John Schieszer

Novel computer technologies for improving medication adherence and safety have ushered in a new era of medication reminder and tracking apps, smart
pill canisters, and medications with nanosized biosensors contained within. Although these technologies represent new treatment paradigms for a variety of diseases, they could have unintended implications.

Antipsychotics—available as oral disintegrating tablets, oral solutions, short-acting intramuscular injections, and long-acting injectable formulations—are now being combined with wireless technology. Tahir Rahman, MD, an associ- ate professor of psychiatry at Washington University School of Medicine in St Louis, Missouri, explained how one approach includes a patch worn on the abdomen to track and record medication adherence. A related smartphone app tracks medication ingestion and activity level data, as well as self-reported mood and other factors.

“I see trackable pills playing an important role in the future. People who are adherent with care don’t really need them, but there are always medications that are difficult to adhere to,” Rahman told 

 These medications include those that require dosing 3 or 4 times a day. “That is where some apps can be helpful to increase adherence.”

With wireless technologies, patients can share their collected data with others, including their health care pro- vider. Aripiprazole tablets with sensors and other similar products are being touted as electronic drugs, nanodrugs, or digital drugs, Rahman explained.

A recently published review on emerg- ing smart technology innovations in the health care sector suggests vari- ous advanced technologies and methods may now significantly improve medication adherence.

 Two significant advances have been the ability to measure medication adherence and safety issues with medication event monitoring systems (MEMS) and smart blister packs containing radio frequency identification technology.

MEMS is a “customizable medication package” capable of recording and storing 4000 dosing events, according to a review published in the 

 Microcircuits record each date and time when the packaging is opened on either the SmartCap or TrackCap product.

The ID-Cap System—another smart medication adherence tool, manufactured by etectRx—includes an ingestible sensor that provides real- time dose-level ingestion event verifcation. According to Eric Buffkin, etectRx president and CEO, the ID-Cap System is currently the only FDA-cleared method to document a dosing event, going beyond reminders and self-reporting. “In addition to the ease of patient use, the ID-Cap System’s real strengths are in the verification of ingestion and thorough reporting and tracking of adherence,” Buffkin said.

In this new era of applied technology, partnerships between pharmacists and software developers are becoming more commonplace in order to maximize medication outcomes and improve overall safety. Pharmacists, Buffkin said, are uniquely positioned to leverage this technology to improve medication safety.“As medications increase in expense and complexity, pharmacists can provide even more value [by] ensuring medications are taken as prescribed, and etectRx would welcome the opportunity to partner with pharmacy further on this initiative,” he added.

Augmented Intelligence and Personalized Medicine

The current technological revolution is paving the way for health care providers to make the move from reac- tive disease management to a predictive and personalized approach. “I think we are in an era of digital health, where we can use wearables, telehealth, digital therapeutics, and health information technology [HIT] to improve medication safety,” said Sandra L. Kane-Gill, PharmD, MSc, a critical care medication safety officer in the Department of Pharmacy at the University of Pittsburgh Medical Center in Pennsylvania.

Kane-Gill refers to this technology as augmented—not artificial—intelligence. The volume of data health care professionals can access for a single patient continues to increase, and augmented intelligence can quickly digest that information in an organized manner.

“Augmented intelligence [is the preferred term] because we are designing [HIT] to support health care professionals’ decisions,” Kane-Gill said.“The [biggest] advantage to aug- mented intelligence is the support it provides by managing large amounts of data with a streamlined process, typically [faster] than humans.”

It may be possible to lower morbidity and mortality across a variety of conditions by using validated aug- mented intelligence algorithms. Rahman believes machine learning will allow providers to spot medication safety issues much earlier than is currently possible.“Machine learning is the future. We can use big databases, and we will know which patients do better on certain drugs,” Rahman said.

Kane-Gill and her team are working to develop machine learning algorithms that can be used to improve drug-related acute kidney injury detection and prevention. Currently, HIT can provide clinical decision support to aid with medication safety. However, HIT has the potential to do much more than pick up on potential drug safety issues.“I think we have moved beyond the first inning,” Kane-Gill said.

The COVID-19 pandemic has expe- dited patient monitoring through telemedicine. Now new transmitting devices may help to maintain effective and sustainable communication. The use of wearables for medication monitoring is increasing and these wearables can handle a huge volume of data and provide real-time responses.“We are not sure when medication monitoring will reach the ninth inning, as we are just beginning to understand multirace, multi-ethnic, and genetic-specific research and technology [needed] to guide advanced therapies,” Kane-Gill said.

Daniel C. Malone, PhD, BSPharm, professor in the Department of Pharmacotherapy at the University of Utah College of Pharmacy in Salt Lake City, said that although medi- cation adherence continues to be an issue, there is not a one-size-fits-all approach. In fact, Malone questions whether patients will be willing to consent to having someone look over their shoulder to observe their medi- cation-taking behavior.

Machine learning, which can detect unique patterns of use associated with a greater risk of negative health outcomes, is useful for generating hypotheses and perhaps identifying some previously undiscovered characteristics.“On the other hand, I don’t see it fitting into the daily practice of pharmacy in a significant manner,” Malone said. “Perhaps some nuggets of gold will come from the approach, but I think those will be relatively rare and less impactful than many anticipate.”

Lisa Schwartz, PharmD, senior director of professional affairs at the National Community Pharmacists Association, said it is exciting to see how advances in technology are providing patients and their care teams with more objective data to assess drug safety and effectiveness. However, she worries soft skills, such as motivational interviewing, may be pushed to the side and patients will lose some continuity of care. “Pharmacists will still make observations and elicit information that helps treat the patient and not just their data,” Schwartz said.

What do you think about the role of technology in medication safety? Share your thoughts and email your comments to lbiscaldi@mjhlifesciences.com.

Pal P, Sambhakar S, Dave V, et al. A review on emerging smart technological innovations in healthcare sector for increasing patient’s medication adherence. 

 2021;5(4):183-189. doi:10.1016/j.glohj.2021.11.006

Articles

From smart pills to augmented intelligence, technology has presented the health care industry with a host of options to improve medication adherence and safety.

Medication Safety 2.0: Advances in Adherence Technology

Amid a huge worker shortage, pharmacies currently are providing the lion’s share of the COVID-19 vaccines (more than 150 million and counting) boosters, and pediatric vaccinations—all on top of providing ordinary patient care.

B. Douglas Hoey, RPh, MBA, CEO of the National Community Pharmacists Association (NCPA) says this is an historic change for community pharmacists. “We are in a new era in the sense that COVID-19 has broken down some of the barriers to pharmacists moving closer to practicing at the top of their training. That’s a good thing and long overdue. Pharmacists have always been critical health care providers, but that’s not always how policymakers saw them,” Hoey told Drug Topics.

With testing, the ability to order immunizations, and now even more COVID-19 therapeutics on the way, Hoey says the opportunity for pharmacists to do more for their patients is enormous. On November 10, 2021, the NCPA released a new survey of independent pharmacists showing that the majority of independent pharmacy owners and/or managers are struggling to fill staff positions and deal with supply chain disruptions. However, market pressures, such as pharmacy benefit manager (PBM) direct and indirect remuneration fees and vertical integration, continue to be the top 2 concerns. 

Findings are based on 318 responses to a survey sent to nearly 5000 pharmacy owners and/or managers between October 26 and November 6, 2021. A strong majority (76%) reported being worried about possible tax increases on small businesses, and 64% reported inflation is a significant concern. Only 31% of respondents described the overall financial health of their business as very good or somewhat good; 28% described it as average, and 41% described it as somewhat poor or very poor. A total of 60% reported they are dealing with supply chain disruptions and nearly 70% of respondents reported struggling to fill staff positions, with the pharmacy technician and clerk/front-end staff slots being the most difficult to hire.

“Generally, the results confirmed what we have been hearing for months. The labor shortage is significant for community pharmacies, though not to the extent of the severity we are reading about with the chain drug stores,” Hoey said. “That’s partially due to the workforce being somewhat more stable at independent pharmacies and because you have the pharmacy owner on the front lines with the rest of the pharmacy team.”

The extra demand for immunization administrations caused by the pandemic has already stretched pharmacy teams. With a small number of applicants, pharmacies are being forced to offer much higher starting salaries. “There is upward pressure on wages, but pharmacies have no recourse to adjust their prices, like most consumer-facing businesses can do, because PBMs determine all pricing decisions,” Hoey added.

At this critical juncture, community pharmacies need to get involved in advocacy. According to Hoey, pharmacists must transform their practices for the future, which means expanding beyond dispensing. “We launched [the Community Pharmacy Enhanced Services Network] CPESN several years ago to get pharmacies involved in clinical services so they can increase their value to payers and patients. CPESN has grown significantly since COVID-19 because it’s part of the federal COVID-19 vaccine partnership. Thousands of pharmacies are getting their COVID-19 vaccine supply through CPESN,” Hoey says.

Everyone instinctively wants to be treated by a familiar face and a person they trust, and that’s the community pharmacist. The big chains can’t compete on the basis of relationships. “COVID-19 reminded everyone how important independent pharmacies are to the health care system, and it’s time to build on that,” Hoey said.

Independent pharmacies are the safety nets protecting their communities, and owners are working overtime, docking their own pay, and doing everything they can to answer the call. Pharmacist Theresa Tolle, BPharm, American Pharmacists Association President-Elect for 2021-2022 and owner of Bay Street Pharmacy in Sebastian, Florida, pointed out that physicians could not manage giving all the vaccines and boosters—and there were just not enough locations to go around. 

“In the testing realm, that elevated the role of our community pharmacies and now they think of us as a healthcare destination. Many are coming back for their boosters,” Tolle told Drug Topics.

Her pharmacy has been operating for 36 years and is just now attracting—for the first time many neighborhood residents. “I think a lot of people who never knew we were here, now know we are here. Many are now transferring their prescriptions to us,” said Tolle.

Brian Mayo, Executive Director, Oregon State Pharmacy Association in West Linn, Oregon, said that many pharmacists and technicians are overwhelmed. In many cases, they are being forced to continue working without required breaks, or voluntarily working longer, unrecorded hours so they can provide care to their customers. “They want to help the patients. That’s why they chose this profession, but it feels like things are getting out of control,” Mayo told Drug Topics.

Pharmacists have played a key role in vaccine administration for decades and especially now during the COVID-19 pandemic. With the ongoing influenza season and the continued COVID-19 vaccine rollout in pharmacies, they are vital to protecting our families, neighbors, and communities, said Mayo, who is hoping all the emergency rules that have been granted during the pandemic become permanent.

1. Majority of independent pharmacies affected by ongoing labor, supply chain issues, NCPA survey says. NCPA. Published November 10, 2021. Accessed November 22, 2021. 

https://ncpa.org/newsroom/news-releases/2021/11/10/majority-independent-pharmacies-affected-ongoing-labor-supply

At some independent pharmacies, pharmacists are voluntarily working longer, unrecorded hours to provide patient care.  

COVID-19 Vaccinations Change the Role of Community Pharmacy 

Mobile apps are changing the treatment landscape in the United States, and pharmacists are poised to play a major role. New apps offer the potential to disclose vital health information earlier than ever before, paving the way for entirely new ways of preventing a myriad of conditions. Researchers at the University of Pittsburgh and Carnegie Mellon University recently built the MyHealthyPregnancy platform, a patient-facing smartphone app and provider-facing portal that helps identify preeclampsia risk factors and other risks related to preterm birth.

“In pregnancy and during lactation, there's a lot of opportunity for improving communication around safe and effective medication [use], as well as medication adherence,” lead author Tamar Krishnamurti, PhD, an assistant professor of medicine and clinical and translational science at the Pitt School of Medicine in Pittsburgh, Pennsylvania, told Drug Topics. “Collaborating with pharmacists to support their critical work in preventive care would be of great benefit to tools like MyHealthyPregnancy.” 

The app currently is available to interested health care systems in the United States to tailor to their specific pregnant patient populations. The team behind the app plans to provide an off-the-shelf version directly to patients, as well as expand to pregnant populations in other countries. Senior study author Hyagriv Simhan, MD, professor and executive vice chair of obstetrical services at Pitt, said that this digital tool has the potential to offer additional support and facilitate further conversation with their providers.

“Pharmacists play such an important role in maximizing the health of our communities. In designing future studies of how best to optimize the health of women and their children, in the context of social drivers of health, will necessitate partnerships with so many stakeholders, including our colleagues in pharmacy,” Simhan told Drug Topics. 

This specific app provides high-quality information, validated risk prediction, and connections to resources within and outside of the healthcare environment. Krisnamurti said there may also be a hidden benefit that comes with this type of mobile healthcare. 

“When appropriate privacy protections are in place, these kinds of apps also can facilitate communication around topics that may be stigmatizing or difficult to discuss. Sometimes the additional layer of technology makes it easier to share sensitive information with your healthcare provider, even if you have a trusting relationship in place with them,” said Krisnamurti. 

Individuals who are caring for older adults living with memory loss and other cognitive impairments can significantly reduce their depression and stress with a new phone app that helps the person focus on what is going on at the moment.2 Mindfulness therapy—the technique behind the Mindfulness Coach App—provides stress and anxiety management through psychoeducation, guided meditation, and mindfulness exercises to reduce symptoms of stress and depression. It was created by a team at the National Center for PTSD Research at the Department of Veterans Affairs.

There are many effective, non-pharmacological behavioral therapies to alleviate psychological symptoms, and mobile health apps don’t require trained professionals who are often expensive and unavailable in many geographic regions. “Pharmacists could certainly consider strategies to provide education or improve adherence to medications via mHealth apps,” said Elissa Kozlov, an instructor in the Department of Health, Behavior, Society and Policy at the Rutgers School of Public Health in New Brunswick, New Jersey. 

Mobile Apps are being developed to combat all kinds of conditions, including depression, anxiety, post-traumatic stress disorder, and suicide prevention, to name a few. “I think apps are going to keep refining and expanding their capabilities to reach more individuals in need. I absolutely think they will be increasingly popular, especially as federal regulations keep pace with the advances we are making in mHealth,” said Kozlov. 

“The FDA is highly interested in digital health which includes mobile health, wearable devices, telehealth, and health information technology. I think we should expect to see a lot more research and implementation surrounding digital health in the future.” 

Lisa Schwartz, PharmD, senior director of professional affairs at the National Community Pharmacists Association (NCPA), said that mobile apps are ideal tools to access information and track data points. However, she cautioned that anyone recommending or using an app for health care should understand the app developer’s privacy practices and liability waivers.

“For example, an app offered by an employer’s health plan is going to be covered by HIPAA, whereas a fitness tracker probably is not. Similarly, an app that is in FDA’s device registry is accountable for being safe and effective,” Schwartz told Drug Topics. 

This revolution in delivering healthcare through a mobile app can have some pitfalls. Adopting something quickly without thoroughly vetting it, could create new health problems. Schwartz cautioned pharmacists need to do their homework before recommending any specific app. “Where applicable, read up on the treatment guidelines built into an app, before using it in practice or recommending it to patients,” said Schwartz. 

1. Krishnamurti T, Davis AL, Rodriguez S, Haet al. 

 JAMA Netw Open. 2021;4(10):e2130804. doi:10.1001/jamanetworkopen.2021.30804 

2. Kozlov E, McDarby M, Pagano I, Llaneza D, Owen J, Duberstein P. 

The feasibility, acceptability, and preliminary efficacy of an mHealth mindfulness therapy for caregivers of adults with cognitive impairment.

 Aging Ment Health. Published online August 25, 2021. doi:10.1080/13607863.2021.1963949

The smartphone can be a powerful clinical tool when used to leverage health care apps.  

Smartphone Apps Deliver Medicines in New Ways 

Pharmacists are uniquely positioned to develop and implement chemotherapy stewardship programs that allow them to lead multidisciplinary teams for establishing treatment paradigms that promote evidence-based, cost-effective therapies, according to Jason Bergsbaken, PharmD, BCOP, pharmacy coordinator for regional oncology services at UW Health in Madison, Wisconsin. Like antimicrobial stewardship programs, chemotherapy stewardships can help improve management of a constantly changing treatment landscape.

Chemotherapy stewardship programs provide the tools needed to improve patient outcomes. Currently, the American Society of Clinical Oncology (ASCO) has no guidance on developing or implementing chemotherapy stewardship programs. According to Kristen Ward, PharmD, an oncology pharmacist based in Sacramento, California, any oncology pharmacist can help establish a formal stewardship program by working collaboratively. “The aim of these programs is to train oncology pharmacists to provide high quality, cost-effective, specialty care to patients with cancer and hematologic disorders [in a way] that promotes independent critical thinking, creativity, and a culture of mutual respect with other health care providers

Bergsbaken, a member of the National Comprehensive Cancer Network (NCCN) Pharmacy Directors Committee, said pharmacists can facilitate informed patient decision making by incorporating anticipated treatment outcomes and costs. “At the individual patient level, pharmacists may help patients navigate complex treatment authorization networks to minimize out-of-pocket burden to patients,” Bergsbaken said. “The costs associated with cancer care are increasing at unsustainable rates and are a burden for patients, health care organizations, payers, and the entire health care system.”

He said that although recent expansions in treatment options are exciting, incremental improvements in patient outcomes are often overshadowed by substantially increased costs resulting in diminishing returns for society. “It is increasingly important to improve transparency of anticipated treatment outcomes with the overarching goal of maximizing therapeutic benefit while minimizing toxicity through the appropriate, targeted, and efficient use of available resources and therapies,” said Bergsbaken.

One of the primary purposes of chemotherapy stewardship programs is to ensure that facility resources are used appropriately based on gold standard guidelines such as NCCN’s or ASCO’s. Pharmacists typically encounter situations where an option for patient care does not align with these guidelines and is denied by a third-party payer. Matthew Paliughi, PharmD, a staff oncology pharmacist who has worked in inpatient and outpatient settings in Fresno and Clovis, California, said in such situations careful case analysis between pharmacist, physician, and insurance authorization team experts can result in a decision that is not detrimental to the patient in terms of efficacy and untowardly high copayment. The interventions require reviewing phase 2 and 3 study data and reporting to prescribers. “Pharmacists are the front-runners in these scenarios as they use their knowledge of alternative therapies and bring these to the care team as an option,” Paliughi said.

“A current opportunity is the incorporation of biosimilar agents into routine prescribing, where pharmacists can be the initiators of conversation with physicians and facility pharmacy and therapeutics (P&T) committees to help provide staggering cost savings to the organization with zero clinical detriment,” Paliughi explained. Paliughi, who recently returned to an outpatient pharmacy management position that oversees 3 infusion centers, said outpatient oncology staff pharmacists are in the highly advantageous position to not only advocate for patient care but to do so in a manner that provides benefit for organizations to expand on such care.

“Oncology is a rapidly evolving field that sees a newly approved agent entering the market on a nearly monthly basis. Because of this, pharmacy can become an asset when working together with the rest of the team to ensure excellent patient care and organizational success,” he said.

Oncology programs provide the tools needed to improve patient outcomes.

Chemotherapy Stewardships Becoming Increasingly Vital

Due to a variety of new communication and technology advances, pharmacists now are much better armed to prevent drug shortages. During the initial surge of the COVID-19 pandemic in April 2020, severe drug shortages plagued health systems. Particularly affected was the supply of sedation medications. However, this was not the case during the second surge this winter, according to Emily Pherson, PharmD, assistant director of medication use policy and clinical informatics at The Johns Hopkins Hospital in Baltimore, Maryland. “In this second surge, we are doing much better than back in the spring,” Pherson told 

Chronic drug shortages have become a much bigger issue in recent years. However, Michael Ganio, PharmD, MS, BCPS, FASHP, senior director of pharmacy practice and quality for the American Society of Health-System Pharmacists (ASHP) in Bethesda, Maryland, said pharmacists now have better software technology for managing inventory control. Typically in hospitals there are seasonal changes, with more respiratory infections in the winter and a greater need for antibiotics. However, centralized inventory allows a pharmacist to better keep track of how specific drugs are being prescribed. This can allow for an immediate alert if a drug is in short supply or headed that way. “The most major thing is communication,” Ganio said, “everything from the purchasers, who may have an early signal that a shortage is going to occur, and then notifying the clinical pharmacist and the providers.”

The COVID-19 pandemic created drug shortages that had not been anticipated. Ganio said in April and May 2020, pharmacists experienced a 300% to 500% increase in the use of intensive care drugs and agents for patients on ventilators. “So the whole country was affected because wholesalers made big shifts,” Ganio said. “That was a very scary time for the pharmacists.”

Artificial intelligence (AI) could be potentially useful in helping prevent drug shortages. However, limitations exist due to the inability of AI to predict a problem at a manufacturing plant or other links in the system. “When it comes down to it, there is not a lot of transparency,” Ganio said.

Most drug shortages are caused by manufacturing quality issues.

 There may be a quality issue identified during an FDA inspection, but the citation may not be posted in a timely matter. “It could be glass, the raw material, or a supply chain issue,” Ganio said. Warning letters can be delayed for months, he noted. AI use may be limited due to these factors and the fact that third parties are involved and often masked.

New drug shortages in general are declining, but the concern among pharmacists is that hundreds of drugs remain in chronic shortage. To address this issue at The Johns Hopkins Hospital, there are weekly task force meetings looking at all drug inventories and stocking practices. One task force examines weekly inventories and the areas of highest need. A second task force is dedicated solely to COVID-19–related treatments. Combined with other strategies, such as analytics solutions, pharmacists work with the providers to restrict drugs to those who are in the most need so each agent can be used the most optimally. “The keys are good management and use of dashboards that can allow for easily pulling data for monitoring and predicting shortages,” Pherson said. “It lets you be more proactive.” 

Woodcock J. To help reduce drug shortages, we need manufacturers to sell quality—not just medicine. Food and Drug Administration. Updated October 24, 2019. Accessed January 31, 2021. 

https://www.fda.gov/news-events/fda-voices/help-reduce-drug-shortages-we-need-manufacturers-sell-quality-not-just-medicine

Hospitals employ several strategies for a proactive approach to shortages. 

Leveraging New Technologies to Prevent Drug Shortages

The best practices for pill disposal are always being updated and policies vary from state to state. Opioids, in particular, are a concern and pharmacists are being called upon to educate their patients on optimal disposal practices.

Community pharmacist Elizabeth Skoy, PharmD, an associate professor at North Dakota State University School of Pharmacy in Fargo, said consumers can look for medication take-back events or drop off unused or expired medications at their local law enforcement office. Some pharmacies provide products that patients can mix with medications before disposing of them, or envelopes they can use to mail a medication to a facility for incineration. “There often is a cost to the patient for these options. There are also states that allow consumers to bring unused or expired medication to kiosks located near their local pharmacy. North Dakota allows for kiosks at the pharmacy, and tons of medication have already been collected and disposed of within the state,” Skoy told 

This issue is now at the forefront because it is estimated that more than half of individuals using prescription pain relievers for nonmedical purposes obtain the medications from a friend or relative.

Skoy said children or pets can access medications left in medicine cabinets or trash cans, which can cause unwanted, even life-threatening adverse effects. She noted that individuals looking to obtain medication for nonmedical purposes often check these areas, making proper disposal paramount.

Policies for opioid disposal vary by state. Community pharmacists should contact their state board of pharmacy to identify disposal options and what may be available for their particular pharmacy location. The FDA has a flush list, which includes opioids and other medications that the agency has identified as being suitable to flush as a method of disposal.

According to the FDA, the known risks from accidental exposure to these medications far outweigh any potential risk to humans or the environment that may arise by flushing them. “If someone is unable to properly dispose of unwanted medications through any of the above disposal options, and the medication is not on the FDA flush list, the last [option] is to dispose of [it] at home. To do this, you can mix the medication with cat litter, coffee grounds, or dirt and then place the mixture in a sealed plastic bag before discarding in the trash can,” said Skoy.

Lisa Schwartz, PharmD, who is the senior director of professional affairs at the National Community Pharmacists Association (NCPA) in Alexandria, Virginia, advises pharmacists to counsel each patient to do what works best for them to keep their household safe and to explain the importance of this issue.

“By disposing of medications in a secure drop-off bin, usually at a pharmacy or law enforcement agency, or using a prepaid medication disposal mailer, you also help protect the environment, especially the lakes and rivers,” Schwartz said.

Amy Tiemeier, an associate professor of pharmacy practice at St. Louis College of Pharmacy at University of Health Sciences and Pharmacy in St Louis, Missouri, said the best way for a consumer to get rid of unused or expired medications would be to dispose of them in a medication drop box or at a take-back event that destroys medications in an EPA-certified incinerator. “Drop boxes can be found throughout the country and the DEA [Drug Enforcement Agency] National Prescription Drug Take Back Days use this method of destruction. The National Association of Boards of Pharmacy has an online search tool where consumers can search for a drop box near them,” she said.

The policies on opioid disposal have changed over the past 5 years and are likely to change again. The FDA has not always recommended medication disposal drop boxes. According to Tiemeier, the federal law allowing medication disposal boxes in pharmacies, hospitals, and long-term care facilities didn’t go into effect until October 2013. “It was at least 6 months after that before any large chains started putting drop boxes in some of their locations, and some states had laws that still didn’t permit it. With the addition of more medication drop boxes that were more widely available to the general public, the recommendation changed to using that method first if available instead of flushing,” she explained.

List of medicines recommended for disposal by flushing. FDA. Updated April 2018. Accessed November 10, 2020. 

https://www.fda.gov/media/109643/download

Jones CM, Paulozzi LJ, Mack KA. Sources of prescription opioid pain relievers by frequency of past-year nonmedical use: United States, 2008-2011. 

 2014;174(5):802-803. doi:10.1001/jamainternmed.2013.12809

Drug disposal. National Association of Boards of Pharmacy. Accessed November 10, 2020. 

Counsel patients on best practices for disposal of unused or expired pain medications.