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

Medication reuse programs: a narrative review of the literature

A proportion of returned medications may potentially meet quality standards to be reused safely. In Australia, there is no regulatory guidance available to facilitate such medication reuse. This narrative review aimed to identify and review international literature describing medication reuse programs to provide insight into their implementation and potential barriers. Using the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) -based guidelines, a literature search was conducted in Medline, Scopus, and Embase using key words such as 'medication' and 'reuse' to identify relevant articles. Two reviewers ascertained eligibility for inclusion. Inclusion criteria included English language and publication after 2010. From the articles selected, identified international medication reuse programs and relevant regulatory aspects were summarized. Details, both regulatory and operational, for the specific medication reuse programs, described in the selected articles was further explored via a grey literature search. Of the 1973 identified articles, 84 were assessed for eligibility and 17 were included in this review. Of these, 14 described scenarios where medication reuse is prohibited, 2 studies described programs allowing the reuse of medication and 1 study did not discuss whether reuse was prohibited or not. From these primary articles, secondary citations were identified, with eight from gray literature. Barriers to medication reuse included exposure to environmental extremes during storage, physical appearance, evidence of tampering, safety, and efficacy concerns for the returned medication. Programs that exist globally have overcome these barriers. Several programs that provide safe and effective reuse of medications were i© The Author(s) 2024. Published by Oxford University Press on behalf of International Society for Quality in Health Care. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site-for further information please contact journals.permissions@oup.com.dentified and described. The findings described in this review should be used to inform frameworks for legislative, regulatory, and professional practice change for medication reuse. Measures implemented in the UK's pandemic response to safely reuse medications in the nursing home and hospice settings and European medication donation programs should be further investigated. The concept of medication reuse is not novel and should be considered for the Australian setting.

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.

Highly Efficient and Wide Range Humidity Response of Biocompatible Egg White Thin Film

Biopolymers are a solution to solve the increasing problems caused by the advances and revolution in the electronic industry owing to the use of hazardous chemicals. In this work, we have used egg white (EW) as the low-cost functional layer of a biocompatible humidity sensor and deposited it on gold (Au) interdigitated electrodes (IDEs) patterned through the state-of-the-art fabrication technology of thermal vacuum evaporation. The presence of hydrophilic proteins inside the thin film of EW makes it an attractive candidate for sensing humidity. Usually, the dependence of the percentage of relative humidity (%RH) on the reliability of measurement setup is overlooked for impedimetric humidity sensors but we have used a modified experimental setup to enhance the uniformity of the obtained results. The characteristics of our device include almost linear response with a quick response time (1.2 s) and fast recovery time (1.7 s). High sensitivity of 50 kΩ/%RH was achieved in the desirable detection range of 10–85%RH. The device size was intentionally kept small for its potential integration in a marketable chip. Results for the response of our fabricated sensor for dry and wet fingertips, along with determining the rate of breathing through the mouth, are part of this study, making it a potential device for health monitoring.

Medicines as Common Commodities or Powerful Potions? What Makes Medicines Reusable in People's Eyes

BACKGROUND

Medicines reuse involves dispensing quality-checked, unused medication returned by one patient for another, instead of disposal as waste. This is prohibited in UK community pharmacy because storage conditions in a patient's home could potentially impact on the quality, safety and efficacy of returned medicines. Our 2017 survey examining patients' intentions to reuse medicines found many favoured medicines reuse. Our aim was to analyse the qualitative comments to explore people's interpretations of what makes medicines (non-)reusable.

METHODS

Thematic analysis was used to scrutinize 210 valid qualitative responses to the survey to delineate the themes and super-ordinate categories.

RESULTS

Two categories were "medicines as common commodities" versus "medicines as powerful potions". People's ideas about medicines aligned closely with other common commodities, exchanged from manufacturers to consumers, with many seeing medicines as commercial goods with economic value sanctioning their reuse. Fewer of the comments aligned with the biomedical notion of medicines as powerful potions, regulated and with legal and ethical boundaries limiting their (re)use.

CONCLUSION

People's pro-medicines-reuse beliefs align with perceptions of medicines as common commodities. This helps explain why patients returning their medicines to community pharmacies want these to be recycled. It could also explain why governments permit medicines reuse in emergencies.

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.

The Validity of the Theory of Planned Behaviour for Understanding People's Beliefs and Intentions toward Reusing Medicines

Background: many factors can impact a person’s behaviour. When the behaviour is subject to prediction, these factors can include, for example, the perceived advantages and disadvantages of performing the behaviour, normative beliefs, and whether the behaviour is thought to be achievable. This paper examines intentions to engage in medicines reuse, i.e., to accept medicines that are returned unused to a pharmacy to be reused. The paper aims to outline the validity of the Theory of Planned Behaviour (TPB) for understanding people’s intentions to engage in medicines reuse by examining this against other long-standing health-related psychological theories of behavioural change. Thus, the Health Belief Model (HBM), Protection Motivation Theory (PMT), Trans-Theoretical Model of Health Behaviour Change (TTM/SoC), Theory of Reasoned Action (TRA), and TPB are examined for their application in the study of medicines reuse. Discussion: the HBM, PMT, TTM/SoC, TRA, and TPB were assessed for their relevance to examining medicines reuse as a behaviour. The validity of the TPB was justified for the development of a Medication Reuse Questionnaire (MRQ) to explore people’s beliefs and intention toward reusing medicines. Conclusion: TPB has been widely used inside and outside of health-related research and it was found to have more accurately defined constructs, making it helpful in studying medicines reuse behaviour.

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.

Can We Create a Circular Pharmaceutical Supply Chain (CPSC) to Reduce Medicines Waste?

BACKGROUND

The increase in pharmaceutical waste medicines is a global phenomenon and financial burden. The Circular Economy, as a philosophy within the pharmaceutical supply chain, aims to promote waste reduction, maximise medicines value, and enable sustainability within this supply chain (increasing circularity). Circularity strategies for pharmaceuticals are not currently implemented in many countries, due to quality and safety barriers. The aim of this study was to determine whether the application of circular economy principles can minimise pharmaceutical waste and support sustainability in the pharmaceutical supply chain; Methods: a detailed narrative literature review was conducted in order to examine pharmaceutical waste creation, management, disposal, and the application of circular economy principles; Results: the literature scrutinised revealed that pharmaceutical waste is created by multiple routes, each of which need to be addressed by pharmacists and healthcare bodies through the Circular Economy 9R principles. These principles act as a binding mechanism for disparate waste management initiatives. Medicines, or elements of a pharmaceutical product, can be better managed to reduce waste, cost, and reduce negative environmental impacts through unsafe disposal.

CONCLUSIONS

the study findings outline a Circular Pharmaceutical Supply Chain and suggests that it should be considered and tested as a sustainable supply chain proposition.

Household storage of pharmaceutical products in Saudi Arabia; A call for utilising smart packaging solutions

BACKGROUND

Limited information is known about the storage conditions of medicinal products post-dispensing in Saudi Arabia (SA). The particularly hot and humid climate in the region may lead to the loss of essential performance specifications.

OBJECTIVE

To investigate the conditions in which medications are held after being dispensed, and up until administration by households in SA. In addition, storage practices adopted by households in the region, as well as their knowledge and awareness are explored. This study also discusses the opportunity of utilising Time-Temperature Indicators (TTIs) in the pharmaceutical industry in SA as a quality-assurance enhancement solution.

METHODS

A cross-sectional questionnaire targeted at households in SA was designed to explore storage practices, background knowledge and awareness of factors that can influence drug stability. Additionally, temperature and relative humidity mapping of 35 different rooms in various homes and cities in SA, as well as car interiors, was performed.

RESULTS

More than 1000 households have participated in this study from all regions of SA. Approximately, 95% have claimed to take part in storing medications at home. First-aid and supplemental purposes were two of the reasons 80.9% have claimed, while 43.2% claimed treatment for chronic conditions. Just over 35% claimed that not knowing how to dispose of medications, is the reason behind their storage. More than 35% of participants could not identify most suitable storage conditions, and >10% were unaware of the effect storage conditions may have on shelf-life. Many were found to store medication in inappropriate areas, liquid dosage forms for example were stored in freezers by more than 3%. Upon monitoring temperatures of all room types, 25ºC was exceeded throughout a 24-hour duration in bathrooms, kitchens and limited use rooms. Temperatures in parked car interiors exceeded 70ºC.

CONCLUSIONS

A significant percentage of households in SA lacked knowledge and awareness of good storage practices. However, due to high temperatures observed in the region, increasing knowledge and awareness is not enough, as medicinal cabinets with basic temperature control (e.g. designated secure fridge) are needed. Additionally, the use of TTIs to provide consumers with accumulated thermal history may enhance quality-assurance of thermally sensitive products.