Estoque e descarte de medicamentos no domicílio: uma revisão sistemática

Do pharmacists counsel customers on the disposal of unused or expired household medications? A national survey among 1,596 pharmacists in Indonesia

Introduction

Pharmacists play a vital role in counseling customers on proper medication disposal, yet their consistency in providing such information is often lacking. This study aimed to assess pharmacists' awareness of appropriate disposal practices for unused and expired household medications. Additional objectives included evaluating whether pharmacists offer disposal information during counseling, measuring their willingness to receive medication waste from the public, and identifying associated factors.

Methods

A national cross-sectional online survey employing convenience sampling was conducted among pharmacists working in hospitals, pharmacies, clinics, or community health centers (CHCs) in Indonesia, using a validated questionnaire to assess awareness, information provision, and willingness to receive medications for disposal. Binary logistic regression, with 95% confidence intervals (CI) and odds ratios (OR), explored potential associations between factors and outcomes.

Results

This study involved 1,596 pharmacists across 37 Indonesian provinces. Most pharmacists were women (80.4 %), aged 31-40 years (49.3 %), with a pharmacist professional background (93.8 %), working in CHCs (41.2 %), and practicing for 1-5 years (51.0 %). More than half were unaware of guidelines for returning medications to health facilities. While 69.9 % never counseled customers on disposal practices, 64.9 % expressed willingness to receive unused and expired medication from the public. Pharmacists practicing for at least six years were more likely to provide disposal information during counseling (OR: 2.54; 95 % CI: 1.44-4.47). Conversely, those in clinics (OR: 2.16; 95 % CI: 1.29-3.62), CHCs (OR: 2.07; 95 % CI: 1.45-2.95), or hospitals (OR: 2.00; 95 % CI: 1.27-3.14) were more likely to be unwilling to receive expired and unused household medication.

Conclusions

The study reveals that most pharmacists, particularly those with limited practice duration, lacked awareness regarding the importance of proper medication disposal and did not provide counseling on appropriate medication disposal to patients. To address this issue, there is a pressing need for intensified education intensified education at the undergraduate level, continuous training for pharmacists, and a clear policy and practical guidelines, particularly targeting pharmacists in clinics, CHCs, and hospitals, to facilitate the acceptance of unused and expired household medications.

Guidance provided by pharmacists to customers regarding to destination of unused household medications: disposal of household medications

BACKGROUND

Discarding pharmaceuticals in the garbage or into the sewage system are still the most common methods in many countries. This study aims to investigate the guidance provided by pharmacists to customers on the disposal of unused and expired household medications in São Paulo State, Brazil.

METHOD

The study population consisted of 630 pharmacists from the State of São Paulo, who work in community pharmacies. They answered an online questionnaire with questions composed in three blocks: demographic, work, and academic information on the pharmacist; guidance about the disposal of household medications; and knowledge regarding the reverse logistics of these medications. An invitation to participate in the questionnaire was made via WhatsApp, individually and collectively. Inferential statistics were performed using the chi-square test and were considered significant when p < 0.05%.

RESULTS

Among the participating pharmacists, the majority were women under 60 years old,56 (8.89%) stated that they never orient the customer regarding the disposal of unused and expired household medications, while 574 (91,12%) indicated that they almost provide guidance. The frequency with which they provided guidance was influenced by the number of years since graduation (p = 0.0047), the time they had worked in pharmacies and drugstores (p = 0.0007), and whether or not they had a graduate degree (p = 0.0181). Regarding the disposal of medications, among the 643 responses provided by the pharmacists,516 (80.25%) indicated that they oriented customers to return them to a pharmacy.

CONCLUSION

A small number of pharmacists always orient customers on the proper disposal that should be followed for unused and expired household medications, prioritizing their return to a pharmacy. In general, these pharmacists have longer periods of work experience and higher academic qualifications. Thus, it is important to increase knowledge through professional training and further education programs.

Ecological risk assessment of pharmaceuticals and endocrine disrupting compounds in Brazilian surface waters

Pharmaceuticals and endocrine disrupting compounds are organic micropollutants that can cause adverse effects at low concentrations. Their occurrence in surface waters has been reported in several countries, including Brazil, at concentrations on the order of ngL-1, while the concentrations at which toxic effects are observed are often in the range of mg.L-1 to μg.L -1, however few studies have been undertaken to characterize risks they represent in Brazilian surface waters. Thus, the objective of this study was to evaluate the ecological risk to Brazilian surface waters caused by the presence of pharmaceuticals and natural and environmental estrogens. Twenty-nine pharmaceuticals, hormones and environmental estrogens were included in the risk assessment while twelve were discarded due to insufficient data availability. The endocrine disrupting compounds were the most frequently detected (39.8% of the reported concentrations), followed by non-steroidal anti-inflammatory drugs (16.3%), antibiotics (6.6%), antiseptics (5.1%), analgesics (5.1%), antihypertensives (4.6%), and to a lesser extent, lipid controllers, anticonvulsants, antidepressants, antihistamines, antivirals and corticosteroids. Bisphenol-A was the most frequently detected compound, followed by diclofenac, 17-β-estradiol, 17-α-ethynilestradiol, naproxen, triclosan and 4-n-nonylphenol. Acute ecological risk was predicted in two thirds and chronic risk in one third of the water bodies surveyed. The presence of diclofenac or triclosan was determinant for acute risk while estrogenic hormones proved to be decisive for chronic risk. In addition to natural and synthetic endocrine disruptors, the pharmacological groups estimated to have the highest average associated risks were non-steroidal anti-inflammatory drugs, followed by anticonvulsants. No discharge limits exist for most of the compounds found to contribute to ecological risks, indicating the need for regulatory action by the proper Brazilian authorities.

Pharmaceutical waste management system - Are the current techniques sustainable, eco-friendly and circular? A review

Most households and healthcare facilities usually dispose of contaminated, unused, or expired (CUE) medicines with municipal wastes, the disposal of which usually amounts to $790/ton in the USA and £450/ton in the UK. Solid (e.g., tablets, capsules, powders) and semi-solid (e.g., ointment, creams) pharmaceuticals are managed with incineration/pyrolysis, encapsulation, and engineered landfills, whereas wastewater treatment plants (WWTPs) are recommended for liquid pharmaceutical wastes (PWs). However, to date, the sustainability and eco-friendliness profile of these techniques are only subjectively ensured, leading to controversial viewpoints in many guidelines. Each technique has relative strengths and weaknesses, and their comparative weighting to maximize these profiles is sought after. The present comprehensive review aims to fulfil knowledge gaps in this regard. Four electronic databases (e.g., PubMed/MEDLINE, Scopus, and ScienceDirect) were searched for PW management (PWM)-related qualitative and quantitative articles published till December 31, 2022. Articles without details of waste disposal techniques and their health and environmental impacts were excluded. Based on the literature review, we determine that incineration can be considered a sustainable option for solid and semi-solid PWs, and WWTPs can be eco-friendly for liquid PWs, whereas encapsulation and landfilling are less sustainable. It is high time that objectively proven sustainable and eco-friendly techniques be implemented for PWM based on their dosage forms or nature of hazards. Medicine take-back, eco-pharmacovigilance, extended producer responsibility, co-payment, and life cycle analysis of pharmaceuticals focusing on reduction, reuse/re-dispensing can be integrated to make existing models sustainable, circular, and eco-friendly.

[Disposal of drugs and the ensuing environmental impacts: an integrative review of the literature]

The scope of this article is to investigate the national and international evidence available on the forms of drug disposal and the presence of drugs in environmental matrices. It involved an integrative review of the literature conducted in the PubMed, SciELO and Virtual Health Library (VHL) databases, which included articles in English, Spanish and Portuguese published between 2010 and 2020. Twenty-six articles were selected, which revealed the incorrect disposal of medicines by professionals and consumers due mainly to the lack of knowledge about the environmental impacts that they may cause. Studies have highlighted the contamination of water, sewage and sediments by incorrectly discarded drugs. Furthermore, it was observed that aquatic living creatures can be impacted by the presence of drugs in environmental matrices. The incorrect disposal of drugs continues to be a reality in the evidence assessed, which leads to the contamination of environmental matrices and is often not removed by wastewater treatment plants and interferes with the equilibrium of environmental life.

Domestic Waste and Wastewaters as Potential Sources of Pharmaceuticals in Nestling White Storks (Ciconia ciconia)

Information on the exposure of wild birds to pharmaceuticals from wastewater and urban refuse is scarce despite the enormous amount of drugs consumed and discarded by human populations. We tested for the presence of a battery of antibiotics, NSAIDs, and analgesics in the blood of white stork (Ciconia ciconia) nestlings in the vicinity of urban waste dumps and contaminated rivers in Madrid, central Spain. We also carried out a literature review on the occurrence and concentration of the tested compounds in other wild bird species to further evaluate possible shared exposure routes with white storks. The presence of two pharmaceutical drugs (the analgesic acetaminophen and the antibiotic marbofloxacin) out of fourteen analysed in the blood of nestlings was confirmed in 15% of individuals (n = 20) and in 30% of the nests (n = 10). The apparently low occurrence and concentration (acetaminophen: 9.45 ng mL−1; marbofloxacin: 7.21 ng mL−1) in nestlings from different nests suggests the uptake through food acquired in rubbish dumps rather than through contaminated flowing water provided by parents to offspring. As with other synthetic materials, different administration forms (tablets, capsules, and gels) of acetaminophen discarded in household waste could be accidentally ingested when parent storks forage on rubbish to provide meat scraps to their nestlings. The presence of the fluoroquinolone marbofloxacin, exclusively used in veterinary medicine, suggests exposure via consumption of meat residues of treated animals for human consumption found in rubbish dumps, as documented previously at higher concentrations in vultures consuming entire carcasses of large livestock. Control measures and ecopharmacovigilance frameworks are needed to minimize the release of pharmaceutical compounds from the human population into the environment.

Presence of pharmaceuticals and their metabolites in wild-living aquatic organisms - Current state of knowledge

In the last decades an increasing number of studies has been published concerning contamination of aquatic ecosystems with pharmaceuticals. Yet, the distribution of these chemical compounds in aquatic environments raises many questions and uncertainties. Data on the presence of selected pharmaceuticals in the same water bodies varies significantly between different studies. Therefore, since early 1990 s, wild organisms have been used in research on environmental contamination with pharmaceuticals. Indeed, pharmaceutical levels measured in biological matrices may better reflect their overall presence in the aquatic environments as such levels include not only direct exposure of a given organisms to a specific pollutant but also processes such as bioaccumulation and biomagnification. In the present paper, data concerning occurrence of pharmaceuticals in aquatic biota was reviewed. So far, pharmaceuticals have been studied mainly in fish and molluscs, with only a few papers available on crustaceans and macroalgae. The most commonly found pharmaceuticals both in freshwater and marine organisms are antibiotics, antidepressants and NSAIDS while there is no information about the presence of anticancer drugs in aquatic organisms. Furthermore, only single studies were conducted in Africa and Australia. Hence, systematization of up-to-date knowledge, the main aim of this review, is needed for further research targeting.

Pharmaceutical Pollution and Disposal of Expired, Unused, and Unwanted Medicines in the Brazilian Context

The occurrence of pharmaceuticals in the environment is an everyday recognized concern worldwide, and drugs as environmental contaminants have been detected in water and soil systems, posing risks to humans and wildlife. The presence of drugs in wastewater, groundwater, and even drinking water occurs in several countries, including Brazil, where the pharmaceutical market is expanding over the years. The adverse, harmful effects of pharmaceuticals in the environment range from the spreading of antimicrobial resistance and species survival to the interference with reproduction and increased cancer incidence in humans. Therefore, it is demanding to count on proper legislation to prevent these pollutants from entering the distinct environment compartments. In some developed countries, laws, directives, programs, and initiatives regarding drug disposal reach a mature status. In Brazil, federal laws dealing with drug residues' management are recent, with flaws that might facilitate non-compliance with drug pollution issues. Besides, pharmacies and drugstores are not obligated to collect unneeded household medicines, while particular State laws aim to ordinate the disposal of drug residues regionally. In this review, we consider the current knowledge about pharmaceutical (drug) pollution, the recommendation and regulations on the disposal of useless medicines in some countries, and in the context of the expanding pharmaceutical market in Brazil. The awareness of emerging contaminants in the environment, besides the joint effort of authorities, consumers, and the general public nationwide, will be required to avoid pharmaceutical/drug pollution and achieve an eco-friendly environment and a sustainable society.

Evaluation of the potential environmental risk from the destination of medicines: an epidemiological and toxicological study

BACKGROUND

The high consumption of medicines by the population and their storage at home might cause an increase in the number of pharmaceutical substances that may be inappropriately discarded in the sanitary sewage, reaching an environmental aquatic. Thus, the effects of these emerging contaminants need more studies.

OBJECTIVES

To identify the profile of most medicines that are discarded by users of community pharmacy and evaluate the toxicity of the most disposed drugs.

METHODS

This was a translational study. A descriptive observational study was carried out for convenience of community pharmacy users using a standardized questionnaire. Subsequently, the lethal concentration 50 (LC₅₀) for medicine that is most frequently discarded was determined. After LC_50, the embryos (n = 144) were exposed to sublethal concentrations for most discarded drug at 24, 48, and 72 h. Mortality, heartbeat, and embryo deformities were used as parameters of toxicity.

RESULTS

Most respondents (96%) had a "home pharmacy." The primary forms of disposal were in the common household waste, kitchen sink, and/or bathroom. The medicines that were most incorrectly discarded by the interviewees were nimesulide (17.1%), dipyrone (10.7%), and paracetamol (5.2%). LC₅₀ of nimesulide was calculated (0.92 μgmL^-1). The toxicological test revealed that embryos exposed to nimesulide showed several abnormalities, such as defects in the spinal cord, tail, yolk sac, as well as pericardial edema. Furthermore, the heartbeat decreased by 30% at a concentration of 0.4 μgmL^-1 as compared with control group. The yolk sac and pericardial areas increased to >100% in all treatment groups when compared with the control group.

CONCLUSION

Respondents disposed medicines in an inappropriate manner primarily in household waste and in the toilet. Nimesulide was the most discarded drug according to study population. Moreover, teratogenic effects such as spinal cord defects, decreasing heartbeats, and increasing pericardial and yolk sac area in embryos were observed after exposure to nimesulide. These results show that nimesulide may promote risk to aquatic organisms and to human health if it is discarded in an unsafe manner.

Gram-negative bacteria carrying β-lactamase encoding genes in hospital and urban wastewater in Brazil

Multidrug resistance mediated by β-lactamase in Gram-negative bacilli is a serious public health problem. Sewers are considered reservoirs of multiresistant bacteria due to presence of antibiotics that select them and favor their dissemination. The present study evaluated the antibiotic resistance profile and β-lactamases production in Gram-negative bacilli isolates from hospital sewage and urban wastewater treatment plants (UWWTP) in Brazil. Bacteria were isolated and identified with biochemical tests. Antibiotic susceptibility testing was performed by the disk-diffusion method and detection of extended-spectrum β-lactamase and carbapenemases by enzymatic inhibitor and conventional PCR. Differences in resistance to amoxicillin clavulanic, aztreonam, cefepime, and cefotaxime were observed in hospital sewage compared with urban sewage (p < 0.05). The multidrug-resistant phenotype was observed in 33.3% of hospital sewage isolates (p = 0.0025). β-lactamases genes were found in 35.6% of isolates, with the most frequent being bla_KPC and bla_TEM (17.8%), and bla_SHV and bla_CTX-M (13.3% and 8.9%, respectively). The data obtained are relevant, since the bacteria detected are on the priority pathogens list from the World Health Organization and hospital sewage could be released untreated into the municipal collection system, which may favor the spread of resistance. Changes in hospital sewage discharge practices, as well as additional technologies regarding effluent disinfection in the UWWTP, can prevent the spread of these bacteria into the environment and negative impact on water resources.