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.  A number of 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 in accordance with federal, state and/or local environmental regulations. Many collected medications are incinerated.

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 of these options in every state, but the website http://www.awarerx.org/get-local provides information on these 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, they should be instructed on safe medication disposal in the household trash. 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 medications that can be harmful to unintentional users. These medications include all opioids, rectal diazepam, and transdermal methylphenidate and buprenorphine (1). 

In 2013, the FDA issued an update regarding the disposal of fentanyl patches in response to 32 cases of accidental exposure to fentanyl since 1997, most of them involving children younger than 2 years old (6). The patches should be folded in half, sticky sides together, and flushed down the toilet. 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 medications down the toilet 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 waste water. Given this, the FDA’s recommendation to flush certain drugs which are very harmful if unintentionally ingested should be followed.

Hospice and Medication Disposal     There are no consensus guidelines or best practices specific to the hospice community around disposal of medication after a patient’s death.  The National Hospice and Palliative Care Organization and the Hospice and Palliative Nurses Association recommend following the FDA and DEA guidelines listed above and stress the requirement for individual hospice agencies to have organizational policies and procedures on the disposal of controlled substances in accordance with the Centers for Medicare and Medicaid Services Hospice Conditions of Participation, Sec. 418.106. (9-11)   In a recent study, nearly 1/3 of hospice nurses were not familiar with these rules (12).

Because of prognostic uncertainty in hospice many 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 (13, 14) and concern by hospice staff about legal and environmental impact and risk for drug diversion (12). At the time of first ordering controlled medications, the hospice should provide the patient or patient representative a copy of the hospice written policy on the management and disposal of controlled drugs. After the patient dies, the medications remain the property of the family and hospice staff should advise family on safe disposal. 

Bottom Line     Ideally, medications should be disposed of at take-back programs, or thrown in the trash. Opioids, including patches, 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. Disposal of Unused Medicines: What You Should Know. US Food and Drug Administration. Available at:  http://www.fda.gov/drugs/resourcesforyou/consumers/buyingusingmedicinesafely/ensuringsafeuseofmedicine/safedisposalofmedicines/ucm186187.htm. Accessed Sep 25, 2015.
2. Pharmacetucials and Personal Care Products (PPCPs). US Environmental Protection Agency. Available at: http://www.epa.gov/ppcp/faq.html. Accessed Sep 25, 20=15.
3. Drug Disposal Information. US Department of Justice. Available at:  http://www.deadiversion.usdoj.gov/drug_disposal/ .  Accessed Sep 25, 2015.
4. How to Dispose of Unused Medicines.  US Food and Drug Administration. Available at: http://www.fda.gov/downloads/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/UnderstandingOver-the-CounterMedicines/ucm107163.pdf. Accessed Sep 25, 2015.
5. How to Dispose of Medicines Properly. US Environmental Protection Agency. Available at: http://water.epa.gov/scitech/swguidance/ppcp/upload/ppcpflyer.pdf. Accessed Sep 25, 2015.
6. Fentanyl Patch Can Be Deadly to Children. US Food and Drug administration. Available at: http://www.fda.gov/forconsumers/consumerupdates/ucm300803.htm. Accessed Sep 25, 2015.
7. Daughton C, Ruhoy S.  Green pharmacy and pharmEcovigilance: prescribing and the planet. Expert Rev Clin Pharmacol. 2011; 4(2):211–232.
8. Kolpin D, Furlong E, Meyer M, et al.  Pharmaceuticals, hormones, and other organic wastewater contaminants in U.S. streams, 1999-2000: a national reconnaissance. Environ Sci Technol. 2002; 36: 1202-1211.
9. COPS—Planning for Success. National Hospice & Palliative Care Organization. Avabilable at: http://www.nhpco.org/sites/default/files/public/regulatory/Drug_disposal-COPS_by_topic.pdf. Accessed Sep 25, 2015.
10. Drug Disposal Guidelines. Hospice and Palliative Nurses Association. Available at:https://www.hpna.org/DisplayPage.aspx?Title=Drug%20Disposal%20Guidelines. Accessed Oct 31, 2014.
11. Conditions of Participation. Centers for Medicare and Medicaid Services. Available at: http://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol3/pdf/CFR-2011-title42-vol3-sec418-106.pdf. Accessed Sep 25, 2015.
12. McCullagh MC, Schim S, Ortner P. Drug disposal among hospice home care nurses: a pilot study of current practices and attitudes. J Pain Symptom Manage. 2012; 43:287-292.
13. Speer N, Dioso BS, Casner P.  Costs and implications of discarded medication in hospice.  J Pall Med.  2013; 16(8):975-78.
14. 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; websites updated and re-copy-edited September 2015.