Background Patients receiving home hospice or palliative care often have a residual supply of opioids and other pharmaceuticals at the time of the patient’s death. Several agencies have recommendations and resources on safe medication disposal, including the Food and Drug Administration (FDA), Environmental Protection Agency (EPA), and the Drug Enforcement Agency (DEA) (1-3). Educating families on proper disposal of medications is an important patient safety measure.

Medicine take-back events or programs Ideally, medications should be given to a secure medication collection site or disposed of through an official take-back program. These programs dispose of medications (most often they incinerate the medications) in accordance with federal, state and/or local environmental regulations. Medication collections sites include police stations, pharmacies, chemical plants; sometimes programs included locked drop-boxes associated with these facilities. There is no unified resource that identifies all these options in every state and families should not assume that a nearby pharmacy will take their medications back for them. The website http://www.awarerx.org/get-local provides information on these take-back sites by state. If the patient does not have internet access, they can call 311 or the FDA: 1-888-INFO-FDA for information about local resources.

Disposal in household trash If the patient cannot access a secure collection site, for most non-controlled medications, safe disposal in the household trash is recommended. The FDA, EPA and other safety programs have created consumer education materials and recommend the following (4,5):

• Remove medications (liquids, tablets, or capsules) from their original container.
• Mix medications (do not crush tablets or capsules) with unpalatable substances (such as kitty litter or used coffee grounds) and seal in a plastic zip lock bag or empty container (such as a margarine tub) and place in the trash.
• Remove identifying information about the patient and medication by covering with permanent marker or scratching off labels.
• Empty pill bottles should be thrown in the trash or recycling (depending upon local guidelines).

Flushing medications If a drop-off program is unavailable or impractical, the FDA recommends flushing down the toilet certain controlled medications that can be harmful to unintentional users. These include all opioids, rectal diazepam, and transdermal methylphenidate (6). Due to accidental exposure to fentanyl (particularly involving young children), the FDA issued a consumer update regarding the disposal of fentanyl patches (7): they should be folded in half, sticky sides together, and if no medication disposal site is available, they may be flushed down the toilet instead of placing them in household trash. While not explicitly stated, it is reasonable to dispose of transdermal buprenorphine and methylphenidate similarly.

Environmental impact of unused medications There has been controversy and media coverage around concerns with flushing medications. The EPA has advised against flushing any medications down the toilet (unless expressly instructed) because of environmental concerns (2). However, others have noted the main way drug residues enter water systems is by passage of drug and drug-metabolites in urine and feces (7,8). Additionally, there is no clear scientific evidence of actual ecological harm brought about by pharmaceutical contamination of wastewater (9). Given this, if no medication disposal site is available, the FDA’s recommendation to flush certain high-risk drugs should be followed instead of placing them in the household trash.

Hospice and medication disposal There are limited guidelines or best practices specific to the hospice community around medication disposal after a patient’s death. The National Hospice and Palliative Care Organization (10) and the Hospice and Palliative Nurses Association (11) recommend following the FDA and DEA guidelines described above and stress the requirement for individual hospice agencies to have their own policies and procedures on the disposal of controlled substances that aligns with the Centers for Medicare and Medicaid Services Hospice Conditions of Participation, Sec. 418.106 (12). The Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act was enacted in 2018 and contained a provision to allow employees of qualified hospice programs to dispose of unused controlled substances by collecting and destroying the drugs in patients’ homes (13). Because of prognostic uncertainty, many hospice patients have unused medications at the time of their death, many of which are opioids or benzodiazepines. There is significant cost associated with discarded medications (14-15) and concern for potential opioid diversion and legal and environmental impacts (11). The hospice agency therefore should provide the patient or patient representative a copy of the hospice written policy on the management and disposal of controlled drugs. When appropriate, the medications should be disposed safely by the family with or without the assistance of a hospice team member.

Bottom line Ideally, medications should be disposed of through a take back option. If not available, all opioids, including patches and buprenorphine in any formulation, and methylphenidate should be flushed down the toilet and not thrown in the trash. Providers should educate patients and families about safe medication disposal, particularly with opioids, which can be deadly if unintentionally ingested.

References

1. Where and How to Dispose of Unused Medications. | FDA Available at: https://www.fda.gov/consumers/consumer-updates/where-and-how-dispose-unused-medicines Accessed March 27, 2024.
2. What To Do with Unwanted Household Medicines | US EPA. Available at: https://www.epa.gov/household-medication-disposal/what-do-unwanted-household-medicines Accessed March 27, 2024.
3. Diversion Control Division | National Prescription Drug Take Back Day (usdoj.gov). Available at: https://www.doj.state.wi.us/dles/prescription-drug-take-back-day#:~:text=On%20Saturday%2C%20April%2027%2C%202024,to%20participate%20in%20this%20program. Accessed March 27, 2024.
4. Year-Round Drop-Off Locations Search Utility | DEA. Available at: https://apps.deadiversion.usdoj.gov/pubdispsearch/spring/main?execution=e1s1 Accessed March 27, 2024.
5. Drug Disposal Locator | National Association of Boards of Pharmacy Available at: https://safe.pharmacy/drug-disposal/ Accessed March 27, 2024.
6. Drug Disposal: FDA’s Flush List for Certain Medicines Accessed March 27, 2024.
7. Accidental Exposures to Fentanyl Patches Continue to be Deadly to Children | FDA. Available at: https://www.fda.gov/consumers/consumer-updates/accidental-exposures-fentanyl-patches-continue-be-deadly-children#:~:text=Young%20children%2C%20in%20particular%2C%20have,seek%20emergency%20medical%20help%20immediately. Updated May 18, 2023. Accessed March 27, 2024.
8. Daughton C, Ruhoy S. Green pharmacy and pharmEcovigilance: prescribing and the planet. Expert Rev Clin Pharmacol. 2011; 4(2):211–232.
9. Khan U, Bloom RA, Nicell JA, Laurenson JP. Risks associated with the environmental release of pharmaceuticals on the U.S. Food and Drug Administration “flush list”. Sci Total Environ. 2017 Dec 31;609:1023-1040.
10. NHPCO’s Standards of Practice Guidelines. Available at: https: www.nhpco.org. Accessed March 27, 2024.
11. HPNA Position Statement: Medication Safety in Hospice and Palliative Care Settings. Available at: https:www.advancingexpertcare.org. Accessed March 27, 2024.
12. Medicare and Medicaid Programs: Hospice Conditions of Participation. Available at: https://www.federalregister.gov/documents/2008/06/05/08-1305/medicare-and-medicaid-programs-hospice-conditions-of-participation Accessed March 27, 2024.
13. U.S. Congress. Substance Use–Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act. 2018. H.R.6 – 115th Congress (2017-2018). Accessed March 27, 2024.
14. Speer N, Dioso BS, Casner P. Costs and implications of discarded medication in hospice. J Pall Med. 2013; 16(8):975-78.
15. Hauser JM, Chen L, Paice J. Down the drain: the cost of medications wasted in hospice. J Pain Symptom Manage. 2006; 31:379-380.

Author Affiliations: Rush University Medical Center, Chicago, IL (SN); Cook County Health and Hospitals System, Chicago, IL (CD).
Version History: Originally published January 2015; 2nd Edition in September 2015; 3rd Edition in April 2024 by Jessica R Bumgarner MSN, APRN, FNP-BC.