A recent Healthcheck television programme brought to public attention a fact that affects pharmacists almost every day - a significant proportion of patients either fail to start their prescribed medication or fail to complete a course of treatment. The pharmacist is acutely aware of the value of these apparently unwanted medicines returned as unopened patient packs for disposal (almost certainly in excess of the £37m per annum cited in the broadcast). Not only is the destruction of these medicines by incineration a waste of limited National Health Services resources, but the NHS also has to finance the costs of collection and incineration. A natural reaction to this ongoing waste of precious medicines is to demand that something be done to reduce the wastage. The only question is: what can be done?
It is obvious that there has to be an objective investigation of the composition of the waste, and the potential causes of the ongoing waste, before any effective measures can be introduced to restrict the wastage (locally, regionally or nationally).
Although the present UK policy of destruction of all medicines returned by patients (alongside the regulated destruction or disposal of date-expired and surplus medicines from manufacturers and wholesalers) is environmentally and ethically laudable, the wholesale destruction of in-date and unopened medicines cannot make economic sense in the context of constant financial shortages in the NHS. A large majority of community pharmacists are eager to find some more satisfactory alternative to the wholesale destruction of intact medicines as "special waste" - at least until effective measures can be introduced to reduce such profligacy.
The article by Donald Macarthur (PJ, February 5, p223), describing the collection and disposal of waste medicines in France by Cyclomed, showed that an alternative approach to the problem is feasible. Cyclomed, operating as a non-profit making company, selectively collects intact and in-date medicines for bulk charitable donation for national and international use. This introduction of an organised, altruistic component into the routine disposal of unwanted medicines was taken up by Pamela Bradshaw in her recent letter to The Journal (February 19, p296).
In this, she asked if it were not time that the UK also looked at ways of making better use of its inwanted medicines - surely altruism is a better option than paying to heat the atmosphere by incineration.
If we accept the basic concept that altruism is at least morally better than incineration, we need to investigate what form of altruism will be really cost-effective. To do this we first have to look beyond the ethical and legal considerations of ensuring that there is no charitable donation of medicines that might be considered to be of less than perfect quality. We must examine the logistic options to see if there is a practicable way of making altruism effective: we cannot contemplate involvement in situations where unsuitable quantities and types of medicines are donated in a reflex response to a disaster. The World Health Organisation has recently updated its guidelines for the charitable donation of medicines but has also had to issue a parallel set of guidelines for the safe disposal of unwanted quantities of medicines after emergency situations have been alleviated by poorly organised charitable donations.
Although it initially seems morally sensible to be making regular charitable donations of appropriate unwanted medicines, the adoption of an organised scheme, whereby the medicines are donated to the warehouses of non-governmental organisations (NGOs) may not represent a cost-effective approach. Most NGOs respond to medical emergencies. Consequently, they have unpredictable and irregular needs for specific medicines. This is in direct contrast to the potential availability of the unwanted medicines if an altruistic element were introduced into the present disposal systems on a large scale. The routine collection of intact and in-date packs of unwanted medicines from more than 10,000 dispensing outlets will, by virtue of the large scale, almost guarantee constant and predictable stocks of many medicines available for donation. If such donations were routinely made to NGOs with unpredictable needs, then it is likely that many donated packs will be in store beyond their expiry dates, leaving the NGO with the problem of disposing of "special waste" material.
We are thus faced with the dilemma of cost-effective donations of unwanted medicines which may be available as regular and predictable stocks. We have to match this with a regular and predictable need for medicinal altruism. Fortunately, there is a possible option in underdeveloped countries between disasters and emergencies. Where there is an adequately funded health service in rural areas of Africa, the basic medical services are usually underpinned by medical or nursing members of religious orders or churches. Almost without exception there is an ongoing chronic need for supplies of basic medicines - such chronic needs are, by definition, regular and predictable. Hence the provision of sustained support to individual rural clinics through the regular charitable donation of medicines could represent a suitable matching of the potentially available predictable sources of our unwanted medicines. Although this form of charitable donation could, in principle, virtually guarantee that all donated medicines would be used and little or nothing would be wasted, we have to appreciate that most NGOs do not provide this type of medicinal support. This is understandable because their resources are already severely stretched by responding to the acute emergency situations which regularly (but unpredictably) occur.
In the absence of any large scale charitable provision of medicines to meet the chronic needs of rural clinics between disasters, we have to be aware of the logistical and ethical demands of attempting to meet these particular charitable needs. To this end, every individual clinic, the specific medicines (type and quantity) needed by each clinic and the routes for delivery to each clinic have to be identified. And the unwanted medicines collected would have to be contained in the WHO list of approved medicines, to be in intact manufacturers' packaging, to be supplied with a shelf-life of more than 12 months, to be matched with prescribing information in the appropriate language, and to be used before expiry to eliminate disposal problems.
In the light of these requirements, it is obvious that the use of charitable donations of medicines to meet chronic needs places serious organisational demands even before such a scheme could be initiated. Such a scheme cannot be entered into lightly since there is clearly a requirement for a large investment of effort even before starting to collect unwanted medicines. However, the investment would surely be worthwhile, provided that the ethical and legal considerations of ensuring that there is no donation of medicines that might be considered to be of less than perfect quality can be met. Not only would the adoption of this altruistic approach be worthwhile, by making perhaps in excess of £20m a year available, it could also be a cost-effective alternative to the wholesale incineration of unwanted medicines.
It is important that we are fully aware of the practicalities involved in ensuring that what might be laudable altruism can be converted into a practicable scheme. It is also essential that we fully appreciate that the charitable donation of medicines involves far more than the ethical considerations of making professional judgments over whether apparently available medicines are waste medicines or unwanted medicines.
Dr Crumplin, of Kirkbymoorside, Yorkshire, is independently involved in the destruction of returned medicines and the charitable donation and delivery of aid to Africa