The Pharmaceutical Journal Vol 267 No 7167 p424
29 September 2001

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Drug wastage — what is acceptable?

By Evelyn Cromarty and George Downie

Figures illustrating the cost of National Health Service medicines that are wasted attract considerable media attention. Dump campaigns over many years have highlighted the high volume of unwanted prescribed medicines returned by patients to community pharmacies for safe destruction. Recent studies have attempted to quantify these returns and extrapolate the data to estimate the total annual cost of such medicines. Despite large variation in the level of returns to individual pharmacies over time and variation between pharmacies, estimates of annual cost in surveys carried out in Ayrshire and Arran, Lancashire and Grampian are similar at 0.5 to 0.7 per cent of the local primary care drugs budget.

The total cost of unwanted medicines may be considerably higher since many such medicines are not returned to pharmacies, but disposed of within household waste, flushed down the toilet or returned to the doctor. Surveys of disposal patterns for unwanted medicines found that between 16 and 34 per cent of people returned unwanted medicines to pharmacies.^1,2 Scottish Office data on weights of returned medicines, which also includes over-the-counter medicines and medicines from surgeries and clinics, indicate considerable regional variation. The cost of collecting and incinerating returned medicines is high and is increasing. In 1997, in Scotland, 43,528kg of unwanted medicines were returned for disposal; collection and incineration of these cost £138,184.

A “brown bag” medication review in Devon in 1995 estimated the cost of unwanted medicines at £1.7m, which represented 1.8 per cent of the Devon drugs budget. This is in broad agreement with extrapolation from surveys of pharmacy returns which may represent one third or less of all unwanted medicines. Returns generally mirror local prescribing patterns, with cardiovascular and central nervous system medicines (particularly analgesics) being most commonly returned. However, several surveys have identified higher than predicted returns of analgesic, non-steroidal anti-inflammatory and antipsychotic drugs.

A recent survey of returned medicines in Grampian found that 28 per cent were unopened and 75 per cent were returned within one year of dispensing. Death of the patient was the most common reason for medicines being returned (33 per cent). Other common reasons included change of medication, side effects, or “no longer required”.

A large study in Canada showed that those aged over 65 years accounted for 23.4 per cent of prescribed drugs in the region, but were responsible for 52 per cent of the drugs returned during the survey. In most cases, in this age group the drugs were returned when the patient died.³

Reduction in wastage

The results of several surveys have been fed back to local doctors and community pharmacists with recommendations on measures to reduce wastage, including:

• Prescribe smaller quantities
• Optimise time intervals for repeat medication and prescribe in phase
• Regularly review repeat medication
• Improve information for patients
• Introduce policy guidelines within acute computer-generated prescribing
• Reduce unnecessary or inappropriate prescribing (this is a form of drug wastage)

If implemented, such measures should reduce wastage. However, it is unclear to what extent, since some wastage is inevitable because of adverse reaction, poor response, changes in medical condition or death. In addition, the repeat prescribing system in primary care balances patient convenience and prescribing and dispensing costs against potential drug wastage. This system operates on an “as needed” basis, which will always involve a certain level of waste, since it relies on patients’ input.

Alternative ways to provide repeat medication are currently under investigation. Pharmacist-led repeat dispensing schemes may offer advantages in terms of drug wastage. A pilot study in Grampian found that 56 per cent of study patients did not require their full quota of prescribed drugs. Approximately 16 per cent of all drugs were not dispensed. This was extrapolated to an annual cost avoidance of £22 per patient on the system.⁴

Patient involvement

In addressing issues of drug wastage, ways of involving the patients and, where possible, simplifying the process must be considered. Attention should be given to increasing patient awareness of how to optimise their treatment strategy through concordance with their drug therapy. The importance of taking care in requesting, storing and using medicines must be stressed.

Campaigns to reduce the level of antibiotic prescribing through increased patient awareness have had positive outcomes. Strategies include encouraging patients to visit the community pharmacist for treatment of colds and sore throats, rather than expecting the doctor to prescribe an antibiotic.

Medication changes associated with hospital admission and discharge generate many unwanted medicines, although the policy in many hospitals of reissuing patients’ own medicines on discharge has reduced waste to some extent.⁵ Poor communication between the hospital and community sectors contributes to the level of unnecessary changes with their associated drug and non-drug costs.

Making progress

There is some evidence of higher levels of drug wastage in nursing and residential homes,⁶ although few data are available in other community care settings. This points to a need for better information obtained from well-designed studies, a fact recognised in the report to the Royal Pharmaceutical Society entitled “Setting the research agenda”. The potential input of the community pharmacist is outlined in a report for the Community Pharmacy Research Consortium, “Pharmacists within the primary health care team — realising the potential”.

Medicines wastage extends beyond the volume of unused treatments returned to pharmacies or otherwise disposed of. It includes areas such as missed therapeutic opportunities associated with sub-optimal prescribing and failure to use medicines in instances where they would be beneficial. At the crux of the matter is the overall efficiency of health care provision. Given that funding for research can pose difficulties, the possible financial saving and improved practice should provide the necessary incentive to progress in this area.

Evelyn Cromarty is prescribing support pharmacist at Highland Primary Care NHS Trust. George Downie is trust pharmacy manager at Grampian Primary Care NHS Trust