Given the current dangers of the opioid epidemic, this author discusses points that clinicians can share with their patients about safe disposal of opioid prescription medication.
The opioid epidemic is a national public health emergency that requires a comprehensive approach. Proper and timely disposal of unused prescription opioids is one method to deter improper use of these medications and prevent overdose. The U.S. Food and Drug Administration (FDA) has identified safe storage and proper disposal of prescription opioid products as essential steps to address opioid misuse and abuse.1
Providers play a prominent role in minimizing opioid misuse. Cautious prescribing habits with limits enforced on the quantity of opioids prescribed, close follow-up and consistent and frequent provision of opioid education are musts. Evidence points to the powerful positive impact of patient education in promoting safety around opioid use.2 Most people who misuse prescription opioids obtain them from family or friends. Storing opioids in the open or not disposing of unused opioids increases the availability of these opioids for misuse by others.2
What The Literature Reveals About Opioid Diversion And Disposal
To better understand patient reasoning for keeping unused opioid pills, Neill and colleagues found 100 patients of those asked planned to dispose of their pills while 117 planned to keep them. The study authors noted no differences in demographics between the groups. Among patients who planned to keep their pills, the mean age was 43 years and 47 percent were male. The analysis by Neill and coworkers revealed four categories of patient responses:
• those who planned to keep the medications "just in case" with reference to a medical condition;
• patients who planned to keep the pills without referring to a medical condition;
• patients who planned to dispose of the pills after the expiration date or were unsure how to dispose of the medication; and
• those who had no defined plans but expressed an intent to keep the medication.3
Using a LexisNexis search, McNamara and team analyzed 263 U.S. newspaper articles (published between January 1, 2014, and June 30, 2017) that contained information on opioids and take-back programs.4 Take-back programs were presented as a recommended disposal strategy for unused prescription opioids in 88.6 percent of the articles. Toilet disposal was presented as a recommended disposal strategy for unused prescription opioids in 3.4 percent of articles and as harmful to the environment in 16.0 percent of articles. Individuals from health care, government and law enforcement were primarily involved in discussing opioid disposal practices.4 Although toilet disposal is recommended by the FDA for disposal of unused prescription opioids when a take-back program is not readily available, it was infrequently presented or recommended in news media articles.4
In a cross-sectional survey of members and fellows of the American College of Obstetricians on the topic of opioid misuse, Madsen and colleagues reported that 81 percent of those surveyed incorrectly identified the main source of diversion (from friends or family members) and 44 percent did not know how to properly dispose of unused prescribed opioid.5
Of the four billion prescriptions filled in the United States every year, one-third of them go unused accounting for 200 million pounds of unused medications.6 Podiatric physicians need to realize the importance of conveying to patients to not share, always lock up and dispose of unused and expired opioids. Clinicians must highlight these points as part of the opioid education they deliver every time they prescribe opioids. Further, podiatric clinicians should share information centered around local drug take-back programs and disposal options.2
Reviewing The Options For Opioid Medication Disposal With Patients
Flushing or dumping opioids down a drain or toilet is not the best way to dispose of this type of medication. Sewage treatment systems cannot remove all the medications from the water released into lakes, rivers or oceans.7 Pharmaceuticals have been detected in the environment and there is genuine concern that this could be causing impacts to human health or to aquatic organisms. A vast array of pharmaceuticals including antibiotics, anticonvulsants, mood stabilizers and sex hormones have been found in the drinking water supplies of at least 41 million Americans.6
The following are the options that one may recommend to patients who are given opioid prescriptions.
Medication take-back programs allow the public to bring unused drugs to a central location for proper disposal. Patients should be instructed to call their local government’s trash and recycling service to see if a program is available.
In addition, the Drug Enforcement Administration (DEA) allows patients to mail back unused prescription medications to pharmacies and other authorized sites using packages available at pharmacies and other locations. Most states have agency collection boxes that are overseen by law enforcement or pharmacies. Podiatric clinicians can give patients the DEA’s Registration Call Center phone number to find box locations or other disposal sites (800–882–9539 or https://nabp.pharmacy/initiatives/awarxe/drug-disposal-locator/ or www.deadiversion.usdoj.gov/drug_disposal/index.html ). Lastly, community coalitions and law enforcement may sponsor “medication take-back events” periodically.8
If these programs are not available in a patient’s residential area, patients may place the drugs in the trash by following these steps:
• Remove them from their original containers and conceal or remove any personal information, including the prescription number, from the container.
• Mix the medications with something inedible, such as coffee grounds or kitty litter.
• Place the empty container and the mixture in a sealed bag or empty can.8
The following are resources/websites that the podiatric physician or staff may give patients who receive opioid prescriptions:
- Environmental Protection Agency: How to Dispose of Medicines Properly. go.usa.gov/xNwXc
- Disposal of Unused Medicines: What You Should Know. go.usa.gov/xNw9z
- Where and How to Dispose of Unused Medicines. go.usa.gov/xNw9S
There are multiple ways to reduce opioid abuse that are strongly supported by healthcare providers, patients, policymakers and other key stakeholders. These include educational endeavors centered on the risks of prescription opioids and other medications if not taken as prescribed, as well as steps to ensure safe storage and disposal of expired, unwanted or unused medications. Podiatric clinicians should remind patients that medications should be stored out of reach of children, and in a safe place, preferably locked, to prevent other family members and visitors from taking them.
Finally, patients should be empowered by podiatric physicians with information centered on the preferred options to dispose of unwanted or unused opioid pills, medicated liquids or other medications by utilizing a local take-back or mail-back program, or medication drop box at a police station, DEA-authorized collection site or pharmacy if the pharmacy has a secure drop-box program.
Dr. Smith currently works as a Clinical Pharmacist at Select Medical Hospital in Daytona Beach, Fla. He is in private practice in Ormond Beach, Fla. Dr. Smith was deployed to Iraq as a member of a medical team to create, establish and operate an inpatient and outpatient pharmacy for military and civilians from 2013 to 2016, and continues to consult for multiple government agencies.
- Bonnie RJ, Ford MA, Phillips JK. Pain management and the opioid epidemic: balancing societal and individual benefits and risks of prescription opioid use. National Academies of Sciences, Engineering and Medicine. Available at: http://nationalacademies.org/hmd/Reports/2017/pain-management-and-the-opioid-epidemic.aspx. Published July 13, 2017. Accessed September 13, 2019.
- Reddy A, de la Cruz M. Safe opioid use, storage, and disposal strategies in cancer pain management. Oncologist. 2019. doi: 10.1634/theoncologist.2019-0242. Accessed September 26, 2019.
- Neill LA, Kim HS, Cameron KA, et al. Who is keeping their unused opioids and why? Pain Med. 2019. doi: 10.1093/pm/pnz025. Accessed September 26, 2019.
- Petrik ML, McNamara PJ, Moeschler SM, Blair BD. Communication of recommendations for the disposal of unused prescription opioid medications by stakeholders in the news media. Pain Med. 2019. doi: 10.1093/pm/pnz104. Accessed September 26, 2019.
- Madsen AM, Stark LM, Has P, Emerson JB, Schulkin J, Matteson KA. Opioid knowledge and prescribing practice among obstetrician-gynecologists. Obstet Gynecol. 2018;131(1):150–157.
- You and the environment. Dispose My Meds. Available at: http://disposemymeds.org/environmental-impact/Accessed September 26, 2019.
- Pharmaceuticals, hormones, and other organic wastewater contaminants in U.S. streams. United States Geological Survey. Available at: http://toxics.usgs.gov/pubs/FS-027-02/pdf/FS-027-02.pdf. Published June 2002. Accessed September 26, 2019.
- How to safely dispose of drugs. Health and Human Services. Available at: https://www.hhs.gov/opioids/prevention/safely-dispose-drugs/index.html Updated February 25, 2019. Accessed September 26, 2019.