Medication wasted – Contents and costs of medicines ending up in household garbage

doi:10.1016/j.sapharm.2018.02.002

Research in Social and Administrative Pharmacy

Volume 14, Issue 12, December 2018, Pages 1140-1146

https://doi.org/10.1016/j.sapharm.2018.02.002 Get rights and content

Abstract

Background

Despite potentially considerable implications for public health, the environment and public funds, medicine waste is an under-researched topic. This study aims to analyse medicines drawn from household garbage in Vienna (Austria) and to assess possible financial implications for public payers.

Methods

Four pharmaceutical waste samples collected by the Vienna Municipal Waste Department between April 2015 and January 2016 were investigated with regard to their content. The value of medicines was assessed at ex-factory, reimbursement and pharmacy retail price levels, and the portion of costs attributable to the social health insurance was determined. Data were extrapolated for Vienna and Austria.

Results

The waste sample contained 1089 items, of which 42% were excluded (non-pharmaceuticals, non-Austrian origin and non-attributable medicines). A total of 637 items were further analysed. Approximately 18% of these medicines were full packs. 36% of the medicines wasted had not yet expired. Nearly two out of three medicines wasted were prescription-only medicines. The majority were medicines related to the ‘alimentary tract and metabolism’ (ATC code A), the ‘nervous system’ (ATC code N) and the ‘respiratory system’ (ATC code R). The medicines wasted had a total value of € 1965, € 2987 and € 4207, expressed at ex-factory, reimbursement and pharmacy retail price levels, respectively. Extrapolated for Vienna, at least € 37.65 million in terms of expenditure for public payers were wasted in household garbage, corresponding to € 21 per inhabitant.

Conclusion

This study showed that in Vienna some medicines end up partially used or even completely unused in household garbage, including prescription-only medicines, non-expired medicines and medicines for chronic diseases. While there might be different reasons for medicines being wasted, the findings suggest possible adherence challenges as one issue to be addressed.

Introduction

Affordable access to effective, high-quality and safe medicines is a major policy objective.¹^,² Responsible use of medicines, also referred to as rational or appropriate use, is a major component to achieve these policy aims,³^,⁴ and inefficient use of resources, including medication wastage, is a serious and highly topical concern.⁵ Medicine waste has been defined as ‘any drug product, either dispensed by a prescription or purchased over the counter (OTC) that is never fully consumed’.⁶ Thus, any type of medicine that is stored in a household without the intention of being used, that is returned to a pharmacy or other health professional or is disposed of properly (e.g., through waste collection places) or improperly (e.g., via household garbage) can be considered waste.

There can be different reasons why medicines are not fully consumed, or are not used at all. Patients and carers that returned medicines to community pharmacies in different countries most frequently mentioned a change in medication by the prescribing doctor, patient death, the improvement of the patient's condition (or her/his subjective perception) and expired medicines as reasons why medicines were not fully consumed.7, 8, 9, 10, 11 This indicates possible issues related to adherence in some cases.

Medicine waste is estimated to have financial consequences. There are few studies that have reported on direct costs resulting from wasted medicines. Based on the assumption that 42% of dispensed prescription medicines were unused, up to USD 117 billion were considered to have been wasted in the United States in 2011.¹² In England, approximately GBP 75 million worth of medicines were assessed to have been returned to pharmacies in 2003.¹³ According to another research, around GBP 250 million were estimated to have been wasted in England in 2008; this sum consisted of GBP 110 million for medicines returned to pharmacies, GBP 90 million worth of medicines stored at home but not intended to be used and GBP 50 million worth of supplied medicines that were disposed of unused by care homes.¹⁴ The value of returned medicines in community pharmacies in Slovenia in 2012 was estimated to amount to € 3.77 million.¹⁵ For Saudi Arabia approximately USD 150 million worth of unused medicines were assessed for the year 2001.⁶ Further studies that analysed medicines returned to pharmacies but did not extrapolate data also suggested high economic implications for payers.⁷^,16, 17, 18 There might also be indirect costs due to limited effectiveness and failure of the therapy, unintended effects of wrongly administered medications and eventually negative impacts on morbidity and mortality as a result of non-adherence.19, 20, 21

Negative consequences of medication wastage are aggravated if medicines are stored and disposed improperly. Children poisoning can result from unsupervised (accidental) ingestions and were found to be a major cause for children's admission to emergency departments.²² Improper disposal can lead to damages to the environment, such as pollution of the surface and ground water.23, 24, 25, 26 Studies suggested that improper disposal of medication through the household garbage, sink and toilet is common practice in several countries.²⁴^,27, 28, 29, 30, 31, 32

In Vienna (capital city of Austria), patients and their carers have different options to properly dispose of medicines that are no longer used. They can return them to community pharmacies or discard them at waste disposal sites or problematic substance collection places that were provided throughout Vienna by the Municipal Waste Department (‘MA 48’).³³ Nonetheless, an investigation of a pharmaceutical waste sample drawn in October/November 2009 showed that in Vienna some medicines ended up in household waste.³⁴

For this study, the authors took advantage of regular collections of residual waste by MA 48: samples of medicines that had been found in household waste in Vienna were analysed. The aim of this research was to assess the relevance, contents and associated costs of medication wastage disposed of in household garbage during one year in Vienna.

Section snippets

Data sources

In 2015/2016, MA 48 collected four samples of residual household waste in Vienna as part of the ‘Viennese recyclable and residual waste analysis 2015–2016’. Their staff drew samples of so-called problematic substances at four points in time: in April 2015, July 2015, October 2015 and January 2016. In a follow-up investigation, a company called ‘FHA GmbH’ (FHA Gesellschaft für chemisch-technische Analytik GmbH) analysed the substances, and their experts sorted out items that they considered to

Characteristics of the sample

The four samples had a total weight of 63.5 kg and contained 1089 items. In line with the defined exclusion criteria, 452 items were excluded (Table 1). Thus, 637 items were considered eligible for further analysis (76 items collected in April 2015, 290 items as of July 2015, 56 items as of October 2015 and 215 items as of January 2016).

Nearly every fifth pack (18%) of the sample was still completely unconsumed (see Table 2 for the distribution of the extent of waste left). Approximately 63% of

Discussion

Our investigation is the first medicine waste analysis in Vienna that also assessed the economic implications of wasted medicines and did an extrapolation for the whole capital city. A previous study done by Vogler et al.³⁴ used a medicine waste sample collected by MA 48 in Vienna in October/November 2009 and analysed its content. A comparison of the findings of this study to the results of Vogler et al. is not possible due to differences in the methodology: Vogler et al. had a smaller sample

Conclusions

The study showed that in Vienna some medicines end up partially used or even completely unused in household garbage. The waste sample contained, among others, prescription-only medicines, non-expired medicines, medicines for chronic diseases and antibiotics. The analysis suggested that every fifth pack had not been opened.

The extrapolated value corresponds to approximately 6% of public pharmaceutical expenditure in the year of survey. While these findings should to be interpreted with caution

Conflicts of interest

The authors declare that they have no conflict of interest.

Acknowledgements

We are very grateful to the Municipal Waste Department of the City of Vienna for agreeing to share the waste sample after the analysis done by FHA GmbH. We thank FHA GmbH for sorting out the preliminary medicine waste sample as well as for being available for our questions. Dipl. Ing. Wojciech Rogalski, Vienna Municipal Waste Department, and Ing. Gerhard Fritz, FHA GmbH, were available to provide background information and to answer our queries. We would also like to thank Friederike Windisch

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Medication wasted – Contents and costs of medicines ending up in household garbage

Abstract

Background

Methods

Results

Conclusion

Introduction

Section snippets

Data sources

Characteristics of the sample

Discussion

Conclusions

Conflicts of interest

Acknowledgements

Clin Therapeut

Res Soc Adm Pharm

Res Soc Adm Pharm

Environ Int

Environ Int

J Environ Manag

Sci Total Environ

Environ Int

Transforming Our World: The 2030 Agenda for Sustainable Development

WHO Policy Perspectives on Medicines. Effective Medicines Regulation: Ensuring Safety, Efficacy and Quality

Equitable Access to Essential Medicines: A Framework for Collective Action

Essential medicines for universal health coverage

Lancet

Tackling Wasteful Spending on Health

Returned medicines in community pharmacies of Barcelona

Spain Pharm World Sci

Reasons why medicines are returned to Swedish pharmacies unused

Pharm World Sci

An analysis of returned medicines in primary care

Pharm World Sci

Investigating unused medications in New Zealand

Pharm World Sci

A systematic review of the literature on ‘medication wastage’: an exploration of causative factors and effect of interventions

Int J Clin Pharm

Returned medicines: waste or a wasted opportunity?

J Public Health

Evaluation of the Scale, Causes and Costs of Waste Medicines

Raziskava Odpadnih Zdravil Zbranih V Zunanjih Lekarnah V Republiki Sloveniji

Medications collected for disposal by outreach pharmacists in Australia

Pharm World Sci

Economic consequences of unused medications in Houston

Texas Ann Pharmacother

Study by Alberta pharmacists indicates drug wastage a “mammoth” problem

Can Med Assoc J

Thinking outside the pillbox — medication adherence as a priority for health care reform

N Engl J Med

Adherence to medication

N Engl J Med