Unused medications: To flush or not to flush?
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Question: I recently decided to clean out my medicine cabinet of old and unused prescription drugs. I did a Google search to find out what do with them. The website of the U.S. Food and Drug Administration says it’s okay to flush some drugs, like opioids, down the toilet. But Health Canada’s website says you should never flush away any drugs because it’s bad for the environment. Who is right?
Answer: The first thing you need to know is that there are places to safely dispose of your medications without dumping them down a drain where they can end up in rivers and lakes and potentially harm aquatic life.
Most pharmacies, in Canada and the United States, will take back drugs, which are then sent to special facilities for disposal. In many cases the drugs are incinerated – eliminating any chance they will end up in the wrong place. Some communities also have other drop-off locations such as police stations.
Unfortunately, most people don’t take advantage of the return programs – at least not in a prompt fashion.
“A lot of medicine cabinets are chock-a-block full of stuff like opioids,” says Dr. Don Redelmeier, a staff physician at Sunnybrook Health Sciences Centre in Toronto.
Indeed, he notes, some physicians overprescribe opioids, especially to patients having operations.
“Surgery hurts, so it’s perfectly logical to prescribe pain killers,” says Redelmeier, who is also a professor at the University of Toronto. “And because doctors don’t want patients to run short, there’s a tendency to send people home from the hospital with far too much narcotics.”
One study found only 41 percent of the dispensed tablets are actually used for post-surgery pain.
This means many homes have a drug stockpile that’s contributing to the “opioid epidemic” – the alarming rise in addiction and overdoses across North America.
Redelmeier says people sometimes inappropriately use their opioid stash when they have minor pain long after their operations – potentially starting them down the road to drug dependency. Other family members, or visitors, may steal the drugs for recreational purposes, he adds.
To reduce the risk of drug misuse and abuse, the U.S. FDA says it’s important to get rid of certain drugs – especially opioids such as fentanyl and oxycodone – as soon as they’re no longer medically needed. Although medicine take-back programs are still the FDA’s preferred disposal method, the U.S. government agency says opioids can also be put down a drain.
“We believe the known risks of harm and even death to humans from accidental exposure to certain potent opioids…far outweighs any potential risk to humans or the environment from flushing,” says FDA spokesperson Sarah Peddicord.
In Canada, however, authorities have adopted a different approach. They put the emphasis on the medication-return programs and advise against dumping any drugs down drains. (If no nearby return program exists, the meds should be mixed with used coffee grounds or kitty litter and placed in the trash.)
The Canadian recommendations arise from growing concerns about the effects of pharmaceutical products on aquatic life. Medications literally pass through patients, ending up in their urine and feces. Many waste treatment plants can’t remove the drugs before the water is released back into the environment, Health Canada spokesperson Anna Maddison said in an email. Deliberately dumping drugs down the drain only makes this problem worse.
Overall, the concentration of pharmaceuticals in surface water is extremely diluted. Even so, “chronic low levels of exposure can have negative impacts,” Maddison says.
For instance, studies show that birth-control hormones in rivers and lakes can disrupt fish reproduction, leading to “intersex” offspring with both male and female characteristics.
Other research suggests antidepressants in waterways can alter fish behaviour, making them less likely to swim together in schools and thereby lowering their chances of survival.
Not much is known about the possible impact of opioids on wildlife, says Chris Metcalfe, a professor in the School of the Environment at Trent University in Peterborough, Ont. The fact is that little research has been done in this area, he says.
About 10 to 20 percent of the pharmaceutical products passing through sewage-treatment plants come from drugs dumped directly down drains, Metcalfe says, pointing to U.S. research. The other 80 to 90 percent is in excreted human waste.
Metcalfe applauds Health Canada’s efforts to discourage drain disposal. “Whatever we can do to reduce the discharge of pharmaceuticals into the sewage system is a good thing.”
Not everyone in Canada agrees. “A strong case can be made to flush drugs. It’s fast, easy and irreversible,” says Dr. David Juurlink, a drug safety expert and head of Clinical Pharmacology and Toxicology at Sunnybrook.
A recent study co-authored by Juurlink, revealed that young children are much more likely to suffer an accidental overdose when opioids have been prescribed to their mothers. “For some opioids, a single tablet is enough to kill a child,” he warns.
Of course, to flush or not to flush wouldn’t be an issue if people returned their leftover drugs to pharmacies right away. But maybe that’s too much to expect from human nature. After all, many of us are procrastinators. And it’s awfully hard to let go of something that’s still perfectly useable.
That’s why Juurlink argues drug disposal should be made as easy as possible. Redelmeier feels the same way.
“You can stand over your toilet and flush those narcotics away. That is less of a hassle than standing in a line at a pharmacy,” says Redelmeier.
Still, if the environment is one of your top concerns, then a timely trip to your local drug store may be worth the extra effort.
Sunnybrook’s Patient Navigation Advisor provides advice and answers questions from patients and their families. His blog, Personal Health Navigator, is reprinted on Healthy Debate with the kind permission of Sunnybrook Health Sciences Centre. Follow Paul on Twitter @epaultaylor.