Opioid Disposal: Dos and Don’ts
Opioid diversion continues to be a serious problem in the United States, with drug overdoses having tripled since 1990, according to the Centers for Disease Control and Prevention. Fueling the fire are the increased amounts of opioid prescriptions being dispensed by retail pharmacies. The National Institute on Drug Abuse estimates that opioid prescriptions totaled 210 million in 2010, up from 76 million in 1991.
To avoid diversion and misuse of opioids, the US Drug Enforcement Administration (DEA) recommends destroying unused or expired opioids or having patients drop off medications to a DEA-designated drop box or take-back program.
Currently, only a DEA-designated official can receive and dispose of a controlled substance. Take-back programs, such as the DEA’s semi-annual National Prescription Drug Take-Back Day, are the best ways to dispose of old or unused opioids. If a program is not available in your local area, the DEA recommends that patients remove the medications from the original bottles, mix them with something unappealing like coffee grounds or used cat litter, seal them in a disposable container or bag, and throw them in the garbage (see Box below).
However, health care providers often make different recommendations to their patients, and physician practices and recommendations for disposing of opioids can vary widely from state to state. Practical Pain Management recently surveyed our readers to find out what they recommend their patients do with unused or expired opioids.
“I ask my patients to return their unused opioids to either my office or their pharmacy. The receiving office, pharmacy, or hospital should do a witnessed- and documented-counting of the medication. I do not like a drop box, because then I have no confirmation of what the patient returned,” said one reader.
Another reader lauded the use of drop boxes, saying, “In Chicago, the city provides five permanent drop-box locations at district police stations. These permanent drop boxes will accept unused controlled substances.”
Another reader had an entirely different recommendation, saying patients should, “retain the medication in case of a flare up in their pain, and then properly discard after 6 months.”
“Unfortunately, it is illegal for a provider to take back unused medication from a patient,” Keith Humphreys, PhD, a professor of psychiatry at Stanford School of Medicine in Stanford, California, and former senior policy advisor under the Obama Administration at the White House Office of National Drug Control Policy, said in an interview with Practical Pain Management.
Dr. Humphreys emphasized the challenges health care providers are facing. “If you prescribe the patient 30 pills of Vicodin [hydrocodone and acetaminophen] and the patient tells you, ‘This isn’t working for me,’ as a responsible doctor you say, ‘Well, I’ll write you a prescription for another opioid, but I want you to bring back the [unused medication].’ If the patient does that and the doctor accepts it, unfortunately, the doctor is breaking the law. At the moment, only a DEA-designated person can accept an unused prescription. So, that’s a problem in the law. It’s too hard to do the right thing.”
The importance of proper disposal of unused opioids was emphasized by Dr. Humphreys during a presentation of “Public Policy on Prescription Opioids: Are We Trapped Between Scylla and Charybdis?” at the American Academy of Pain Medicine’s (AAPM) Annual Meeting, which was held February 23 to 26, 2012, in Palm Springs, California.
In his presentation, Dr. Humphreys spoke about the epidemic of opioid overdose deaths in the United States, with most instances of misused opioids resulting from leftover medications obtained by family and friends—usually from unlocked medicine cabinets. Dr. Humphreys also debunked another common practice—flushing unused opioids down the toilet—“this can actually damage the water supply.”
Both pharmacists and physicians face similar challenges regarding opioid disposal—neither are allowed to take back unused prescriptions. “Pharmacies are hamstrung by the same rules as physicians. They can’t just take back a handful of Vicodin from a patient,” said Dr. Humphreys, who stressed the importance of new laws being passed to improve drug disposal from a physician and pharmacist standpoint.
“When I was growing up, we had recycling days for separating glass, cans, etc. At the time, it was such a strange concept. Now, we don’t have recycling days anymore, it’s just something you do. New laws are needed. Culturally, medication recycling must become just something you do, and in order for that to happen, you have to make it legal. Why can’t every pharmacy just have a tube going down into a safe to get rid of old medications?”
Take-back days are the best method for disposing of unused opioids. The DEA recently held its fourth National Prescription Drug Take-Back Day on April 28, 2012. During this event, which is organized with law enforcement, patients have the opportunity to anonymously turn in unused, expired, or unwanted medication—no questions asked. A database of participating locations can be found on the DEA Office of Diversion Control’s Web site athttp://www.deadiversion.usdoj.gov/drug_disposal/takeback. The DEA holds this event on a national level every 6 months, but Dr. Humphreys encourages physicians to get involved with local law enforcement throughout the year to organize such events.
“I’m all for the take-back days,” said Dr. Humphreys. “I think it’s a great thing, and I think doctors should talk to the patients about the take-back days. Doctors should be calling their local [law enforcement agencies] saying, ‘Why don’t you do this?’ But, that still leaves the other 364 days of the year. You can’t bring [opioids] back to the pharmacists. You can’t bring [opioids] back to patients’ doctors. And leaving them in the medicine cabinet is actually a bad idea. Most people who are addicted say they get [the opioids] from friends and family. It’s a real problem.”
So, what does it take for a physician to organize a local take-back day? According to Dr. Humphreys, the process is standard procedure and very simple. “You need the DEA to essentially deputize someone to be a legal recipient, which would be law enforcement personnel,” said Dr. Humphreys. “The DEA does this automatically, and it’s not a difficult process. They would designate an appointed sheriff to coordinate the event.”
Prescription-monitoring programs can help physicians keep track of the opioids they prescribe, and may help eliminate diversion. However, those systems can also be flawed. “For pharmacists and physicians, [they should] consistently be using prescription-monitoring programs,” said Dr. Humphreys. “I recognize there are challenges to using them, but to protect yourself and your patients, you really ought to be checking out [your state’s program]. In some cases, the monitoring program is junky. In that case, AAPM and other medical societies should get involved in efforts to get engaged in the development of a good prescription-monitoring program.”