Pharmaceutical waste and sustainability: what's our role in psychiatry?

Katie Blissard-Barnes of the RCPsych Sustainability blog team asks what we as a college can do about pharmaceutical waste.

One of the biggest challenges when it comes to improving our sustainability as a college is to look at our pharmaceutical waste.

It is all too often overlooked because we don't physically see the waste, but if evidence is right and only 40% of prescribed medications are taken by those with severe mental illness (SMI), tonnes of medicines are  collected each month but never taken (Carvajal, 2004; Misdrahi et al, 2002).

This waste either sits in patients’ houses or is thrown in the bin.  There are lots of reasons for non-adherence to medications of course, but the critical thing from a sustainability point of view, is to try and reduce this waste.

This isn't just specific to Psychiatry of course. Healthcare as an entire sector shows vast amounts of pharmaceutical waste, much of which we are not aware of and cannot collect data for because patients won't necessarily admit to their clinician that they are non-concordant.

This isn't just a problem in terms of sustainability and the sheer waste of such medications but it also comes with the huge financial cost of prescribing and dispensing these unused medications.

In addition, there is also a concern that pharmaceuticals may leach into drinking water and this in part may be due to inappropriate disposal of medications (Wu & Janssen, 2011).

The World Health Organisation has written a document outlining the presence of pharmaceuticals in drinking streams and has identified several studies that demonstrate the presence of a variety of medications including fluoxetine in these water supplies (WHO, 2011).

Statistics

• It is estimated that the NHS spends around £300 million every single year on wasted medications (NHS, 2015).
• £90 million of this are predicted to be unused medications that patients keep at home without taking.

• Results vary but approximately 40% of patients on antipsychotics have been found to be non-adherent (Ascher-Svanum et al, 2008).
• Of note - this study looked at medical record prescription data, so there could be patients storing medication but not admitting to their non-adherence.
• This study also noted large differences in adherence depending on the actual antipsychotic prescribed e.g. 65% were non adherent if on haloperidol.

What can we do?

1. Optimise our prescribing

As clinicians, we can regularly review the medications our patients are prescribed followed by the need for these medications. 

We can then revise these regular medications accordingly in order to reduce the amount we are prescribing and in doing so, reduce the risk of polypharmacy.

2. Reduce unnecessary dispensing

In addition, we need to try and get our patients to confide in us if they aren't taking their medications. If this is the case and it is felt the patient has the capacity to make this decision, this should be communicated to the GP and their records updated accordingly so these medications are not being dispensed unnecessarily.

We must also encourage patients to bring in any un-used medications to their local pharmacy so that they can dispose of it safely.

3. Enable appropriate disposal

It is believed approximately £50 million worth of medications are disposed of by care homes every year.

Strategies to ensure this is being disposed of appropriately should be put into place to support care homes with this. In addition, advising patients to bring unused medication to the pharmacy for safe disposal if they are not adhering to their medication plan is one way of reducing the medications being stored up.

Furthermore, this can then lead to a discussion about reducing / stopping dispensing of this medication.

These strategies are being used throughout the country with several case studies available to review (NHS, 2015). This includes pharmacist-led interventions to optimise medications and reduce polypharmacy, which in turn is leading to massive cost savings for the trusts.

The importance of reducing pharmaceutical waste cannot be over-emphasized. Not only is this wasting a lot of money for the NHS overall, as well as psychiatry, but those medications that are specifically being disposed of incorrectly e.g. flushed down the toilet or thrown in the bin to end up in landfill can contaminate the water.

References

• Ascher-Svanum. H, Zhu. B, Faries. D et al, 2008, Adherence and persistence to typical and atypical antipsychotics in the naturalistic treatment of patients with schizophrenia, Patient Preference and Adherence, 2, pp 67-77
• Carvajal. C, 2004, Poor Response to Treatment: Beyond Medication, Dialogues in Clinical Neuroscience, 6 (1), pp 93-103
• Misdrahi. D, Llorca. P, Lançon. C et al, 2002, Compliance in schizophrenia: predictive factors, therapeutical considerations and research implications, L’Encephale, 28 (3 Part 1), pp 266-273
• NHS, 2015, Pharamceutical waste reduction in the NHS [online], accessed 3rd April 2019, available at https://www.england.nhs.uk/wp-content/uploads/2015/06/pharmaceutical-waste-reduction.pdf  
• WHO, 2011, Pharmaceuticals in Drinking Water [online], accessed 3rd April 2019, available at https://www.who.int/water_sanitation_health/publications/2011/pharmaceuticals_20110601.pdf
• Wu. M & Jannsen. S, 2011, Dosed Without Prescription: A Framework for Preventing Pharmaceutical Contamination of Our Nations Drinking Water, Environmental Science and Technology Viewpoint, 45, pp 366-367

This blog was included in the April 2019 eNewsletter.