We in Niagara County, NY, are currently working on a Pharmaceutical Waste Collection Program because, in part, an Associated Press article in the spring of 2008 reported on a five month inquiry into the drinking water of 62 metropolitan areas and 51 smaller cities. They found that the drinking water of at least 24 American cities contains trace amounts of a wide array of pharmaceuticals and their by-products. These include antibiotics, heart medications, psychiatric drugs, hormones such as those in birth control pills, and others.

Municipal drinking water supplies are extensively regulated by the US Environmental Protection Agency (EPA), which sets limits on certain contaminates, but there are no federal regulations handed down that include pharmaceuticals. The 24 cities that detected pharmaceuticals through voluntary testing efforts are under no obligation to report them, or treat for them. About half the utilities surveyed do not normally test for pharmaceuticals.

Environmentalists have been watching the feminization of fish increase and hypothesize the presence of hormones flushed into watersheds as a possible explanation.

According to research done by the Kaiser Family Foundation in 2006, the average number of prescriptions for each person increased from 7.9 in 1994 to 12.5 in 2005. Many older or chronically ill Americans have many more. Often, after the death of a parent or loved one, surviving family members are left with large amounts of powerful and potentially dangerous narcotics. Accidental overdose or the misuse of prescription medications has become a significant problem. Prescription narcotic abuse has become epidemic among adolescents. The source of those medications is typically their parents’ bathroom cabinets.

On June 7, 2008, the City of Rochester Water Bureau had a goal to collect 10,000 pills for the EPA Great Lakes 2008 Earth Day Challenge. The event was an overwhelming success with 80,000 pills being collected. When combined with the 46,000 pills collected at a previous event, the final result is that the Rochester area collected 126,000 pills! That is 126,000 pills that have been kept out of the hands of adolescents and out of our ground water, drinking water and soil.

It is my hope that you will print this letter to encourage public officials to hold pharmaceutical waste collections.

DEAR READER:
Shortly after I printed that article, I received a truckload of letters telling me my error, some polite, others more harsh. When I received your letter, I was very impressed with the information you provided. Not only were you polite and informative, you also provided me with an opportunity to promote an excellent program. Your county appears to have done an amazing job collecting over 125,000 unused or outdated pills.

I have printed your letter in its entirety in the hopes that others counties and states around the country will use your program as an example. It not only keeps pills out of the soil and water, it also, as you pointed out, keeps them out of the hands of our youth. Thank you for writing.

Your conclusion that it was not working was incorrect. Finding the pill in the stool is perfectly normal. Allegra-D is an extended-release product. It works like a little pump as it passes through the GI tract, slowly releasing the medications contained therein over a certain time period. The spent carcass of the dosage form is expelled upon defecation which is why the tablet must be swallowed whole, not crushed or chewed. Many controlled-release/extended-release/time-release tablets and even some capsules (usually, but not always designated CR, SR, XL, ER, LA, etc.) are formulated to perform quite normally in this manner. Pharmacists have been dealing with this patient concern for many years.

Rarely, there have been cases of “perpetual pills” (tablets that should have dispersed in the gut but didn’t and passed into the stool) often because of poor manufacturing or adulteration, but the products are always recalled when discovered.

I hope that you can correct the information in your column.

DEAR READER:
On occasion I goof. However, I am not entirely sure I did in this instance.

According to the 2008 Physician’s Desk Reference (PDR) “Patients should be told that the inactive ingredients may occasionally be eliminated in the feces in a form that may resemble the original tablet.” I would like to point out that this specifically says “MAY OCCASIONALLY…” and “MAY RESEMBLE…”. This suggests to me that the vast majority of time, pills will not be found in the feces.

The individual who wrote claimed that she found whole pills after nearly every bowel movement, not occasionally. Her husband also found the pills in the septic tank during its yearly cleaning. That would mean that at least some of these pills are not dissolving properly, even after up to one year in urine, feces, and anything else that makes its way into the tank. Or perhaps you are correct that these may be “ghost” pills that are left after digestion and the medication has been released.

I am human; I make mistakes and when I do, I make every effort to correct them. I will do the same for this situation. If I am incorrect that her frequent passing of Allegra-D pills is abnormal, I apologize. However, given the information in the PDR and the claims of the individual, I feel that she may not be properly absorbing and benefiting from the medication.

Thank you for writing. I hope there are many more pharmacists as concerned, considerate and knowledgeable as you, helping to care for the community.

Readers who would like related information, can order my Health Report “Consumer Tips on Medicine”. It can be ordered by sending a self-addressed, stamped number 10 envelope and $2 to Newsletter, PO Box 167, Wickliffe, OH 44092. Be sure to mention the title.

DEAR READER:
Since my article appeared in late May, I have received several letters on the subject. While some were not as strong as yours, I have chosen to address the subject again with the hope I can redeem myself.

Unused over-the-counter and prescription medications can be found in almost every household, nursing home and hospital in the country.
In the past, discarded pharmaceuticals were commonly flushed away. Out of sight, out of mind. Since those days, studies have revealed that over-the-counter and prescription drugs may have a harmful effect on water supplies and soil. The trace levels are extremely low, but do exist. The major concern is the possibility of drugs ending up in drinking water sources.

To confuse the issue and to my reporting credit, the Office of National Drug Control Policy (www.WhiteHouseDrugPolicy.com) advises that more than a dozen drugs, including oxycontin and morphine, be flushed and gives other approved disposal methods.

There are several organizations that recycle drugs. Such organizations generally use leftover drugs prescribed to American HIV patients for HIV sufferers in other countries. The expensive retroviral medications are collected after patients in the United States switch prescriptions, stop the medication or die. They are then passed onto individuals throughout foreign countries. The organizations enlist the help of a physician, clinic or hospital who collects and ships the medicine to the programs. Laws in the United States don’t allow redistribution of any medications in this country but there is no prohibition when exporting to other countries.

Data provided from the FDA Shelf Life Extension Program reveals that almost 100 different drugs stored in their unopened original containers would remain stable for almost five years following their expiration date. One very expensive antibiotic was tested and found to be safe and effective nine and a half years after the expiration date listed. Two other medications were found to be effective after 25 years and retained antiviral activity after boiling and being held at 149-185 degrees Fahrenheit for several days. Medical Letter journal consultants believe most drugs — even those opened and stored under reasonable conditions, retain up to 80% of their potency for up to two years after the expiration date. Despite this evidence, most manufacturers urge disposal of “expired” medications. However, they can be a great benefit to recycling programs.

Many states have a hazardous waste collection program that can properly dispose of medications. Check with your local pharmacy or hospital, or even your state offices to determine if they have a program in place to aid in the disposal of unwanted medications.

DEAR READER:
A short time ago I responded to a reader who indicated she was reluctant to dispose of empty prescription bottles in the garbage because of all the personal information contained on the label. I suggested she use a magic marker to cover the information, or soak the bottles in warm to hot water for ease of removal of the label. Since that article appeared, I have received several letters from readers with varying thoughts I will share with you.

A blow dryer applied to labels for a few seconds will provide instant removal of the label.

Place the empty bottle in a container of water and heat it in the microwave for one or two minutes for removal of the label.

Use a single-edge razor blade to scrape labels off, taking extra care to make sure your hand doesn’t slip and cause any cut fingers.

Ask your local pharmacy staff if they have a means of shredding and disposing of old prescription bottles. Many have the capability, and they will dispose of unused medications, too. This suggestion sounds great to me as it guarantees your privacy and helps with recycling at the same time.

Out-dated medications can easily be discarded by flushing down the toilet. Birth control pills are also excellent plant fertilizers (one pill every two or four weeks).
Readers, thank you for your ideas.

DEAR READER:
For millions of people, generic drugs are as effective as brand-name versions. But not always.

In general, the difference between generic and name brand medications is very minimal. They have the same amounts of active ingredients and usually have similar inactive ingredients. However, for a few individuals, these minute alterations can make the difference between an effective treatment and an ineffective one. Many times the more costly name brand version can be avoided by simply taking a slightly higher dose of the generic.

If your generic product is not doing the job despite fine tuning, talk to your doctor about a trial with the name brand product.