Develop a safer, better process for handling pharmaceutical waste

Dumping drugs down drain no longer advisable

As the world has focused on millions of gallons of oil spilling into the ocean from the BP off-shore drilling disaster, another waterway issue is beginning to impact how hospitals and nursing homes handle pharmaceutical waste.

New York Attorney General Andrew M. Cuomo recently targeted two hospitals and three nursing homes in an effort to stop their standard practice of flushing painkillers, hormones, antidepressants, and other drugs down sinks and toilets. Cuomo's office reached a settlement by which the institutions agreed to stop disposing of the pharmaceutical waste in the sewage system, and they also will pay penalties for their violations of hazardous waste rules.

While this might be the first time a state has taken such an action against hospitals, it also could be the beginning of a trend since hospitals and nursing homes dispose of an estimated 250 million pounds of drugs each year, according to a 2008 report by the Associated Press.

The solution is for hospital pharmacies to take the lead on developing pharmacy waste solutions and processes that will meet all current regulations and anticipate stricter future rules.

"A consensus is developing that we should stop deliberately putting drugs in sewer systems or in anybody's water," says Charlotte A. Smith, RPh, MS, director of PharmEcology Services, WM Healthcare Solutions Inc., Houston, TX.

Hospitals should make this a priority since it's received national media attention, particularly with the New York Office of the Attorney General's efforts to enforce appropriate disposal of pharmaceutical waste by health care facilities' under the Resource Conservation & Recovery Act (RCRA) of 1976.

"I think the whole point is concern about slowing down this process of disposing of pharmaceuticals in the sewer system," Smith adds. "We need to find another way of managing these pharmaceuticals."

Smith offers these guidelines on how to establish and improve a hospital's pharmaceutical waste disposal process:

1. Pharmacy should take the lead.

Hospital pharmacy directors should become project champions of revising the hospital's pharmaceutical waste practices, Smith suggests.

After obtaining commitment from hospital leaders, pharmacy directors should form a working committee that includes nursing, environmental services, facilities management, infection control, and other departments.

The committee's goals would be to obtain information about vendors who could assist with pharmaceutical waste disposal, as well as to assess the hospital's current practices.

Committee members also could devise a budget that includes the costs of consulting services, containment measures, transportation, and treatment of waste.

2. Know the drugs in your inventory and their disposal requirements.

Pharmacists and the committee will need to review the pharmaceuticals and chemicals used, dividing them into lists, Smith says.

The two primary lists are the "P" list and "U" list. They contain chemicals the federal government has defined as hazardous waste. This list does not include every pharmaceutical that could be considered hazardous waste because the list itself was devised more than 30 years ago and has not been updated, she notes.

"Any pharmacist can do this, but it's time-consuming," she adds. "The hard part is determining which drugs meet the characteristics of hazardous waste, which are in addition to the listed drugs."

P list drugs are acutely hazardous and have an oral LD50 of 50 mg/kg or less, meaning it takes just this small a dose to kill half of the laboratory animals that consume them.

Here are some examples of P-listed pharmaceutical waste:

- Arsenic trioxide (chemo) P012;

- Epinephrine base P042;

- Nicotine P075;

- Phentermine (CIV) P046;

- Physostigmine P204;

- Physostigmine Salicylate P188;

- Warfarin > 0.3% P001.

Here are some examples of U-listed pharmaceutical waste:

- Chloral Hydrate (CIV) U034;

- Streptozotocin U206;

- Chlorambucil U035;

- Cyclophosphamide U058;

- Lindane U129;

- Daunomycin U059;

- Selenium Sulfide U205;

- Diethylstilbestrol

- Melphalan U150;

- Uracil Mustard U237;

- Warfarin < 0.3% U248;

- Mitomycin C U010.

There are also four characteristics of hazardous waste that need to be considered, including ignitability, corrosivity, toxicity, and reactivity.

For example, waste with the characteristic of ignitability includes aqueous solutions containing 24% or more alcohol. Also, there are 40 chemicals which must be below specific leaching concentrations and must pass the Toxicity Characteristic Leaching Procedure.

A pharmaceutical waste disposal committee also needs to define chemotherapy waste according to whether it's trace chemotherapy, including empty vials, syringes, IVs, gowns, gloves, Zip-lock bags, etc., or bulk chemotherapy waste.

3. Assess disposal options.

Hospitals need to contract with a hazardous waste broker, who should provide expertise for waste profiling, manifest preparation, and land ban preparation when disposing of RCRA hazardous waste, Smith says.

"In addition to properly disposing of RCRA hazardous waste at a permitted facility, the hospital needs to decide whether to incinerate all drugs," she says. "Both regulated medical waste incinerators and municipal waste-to-energy facilities may be permitted to accept non-hazardous drug waste."

"These are considered a green technology because they utilize waste to produce electricity," Smith says. "This is an alternative to putting the drugs down the drain."

"Bulk" chemotherapy waste should be placed in a RCRA hazardous waste container, along with chemotherapy spill clean-up waste.

4. Address labeling and staff education.

"We recommend you label the products that will go into the hazardous waste stream and train people to put everything else in the nonhazardous disposal category," Smith says. "You can label these with shelf stickers in the pharmacy."

In the nursing unit, there are different ways of handling the labeling. For example, if the hospital has an electronic medication administration record (eMAR), then it might be possible to put in automatic messages that will assist with waste labeling, she notes.

The eMAR system can have a pop-up box that instructs nurses that the product is a federal hazardous waste that should be disposed of in a particular manner.

"Some hospitals have black dots they use as labels or they put these labels on Zip-lock bags," she adds. "They train nurses that if they see this label or message then they need to put the product in the black container, or if there is not a black dot then they put it in the white container."

One labeling strategy that doesn't work is having a list, Smith says.

"Lists are too difficult to follow, and there are too many drugs involved, so these need to be labeled at the drug level," she says.

5. Improve inventory management.

As increasing numbers of hospitals move away from the drain disposal of pharmaceutical waste, they'll need to find ways to reduce their disposal costs. One smart strategy is to create better inventory management systems.

"Good inventory management reduces the number of drugs that become outdated," Smith says. "When a drug becomes outdated, you first consider that for reverse distribution."

Smith previously owned a reverse distribution company that served as a clearinghouse for outdated drugs. This type of company inventories the drugs and sends them to drug manufactures for product return credit.

There are other strategies hospital pharmacies can employ to reduce pharmaceutical waste. One of these is to create dosing sizes that more closely correspond to what patients use, thereby eliminating leftover product that must be discarded.

Sometimes a solution would be to give manufacturers data and feedback that the hospital needs 1 mL ampules instead of 2 mL ampules or a 5 mg tablet instead of a 10 mg tablet, she adds.

"The unused ointment or the partial inhaler that remains when a patient is discharged are difficult to get relabeled for in-home use," Smith says. "So there's a lot of waste in the hospital that essentially is part of the process, and that's not related to tight inventory control."