Fish Pharm: Pharmaceutical Waste and the Environment

This was going to be a quick and easy post pinching the above video my mate Ves had on his blog showing the making of a information graphic for the National Geographic article Pharmaceuticals in Drinking Water. Here’s the link to the full size illustration.

But that idea went down the toilet (but not with any pharmaceuticals) when Ben from the Health Impact Assessment Blog sent me an article titled Drugs in the Environment: Do Pharmaceutical Take-Back Programs Make a Difference?. With this topic being a bit of a favourite of mine (here and here) along with me recently viewing a few videos of the inane way drug disposal is carried out in the States I couldn’t help myself.

Removing unwanted and unneeded pharmaceuticals from the home and also from waste reduces the chance of misuse. That in itself is an important enough reason for a removal program. However the article also states:

The bulk of human pharmaceuticals found in waterways most likely got there by way of sewage. Taking unused pharmaceuticals out of landfills may make only a small difference in the concentrations of APIs found in water, say critics and supporters alike of such programs.

The article looks at the SMARxT Disposalâ„¢ program:

a partnership of the U.S. Fish and Wildlife Service, the American Pharmacists Association, and the Pharmaceutical Research and Manufacturers of America recommends that medications be crushed and/or dissolved, mixed with kitty litter or other unappealing material (to discourage consumption), then enclosed in a container or sealable baggie before disposal in the trash.

In reading the article, despite a box talking of waste drugs flushed or placed into septic systems I get the feeling that they assume flushing medications down the toilet is not a huge problem and what appears in the sewage and waterways is entirely from urinary excretion into the sewage system.

Perhaps I am reading it wrong. But I can’t believe the majority of waste drugs is disposed of using the “approved” method. Look for yourself. Would you dispose of your unwanted medications this way each time?

No, I thought not.

The article is quite informative at looking at all aspects of the waste pharmaceutical process in the USA highlighting cases of drugs in waterways affecting fish populations, land fills, accepted and approved waste disposal methods and the hurdles in implementing “take back” programs. Compare this to Australia where the Return of Unwanted Medicines Project has been running for twelve years. A simple motto:

Consumers can return medicines

TO ANY PHARMACY – ANYTIME

The article highlights an unhealthy obsession about drugs, even waste drugs in the USA, worrying about diversion and legalities of who can accept them back. I think it goes to the absurd when we have to take back our out of date paracetamol to the police station for disposal.

Reference: Lubick N 2010. Drugs in the Environment: Do Pharmaceutical Take-Back Programs Make a Difference? Environ Health Perspect 118:a210-a214. doi:10.1289/ehp.118-a210
Link

Pharmaceutical Waste

The Return of Unwanted Medicines (RUM) Project removes about 400 tonnes of pharmaceuticals from the Australian waste system each year ensuring protection for the public and environment. There are no figures that I can find but I guess a substantial amount is also discarded in the rubbish.

Some time ago I wrote about the major differences between the USA and Australian in the way they handle pharmaceutical waste.

The main difference is that in Australia consumers can return medicines TO ANY PHARMACY – ANYTIME

wasteAt the time of writing this post the Australian population clocked in at 22,018,292 people and the USA had 307,708,421 people.

Now bear with me as I fly by the seat of my pants on the back of an envelope and make some huge assumptions. Assumptions like both countries are prescribed the same number and collect the same number of prescriptions per head.

If we accept this it means the USA has roughly 5590 tonnes of pharmaceuticals being disposed each year, following the FDA recommendations. Using local collection services if they exist otherwise flushing controlled drugs down the toilet and the rest in the rubbish mixed with used kitty litter!

For my American readers that is about 6161 tons (US). This is the equivalent of 199 full semi trailers (semi-tractors) of pharmaceutical waste each year.

No wonder there are worries about water contamination by pharmaceuticals in the United States.

Truck calculation
In the USA a loaded semi trailer (semi tractor weight)can weigh up to 80 000 pounds. Lets say each semi trailer weighs 18000 pounds. With each truck carrying 62000 lbs it requires the equivalent of 199 semi trailers (semi tractors) to remove the 6161 tons of waste. If they were still in their packaging it would be at least twice that number of trucks.

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A Wander Through Chronic Disease and Indigenous Health

In 2004-05 two surveys were undertaken by the Australian Bureau of Statistics to enable comparisons between the health of Indigenous Australians and non-Indigenous Australians.

The survey showed that approximately 6% of indigenous Australians reported either having diabetes or High Sugar Levels (HSL). Indigenous people living in the towns and cities of Australia had close to half the incidence of diabetes or HSL than those indigenous Australians living in remote Australia (5% compared to 9%).

But how does the incidence of diabetes in Aboriginal and Torres Strait Islanders compare to the rest of Australia?

This is not a trick question.

The answer of course is “pretty poorly”. Overall Australia’s Indigenous population was three times more likely to have diabetes than the non-Indigenous population. But it was much worse depending on where you live.

Indigenous people living in remote areas of Australia were more than eight times more likely to report having diabetes or HSL than non-Indigenous people.

In remote areas, Indigenous females were fourteen times as likely to have diabetes or HSL as non-Indigenous females. Indigenous males were nearly six times as likely to have diabetes or HSL as non-Indigenous males living in remote areas.

Diabetes & HSL rates by Indigenous status 2004-05

Diabetes & HSL rates by Indigenous status 2004-05

There is a little, well, rather a big project underway in Australia analysing HbA1c data by postcode for five years.

The “Mapping Glycaemic Control Across Australia Project” will collect, clean and analyse the HbA1c data annually for the next five years. Annual updated summary data will be made available for access through the Changing Diabetes Map providing a framework to track and monitor HbA1c levels.

For the lay person reading this – the HbA1c is a measure of the amount of “sugar” in our red blood cells. As red blood cells last in our our body and are replaced in theory every three months or so it gives us a good picture of the last three months. The project states Australia’s average HbA1c is 7.6%. A well controlled diabetic would aim to have a HbA1c below 7%.

hba1c

The map searches by postcode. Except for remote areas that is. Then it uses huge geographic regions not allowing us to see HbA1c averages in remote Indigenous areas. It does show the increasing HbA1c levels generally seen in remote and rural areas compared to more urban areas.

A recent news article stated Indigenous Australians have ten times (10x) the incidence of renal disease than other Australians (The same article quoted the figures that Native Americans have double the incidence of end-stage renal disease, and in Canadian Indians the incidence is two and a half times greater, compared with non-indigenous North Americans.)

Now I don’t have a breakdown for renal disease for remote areas compared to non-remote areas as I do for diabetes. But with these much higher levels of disease you would expect healthcare and pharmaceutical costs to be through the roof compared to other Australians.

Sit down for a little surprise.

There is a lovely little report titled ‘Expenditures on health for Aboriginal and Torres Strait Islander peoples 2004-05‘. Note it covers the same period as the ABS diabetes statistics.

Renal disease at ten times the incidence, diabetes (in remote areas) at eight times higher incidence yet the higher spend on healthcare for indigenous Australians was pitiful, especially when you look at the cost of providing healthcare in remote areas.

In 2004-05, $1.17 per person was spent on Aboriginal and Torres Strait Islander health for every $1.00 spent on the health of non-Indigenous Australians. Average total health expenditure per Aboriginal and Torres Strait Islander was $4,718 compared with $4,019 per person estimated for non Indigenous Australians.

The pharmaceutical spend was deplorable. The average expenditure on pharmaceuticals for Australia’s Indigenous population in 2004-05 was 40% of what Australia as a whole spent per individual (PBS subsidy). $140 spent per Indigenous Australian compared with $273 for each non-indigenous Australian.

In remote areas medications are provided by what is called the S100 scheme. This gives us dollar values of what was shipped to remote clinics. Not necessarily what was used by patients. The government figures state that remote Indigenous Australians use $186 of Pharmaceutical Benefit Scheme medications per head. This figure is pathetic considering the incidence of these chronic diseases.

But this Amount of $186 per remote Indigenous person overstates the amount of medications used to treat chronic diseases.

This figure is the value of PBS medications shipped to clinics, not what is used on patients. Some clinics have massive waste due to not having ordering systems in place. And you do need to run with a slight excess and carry some emergency drugs that may go out of date (eg Reteplase at over $1000).

Remote clinics also handle the acute presentations that in urban areas are looked after by hospitals. While these items are not expensive large numbers are used. Benzathine Penicillin, Normal Saline bags for IV use, Ceftriaxone and other parenteral antibiotics in numbers you would not see being dispensed by your normal pharmacy on the PBS. There is no where near $186 dollars per head being spent in providing medications to treat chronic disease in remote Australia.

So what have we got. Massive incidences of chronic diseases in our Indigenous population compared to the rest of us. Despite chronic disease many higher in Indigenous Australians than other Australians there is overall only 17% increased health spending and well under half the usage of medications required to adequately treat these diseases.

Looking at those figures it will come as no surprise that the same report states hospital separations for Indigenous Australians in remote and very remote areas are 820 and 606 per 1000 people respectively.

Is it just me or is there something quite wrong in all this?

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Disposal of Pharmaceuticals: A Comparison

Dramatic inhibition of sperm activity in certain aquatic organisms can be effected by calcium-channel blockers.
Antiepileptic drugs (e.g., phenytoin, valproate, carbamazepine) have potential as human neuroteratogens, triggering extensive apoptosis in the developing brain, leading to neurodegeneration.

These facts and other amazing little delights can be found on the EPA-USA FAQ page. The EPA-USA said they have been looking into this problem since 1999. You can read a doozy of a 41 page report quaintly titled errata.pdf.

Should you be worried about your health? Again we refer to the EPA-USA FAQ page: Studies have shown that pharmaceuticals are present in some of our nation’s water bodies. Further research suggests that there may be some ecological harm when certain drugs are present. To date, no evidence has been found of human health effects from PPCPs in the environment.

The American Pharmacists Association produced a press release in February of 2007 on how to correctly dispose of pharmaceuticals. Here’s a few highlights.

DO NOT FLUSH unused medications. Consumers were once advised to flush their expired or unused medications

When tossing unused medications…..Crush solid medications or dissolve in water and mix with kitty litter or a solid kitchen substance….. then place in a sealed plastic bag …before tossing in the trash.

Check for approved state and local collection programs or with area hazardous waste facilities. In certain states, you may be able to take your unused medications to your community pharmacy.

This year the EPA-US Great Lakes ran the Great Lakes 2008 Earth Day Challenge with one of the aims to collect “1 Million Unwanted Pills”. To reinforce the point here’s a quote from the same page:

Traces of medicines have been found in streams and the Great Lakes where we get our drinking water and have also been detected near wastewater treatment outflows. Some of these medicines can lead to reproductive and developmental problems in fish and other animals. We often treat leftover medicine as a common household waste. More than half of people surveyed throw their unused medicines in the trash while a third flush them down the drain. In both cases, the medicines have the potential to be released into our rivers and lakes

August 6th 2008: Another press release from the EPA titled “EPA Continues Work to Understand Potential Impacts of Pharmaceuticals in Water”

The agency’s work to increase industry stewardship and scientific understanding of pharmaceuticals in water continues,” said Benjamin H. Grumbles, EPA’s assistant administrator for water. “By reaching out to the National Academy of Sciences and requesting information from the health care industry, EPA is taking important steps to enhance its efforts.

There’s a lot more words in that press release but I think you will agree that there is an adhoc approach in the USA for dealing with pharmaceutical waste, with a lot of nice words thrown in.

What’s happening in Australia?

It really is as easy as 1,2,3. July 2008 marked the 10 year anniversary of the Return of Unwanted Medicine Program. Simply walk into any retail pharmacy in Australia with your out of date or unwanted medications and they are accepted and placed in a yellow 20 litre sealable container. They are returned to the pharmaceutical wholesalers and from there collected by the waste disposal experts for high temperature incineration which is the safest way to destroy this sort of waste. Drivers are accredited and random audits are carried out. There is the chance for diversion but in 10yrs there have only been a handful of instances.

The RUM Project is funded by the Commonwealth Department of Health & Ageing.

It is supported by many pharmaceutical and consumer bodies including the Pharmacy Guild of Australia, the Pharmaceutical Society of Australia, Council on the Ageing (COTA), and Environmental Health Australia.

Consumers can return medicines TO ANY PHARMACY – ANYTIME

Over 400 Tonnes (440t US)of unwanted and out of date medicines are collected every year.

( As an aside, Australia has about 22 million people. The USA had 305 million or so when I checked at the population clock. Would 6100t (US) of pharmaceutical waste really be stopped from going into normal waste in the States?)

If I’m writing this there has to be a bush slant. There is.
Our clinics are in one state, our head office and a lot of logistics come from another state (still one of the closest towns to us). When a pharmaceutical item goes out of date and put in the bin it becomes waste. This is then legally not allowed to cross state borders! Several years ago pharmaceutical waste was sometimes placed in the correct containers but most often not as it was difficut to have empty buckets supplied by plane. It was then driven back in the back of a troopie by anyone going into town to one of our suppliers, repacked (i.e. now double-handling waste) into the appropriate containers then entering the RUM process.

To improve this process we now deal direct with RUM. Our environmental health bloke and myself move around the lands and we are the ones who remove waste and sharps sealed in approved containers to a central point. The pharmaceutical waste is then placed into metal crates supplied by RUM and locked and trucked to Perth using a driver accredited to handle waste (again done by RUM for us). I have a key and the contracted waste management company in Perth has a key.

Now all we need is for the roads to be capable of taking trucks again and I can get some trucked out.

The system we run is probably the best, and simplest in the country and I hope can be emulated by other remote health services.

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