Raiding the Medicine Cabinet
by Carole Bartoo
[Originally published in the Fall 2011 issue of Vanderbilt Nurse]
America has a drug problem. But it’s not what you think; in fact this drug problem is probably happening in your community – even in your own home.
The problem is the accumulation of prescription drugs with no good plan for disposing of them. As the number of prescriptions continues to climb nationwide along with stockpiles of unused doses, people involved in public health and safety are beginning to see dangerous effects.
Carrie Plummer, MSN, instructor at the Vanderbilt University School of Nursing, says she became aware of the drug disposal problem when older patients would come into the Vanderbilt University Medical Center emergency department suffering from delirium. The suspected cause was often the improper use of their own prescribed medications.
“Families would bring in bags of all these prescription drugs, many of them expired. Or I would open a bottle in the emergency department and there would be three different doses of a medication in the same bottle,” Plummer said.
Part of the problem is a notoriously high national rate of prescribing. According to the Kaiser Family Foundation, the United States averages 12 prescriptions per person. Tennessee has one of the highest prescription rates at 17 prescriptions per person. While many prescriptions are one-time orders for antibiotics, or pain medications that don’t get refilled, seniors with multiple chronic health conditions commonly take five or more medications daily. In a 2005 Kaiser survey, four of 10 senior citizens reported they did not take all the drugs their doctors prescribed for them because costs were too high, they didn’t think the drugs were helping them, or because they didn’t think they needed them. More than half of those with the highest number of prescriptions said they did not take all their drugs as prescribed.
“This is a generation that doesn’t like to waste and medications are very expensive, so even if a doctor replaces one medication for another or increases a dose, if there are pills left over from the last prescription, they feel they should hang on to it ‘just in case,’” Plummer said.
Plummer says she suspects the volume of medications stored in the average older adult’s home is quite high, increasing the risk of taking the wrong pill for the wrong thing or in the wrong way.
Meanwhile, Officer David Cole, the crime prevention officer for the Dickson Police Department (a distant suburb of Nashville) sees the same problem – but from a very different angle.
“We heard through the grapevine that young people would have these ‘skittles’ parties. Teens would go into a medicine cabinet and just take one or two pills from each bottle so it wasn’t noticed, and they’d put them all in a bowl and just start taking them,” Cole said.
Abuse of prescription drugs, especially by teens, is well documented. According to research by the Substance Abuse & Mental Health Services Administration (SAMSHA), for the first time, there are just as many new abusers (12 and older) of prescription drugs as there are for marijuana. The rate of teen abuse of prescription drugs in Tennessee is among the worst with the sixth highest abuse rate for painkillers in the nation.
Cole began to attend meetings of the Community Anti-Drug Coalitions Across Tennessee (CADCAT) in hopes of finding a way to deal with what his department viewed as the growing problem of prescription drug abuse in Dickson County.
Plummer came to CADCAT at the same time, pursuing her interest in the problem of drug disposal for her doctoral dissertation.
“There is a lot of research on non-adherence to medication regimens, but this is a different twist. I was realizing the problem was people had all these medications accumulating at home for a lot of reasons, and with no real option to dispose of them,” Plummer said.
For Cole, a ‘light bulb moment’ came when he watched coalition members demonstrating the tidy disposal of prescription medications by collecting and incinerating them.
“There was this lady from Florida with a table set up for something called ‘Operation Medicine Cabinet.’ I said to her, “I think there’s a reason God brought me here to this event today because what you have here is what we need in Dickson County,’” Cole recalled.
Cole asked members of the group how he could organize such an event in Dickson County. Plummer jumped at the opportunity to help.
“I had just started teaching a community health course. This would be a great service learning program for my students to take part in, and we could do some research at the same time,” Plummer said.
Plummer recognized it was necessary to have pharmacy students there if they were to collect data. Soon the event combined efforts of VUSN faculty and students, the Dickson Police Department, David Lipscomb University pharmacy and Belmont University pre-pharmacy students and faculty, the Hamblin County Anti-Drug Coalition, community pharmacists and other business and faith-based partners.
The first drug disposal event was held on a hot day at a Kroger store parking lot in July 2010. Thousands of medications were collected, identified, counted and incinerated including one man who literally brought enough medications to fill an entire shopping cart – all by himself.
“The response floored me. The first year we had right at 75 pounds of pills and incinerated all those right there in the Kroger parking lot,” Cole said.
The second event, in April 2011, held in Horizon Medical Center’s parking lot, was equally successful. By then, Dickson’s 23rd Judicial District Anti-Drug Taskforce had bought an incinerator of its own. That day 49,000 doses of prescription and over-the-counter medications were collected with an estimated street value of $43,800. More than 5,000 doses of controlled substances were collected and destroyed, about 60 percent more than during the previous year’s event. Pills collected included tablets of painkillers, benzodiazepines, ADHD medications and sleeping pills.
“We saw it all,” said Plummer.
“One person dropped off over 300 pills of hydrocodone and 200 of morphine. Another turned in an expired pack of Russian thyroid medicine. Our oldest medication was a bottle of Iodine circa 1960.”
The process works like this: people drive to the disposal event and hand bags of old medications to police officers. By law, the only person who can “take back” certain medications that are considered controlled substances is an officer of the law. The officers then remove the controlled substances and run them through a specialized counting and logging system required by the state. The rest of the prescription and over-the-counter medications are handed to supervised nursing and pharmacy students. Each pill is identified, counted and logged before being placed in a metal container for incineration.
The logging and counting of the non-controlled substances is part of Plummer’s research, to learn more about both the prescribing practices of health care providers, and patients’ habits for taking them. Organizers focus on using this as a way to help get prescription drugs off the streets and out of the schools. And the events speak to environmental concerns as well, because the incineration process is highly regulated by the Environmental Protection Agency and is considered safer than other disposal methods. Medications may be harmful to the environment if flushed into the waste water system, or allowed to leach into the groundwater at a landfill.
According to a January 2010 survey by the Natural Resources Defense Council, 80 percent of samples taken from 139 streams in 30 states contained organic and pharmaceutical contaminants. Research is under way to determine the impact on human health as well as potential damage to ecosystems.
“This is a big issue. People kept asking us ‘what do we do when Uncle John dies from cancer and they have all these pills.’ In Dickson, we already have lawsuits about what leaches from the landfill into nearby water wells, and we don’t want people to flush them,” Cole said.
Jennifer Taylor, a Family Nurse Practitioner student, took part in the event this past spring. As a Dickson resident and parent of three young children, she found the experience to be among the most educational of her pre-specialty year.
“I was a little shocked, taken aback, because I thought Nashville would be the kind of city I would think about for a drug disposal event (instead of Dickson). That day we had a huge bag of morphine from a patient whose mother had cancer. When we asked some of the participants what age groups frequent their home, most said they had grandkids and teens in their home a lot,” Taylor said.
Taylor and her classmates say the drug disposal events teach them many lessons, but most importantly, they open their eyes to an issue that is right under their own noses, in fact, in their own medicine cabinets. Taylor says she has already changed the way she disposes of her own unused medicine (she used to flush them), and she will continue to watch the drug disposal issue from now on.
“It taught me a lot of things. There are certain medications that are prescribed too much and certain medications, like antibiotics, that people don’t finish or don’t take as prescribed. As a nurse, this helps solidify the importance of educating patients on every level, following up with them and asking them what they do to dispose of their drugs,” Taylor said.
Plummer, who recently got a crash course in the current regulations at a nine-week internship with the Office of National Drug Control Policy, says laws are changing to give communities better options for drug disposal. But at the moment, only police departments can take back controlled substances like painkillers and ADHD medications, and pharmacies are generally no better equipped to dispose of medications than regular citizens.
“This issue hits on public health and safety issues, environmental concerns, and it impacts people across the lifespan. These are at the core of my interests,” Plummer said. “People want to do the right thing, but there is no place to take these drugs. These events provide that.”