A family member has died. Left behind are blood pressure, thyroid and pain medications, antibiotics and other drugs. What do you do with them?
For decades, health officials advised people to flush them down the toilet. Not any more.
Traces of pharmaceuticals and antibiotics have been detected in streams worldwide, including major waterways in Oregon. This has led to worries over discarded drugs' effects on wildlife and drinking water supplies.
Recent studies have shown that hormonal drugs flushed by humans may be changing the gender of fish and decreasing the chance of survival for their eggs.
There is even concern that ingestion of low levels of antibiotics through tap water could eventually make them ineffective, said Jim Hill, administrator for the region's water reclamation facility on the Rogue River.
Hill said measurements of pharmaceuticals have not been taken on the Rogue, but he doesn't doubt their presence.
"I would believe that they would be there, because they're everywhere," he said.
Including Oregon. The U.S. Geological Survey conducted a study on the Columbia and Willamette rivers in Oregon in 2004-05. Endocrine disruptors, acetaminophen, antihistamines and antibiotics were among the chemicals detected. The report noted that discharge standards for aquatic or human life have not been established for most of the compounds measured, so technically they do not exceed the standards.
Hill said he's been working on this issue since 1999, after European studies revealed that trace amounts of hormones from birth control pills in the rivers were causing gender and reproductive abnormalities in fish.
"Conventional wastewater treatment does not, at this point in time, treat these compounds," he said. Reverse osmosis (a high-pressure, ultra-filtration process) could remove many of the chemicals, but it would cost the water reclamation facility as much as $200 million to build, he said. And it would generate a filtered sludge that would require disposal.
Hill is part of a statewide task force that has been brainstorming new guidelines (Correction: See below.) for disposal of unwanted medications. Among them is a take-back program that would funnel drugs to incinerators rather than waterways.
The task force is made up of 26 stakeholders, including representatives from law enforcement, environmental quality, public health, pharmacies and pharmaceutical companies as well as municipalities and water reclamation facilities. Meeting in Salem since October, the group is finalizing its draft plan for safe disposal of medications.
The plan calls for substantial funding from the pharmaceutical industry, however, which is not on board with the program.
Janet Gillaspie, director of the Oregon Association of Clean Water Agencies in Portland and a member of the task force, said the problem is not just that some 60,000 pounds of unused drugs are getting dumped down toilets and making their way to streams every year. They're also winding up in the hands of children, resulting in accidental poisonings, drug abuse and death.
According to ACWA, 77 percent of the pediatric hospital visits in Oregon in 2004 were from accidental poisoning by prescription drugs. In the U.S., poisoning is the second leading cause of death for 35- to 54-year-olds, the third leading cause for 25- to 34-year-olds.
Those age 12 to 17 constituted one-third of all new abusers of prescription drugs in 2005, according to statistics compiled by the Office of National Drug Control Policy. The majority of those teens said they received the drugs from a friend or relative.
Health care practitioners historically have advised patients to flush unused or expired medications down the toilet or drain to keep them away from children, experimenting teens or drug users. Then in February the federal government released new Environmental Protection Agency guidelines to reduce the diversion of prescription drugs into the wrong hands while protecting the environment. The guidelines recommend mixing prescription drugs with an undesirable substance, such as kitty litter or coffee grounds, then throwing them in the trash.
Task force members hope to raise public awareness of the new guidelines.
"Number one: Don't flush them down the toilet," said Jim Thompson, executive director of the Oregon State Pharmacy Association in Wilsonville and task force member.
"We need to get into some kind of safe depository system," he said.
While pharmacists are not to blame for the problem, they can certainly aid in the solution, Thompson said.
The best alternative is for patients to take their pills, he said. "People should finish their medication as directed."
Locally, Providence Medford Medical Center follows the new guidelines of mixing unused drugs with undesirable substances and throwing them in the trash. Staff members advise families of hospice patients to do the same. But medications are still ending up in the wrong hands.
"I think that disposal the way we are currently doing it is not working," said Mike Inscore, director of clinical support for Providence Medford.
Under the state task force's take-back program, households and long-term care facilities could return unused over-the-counter and prescription drugs at a bin at a pharmacy or mail them to law enforcement or another agency. The drugs would then be burned in the same incinerators used by law enforcement to dispose of illegal drugs.
The proposal is modeled after one in British Columbia. Since 1996, unused drugs have been returned to 844 participating pharmacies in 131 cities. The program is funded by the pharmaceutical industry. In 2005, the program collected 39,710 pounds of unwanted drugs, and cost $190,935 in U.S. dollars.
An Oregon drug take-back program could reduce accidental poisonings and drug abuse and help improve water quality, Hill said. It would cost about $800,000 a year, or less than 2.5 cents per prescription, he said.
Medford Police Chief Randy Schoen said he supports the proposal.
"I think it's a good thing," he said. "We're seeing an increase in use or abuse of prescription narcotics."
Michael Hooper, Phoenix Pharmacy owner/pharmacist, said he had not heard of the proposal.
"It sounds like a good idea in theory," he said. If pharmacies end up being drop-off sites for unused drugs, he would have reservations about being responsible for the controlled substances, he said. Hooper also wondered whether staff would be required to do more paperwork.
"How is the program going to be funded to compensate for the increased staffing by us that's going to be necessary?" he said.
The task force has some formidable hurdles, not the least of which is the reluctance of pharmaceutical manufacturers to participate.
Pharmaceutical Research and Manufacturers of America said it does not support the program in a June 8 letter to ACWA.
"PhRMA advocates that unused prescription medicines are disposed in accordance with the Environmental Protection Agency's guidelines," wrote Leslie Wood, director of state policy for PhRMA. She wrote that PhRMA would prefer drugs be taken to a collection site much like hazardous materials programs in communities. A pharmacist should be present to catalog drugs and to separate out controlled drugs, and law enforcement should then take possession of them, she wrote.
Another hurdle for the task force is that under controlled substances regulations, only law enforcement officers can collect unwanted controlled drugs such as Vicodin, Demerol, Ritalin and Xanax.
The proposal seeks an exception and is asking the U.S. Drug Enforcement Agency for help in establishing effective drug take-back programs nationally.
Chief Schoen said the controlled substances law could be a challenge.
It could be difficult to verify that the person carrying someone else's medication is actually intending to deliver it to a take-back site, he said. Schoen suggested the program include a way people can call ahead to indicate they're in route with these drugs, then it could be verified if it needed to be.
Hill said the task force is hopeful it can get an exception or waiver from the DEA for controlled substances. "Our controlled substances act ... makes it very difficult for the honest person to dispose of the drugs," said Hill.
Hill said he hopes the pharmaceutical manufacturers will voluntarily support the program, as has happened in British Columbia.
"We're working with them and hopefully we'll get them to join us," he said.
Hill said a draft report for the take-back program is due to come out in October, and the group is aiming to have a proposal for the 2009 Legislature.
"We're either going to have to figure out how to treat it, or we're looking at product modification," he said.
Reach reporter Meg Landers at 776-4481 or e-mail firstname.lastname@example.org.
Correction: The original story misstated the efforts of the statewide task force on disposing of medications. This version has been corrected.