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 Table of Contents  
REVIEW ARTICLE
Year : 2019  |  Volume : 4  |  Issue : 1  |  Page : 1-6

Storage and disposal practice of unused medication among the Saudi families: An endorsement for best practice


1 Department of Pharmacy Practice, College of Clinical Pharmacy, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
2 Department of Pharmacy, King Fahad University Hospital, Dammam, Saudi Arabia

Date of Submission18-Dec-2018
Date of Acceptance15-Jan-2019
Date of Web Publication20-Feb-2019

Correspondence Address:
Dr. Jisha M Lucca
Department of Pharmacy Practice, College of Clinical Pharmacy, Imam Abdulrahman Bin Faisal University, Dammam
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijas.ijas_21_18

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  Abstract 


Improper storage and disposal of medications potentially pose a significant risk to both humans and animals. It also increases the economic burden to the society. The objective of this study was to investigate the storage and disposal habits of medications among the public of Saudi Arabia. The common place for storage for most of the medications was the fridge, followed by bedroom, kitchen, living room, and bathroom. An average of one to five unused medications were stored inside the house in Saudi. Antipyretic, pain medications and cough medications were the most common stored medications. Furthermore, we attempt to endorse the guidelines by the Food and Drug Administration for the best disposal practices.

Keywords: Best practices, disposal, Saudi Arabia, storage, unused medication


How to cite this article:
Lucca JM, Alshayban D, Alsulaiman D. Storage and disposal practice of unused medication among the Saudi families: An endorsement for best practice. Imam J Appl Sci 2019;4:1-6

How to cite this URL:
Lucca JM, Alshayban D, Alsulaiman D. Storage and disposal practice of unused medication among the Saudi families: An endorsement for best practice. Imam J Appl Sci [serial online] 2019 [cited 2019 Aug 24];4:1-6. Available from: http://www.e-ijas.org/text.asp?2019/4/1/1/252594




  Introduction Top


Improper disposal of unused medications and storage of expired or extra medications by the families is a universal problem. Medications or pharmaceuticals wastage is raising concern because it is not only associated with financial burden but also has negative impacts on the safety of human health as well as the environment.[1],[2] It is also has been proven that unused or “extra” medicines pose a significant risk for diversion, abuse, and accidental overdose.[3] Newer and more sensitive analytical techniques showed the presence of organic pharmaceutical compounds in groundwater and potable water even after treatment and purification.[4],[5] Unused or extra medications can arise either from households or health-care settings which can both contribute to the increase in medication wastage. Medication wastage may be resulted by patient's non-compliance, manufacturers' promotional practices, physicians' prescribing practices, or dispensers' practices.[6] Other causes of medication wastage included change in therapy, death, improved patient condition, and easy access to over the counter (OTC) medication.[7]

The regulation of medication disposal is defined in many countries. The United States has developed federal guidelines to govern the medication disposal.[8] The Australian Government has established a national return and medication disposal program in the community.[9] In the United Kingdom on behalf of the National Health Services, selected pharmacies are required to accept the unused medication from patients.[10] In Sweden and the Netherlands, public are encouraged to return extra medications to the pharmacies by a Take-Back Programs.[11] Similarly, in Serbia, pharmacies are obligated by law to accept the unused and expired medications from public and return them as pharmaceutical waste to wholesalers and manufacturers. Some states in Mexico has also implemented programs for collecting unwanted medications from households.[12]

In the developing counties, such as the Kingdome of Saudi Arabia, there is no established comprehensive medication waste management policy. The fact that all Saudi citizens are provided with free health-care access and medications by the government. Furthermore, low awareness among public regarding the consequences of medication waste might have contributed to increase number of unused and extra medications in Saudi houses. There is a paucity lack in number of researches to explore the unused medication storage and disposal practices in Saudi Arabia.[13] There has been no systematic review articles that discuss this topic in details. Taking into consideration these reasons, we conducted a systemic review to critically evaluate and summarize the presently available evidence on the current medications storage and disposal practice of households in Saudi Arabia. In addition, we highlighted the best practice given by the U.S Food and Drug Administration (FDA) for the disposal of unused medications.


  Methodology Top


This systemic review was carried out using the Cochrane Collaboration methodology for conducting systematic reviews based on the PRISMA statement and used the 27-item checklist and a flow diagram to develop a systematic review protocol for the study. This systemic review was carried on literatures published between the years of January 2000 and June 2018.

Search strategy

We electronically searched PubMed, Google Scholar, MEDLINE, EMBASE, and the ISI the Web of Science. The approach of selecting studies was done using a two-stage duplicate and independent screening process by two reviewers with language restrictions to either Arabic or English. We included all observational studies (i.e., cohort studies, case–control studies, and cross-sectional studies) and cohort studies and cross-sectional studies assessing the improper disposal and storage of unused and expired medications. To identify the studies, we used following combination of search terms “medication or medicine or drug,” and “storage, unused medicines, medicine wastage, medical disposal” “expired medications” “extra medications” and “household, residential or home” and “KSA or Saudi Arabia.” The bibliographies of the retrieved study reference were also searched.

Eligibility criteria

The inclusion criteria were studies that clearly articulate their research methodology (design, methods, and sample size), studies that evaluate the storage and disposal methods in household or individual in Saudi Arabia and or studies focused on public awareness. We also included studies that were published in either English or Arabic languages.

Exclusion criteria

Exclusion criteria were individual studies in the review that focused solely on storage of unexpired medication or home-generated medical wastes (gloves and masks) or studies that discuss pharmaceutical wastages in hospitals and the publication types of “abstract only,” “letters,” “editorials,” and “comments.”

Data collection and quality assessment

A multistep approach based on thePRISMAcriteria was used. Two independent investigators extracted data independently from all eligible papers on the basis of the predetermined selection criteria. The first selection was based on the title followed by abstract then full text.


  Results Top


The systematic search PubMed, Google Scholar, MEDLINE, EMBASE, and the ISI the Web of Science generated a total of 25 citations, after adjusting for duplicates. Of these, 17 were excluded based on the initial abstract screening and according to the exclusion criteria. This yielded eight studies to be included in this systematic review. The number of studies by reason for exclusion at each stage of the eligibility assessment is outlined in [Figure 1]. Of the included studies, three of them[14],[15],[16] discuss the storage of medications in Saudi households. The rest of the studies[7],[13],[17],[18],[19] discuss the disposal practice of expired or unused medications in the different part of the country. Majority of the studies were carried out in the central region or western province of Saudi Arabia. [Table 1] summarizes key data of the included studies.
Figure 1: PRISMA flowchart of the literature search

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Table 1: Pattern of studies from Saudi Arabia

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A quality assessment was performed all studies were cross-sectional design and used either self-administered questionnaire, online or computerized questionnaire as a research instrument. One study[18] employed both questionnaire and investigators inspection to the household. Sample size and study population vary between the studies. General public, outpatients, university students, and families were the targeted study population.

Places of medicine storage

The pattern of unused medicine storage in Saudi Arabian household was assessed in three different studies.[14],[15],[16] In all of these studies, the commonplace for storage for most of the medications was the fridge, followed by bedroom, kitchen, living room, and bathroom.[14],[15],[16] Koshok et al.[14] and Abou-Auda[18] reported that approximately 15% of the people store their medications in their vehicles. A large number of prescription and OTC medications were located in the glove compartment of the vehicles. Abou-Auda[18] and Ruwaili et al.[16] studies have shown that 93% of the patients did not store their medications in safe or secured places, half of them stored their medication above the eye level of an adult. On the contrary, finding from AL Haddad[15] reveals that 34% of the study population who store their medicine at home kept them within the reach of children while 50% of them have special medication cabinet at home to keep their medications safe. For liquid antibiotics, majority of people keep them in the fridge after at home reconstitution.

Types of medications stored at home

AL Haddad[15] and Ruwaili et al.[16] report that an average of one to five unused medications were still stored inside the house. Antipyretic, pain medications, cough medications, decongestant medications, antibiotics, and vitamins were the most common stored medications.[14],[15],[16] OTC medications remained the most commonly unused medications in the central region of the country.[18] For the condition of the unused medications, many of them were in their original package while few of them were not in the original package but identifiable. AL Haddad[15] showed the most common unused dosage forms were tablets and capsules followed by syrups and creams. Few have reported ampules in the unused list. Most of the residents reported that they store the medication at home in case they need it in future.[15],[16] A report from Taif University disclosed that regardless of future need or expiry date, the medications are saved at home owing to its cost.[15] Checking the expiry date of the medications before usage is not a common practice among study population in Saudi Arabia.[15] More than 60% of them were not checking the expiration date before administration.[18] Surprisingly, 16% of college students were willing to use expired medicines.[15] The disconsolation of treatment on symptomatic relief and change in the prescription were the most common reasons for storing unused medications in the houses. Other reasons included but not limited to non-adherence to the therapy and prescriptions of more than what patients' need. Interestingly, self-medication was shown to be one of the contributing factor for drug misuse and wastage in Saudi Arabia.[18] In addition, pharmacists were the main source of convincing patient for acquirements of medications for minor ailment, followed by relatives and friends.

Methods of medication disposal in Saudi Arabia houses

The most common drug disposal practice in Saudi Arabia was by discarding unused medications in the household garbage or flushing them down to the toilet.[7],[13],[17],[18],[19] Other practices included keeping the medications to hazardous waste collection, sharing them with the friends, or burning the leftover medications.[7],[13],[17] Rarely, people in Saudi Arabia, offer the leftover medications to non-Saudi citizens who are not eligible for governmental health-care access or could not afford the treatment.[17] Returning the leftover medication to the pharmacy or physician is occasionally practiced in Saudi Arabia.[7],[13],[17],[19] Interestingly, Abdallah et al.[7] reported that 50% of the survey respondents keep the medications in a sealed bags or container before disposing them to the rubbish bin. In addition, it was identified that a limited number of citizens crush the solid dosage form before dumping it into the rubbish bin. Similarly, 50% were directly throwing the bottles of liquid dosage forms to the garbage bin, while the rest empty the bottle before discarding them. Interestingly, a small percentage of the residents where mixing the unused medication with other products before discarding it.[7] Medications expiry, change in medication color, and completion of the therapy were the most common reasons for discarding medications in Saudi Arabia.[7]

Economic impact of unused medication in Saudi Arabia

The financial impact of medication waste in Saudi Arabia revealed to be large relative to the gross national product of the country. Abou-Auda[18] report that nearly US $150 million spent each year on unused medications in Saudi Arabia. Unfortunately, this report was collected from small (1641) number of population. If we generalizing these statistics to the entire Kingdom, the economic impact of medication waste would be enormous.

Citizens opinion about proper disposal of medications

According to several studies, majority of the public in Saudi Arabia expressed that public education on proper disposal of unused medication is needed.[13],[17],[19] They also think that the Ministry of Health and Saudi Food and Drug Authority should take the responsibility of educating the public. Social networks, smartphone application, pharmacists, education campaign, television, physicians, or educational booklets are the preferred educational methods suggested by the citizens within the country.[13] A large number of the public believe that returning the unused medication to health-care providers is comfortable practice for disposing the unused medication. They also recommended keeping a secure container to collect the leftover medications in the private pharmacies, and primary care centers.[13]


  Discussion Top


The overall status of medication or pharmaceutical wastage is not at the satisfactory level around the world except in small number of developed countries.[20] This systematic review concentrated on the unused or expired medication disposal practice of general public around Saudi Arabia. Very limited studies were published about this topic in Saudi Arabia. All of them used the same methodology as a questionnaire. The studies were performed in general public household or university students. Two studies randomly approached patients in outpatient clinic settings.[14],[19] All these make the comparison of studies difficult.

The consequences of medication wastage can be thoughtful. The present review found that majority of the household in KSA had leftover, unused, or unwanted medications. They concluded that majority of them practices irrational methods of disposing medications. Majority of them linked this with the reasons such as low awareness and lack of proper disposal system. In addition, studies reviled that the economic cost of medication wastage was $150 million annually in Saudi Arabia.[18] This wastage can be minimized by encouraging physicians and pharmacists to console patients during their medical visit.[20] Establishing national level policy regarding medicine disposal by the Saudi Government and including them in the legislation should be put in place to have a successful program.

Recommendations for proper storage of unused medications

The US FDA[21] suggested few recommendations for proper storage and disposal of unused medications. FDA recommended to perform the inventory every 6 months, or at least once a year. Also given details of each items in the inventory such as check the expiry date, look for faded, dried out, smashed medications, and dispose them. Take out the excess prescription medicines from previously treated disease. Later, it should be stored in cool and dry medicine cabinet, out of reach of children. Individual members of the family should keep medications separately to avoid improper selection of medications. It is a good practice to stock the medicine in its original bottle, and not to mix different medicines in the same bottle. The lids of pill bottles should be tightly closed and remove the cotton from inside the bottle as cotton can absorb moisture and spoil the medicine.

Recommendations for proper disposal of unused or expired medication

The US FDA[21] has launched a consumer guidance for proper disposal of prescription drugs. Best choices for disposal of unused or expired medicines include Medicine take-back programs, disposal in the household trash and flushing the medicines [Figure 2].
Figure 2: Drug disposal options by the Food and Drug Administration[21]

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Medication take-back programs

Medicine take-back programs are the preferred method for safely dispose of unneeded medicines. The US FDA[21] has launched two kinds of take-back programs: periodic events and permanent collection sites. The Drug Enforcement Administration (DEA) hosts National Prescription Drug Take-Back events where temporary collection sites are set up in communities. While permanent collection, consumers dispose the unwanted medicines to DEA-registered collectors, which then safely and securely collect and dispose. In fact, in the Kingdome of Saudi Arabia, few pharmacies willingly take back such medications for proper disposal. The pharmaceutical care services department at KAMC, Jeddah, has a policy that allows the receipt and disposal of returned medications from patients. However, patients were seldom aware of the existence of this service.[13]

Household trash

Placing unused medication in the household trash is extensively advisable method for drug clearance. FDA[21] has commenced few simple steps for consumers before tossing the medications [Figure 2]. In the Initial step, delete all personal information on the prescription label of pill bottles or medicine packaging, then (do not crush tablets or capsules) mix unwanted medication with undesirable substances (used coffee grounds or kitty litter, or dirt). After that, put the mixture in an empty can or bag or sealed in an opaque container. Later, throw the container in trash on the same day the trash is collected, as safely secure from children, pets, and others.

Flushing the medicines

FDA has listed a group of medications that can be flushed when they are no longer needed [Table 2]. FDA[21] consider that the danger related with unintentional exposure to this drugs outweighs the possible threat associated with disposal by flushing. In addition, FDA insists to read insert directions unless otherwise stated do not flush medication down the drain toilet.
Table 2: FDA approved list of drug that can flush

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Proper education to society

Educating the public about proper storage and disposal of prescribed medicines is crucial. In Saudi Arabia and other Gulf countries, awareness on this issue is lacking. Therefore, awareness can be started from the medical institution to the community. Moreover, the government should bring policies and procedure for suitable storage and disposal unused medications. Likewise, pharmacists along with the Ministry of Health should look forward for take-back programs. Physicians should avoid over-prescription, which will minimize the burden of unused medication medicines disposal and decreases economic burden and chances of resistance in the society.


  Conclusion Top


In Saudi Arabia, the improper disposal of medications may be dangerous as it can cause a contamination in the water supplies which could be used by humans. Expired medications may come into the hands of kids and cause accidental poisoning. Our review showed that there are undefined programs for medical wastage by the public in Saudi Arabia. The government should provide sufficient funds to establish successful programs such as education campaigns and public awareness programs. The national level policy with better allocation of the governmental and nongovernmental funds might contribute to a successful medical disposal management program in Saudi Arabia. Further studies have to be formulated once a medication wastage program is implemented in Saudi Arabia to monitor its success.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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