What Should Patients Do With Unused Narcotics?

From Medscape Pharmacists > Ask the Experts

Jeffrey Fudin, PharmD

Question

Clinicians often tell patients to save their remaining narcotics for "next time." Is that sound advice?

Response from Jeffrey Fudin, PharmD Adjunct Associate Professor, Pharmacy Practice, Albany College of Pharmacy and Health Sciences, Albany, New York; Clinical Pharmacy Specialist, Stratten Veterans Affairs Medical Center, Albany, New York

Safety and environmental considerations have been widely overlooked in the disposal of medications. Customarily, patients were advised to flush medications down the toilet or pour them down the sink. Subsequently, trace amounts of medicinal byproducts have been found in the water supply. Although short-term studies fail to demonstrate harm to humans and animals, long-term effects, including endocrine disturbances, growth inhibition, and mutagenicity, still remain unclear.^[1,2]

The US Food and Drug Administration (FDA) published guidelines in 2007 with instructions on how to properly discard all prescription and nonprescription medications.^[1] In addition, the US Fish and Wildlife Service, the American Pharmacists Association, and the Pharmaceutical Research and Manufacturers of America have collaborated to promote environmentally safe discarding of medications in a program called "SMARxT Disposal."^[3] SMARxT Disposal recommendations include:

• Before any medication disposal, patients should read the product instructions or label carefully. If it states to flush the unused product down the toilet, the patient should follow those directions. Medications that carry such instructions are scheduled drugs with high abuse potential.
• Unless specified otherwise, medications should be crushed or dissolved with water and mixed with an undesirable material (eg, coffee grounds, saw dust, kitty litter) in a plastic baggie. The bag should then be sealed and discarded in the trash. Doing this reduces the appeal to children and animals.
• All medications should be taken out of original containers before recycling or disposal. Labels should be removed and personal information scratched off or destroyed to ensure patient confidentiality.

Approved state and local collection programs may be available to assist patients with medication disposal.

Narcotics may require special disposal procedures. According to the FDA guidelines, "about a dozen drugs, such as powerful narcotic pain relievers and other controlled substances, carry instructions for flushing to reduce the danger of unintentional use or overdose and illegal abuse."^[1] For example, a fentanyl transdermal patch contains active medication within the glue or ethyl cellulose matrices even after removal from the skin. Thus, the patch should be folded so the adhesive side adheres to itself and then flushed in the toilet immediately after removal.^[4] Disposal in this manner reduces the accessibility to children and pets.

Healthcare providers and pharmacists should stress the following general points to their patients:

• Do not keep leftover or expired medications for "later use" because storage of these medications may lead to abuse or accidental ingestion by other persons in the household. If a medical provider discontinues a medication and the patient has a remaining supply, he or she should be advised not to keep the medication in anticipation of returning symptoms.
• Taking medications after discontinuation by the prescriber could be dangerous. Discontinued medications could interact with newer prescriptions or medical conditions, contributing to life-threatening adverse reactions. In addition, degraded medications may contain a toxic byproduct. For example, use of degraded tetracycline has been associated with development of lactic acidosis and Fanconi's syndrome.^[5]

Failing to instruct patients on how to dispose of narcotics and other medications is a missed opportunity for important patient counseling.

The author wishes to acknowledge the assistance of Marissa Jean Cavaretta, student pharmacist, Albany College of Pharmacy & Health Sciences, Albany, New York

References

1. How to dispose of unused medicines. US Food and Drug Administration. Available at: www.fda.gov/ForConsumers/ConsumerUpdates/ucm101653.htm Accessed August 20, 2009.
2. Touraud E, Roig B, for ARMINES - Ecole des Mines d'Alès. KNAPPE: Knowledge and need assessment on pharmaceutical products in environmental waters. Available at: http://environmentalhealthcollaborative.org/images/KNAPPE_REPORT_FINAL.pdf Accessed September 8, 2009.
3. A prescription for a healthy planet. SMARxT Disposal. Available at: www.smarxtdisposal.net Accessed August 20, 2009.
4. Institute for Safe Medication Practices. ISMP Safe Medication Alert! New fentanyl warnings: more needed to protect patients. Available at: http://www.ismp.org/Newsletters/acutecare/articles/20050811.asp Accessed August 26, 2009.
5. 5. Montoliu J, Carrera M, Darnell A, Revert L. Lactic acidosis and Fanconi's syndrome due to degraded tetracycline. Br Med J (Clin Res Ed). 1981;283:1576-1577