Disposal of unused medications and other controlled substances is an expensive logistical challenge. Pouring controlled substances into sewer systems is harmful. Incineration costs are prohibitive.
Federal drug policy is pushing hospitals and other healthcare facilities into a corner. Unused medications are increasingly recognized as hazardous waste that should be incinerated. But the Drug Enforcement Administration's rules on controlled substance disposal are forcing many hospitals to flush unused medications.
The alternative is waste disposal under the surveillance of law enforcement personnel or someone registered with DEA. Witnessed disposal is expensive.
"That's a huge financial hit that can't be passed on to our patients," Steven Waderich, hazardous waste disposal manager at Abbott Northwestern Hospital in Minneapolis, said. "It's the right thing to do environmentally, but it is not reimbursed by anyone."
Controlled substance incineration costs about $38 per pound, Waderich added. Abbott will generate more than 1,000 pounds of unused controlled substances this year, accounting for 75 percent of his entire hazardous waste disposal budget. "We have to manage controlled substances as DEA materials as well as hazardous materials under Minnesota law," Waderich said.
Waderich could be spending more. Abbott's Pyxis medication control system reports nurses squirt about four gallons of unused medications into hospital sinks every year.
The typical scenario is a physician order for 6 ml of a product that is stocked in 10-ml vials. The remaining 4 ml is waste. For busy nurses, washing the excess down the nearest sink is the most time-effective solution. Two nurses witness each disposal and document the event.
Most hospitals put part or all of their controlled substance waste into the sewer, Shirley Reitz, associate director of pharmacy clinical services for Group Health Cooperative in Seattle, said. "When we waste part of a vial, we shoot it down the sink with witnesses," she said. "If you don't put controlled substances down the drain, you have to bring in hazardous waste management."
But not everywhere. Abbott Northwestern has managed to keep most of its controlled substance waste out of the sewer. San Francisco General Hospital doesn't pour any controlled substances down the sink, Sharon Kotabe, pharmacy director for the city Department of Public Health, said.
Instead, the hospital uses secure containers with absorbent materials to soak up liquid waste. SF General's nurses follow the DEA's familiar witnessed-disposal procedures, but squirt into a bin instead of a sink. The containers are collected on a regular basis for incineration. The San Francisco system, or something similar, could become standard across the country. "Every state is looking to ban flushing meds," said Gene Memoli, RPh, president elect of the Connecticut Society of Consultant Pharmacists and a member of the Drug Topics Editorial Advisory Board. "Pharmaceutical disposal is on everybody's mind. If there isn't a regulation in your state yet, there will be."