Proper disposal of unused prescription medication remains a major public health priority for the FDA, particularly for prescription opioid pain medicines, due to our nation’s ongoing crisis of misuse, abuse, addiction and overdose.
In 2017, retail pharmacies dispensed more than 191 million opioid prescriptions to almost 60 million patients. According to FDA data, as many as 90% of patients who received a prescription for an opioid reported that they did not finish what was prescribed to them, leaving potentially millions of unused and unnecessary doses of opioids in households across America, and posing harm to those for whom these medications were not prescribed. During that same year, 47,600 people died of an overdose involving opioids. Sadly, we know that many of these deaths resulted from the victim having obtained opioids from friends, family, or others. In addition, children and pets also continue to be harmed by unused drugs that they find in the home.
To flush or not to flush— That is the question
One of the most frequent and confusing drug disposal questions that the FDA receives is whether unused and unwanted prescription medications can be disposed of by flushing them down the toilet.
The answer is yes, for certain medications, but the preferred disposal method is to bring them to an authorized drug disposal, or “take back,” site. Authorized locations may be in retail pharmacies, hospital or clinic pharmacies, and law enforcement facilities. Some authorized collection sites may also offer mail-back programs or drop-boxes to further assist patients. The Drug Enforcement Administration website enables patients to search for the nearest disposal site by ZIP Code.
If there is no option for a patient to bring their medicine to an authorized disposal site, most medications should be disposed of in household trash as opposed to flushing. Currently, patients are instructed to first mix the medicine (not crushed) with an unpalatable substance such as dirt, cat litter or used coffee grounds and then place the mixture in a closed container such as a sealable plastic bag before disposing in the household trash. FDA is aware of efforts underway — and interested in new ideas innovators may have — to develop new disposal technologies aimed at providing additional options for patients to use to dispose of medicines in the household trash.
A small number of prescription medications have specific instructions to immediately flush when they are no longer needed and a take-back option is not readily available. These medications may be especially harmful and, in some cases, fatal with just one dose if they are used by someone other than the person for whom they were prescribed. A list of these medications — most of them potent opioids — is available on the FDA website, along with other useful information for patients on how to safely dispose of medicines.
There are 14 active ingredients on the FDA’s current “flush list,” representing about 50 different brand name products with those ingredients, and their generic equivalents if available. All but two of the active ingredients on the list are opioids. The two nonopioids on the list are diazepam rectal gel and sodium oxybate solution.
Does flushing these medicines pose a health or environmental risks?
The FDA is aware of reports of very low, but measurable levels of medications in rivers and streams, and to a lesser extent in drinking water. Most medications found in water are actually a result of the body’s natural routes of drug elimination (in urine or feces). Disposal of these select few medicines by flushing, especially if done only when take-back options are not readily available, would contribute only a small fraction of the total amount of medication found in our surface and drinking water.
Based on the available data, FDA believes that the known risk of harm to humans from accidental exposure to these medicines far outweighs any potential risk to humans or the environment from flushing them.
How can prescribers help patients with drug disposal?
FDA has made it easier for prescribers to confidently answer their patients’ questions and help patients understand the importance of safely disposing of unused and unwanted opioid medications.
As part of its Remove the Risk campaign, three patient-friendly fact sheets are available that prescribers or office staff can print, at no cost, from the FDA website and share with patients. Each is titled, It’s Important to Safely Remove Opioids From Your Home, but is targeted to different audiences, one to a general audience, one to parents and caregivers of children, and one to parents and caregivers of teens. Each is available in English and Spanish.
Accidental exposure to medicine in the home is a major source of unintentional pediatric poisonings in the United States. Each year in the U.S., approximately 60,000 ED visits and 450,000 calls to poison centers are made after children younger than 6 years of age find and ingest medication without caregiver oversight. More than two-thirds of ED visits for accidental pediatric medication exposures involve 1- or 2- year old children and nearly 20% result in hospitalization.
Keeping medicines after they are no longer needed creates an unnecessary health risk in the home, especially if there are children present. Even child-resistant containers cannot completely prevent a child from taking medicines that belong to someone else. In a study that looked at cases of accidental child exposure to a grandparent’s medicine, 45% of cases involved medicines stored in child-resistant containers.
Prescribers and/or office staff can refer patients to the FDA’s drug disposal website, which is filled with useful information for patients on how to safely dispose of medicines.
The FDA urges prescribers to engage with patients and stress the importance of safe disposal of medications that are no longer needed. With your help, we can reduce unintended consequences and save lives. - by Douglas C. Throckmorton, MD
Disclosures: Throckmorton is deputy director for regulatory programs at the FDA’s Center for Drug Evaluation and Research.