed by measuring drug wastage. Active pharmaceutical ingredients (APIs), primarily polar compounds known as “small molecules,” contribute to micropollutants found in the aquatic environment in the milligram or nanogram range.
Why safe disposal is required? (Let us design this as separate box)
- Contamination of drinking water
- Prevention of aquatic life
- Antimicrobial resistance (disposal of antibiotics)
- Hormonal disruption (disposal of hormones, steroids)
- Burning of products in open container at low temperature results in release of toxic pollutants into the air
- Inefficient and insecure disposal of drugs may result problem of resale and unintended use (abusive products)
Polices, acts and regulations (Let us design this as separate box)
11 different policies, act, regulation pertaining to management of expired medicines or health care waste are available:
- National health policy 2076 (2019)
- Environmental protection act 2076 (2019) and regulation 2077 (2020)
- 15th periodic plan
- Minimum service standards for different HCF 2076 (2019)
- Public health service act 2075 (2018) and regulation 2077 (2020)
- Labor act 2073 (2017)
- Local government operation act 2074 (2026)
- Industrial enterprise act 2073 (2016)
- Guideline for health institution establishment, operation and upgrade standard 2071 (2014)
- Solid waste management act 2068 (2011)
- Drug act 2035 (1978)
Impact of Improper Medicine Disposal Practices
Pharmaceuticals released into nature from human use, such as estrogens and diclofenac, have notable impacts on the environment, evident through chemical analysis. The diclofenac disaster, for instance, resulted in a reduced vulture population when they were used indiscriminately in cattle, the vultures feeding on the carcass of cattle died in big numbers. The presence of estrogens, by-products from industries, is linked to the feminization and demasculinization of male fish. The environmental threat escalates when unused post-expiry date medicines, like expired tetracyclines causing renal tubular damage, are not properly managed.
Improper disposal of medicines leads to consequences like childhood poisoning, environmental pollution, and antibiotic resistance. The accumulation of pharmaceuticals in households reflects a lack of awareness regarding proper disposal techniques, emphasizing the urgency of education and responsible waste management.
Accumulation of unused and expired medicines in households is often a consequence of excessive prescribing by doctors or poor patient adherence. Research in the UK uncovered unhealthy practices among households, where pharmaceuticals were disposed of as household waste, down the sink, or toilet. Similarly, an Indian study highlighted the need to enhance awareness about safe disposal methods. Sink, toilet, and rubbish bins are commonly used but environmentally unfriendly methods of drug disposal. The substantial buildup of expired and unused medications in household medicine cabinets reflects a lack of knowledge regarding proper disposal techniques.
Methods to manage expired medicines
- Burial method
- Encapsulation
- Interization
- Burial pit
- Sanitary landfill
- Thermal method
- High temperature incineration
- Low temperature treatment
- Burning
- Chemical decomposition
- Sewer
Encapsulation
Encapsulating of expired medicines in inert material like cement mortar. The solid structured waste form creates a durable barrier, isolating the waste from the environment.
Interization
The process of interizing involves treating the medicines to make them less harmful before burial.
Remove products from the packaging materials. Crush the products to fine powder.
Mix powdered product in ratio 65:15:15:5 Pharmaceutical waste: Lime: Cement: Water: 5% to form a uniform paste.
The paste solidifies that can be disposed in landfill.
Ensure worker safety with proper PPEs.
Reasonably cost effective for operation and requires less investment equipment.
Burial pit
Used for hazardous products.
2-5 m deep and 1-2 m wide pits should be constructed.
Expired products and soil are layered alternately.
Top layer covered with cement embedded wire mesh with soil over that layer.
Should not be constructed in flood prone area.
Sanitary Landfill
Expired medicines are disposed of in a controlled landfill designed to minimize environmental impact.
High temperature incineration
Medicines are burnt at a temperature of more than 850 degree Celsius
Double chambered kiln incinerator
Cement kiln could be used at temperature 850-1450 degree Celsius.
The expired medicines serve as fuel for cement manufacturing.
Should not affect the quality of cement.
Not more than 5% of expired products to be added.
Low temperature treatment
Autoclave at 121-degree Celsius for 16-35 PSI pressure for 30-60 minutes used for disposal of biological products including vaccines.
Can be used for small volume products.
Chemical Decomposition
Preferred treatment for liquid infectious wastes. But can also be used in treating solid waste too.
Chemotherapy waste (including bulk cytotoxic agents) can be disposed by chemical decomposition. 5% sodium hypochlorite; acid hydrolysis followed by alkaline hydrolysis, reduction using zinc powder, or degradation using 30% hydrogen peroxide.
Sewer system
Certain liquid pharmaceuticals, such as syrups and intravenous (IV) fluids, can be safely diluted with water and disposed of in small amounts through sewer systems over time without major adverse effects on public health or the environment.
Similarly, well-diluted liquid pharmaceuticals or antiseptics may be flushed in small quantities through fast-flowing watercourses.
Useful for small quantity of expired products.
Insights from Research
In Nepal the problem of improper disposal of unused and expired medicines remains as a challenging problem. Various studies have been conducted on this issue. We had conducted a research among medical and dental students in Nepal with a view to explore their knowledge and attitude regarding disposal practices of unused and expired medicines in 2022. The research article published in JKMC revealed that 109 students (53.2%) adhered precisely to their prescribed medication regimen, while 96 (46.8%) did not. Notably, 118 students (57.3%) obtained their medications through prescriptions, 76 (37.1%) directly over the counter, and 11 (5.3%) from friends or relatives. The primary reason for medication stockpiling was the surplus purchase leading to unused drugs. A substantial majority (90.3%) of students believed that the government could play a more active role in reducing medication wastage. Opinions on the ideal entity to address medical waste varied among students, ranging from educational institutes and hospitals to individuals, medical professionals, and the government.
Similarly, a study was conducted in Kathmandu valley in 2021. In this study 210 households were included and around half the respondents were from the Kathmandu district, nearly 20% were from Bhaktapur and 30% were from Lalitpur. Nearly 90% of respondents agreed that storage of excess medicines at home may promote self-medication. Similarly, 97.6% of respondents agreed there is a lack of adequate information on the safe disposal of unused medicines. The majority [125 (59.5%)] of participants always checked the expiry date of medicines. The safe methods of medicine disposal were not known by 137 (65.2%) participants. Throwing in a dustbin was the preferred method of disposal of expired medicine. Such studies gives us the some knowledge on disposal practices of our country.
Top of Form
In terms of medicine management, it has been reported that many of the healthcare facilities in developing countries lack a proper healthcare waste management system. Keeping this view, WHO came up with the agenda to develop standard operating procedures (SOP) to address this issues of waste management in developing world.
Collaborative Solutions
Hence it can be said that the problem of improper disposal practices of unwanted medications needs a combined effort from the general public and the government of the respective countries. In Nepal Central government, local government and general public should form a community and develop some guidelines for proper disposal practices. Some of the important points to be considered are
- Return to Pharmacy or Health Facility:
Many pharmacies and healthcare facilities have take-back programs where patients can return unused or expired medicines. Check with the pharmacy or health facility where the medicines were purchased to see if they have a return or disposal program.
- Community Collection Programs:
Some areas may organize periodic collection drives for the safe disposal of pharmaceuticals. This could be coordinated by local health authorities, non-governmental organizations (NGOs), or other community groups.
- Environmental Considerations:
Be mindful of the environmental impact. Avoid disposing of medicines in a way that may contaminate soil or water sources.
- Educational Campaigns:
Public awareness campaigns may be conducted to inform the public about the proper disposal of medicines. These campaigns may include information on local disposal options and the potential risks associated with improper disposal.
Conclusion
In Nepal we are witnessing a burgeoning pharmaceutical industry and increased availability of medications, which have led to a parallel rise in drug utilization and, consequently, the accumulation of pharmaceuticals in households, a significant part of which undergoes expiry. The expired medicines, often overlooked remnants of the pharmaceutical lifecycle, pose not only financial losses but also potential harm to individuals and the environment. Safe disposal of unused and expired medicines is imperative to mitigate various consequences, including contamination of drinking water, prevention of harm to aquatic life, resistance to antibiotics, hormonal disruptions, and the release of toxic pollutants into the air. While Nepal has several policies, acts, and regulations related to the management of expired medicines and healthcare waste, effective implementation and adherence to these guidelines is crucial. The road ahead necessitates a collaborative effort involving the general public, healthcare professionals, and government bodies to develop and enforce guidelines for proper disposal practices. Return programs to pharmacies or health facilities, community collection initiatives, environmental considerations, and educational campaigns can collectively contribute to a safer and more sustainable approach to the disposal of unused and expired medicines. As the healthcare landscape evolves, ensuring the responsible disposal of medicines will play a pivotal role in safeguarding public health and preserving the environment for future generations.
