Willingness of patients to use unused medication returned to the pharmacy by another patient: a cross-sectional survey

Optimising oncology drug expenditure in Ireland

A combination of improvements in patient survival, increasing treatment duration, and the development of more expensive agents has led to a doubling of per-capita spending on cancer medicines in Ireland (2008-2018). Despite this, access to new drugs is poor in comparison to other EU countries. We examine methods to optimise oncology drug spending to facilitate access to newer anticancer agents. Key targets for spending optimisation (biosimilar use, clinical trials and expanded access programs, waste reduction, avoidance of futile treatment, and altered drug scheduling) were identified through an exploratory analysis. A structured literature search was performed, with a focus on articles relevant to the Irish Healthcare system, supplemented by reports from statutory bodies. At the present time, EMA-approved agents are available once approved by the NCPE. Optimising drug costs occurs through guideline-based practice and biosimilar integration, the latter provides €80 million in cost savings annually. Access to novel therapies can occur via over 50 clinical trials and 28 currently available expanded access programmes. Additional strategies include reversion to weight-based immunotherapy dosing, potentially saving €400,000 per year in our centre alone, vial sharing, and optimisation of treatment schedules. A variety of techniques are being employed by oncologists to optimise costs and increase access to innovation for patients. Use of biosimilars, drug wastage, and prescribing at end of life should be audited as key performance indicators, which may lead to reflective practice on treatment planning. Such measures could further optimise oncology drug expenditure nationally facilitating approval of new agents.

Understanding medication recycling practices in Canadian hospitals

BACKGROUND

Medication recycling within hospitals has proven financial and possible environmental benefits according to local evaluations done in British Columbia. Despite this, the extent of medication recycling in Canadian hospitals remains unclear in the literature.

OBJECTIVE(S)

To determine if Canadian hospitals recycle medications, provide an estimate of how much medication is recycled by dosage form, and identify medication recycling barriers through the distribution of a cross-sectional survey.

METHODS

A nine-question survey was distributed to 171 hospital pharmacy departments across Canada that consented to complete the survey. The survey identified whether sites recycled unused medications, an estimate of how much is recycled based on dosage form, and barriers to recycling.

KEY FINDINGS

Of 62 respondents, the majority indicated they do have medication recycling procedures; however, the frequency of recycling is suboptimal (30-50% of medications are not recycled), and not all medication types are always recycled. Individually packaged oral tablets were most often recycled, and oral liquid medications were least often recycled. Many multi-dose medications were not tamper-proofed. Most respondents selected "sanitization/infection control" and "resource constraint" as reasons for not recycling all medications.

CONCLUSIONS

Among respondents, the proportion and type of unused medicines that are recycled varied. For sites that did not respond, this might suggest that medication recycling is not a priority. This could represent a missed opportunity to standardize practices and increase medication recycling in hospitals, both of which could represent a meaningful step towards responsible use of medications and reduction of negative impacts on human health and the environment.

A study on the quantity, type, economic value and reasons for pharmaceutical waste returned to pharmacies in Finland

INTRODUCTION

Some medicines purchased are not used, resulting in pharmaceutical waste. Finland, among many other countries, is seeking to reduce the amount of pharmaceutical waste, but little information on this is currently available. This study aimed to evaluate the quantity, type, economic value, and reasons for returning pharmaceutical waste from households to community pharmacies in Finland.

METHODS

Community pharmacies (n = 82) quantified and qualified the amount of pharmaceutical waste returned to them over three days in May 2022. The data was collected using an electronic form. The reasons for returning medicines were asked from customers who returned medicines using a paper questionnaire. The data was analyzed for frequencies and percentages. To estimate the economic value, we used the Finnish medicines prices at the end of June 2022. The annual economic value was calculated by means of a pharmacy size-weighted average. The confidence intervals were estimated using the non-parametric bootstrap method. Sensitivity analyses were conducted to examine the reliability of the results.

RESULTS

In total, 5173 medicines were returned to pharmacies, of which 66 % were prescription medicines. The most common medicines group returned were medicines for nervous system (18 %), respiratory system (16 %), and alimentary tract and metabolism (12 %). The estimated annual economic value of the medicines returned was 81 million euros (CI 95 % M€61-M€103), of which the cost to society was 43 million euros (CI 95 % M€30-M€60). 799 customers responded to the questionnaire (Response rate 81.9 %). The limited shelf life of the medicine after opening (36 %), improvement of the medical condition or symptom (25 %), and the unnecessarily large pack size (22 %) were common reasons for returning.

CONCLUSION

A considerable amount of pharmaceutical waste is returned to pharmacies, causing unnecessary costs to both individuals and society, indicating the need to reduce waste. The limited shelf life and large pack sizes of medicines account for a large proportion of causes for household pharmaceutical waste. Reducing pharmaceutical waste requires action from all actors in the pharmaceutical chain.

Redispensing of expensive oral anticancer medicines: A practical application

INTRODUCTION

Increasing use of expensive oral anticancer medicines comes with the downside of a financial and environmental burden, partially caused by unused medication. Returned oral anticancer medicine to the pharmacy could be considered for redispensing providing guaranteed quality. This study aimed to identify and implement quality aspects and criteria for redispensing oral anticancer medicine in daily pharmacy practice.

METHODS

A systematic analysis was conducted to determine the eligibility of oral anticancer medicine for redispensing. Over a one-year period, the number of returned oral anticancer medicine accepted for redispensing was quantified, and the reduction in financial waste and environmental burden calculated based on this assessment.

RESULTS

Four categories of quality aspects were identified for determining the eligibility of oral anticancer medicine for redispensing: Product presentation suitability (stability characteristics, storage requirements), physical condition (unopened or opened secondary or primary packaging, visual appearance), authentication (Falsified Medicines Directive, confirmation of initial dispense, recall), and additional aspects (remaining shelf life, period of storage in uncontrolled conditions). A standardized procedure for redispensing was implemented in daily pharmacy practice. During the study period, 10,415 oral anticancer medicine dose units out of 13,210 returns (79%) were accepted for redispensing. The total value of oral anticancer medicine accepted for redispensing was €483,301, accounting for 0.9% of the total value dispensed during this period. Furthermore, the potential reduction in environmental burden was estimated at 1132.1 g of potent active pharmaceutical ingredient.

CONCLUSIONS

By implementing strict procedures considering all relevant quality aspects, redispensing of oral anticancer medicine can be successfully implemented into daily pharmacy practice, resulting in a significant reduction in financial waste and environmental burden.

Assessing city-wide pharmaceutical emissions to wastewater via modelling and passive sampling

With increasing numbers of chemicals used in modern society, assessing human and environmental exposure to them is becoming increasingly difficult. Recent advances in wastewater-based epidemiology enable valuable insights into public exposure to data-poor compounds. However, measuring all >26,000 chemicals registered under REACH is not just technically unfeasible but would also be incredibly expensive. In this paper, we argue that estimating emissions of chemicals based on usage data could offer a more comprehensive, systematic and efficient approach than repeated monitoring. Emissions of 29 active pharmaceutical ingredients (APIs) to wastewater were estimated for a medium-sized city in the Netherlands. Usage data was collected both on national and local scale and included prescription data, usage in health-care institutions and over-the-counter sales. Different routes of administration were considered as well as the excretion and subsequent in-sewer back-transformation of conjugates into respective parent compounds. Results suggest model-based emission estimation on a city-level is feasible and in good agreement with wastewater measurements obtained via passive sampling. Results highlight the need to include excretion fractions in the conceptual framework of emission estimation but suggest that the choice of an appropriate excretion fraction has a substantial impact on the resulting model performance.

Factors Influencing Public Willingness to Reuse the Unused Stored Medications in Jordan: A Cross-Sectional Study

The reissuing, redispensing, redistributing, or even recycling of the returned unused stored medicines is referred to as medicine reuse. A few studies have examined people's willingness to reuse unused stored medicines. This study aims primarily to explore the public's willingness to reuse unused stored medicines in the future and the factors affecting their decisions, and to assess the pharmacological types and formulations of the unused stored medicines by the public. A cross-sectional study was conducted using a convenient sampling technique over three weeks (February-March 2022) among Jordanian populations. Data were collected from 681 participants who agreed to fill out a questionnaire, which was distributed online. Participants showed a positive perception of reusing any of the unused stored medicines in the future; of those, 79.6% (n = 400) believed that reusing "unused medicines" has economic benefits and 50% (n = 251) believe there are environmental benefits. Moreover, more than half of the participants believed that reusing "unused medicines" is safe (n = 256, 51%), but provided that a pharmacist or a doctor evaluates their quality or that the unused medicines are stored well. Results from this study show that the public positively endorses the idea of reusing unused stored medicines if the quality and safety are assured. However, future studies are needed to evaluate the Jordanian healthcare professionals' perceptions towards medicine reuse and pharmaceutical companies' willingness to be a part or facilitator of medicine reuse.

Household Pharmaceutical Waste Disposal as a Global Problem-A Review

The negative effect of the pharmaceuticals presence (persistence?) in various components of the environment is a global problem today. These compounds are released into the environment as a result of, inter alia, their use and improper disposal. Therefore, it is important to reduce excessive drug consumption and to develop a system for the collection of unused/expired pharmaceuticals. The effectiveness of actions in this area is inextricably linked with the need to educate society on how to deal properly with unwanted medications. The aim of the study was to show that the inappropriate handling of unused/expired drugs by society is an important problem in waste management systems, and it impacts the state of the environment. Forty-eight scientific articles published between 2012 and 2021 were taken into account that discussed the systems in various countries for the collection of unused/expired pharmaceuticals. This literature review shows that the main method of disposing of unused/expired medications, according to respondents from different countries, is either by disposing of them in household waste or flushing them into the sewage system. This is also the case in countries with systems or programs for the return of redundant drugs, which indicates that these systems are not sufficiently effective. This may be influenced by many factors, including the lack or ineffective education of the society.

Management of Medicines Wastage, Returned Medicines and Safe Disposal in Malaysian Community Pharmacies: A Qualitative Study

Introduction

In supplying medicines to patients and consumers waste can occur in prescribing, dispensing, and leftover stages. Pharmacists in community pharmacies play a crucial role in dispensing and should share information on appropriate medicines disposal with consumers. This qualitative study explored how Malaysian community pharmacists manage medication wastage, returned medicines, and medicines disposal by eliciting their opinions on medicines wastage, the challenges faced, and feasibility of medicine return and safe medicine disposal in the setting of Malaysian community pharmacy.

Methods

Telephonic interviews were conducted using a pre-validated interview guide among community pharmacists. Purposive sampling was used to ensure heterogeneity of participants in terms of gender, age, and position in the pharmacy. The interview was conducted until a point where no new information was obtained. Interview data were thematically analyzed.

Results

The analysis identified nine themes organized into four domains. The results revealed that pharmacists have positive perceptions of the safe disposal of medicines. Pharmacists mentioned that medicine returns to service in community pharmacies are not common due to a lack of facilities in the management of unwanted, expired, and returned medicines. As such pharmacists have suggested a few ways to minimize medicinal wastage.

Conclusions

Respondents aimed to minimize medicines wastage (unused medicines) in order to minimize loss of revenue. Respondents did not usually accept returned medicines due to the operational costs of safe disposal. Disposal of unused medicines was undertaken by centralizing the stocks at an organization facility before being disposed of by outsourced waste management companies.

Tackling the increasing contamination of the water supply by iodinated contrast media

Contrast media are essential for diagnostic and interventional procedures. Iodinated contrast media are the most commonly used agents, with CT requiring the largest overall quantities. Data show that these iodinated contrast media are found in sewage water, surface water and drinking water in many regions in the world. Because standard drinking water purification techniques only provide poor to moderate removal of iodinated contrast media, these substances pose a problem for drinking water preparation that has not yet been solved. There is a growing body of evidence supporting the negative environmental effects of iodinated contrast media via their breakdown products. The environmental impact of iodinated contrast media can be mitigated by measures focusing on the application of contrast media or the excretion of contrast media. Measures with respect to contrast application include reducing the utilization of contrast media, reducing the waste of contrast media and collecting residues of contrast media at the point of application. The amount of contrast media excreted into the sewage water can be decreased by introducing urine bags and/or special urine collection and waste-water processing techniques in the hospital. To tackle the problem of contrast media in the water system in its entirety, it is necessary for all parties involved to cooperate, from the producer of contrast medium to the consumer of drinking water. This paper aims to make health professionals aware of the opportunity to take the lead now in more conscious decisions regarding use of contrast media and gives an overview of the different perspectives for action.

Medication Use and Storage, and Their Potential Risks in US Households

Background: Medications stored in US households may pose risks to vulnerable populations and the environment, potentially increasing societal costs. Research regarding these aspects is scant, and interventions like medication reuse may alleviate negative consequences. The purpose of this study was to describe medications stored in US households, gauge their potential risk to minors (under 18 years of age), pets, and the environment, and estimate potential costs of unused medications. Methods: A survey of 220 US Qualtrics panel members was completed regarding medications stored at home. Published literature guided data coding for risks to minors, pets, and the environment and for estimating potential costs of unused medications. Results: Of the 192 households who provided usable and complete data, 154 (80%) reported storing a medication at home. Most medications were taken daily for chronic diseases. The majority of households with residents or guests who are minors and those with pets reported storing medications with a high risk of poisoning in easily accessible areas such as counters. Regarding risk to the aquatic environment, 46% of the medications had published data regarding this risk. For those with published data, 42% presented a level of significant risk to the aquatic environment. Unused medications stored at home had an estimated potential cost of $98 million at a national level. Implications/Conclusions: Medications stored at home may pose risks to vulnerable populations and the environment. More research regarding medications stored in households and their risks is required to develop innovative interventions such as medication reuse to prevent any potential harm.

Key factors underlying the willingness of patients with cancer to participate in medication redispensing

BACKGROUND

Redispensing medication unused by patients to other patients could reduce the environmental burden of medication waste. Simultaneously, associated financial loss could be reduced, particularly for expensive medication such as oral anticancer drugs. An important determinant for successful medication redispensing is patient participation.

OBJECTIVE(S)

To identify key factors underlying the willingness of patients with cancer to participate in the redispensing of unused oral anticancer drugs.

METHODS

Semi-structured interviews via telephone or video call were conducted with adult patients diagnosed with cancer from two Dutch hospitals. The interview guide was framed using the COM-B model for behavioural change, to elicit patients' capability, opportunity and motivation to participate in medication redispensing. Questions were related to patients' willingness to accept redispensed medication, reasons thereof, perceived concerns and needs. Inductive thematic analysis was applied.

RESULTS

Seventeen patients (aged 38-82 years, 71% female), with nine different types of cancer participated. The majority of participants supported medication redispensing. Four categories of key factors underlying the willingness of patients with cancer to participate in medication redispensing were identified. First, the driver for participation was having positive societal impact, relating to affordability and sustainability of healthcare. Second, having trust in product quality was a requirement, influenced by preconceived beliefs, quality assurance and patients' knowledge of this process. Third, a facilitator for participating in medication redispensing was adequate provision of information. This concerned awareness of medication waste, information about medication redispensing, support from healthcare providers and other patients, and insight into medication dispensing history. Last, a convenient process for returning unused medication to pharmacies would facilitate participation in medication redispensing.

CONCLUSIONS

The willingness of patients with cancer to participate in medication redispensing relates to a drive for achieving positive societal impact, provided that medication is of high quality, there is adequate information provision and a convenient process.

The Effect of Quality Indicators on Beliefs about Medicines Reuse: An Experimental Study

Background: A number of studies have examined beliefs about medicines reuse. Although the practice is prohibited in UK community pharmacy, it does take place elsewhere in the world where it relies on visual checks of returned medicines as an indicator of their quality. One proposal is to integrate sensor technology onto medication packaging as a marker of their quality instead. Our aim was to gauge people’s beliefs about medicines reuse, in an experiment, with or without sensor technology and with or without the promise of visual checks completed by a pharmacist, as experimental conditions, should the practice be sanctioned in the UK in the future. Methods: A between participant study was designed with two independent factors testing the hypothesis that sensors and visual checks would increase pro-medicines-reuse beliefs. A questionnaire was used to measure medicines reuse beliefs and collect qualitative comments. Results: Eighty-one participants took part. Attitudes toward medication offered for reuse, participants’ perceived social pressure to accept the medication, and their intention to take part in medicines reuse all increased with the presence of sensors on packaging and with the promise of pharmacist visual checking, with the former causing a greater increase than the latter, and the combination of both making the greatest increase. People’s qualitative comments explained their concerns about medicines reuse, validating the findings. The use of sensors on medication packaging warrants further investigation if regulators are to consider approving medicines reuse in the UK.

Stakeholder Views on the Idea of Medicines Reuse in the UK

People’s views about medicines reuse are being examined in a handful of qualitative studies and this commentary adds to that work by drawing on our own discussions with groups of stakeholders in the UK in the past two years. The reuse of medicines within the community pharmacy setting is not permitted in the UK but our multidisciplinary team anticipates that this position will change in the coming years as medication shortages and worries about environmental waste and financial losses from the destruction of unused medicines are brought to the fore. Indeed, for many stakeholders, the issue of waste is a strong feature of conversations about medicines reuse. In addition to this, stakeholders identify the numerous barriers to medicines reuse in the UK. This includes the current uncertainty about the quality of unused medicines returned to pharmacies, which could otherwise be reused. However, stakeholders have also been very willing to propose solutions to a range of existing barriers. Our commentary draws on stakeholder meetings to elaborate the range of views about medicines reuse within a UK context. The challenge is to move forward from these views to advance the technologies that will facilitate medicines reuse practically as well as legally.

Public Attitudes towards Medicinal Waste and Medicines Reuse in a 'Free Prescription' Healthcare System

This study investigates public attitudes towards medicinal waste and medicines reuse within a ‘free prescription’ healthcare system. A quantitative online survey was employed in a sample drawn from the population of Wales, where prescription medicines have been ‘free’ since 2007. Qualitative interviews informed the content of the attitude statements with categorical or ordinal response options assigned. The questionnaire was hosted on the HealthWise Wales platform for 1 year from October 2017. Of the 5584 respondents, 67.2% had at least one medicine on repeat prescription. Overall, 89.1% held strong concerns about medicinal waste. High acceptance for the reuse of prescription medicines which have been returned unused by patients to pharmacies was reported for tablets (78.7%) and capsules (75.1%) if the medicine is checked by a pharmacist first (92.4% rated essential). Concerns identified related to tampering of packs (69.2%) and the need for hygienic storage (65.4%). However, those working in healthcare had less concern about the safety of reusing medicines. The level of public acceptance for the reuse of medication was higher than previously reported. This is the largest survey to capture these views to date, which has implications for the future design of medicines reuse schemes.

Towards Medicines Reuse: A Narrative Review of the Different Therapeutic Classes and Dosage Forms of Medication Waste in Different Countries

BACKGROUND

Medicines reuse, the idea of re-dispensing returned medicines to others following quality control, is yet to be implemented in the UK. This practice is potentially a sustainable way of dealing with returned medicines, which are otherwise classed as medication waste and destroyed. To inch towards medicines reuse, it is important to know more about the different therapeutic classes and dosage forms that make up medication waste. For example, it is helpful to know if medicines being returned are mostly solid-dosage forms and thus have the potential to be reused or are from therapeutic classes that would make medicines reuse cost-effective. Little is known about the therapeutic classes and the dosage forms of wasted medicines. This study aimed to narratively review and report findings from the international literature on the different therapeutic classes and the dosage forms of medicines that are returned by patients to community pharmacies, hospitals, general practitioners' clinics, or collected through waste campaigns. Studies based on surveys without physically returning medicines were also included where relevant.

METHODS

A comprehensive electronic search of databases, including PubMed and Google Scholar, was carried out over one month in 2017 and updated by 5 November 2020, using a combination of carefully created keywords.

RESULTS

Forty-five studies published in English between 2002 and 2020, comprising data from 26 countries were included and reviewed. Oral solid dosage forms (mostly tablets) were the commonly reported dosage form of all wasted medicines in 14 studies out of the 22 studies (64%) that described the dosage form, with percentages ranging from 40.6% to 95.6% of all wasted medicines. Although there was variability among the levels of medication waste reported in different countries, findings from the UK and Ethiopia were relatively consistent; in these, medicines for the cardiovascular system and anti-infective medicines, respectively, were the most common therapeutic classes for medication waste.

CONCLUSION

This narrative review provides insights about the different therapeutic classes and dosage forms of medication waste either returned by patients, collected through waste campaigns, or indicated in survey responses. The findings could help policy makers understand the potential implications of treating most unused medicines as medication waste and whether therefore pursuing a medicines reuse scheme could be environmentally or financially logical. The quality and the safety of these returned medicines using criteria related to the storage conditions (such as heat and humidity), physical shape (such as being sealed, unopened, unused, and in blister packaging), and tampering are other important considerations for a medicines reuse scheme.

Intentions to "Reuse" Medication in the Future Modelled and Measured Using the Theory of Planned Behavior

BACKGROUND

A range of pro-environmental behaviors are recognized, promoted, and investigated, but urgent action is also needed to tackle the direct and indirect environmental impact of medication waste. One solution is to reissue medicines, returned unused to pharmacies (i.e., reuse medicines). Yet, if medicines reuse is to be formally introduced in the UK, it is imperative also to understand people's willingness to take part in such a scheme and importantly, the underpinning drivers. This study aimed to develop, validate, and evaluate a Theory of Planned Behavior model aimed at predicting medicines reuse behavioral intentions.

METHODS

The behavior of interest, medicines reuse, was defined according to its Target, Action, Context, and Time. Then themes from an existing qualitative study were used in order to draft, validate and pilot a Theory of Planned Behavior-based questionnaire before its completion by a representative sample (n = 1003) of participants from across the UK.

RESULTS

The majority expressed pro-medicines reuse intentions. The three direct measures accounted for 73.4% of the variance in relation to people's intention to reuse medicines in the future, which was statistically significant at p < 0.001. People's specific beliefs about medicines reuse and how they evaluate other people's expectations of them had a substantial impact on their intentions to reuse medication in the future, mediated in an intricate way via attitudes, subjective norms and perceived behavioral control (PBC).

CONCLUSIONS

This study shows how people could embrace medicines reuse via practical measures that illustrate the safety and quality assurance of reissued medicines, educational interventions that bolster beliefs about the pro-environmental benefits, and norm-based interventions encouraging doctors and pharmacists to endorse the practice. The findings add to the emerging work on medicines reuse and, significantly, provide a theoretical framework to guide policymakers and other organizations looking to decrease the impact of medication waste through medicines reuse schemes.

Enabling Medicine Reuse Using a Digital Time Temperature Humidity Sensor in an Internet of Pharmaceutical Things Concept

Medicinal waste due to improper handling of unwanted medicines creates health and environmental risks. However, the re-dispensing of unused prescribed medicines from patients seems to be accepted by stakeholders when quality and safety requirements are met. Reusing dispensed medicines may help reduce waste, but a comprehensive validation method is not generally available. The design of a novel digital time temperature and humidity indicator based on an Internet of Pharmaceutical Things concept is proposed to facilitate the validation, and a prototype is presented using smart sensors with cloud connectivity acting as the key technology for verifying and enabling the reuse of returned medicines. Deficiency of existing technologies is evaluated based on the results of this development, and recommendations for future research are suggested.

Enhancing Pharmaceutical Packaging through a Technology Ecosystem to Facilitate the Reuse of Medicines and Reduce Medicinal Waste

Background: The idea of reusing dispensed medicines is appealing to the general public provided its benefits are illustrated, its risks minimized, and the logistics resolved. For example, medicine reuse could help reduce medicinal waste, protect the environment and improve public health. However, the associated technologies and legislation facilitating medicine reuse are generally not available. The availability of suitable technologies could arguably help shape stakeholders' beliefs and in turn, uptake of a future medicine reuse scheme by tackling the risks and facilitating the practicalities. A literature survey is undertaken to lay down the groundwork for implementing technologies on and around pharmaceutical packaging in order to meet stakeholders' previously expressed misgivings about medicine reuse ('stakeholder requirements'), and propose a novel ecosystem for, in effect, reusing returned medicines. Methods: A structured literature search examining the application of existing technologies on pharmaceutical packaging to enable medicine reuse was conducted and presented as a narrative review. Results: Reviewed technologies are classified according to different stakeholders' requirements, and a novel ecosystem from a technology perspective is suggested as a solution to reusing medicines. Conclusion: Active sensing technologies applying to pharmaceutical packaging using printed electronics enlist medicines to be part of the Internet of Things network. Validating the quality and safety of returned medicines through this network seems to be the most effective way for reusing medicines and the correct application of technologies may be the key enabler.