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INTRODUCTION

The safe and responsible disposal of medications is an important public health initiative that directly relates to both pharmacy providers and consumers. Improper storage and disposal of expired or unused medications has the potential for negative consequences, including harm to the environment, accidental poisonings, and drug diversion. Although there are limited approaches currently available for the appropriate disposal of expired or unused medications, newer federal regulations have expanded options for consumers that will improve environmental safety and help prevent poisonings and drug diversion. When medications and other substances are disposed of as solid waste or into a wastewater disposal systems, including sewerage or an on-site septic system, they are afforded access to the environment. Importantly, the active ingredients from prescription drugs that have been found in water bodies in the United States (US) are of particular public concern.¹ Many wastewater treatment facilities are not designed to remove medications from the water supply, which can lead to both ecological and human health effects.

Another concern that has gained national attention is when individuals store their expired or unused prescription medications in their homes. This practice allows certain individuals access to medications that were not prescribed to them. The nonmedical use of prescription medications is a growing problem in the US. When patients do not appropriately dispose of their expired or unused medications, the opportunities for accidental poisonings and intentional drug diversion increase.

To these points, it is important that medication disposal practices are environmentally sound and effective in order to prevent accidental drug poisonings and intentional drug diversion. Furthermore, these practices must be performed while following applicable federal, state, and local laws and regulations, which necessitate coordination among multiple stakeholders. Yet following these procedural steps may perhaps lead to a more complex medication disposal process in the US, which could create confusion for patients and health care providers alike.

Health care professionals, including pharmacy technicians, play an important role in the safe and responsible disposal of medications. With an increase in medication use in the US as well as pharmacy providers being readily available medication experts, the public often turns to them for advice regarding medication disposal. One way to protect the environment and prevent poisonings and diversion is to dispose of medications properly; however, until recently, there has been little investigation into what happens after the medication has been dispensed to the patient. Therefore, it is important for pharmacy personnel to understand proper medication disposal and the legal issues surrounding these processes. Pharmacy personnel can educate patients, apply appropriate medication disposal standards to every day practice, potentially assist with disposal efforts, and take the necessary steps to remain up-to-date regarding newer laws and regulations surrounding medication disposal.

ENVIRONMENTAL CONCERNS

There are various environmental concerns that have led to a significant public outcry in recent years, especially with the realization that pharmaceuticals and personal care products (PPCPs) have appeared in multiple water bodies in the US. PPCPs consist of products used for personal health or cosmetic reasons, which include thousands of chemicals such as those found in prescription and over-the-counter (OTC) medications, fragrances, lotions, and cosmetics.²

In 2008, the Associated Press (AP) completed a study that set out to determine if pharmaceuticals or byproducts were detectable in drinking water supplies. The AP's 5-month inquiry found a wide array of pharmaceutical products in US drinking water, including antibiotics, anticonvulsants, mood stabilizers, and sex hormones (Table 1).³ The majority of these products were found in parts per million or parts per billion, which is far below standard doses of commonly prescribed medications. However, even at very small concentrations, multiple researchers have found that select medications have produced unwanted effects in fish, plant species, bacteria, surrounding wildlife, and even in ex vivo human cell studies.³ These unwanted effects range from developmental problems, infertility in fish, smaller plant species, antibacterial resistance, and cell proliferation concerns in ex vivo human cells. The current overall effects in humans are unknown, but exposure to small concentrations of medications over a lifetime may produce unwanted physiologic effects. To add to these concerns, water treatment facilities typically do not remove drug residue, and federal regulations regarding this matter are absent.³

Table 1. Associated Press Study: Compounds Found in US Water Supply
Acetaminophen Diclofenac Ibuprofen Naproxen Amoxicillin Azithromycin Sulfamethoxazole	Tetracycline Caffeine Cotinine Carbamazepine  Meprobamate Phenytoin Clofibric acid	Estrone Estradiol Codeine Diphenhydramine Prednisone
Reference 3

The environmental concerns with medications not only arise from their metabolism and excretion, but also from their improper disposal. The sheer amount of medication waste from the homes of consumers is an important contributing factor to the environmental concerns. Specifically, expired and unused medications often accumulate and eventually end up in the environment. For years, the most common practice has been to flush unwanted or expired medications, but this practice allows medications to enter the water supply. Further, disposing of medications in the household trash allows medications to run off into the environment and, subsequently, the water supply. Various federal entities, including the US Food and Drug Administration (FDA),^4,5 the Drug Enforcement Administration (DEA),⁶ and the United States Environmental Protection Agency (EPA),⁷ have offered resources and guidance regarding the appropriate disposal of unwanted or expired medications, which will be discussed below. Even with guidance from these agencies, the primary purpose of appropriate medication disposal is to prevent abuse and misuse of medications rather than protect the environment (Table 2).

Table 2. Links to Consumer Guidance Disposal Documents and Information About Disposal
Guidance	Link
US Food and Drug Administration (FDA) Disposal of Unused Medicines: What You Should Know	http://www.fda.gov/Drugs/ResourcesForYou/Consumers/ BuyingUsingMedicineSafely/EnsuringSafeUseofMedicine/ SafeDisposalofMedicines/ucm186187.htm
FDA Consumer Health Information  How to Dispose of Unused Medicines	http://www.fda.gov/downloads/Drugs/ResourcesForYou/ Consumers /BuyingUsingMedicineSafely/Understanding Over-the-CounterMedicines/ucm107163.pdf
US Department of Justice Drug Enforcement Administration Drug Disposal Information	http://www.deadiversion.usdoj.gov/drug_disposal/
US Environmental Protection Agency How to Dispose of Medicines Properly	https://www.epa.gov/sites/production/files/2015-06/documents/how-to-dispose-medicines.pdf
References 4-7

Accidental Poisoning Concerns

Accidental exposure to medicine in the home is a major source of unintentional poisonings in the US. According to the Centers for Disease Control and Prevention (CDC), every day over 300 children in the US aged 0 to 19 years are treated in an emergency department, and 2 children die from exposure to poisonous substances.⁸ In 2013, there were approximately 1.34 million calls made to poison control centers nationally for children age 19 and under.⁹ Approximately half of the calls were related to medications, and of the calls analyzed, 81% were for children getting into medicine not intended for them.⁹

Keeping medicines in the home after they expire or are no longer needed creates unnecessary health risks, including unintentional poisonings. Likewise, access to needed medication stored in the home also creates unnecessary health risks. Although child resistant containers may help prevent unintended access by children, these containers do not completely prevent a child from ingesting medications that belong to someone else. In a study that looked at cases of accidental child exposure to a grandparent's medicine, 45% of cases involved medicines stored in child-resistant containers.¹⁰  Therefore, in addition to promoting the proper disposal of unused or expired medications, it is also imperative to educate patients on the proper storage of prescription and nonprescription medications that are kept in the home. Proper storage includes keeping medications in their original containers and storing them in a cool, dry, and secure place out of a child's reach. If possible, medications should be stored in a locked box or cabinet in certain high risk situations that involve children.¹¹ Also, pharmacies should advise consumers to have the nationwide poison control center phone number readily available (1-800-222-1222), which can be programmed into cell phones or left near telephones in the home. Pharmacy providers should also educate patients to call 911 immediately if they encounter a poison emergency, including when a child is not breathing or has collapsed.⁸

PRESCRIPTION DRUG ABUSE AND DIVERSION CONCERNS

In 2011, the White House released a document and action plan entitled Epidemic: Responding to America's Prescription Drug Abuse Crisis.¹² Within this document, data from various studies were shared that highlighted how prescription drug abuse is the fastest-growing drug problem in the US. Interestingly, almost one-third of people aged 12 years and older who abused drugs for the first time in 2009 began by using a prescription drug for nonmedical purposes, and more than 70% of those who abused prescription pain medications obtained them from relatives or friends.¹² Medicine cabinets, friends or relatives, and even household trash routinely provide access to many of the medications that are being abused.

Prescription opioid abuse has continued to be a growing national concern. The total number of opioid pain relievers prescribed in the US has skyrocketed in recent decades, from 76 million in 1991 to almost 207 million in 2013.¹³ The US is also the largest global consumer of opioid medications, accounting for 81% of oxycodone consumption and nearly 100% of the world total for hydrocodone.¹³ In 2014, 4.3 million people aged 12 years or older used narcotic prescription pain relievers for nonmedical reasons.¹⁴ To help minimize the abuse of prescription drugs while ensuring access to their legitimate use, government agencies have focused their efforts in 4 major areas: education, monitoring, proper disposal, and enforcement.

Educating parents and consumers of all ages is essential to support and promote an evidence-based public education campaign about the appropriate use, storage, and disposal of nonprescription and prescription drugs, especially controlled substances. Pharmacy technicians can help with the promotion and dissemination of public educational materials and increase awareness of prescription drug misuses and abuse. Likewise, manufacturers have helped develop effective educational materials for patients about the appropriate use and disposal of opioid pain relievers and other commonly abused medications, considering the collection and disposal of medications in an environmentally safe manner is vital to protecting human health and the environment; disposing of unwanted medications that have been accumulating in consumers' homes is one approach that reduces the number medications available for diversion.

In addition to recent state and national reports that focused on prescription drug abuse and why proper medication disposal is an important component to help address this ongoing epidemic, recent reports have placed increased attention on heroin abuse. There is evidence to suggest a relationship between the increased nonmedical use of opioid analgesics and heroin abuse.^13,15 The current trend includes a rise in select individuals who switch from opioids to heroin, particularly young people. Heroin abuse, like prescription opioid abuse, is dangerous because of the drug's addictive properties and its risk of overdose can be quite high. Unlike prescription opioids, the purity of illicit heroin products is a concern, and abusers are not always aware of the strength or other added ingredients.¹³

MEDICATION DISPOSAL OPTIONS AND LEGAL CONSIDERATIONS

Until recently, basic options for the disposal of expired or unused medications were limited. These options included the following: flushing the medication into the sewerage system, throwing the medication away in the trash, and having limited access to medication collection programs. In October 2014, new federal regulations went into effect that expanded the options for consumers to dispose of unused or expired medications. Regardless of the method used, consideration must be given to the applicable federal, state, and local laws as well as regulations and guidance.

Medication disposal is an area where pharmacy providers can play an important role. For instance, pharmacy technicians can educate patients regarding safe and responsible methods to dispose of medications. In addition, they can provide guidance from a variety of federal, state, and local agencies, some of which were provided earlier in this article (Table 2). These resources can easily be shared and provided to patients in any pharmacy setting to help educate and assist consumers about the proper disposal of their medications.

Self-disposal of medications

One potential option, although not the preferred method, for patients to dispose of their expired or unused medication would be to self-dispose of these substances at their residence. Common options for self-disposal in the residential setting include the sink, the toilet, or a solid waste disposal. One study estimated that individuals in residential settings generate 66% of all unused medications; 54% of the unused medications were disposed of as solid waste and 35% were dumped into a wastewater system.¹⁶ There is guidance available for individuals who decide to dispose of their medications in the residential setting, which functions to mitigate the environmental and diversion issues presented by improperly discarded medication (Table 2). Additional information on self-disposal is provided later in this article.

Medication collection and disposal programs

The current preferred option for individuals who desire to dispose of medications is to utilize programs that facilitate the collection and destruction of unwanted, unused, or expired medications. In addition to programs available from local and state law enforcement agencies, the newer federal rules on medication disposal now allow private entities, including community pharmacies, to become registered (voluntarily) to collect medications that patients or consumers desire to dispose. However, due to barriers surrounding the collection and disposal of controlled substances, available programs may be limited.

Legal barriers surrounding the disposal of controlled substances

Some major concerns for medication collection programs are the legal issues surrounding the collection of controlled substances. Until recently, under the Federal Controlled Substances Act (CSA), the DEA only had rules for registrants, such as pharmacies, to dispose of controlled substances that they no longer needed; the DEA had no rules or provisions for ultimate users, such as patients, to dispose of controlled substances. Further, the DEA prohibited ultimate users from transferring a controlled substance that they no longer needed back to a health care provider, such as a pharmacist or prescriber, to dispose of these medications. To further hinder collection efforts, until recently, take-back programs were only permitted to accept controlled substances if a law enforcement officer was present to receive the controlled substances directly from the individuals who wanted to dispose of them.

The DEA recognized that these collection and disposal barriers were a major concern and acknowledged that the lack of programs available to allow for the safe disposal of controlled substances was forcing many consumers to keep their unused or expired medications in their possession, ultimately contributing to poisonings and the diversion of controlled substances. To help with these concerns while developing new regulations, the DEA allowed state and local law enforcement agencies to accept controlled substances during scheduled take-back events. In addition, the DEA has sponsored 2 national prescription take-back events per year since 2010, paying for the incineration of the medications collected at registered law enforcement locations across the country. Knowing a long-term solution was needed regarding the disposal of controlled substances, the President signed the Secure and Responsible Drug Disposal Act of 2010 into law, and the rules and regulations implementing this law were finalized by the DEA and became effective in October 2014.^17,18

Summary of the DEA regulations implementing the Secure and Responsible Drug Disposal Act of 2010

The Secure and Responsible Drug Disposal Act of 2010 amended the CSA and required the DEA to pass new regulations regarding the disposal of controlled substances. The DEA rules became effective October 2014 and expanded the options available to collect controlled substances from ultimate users for the purpose of disposal, which include the following: take-back events, mail-back programs, and collection receptacle locations.¹⁹ The new DEA rules continue to permit law enforcement to voluntarily conduct take-back events, administer mail-back programs, and maintain collection receptacles. In addition, the new rules allow authorized manufacturers, distributors, reverse distributors, narcotic treatment programs, hospitals/clinics with an on-site pharmacy, and retail pharmacies to collect pharmaceutical controlled substances from ultimate users by voluntarily maintaining collection receptacles or assisting with mail-back programs.¹⁸ In addition, hospitals/clinics and retail pharmacies may voluntarily maintain collection receptacles at long-term care facilities to dispose of patients' unused medications. For entities that are now permitted to collect, such as retail pharmacies, authority to do so must first be obtained by the DEA. Further, new compliance and cost considerations, including DEA registration, recordkeeping, and security requirements, in addition to funding of the disposal costs of collected medications, accompany the DEA authorization process. Additional considerations for health care providers regarding the new DEA rules on drug disposal include¹⁹

• "Authorized collectors may maintain collection receptacles inside their registered location; and federal, state, tribal, or local law enforcement may continue to maintain collection receptacles inside their physical location."
• "Collectors are not authorized to conduct take-back events. Law enforcement may continue to conduct take-back events at any time. Any person or community group, registrant or nonregistrant, may partner with law enforcement to conduct take-back events."
• "Authorized collectors with an on-site method of destruction may operate a mail-back program."

Furthermore, under the newer DEA rules, medications collected for disposal must be rendered "non-retrievable" to remain in compliance with all applicable federal, state, and local laws.¹⁹ This DEA standard is intended to allow public and private entities to develop a variety of destruction methods that are secure, convenient, responsible, and consistent in preventing the diversion of controlled substances. Although the new DEA rules do not require a particular method of destruction at this time, the preferred method of destruction has been incineration. For the DEA sponsored national take-back events held from 2010 to 2014, the DEA funded the cost of incineration after collecting the medications from local law enforcement agencies around the country. However, in 2014 the DEA indicated that they would no longer host and sponsor national take-back events. Yet that decision was reversed by the DEA in July 2015 because of the ongoing prescription drug abuse epidemic. On October 22, 2016, the DEA hosted its 12th National Prescription Drug Take-Back Day.

Moreover, according to the amendments made to the Secure and Responsible Drug Disposal Act of 2010, the cost of disposal at the local level will no longer be funded by the federal government. Since incineration is costly, local law enforcement, community partners, and those now authorized to voluntarily collect medications have major concerns and challenges centered on funding the cost of disposal. Due to a variety of reasons, including compliance and costs concerns, pharmacies may be hesitant to seek DEA authorization to collect medications. Therefore, it remains to be seen what collection and disposal options will be available and most effective for ultimate users.

In addition to being knowledgeable about the medication collection and disposal options available at the state and local levels, pharmacy providers should also be aware of any programs that may have been implemented at the state level to assist with the removal of accumulated medications. For example, numerous states have passed laws that create prescription drug recycling, repository, or redistribution programs for unused medications.²⁰ Although details of programs may vary from state to state, many allow for the return of prescription medications in single use or sealed packaging, which can then be reused or donated to indigent patients. However, these programs are usually limited to noncontrolled medications in the institutional setting, such as long-term care facilities. Pharmacy providers can learn more about the availability of these programs by contacting their state board of pharmacy or state pharmacy association.

DECREASING ACCUMULATION OF MEDICATIONS IN THE HOME

The primary focus of this article has been about how the proper disposal of medications can help protect the environment and prevent unintentional poisonings and diversion. Although each of these areas is of critical importance, another point of emphasis that needs to be addressed is reducing the overall need for medication disposal. One way to do this is to decrease the amount of medications that accumulate in the home. There are a number of reasons medications accumulate in the home. These include medication adherence problems, inappropriate prescribing, adverse drug reactions that lead to shorter than anticipated overall usage, dosage changes, and medications that are leftover when a patient dies. Regarding improper prescribing, there has recently been various national and state guidance documents issued to help practitioners improve on how opioids are prescribed and dispensed.

In today's practice environment, pharmacy providers are in an ideal situation to improve many of the above-mentioned reasons for drug accumulation in the home. For example, not only can pharmacists and pharmacy technicians improve patient adherence, but they can also work directly with prescribers to ensure that a patient's drug therapy regimen is not likely to result in unused or unneeded medicine.

RESOURCES AND RECOMMENDATIONS FOR PHARMACY PROVIDERS REGARDING DRUG DISPOSAL

Most of the guidance and resources that are currently available regarding medication disposal agree on the following recommendations for individuals who have unwanted or expired medications that they wish to dispose^4-7:

• Patients should take advantage of available community medication take-back programs. Patients can contact their health care providers, local law enforcement, or the DEA to learn what take-back options are available in their community.
• If no take-back program is available in the patient's area, they should throw the drugs in the household trash, but first⁴:
  • "Mix medicines (do NOT crush tablets or capsules) with an unpalatable substance such as kitty litter or used coffee grounds";
  • Before throwing out the empty pill bottle or other empty medicine packaging, the patient should remember to scratch out all information on the prescription label to make it unreadable. This will help protect the patient's privacy of personal health information.
  • Prior to disposing any medication in the household trash, patients should also check and follow any specific disposal instructions provided on the medication label or patient information that accompanies the product. It is important to understand that a small number of medicines may be especially harmful (some are fatal with just 1 dose) if they are taken by someone other than the person for whom the medicine was prescribed. For this reason, some medicines have specific disposal instructions informing the patient to flush them down the sink or toilet when they are no longer needed. For example, one should flush strong pain medicines such as oxycodone down the drain as soon as they are no longer needed. When one disposes of these medicines down the sink or toilet, they cannot be accidentally taken by children, pets, or anyone else. A list of medications recommended for disposal by flushing is available from the FDA and provided in Table 3.
• When in doubt about proper medication disposal, patients should be instructed to consult a pharmacy provider.

Table 3. Medicines Recommended for Disposal by Flushing*
Medicine	Active Ingredient
Abstral, tablets (sublingual) Actiq, oral transmucosal lozenge* Avinza, capsules (extended release) Belbuca, soluble film (buccal) Buprenorphine hydrochloride, tablets (sublingual) * Buprenorphine hydrochloride; naloxone hydrochloride, tablets (sublingual) * Butrans, transdermal patch system Daytrana, transdermal patch system Demerol, tablets* Demerol, oral solution* Diastat/Diastat AcuDial, rectal gel Dilaudid, tablets* Dilaudid, oral liquid Dolophine hydrochloride, tablets* Duragesic, patch (extended release)* Embeda, capsules (extended release) Exalgo, tablets (extended release) Fentora, tablets (buccal) Hysingla ER, tablets (extended release) Kadian, capsules (extended release) Methadone hydrochloride, oral solution* Methadose, tablets* Morphabond, tablets (extended release) Morphine sulfate, tablets (immediate release)* Morphine sulfate, oral solution* MS Contin, tablets (extended release)* Nucynta ER, tablets (extended release) Onsolis, soluble film (buccal) Opana, tablets (immediate release) Opana ER, tablets (extended release) Oxecta, tablets (immediate release) Oxycodone hydrochloride, capsules Oxycodone hydrochloride, oral solution Oxycontin, tablets (extended release)* Percocet, tablets* Percodan, tablets* Suboxone, film (sublingual) Targiniq ER, tablets (extended release) Xartemis XR, tablets Xtampza ER, capsules (extended release) Xyrem, oral solution Zohydro ER, capsules (extended release) Zubsolv, tablets (sublingual)	fentanyl fentanyl citrate morphine sulfate buprenorphine hydrochloride buprenorphine hydrochloride buprenorphine hydrochloride; naloxone hydrochloride buprenorphine methylphenidate meperidine hydrochloride meperidine hydrochloride diazepam hydromorphone hydrochloride hydromorphone hydrochloride methadone hydrochloride fentanyl morphine sulfate; naltrexone hydrochloride hydromorphone hydrochloride fentanyl citrate hydrocodone bitartrate morphine sulfate methadone hydrochloride methadone hydrochloride morphine sulfate morphine sulfate morphine sulfate morphine sulfate tapentadol fentanyl citrate oxymorphone hydrochloride oxymorphone hydrochloride oxycodone hydrochloride oxycodone hydrochloride oxycodone hydrochloride oxycodone hydrochloride acetaminophen; oxycodone hydrochloride aspirin; oxycodone hydrochloride buprenorphine hydrochloride; naloxone hydrochloride oxycodone hydrochloride; naloxone hydrochloride oxycodone hydrochloride; acetaminophen oxycodone sodium oxybate hydrocodone bitartrate buprenorphine hydrocloride; naloxone hydrochloride
Reference 4 *These medicines have generic versions available that should follow the same guidance—list updated April 2016

Beyond governmental resources and recommendations, nongovernmental entities have developed additional resources, information, and public awareness programs to address the issue of medication disposal. These programs vary by location. One example includes Dispose My Meds (DisposeMyMeds.org), which is an online resource designed to assist with locating medication disposal programs offered through independent community pharmacies. The Dispose My Meds resource, developed by the National Community Pharmacists Association (NCPA) and its partners, encourages community pharmacists to consider voluntarily initiating medication disposal programs. NCPA encourages community pharmacies to have an active role in all aspects of pharmaceuticals from dispensing to disposal. This includes pharmacists applying their clinical knowledge when assisting with medication disposal. For example, when patients request assistance with the disposal of their unused medications, the pharmacist can speak with them about why they discontinued their medication. This communication could also lead to improved adherence, which may help decrease the accumulation of medications in the home. In addition to offering access to a system that helps locate participating pharmacies, the Dispose My Meds resource also provides additional resources, including videos and articles about medication disposal, statistics regarding medication disposal, and medication safety tool kits for families.

Medication Disposal in Health Care Facilities

It is important to note that health care facilities, such as hospitals, also have concerns about appropriate medication disposal. Compared to individuals in the community and residential settings, health care facilities face additional concerns when it comes to proper disposal of unused medications. Although this topic is outside of the scope of this article, there are a variety of resources available to pharmacy providers in health care facilities; several resources are provided in Table 4.

Table 4. Resources for Pharmacy Providers in Health Care Facilities

US Environmental Protection Agency Unused Pharmaceutical Disposal at Health Care Facilities https://www.epa.gov/eg/unused-pharmaceutical-disposal-health-care-facilities Resource Conservation and Recovery Act (RCRA) Laws and Regulations https://www.epa.gov/rcra EPA Hazardous Waste https://www.epa.gov/hw Practice Greenhealth Managing Pharmaceutical Waste: A 10-Step Blueprint for  Health Care Facilities In the United States http://www.hercenter.org/hazmat/tenstepblueprint.pdf American Society of Health-System Pharmacists Managing Pharmaceutical Waste: A Discussion Guide for Health-System Pharmacists http://www.ashpadvantage.com/docs/PharmaWaste-Discussion-Guide.pdf  ASHP. ASHP Guidelines on Handling Hazardous Drugs. http://www.ashp.org/DocLibrary/BestPractices/PrepGdlHazDrugs.aspx US DOJ, DEA, Office of Diversion Control, Drug Disposal Information http://www.deadiversion.usdoj.gov/drug_disposal/ Pharmacist's Manual Section IV Transfer or Disposal of Controlled Substances http://www.deadiversion.usdoj.gov/pubs/manuals/pharm2/pharm_manual.htm  Practitioner's Manual – Disposal of Controlled Substances http://www.deadiversion.usdoj.gov/pubs/manuals/pract/section4.htm

CONCLUSION

The issue of medication disposal is a complex matter that requires coordination among multiple stakeholders. Because the public often turns to their local pharmacy for advice about medication disposal, pharmacy providers have an obligation to educate patients and provide sound professional advice. To do this, pharmacy providers, including pharmacy technicians, must be aware of the negative consequences of improper medication disposal, the legal issues surrounding medication disposal, and the current medication disposal options.

Medication collection programs vary, requiring pharmacy providers to further research the options and requirements in their area. For local areas that do not have medication collection and disposal programs available or for medications that do not have disposal instructions included, national prescription drug take-back days as well as FDA and EPA guidance on drug disposal are the best available recommendations. Ultimately, patients should be advised to store medications in a safe, secure place and dispose of any unused or expired medications at an available collection site or dispose of them according to federal guidance.

REFERENCES

1. Blair BD, Crago JP, Hedman CJ, Klaper RD. Pharmaceuticals and personal care products found in the Great Lakes above concentrations of environmental concern. Chemosphere. 2013; 93: 2116-2123.
2. Boxall A, Rudd M, Bryan W, et al. Pharmaceuticals and Personal Care Products in the Environment: What Are the Big Questions? Environmental Health Perspectives. 2012; 120 (9): 1221-1229.
3. Donn J, Mendoza M, Pritchard J; Associated Press. Drugs found in drinking water. USA Today. September 12, 2008. http://usatoday30.usatoday.com/news/nation/2008-03-10-drugs-tap-water_N.htm. Accessed November 17, 2014.
4. Disposal of unused medicines: what you should know. US Food and Drug Administration website. http://www.fda.gov/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/EnsuringSafeUseofMedicine/SafeDisposalofMedicines/ucm186187.htm. Accessed October 25, 2016.
5. US Food and Drug Administration (FDA), FDA Consumer Health Information. How to Dispose of Unused Medications. http://www.fda.gov/downloads/Drugs/ResourcesForYou /Consumers/Buying Using MedicineSafely/UnderstandingOver-the-CounterMedicines/ucm 107163.pdf. Accessed October 25, 2016.
6. Drug disposal information. Drug Enforcement Administration website. http://www.deadiversion.usdoj.gov/drug_disposal/. Accessed October 25, 2016.
7. US Environmental Protection Agency. How to Dispose of Medicines Properly. https://www.epa.gov/sites/production/files/2015-06/documents/how-to-dispose-medicines.pdf. Accessed October 25, 2016.
8. Injury Prevention & Control: Protect the Ones You Love – Child Injuries are Preventable. Centers for Disease Control and Prevention website. http://www.cdc.gov/ safechild/poisoning/. Accessed October 25, 2016.
9. Medicine Safety for Children: An In-Depth Look at Calls to Poison Centers, March 2015. Safe Kids Worldwide website. https://www.safekids.org/research-report/medicine-safety-children-depth-look-calls-poison-centers-march-2015. Accessed November 1, 2016.
10. Medication disposal: questions and answers. US Food and Drug Administration website. http://www.fda.gov/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/EnsuringSafeUseofMedicine/SafeDisposalofMedicines/ucm186188.htm. Accessed October 25, 2016.
11. The Quick Scoop: Medicines and Your Family; Safely Storing and Disposing of Medicines. The Center for Improving Medication Management and the National Council on Patient Information and Education website. www.learnaboutrxsafety.org/quick-scoop.aspx#safely. Accessed Nov. 1, 2016.
12. Office of the President of the United States Executive Office. Epidemic: Responding to America's Prescription Drug Abuse Crisis. The White House website. http://www.whitehouse.gov/sites /default/files/ondcp/issues-content/prescription-drugs/rx_abuse_plan.pdf. Accessed October 25, 2016.
13. America's Addiction to Opioids: Heroin and Prescription Drug Abuse. National Institute on Drug Abuse website. https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2016/americas-addiction-to-opioids-heroin-prescription-drug-abuse. Accessed October 25, 2016.
14. Substance Abuse and Mental Health Services Administration, US Department of Health and Human Services. Behavioral Health Trends in the United States. Results from the 2014 National Survey on Drug Use and Health. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2016. HHS Publication No. (SMA) 15-4927. NSDUH Series H-50. http://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf. Accessed November 1, 2016.
15. Vital Sign: Today's Heroin Epidemic. Centers for Disease Control and Prevention website. http://www.cdc.gov/vitalsigns/heroin/index.html. Accessed November 1, 2016.
16. New Hampshire Department of Environmental Services. How to address unused medicine disposal in New Hampshire. http://www.ovitztaylorgates.com/how-to-address-unused-medicine-disposal/. Published April 2009. Accessed October 25, 2016.
17. US Government Printing Office (GPO). Secure and Responsible Drug Disposal Act of 2010 (Pub. L. 111-273). GPO website. http://www.gpo.gov/fdsys/pkg/PLAW-111publ273/pdf/PLAW-111publ273.pdf. Accessed November 1, 2016.
18. US Department of Justice, Drug Enforcement Administration. Disposal of Controlled Substances: Final Rule. Arlington, VA: US Department of Justice. Drug Enforcement Administration; 2014. Vol. 79 No 174: 53520-570. http://www.gpo.gov/fdsys/pkg/FR-2014-09-09/pdf/2014-20926.pdf. Accessed November 1, 2016.
19. US Department of Justice, Drug Enforcement Administration, Office of Diversion Control. Disposal Regulations: Registrant Fact Sheet.  https://www.deadiversion.usdoj.gov/drug_disposal/fact_sheets/disposal_registrant.pdf. Accessed October 25, 2016.
20. State prescription drug return, reuse and recycling laws. National Conference of State Legislature website. http://www.ncsl.org/research/health/state-prescription-drug-return-reuse-and-recycling.aspx. Accessed October 25, 2016.

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