J o u r n a l o f t h e Ame r i c a n Ph a r ma c i s t s As s o c i a t i o n www. j apha . org JAN IIB 2uuu - 4u. !

- JAPhA 65
RESEARCH NOTES
Abstract
Objective: To assess the effect of an educational interven-
tion on pharmacists attitudes and knowledge about medica-
tion disposal.
Methods: In September 2005, a survey was mailed to 488
registered pharmacists serving as experiential education pre-
ceptors to Massachusetts College of Pharmacy and Health Sci-
ences students in 27 states throughout the country. Mailing of
this presurvey occurred 2 months before an educational inter-
vention. An identical postsurvey was mailed to the 223 respon-
dents to the presurvey 3 months after the intervention. The
main outcome measure was change in pharmacist attitudes
and knowledge about medication disposal after educational
intervention.
Results: 158 pharmacists (32% response rate) completed
the pre- and postsurveys. Before the intervention, 47% of phar-
macists perceived inappropriate medication disposal to be an
environmental problem compared with 57% after the interven-
tion (P = 0.03). Similarly, when asked about medication dis-
posal, 10% correctly indicated that patients could arrange for
hazardous waste pick up compared with 20% postintervention
(P < 0.01). Conversely, 19% incorrectly indicated that patients
should wash medications down the sink compared with 5.6%
postintervention (P < 0.01).
Conclusion: A brief educational intervention is effective at
changing pharmacists attitudes and knowledge of inappropri-
ate and environmentally unsafe medication disposal practices.
Pharmacists receiving the educational intervention were more
likely to report that they would recommend appropriate meth-
ods of medication disposal. Further educational efforts are
necessary for improving pharmacists knowledge regarding
safe medication disposal practices.
Keywords: Medication disposal, environmental effects,
public health, unused medications, expired medications, OTC
products.
J Am Pharm Assoc. 2009;49:6568.
doi: 10.1331/JAPhA.2009.08032
Educational campaign for
proper medication disposal
Courtney I. Jarvis, Sheila M. Seed, Matthew Silva,
and Karyn M. Sullivan
Received February 23, 2008, and in revised form July 9, 2008.
Accepted for publication August 23, 2008.
Courtney I. Jarvis, PharmD, is Associate Professor of Phar-
macy Practice, Sheila M. Seed, BPharm, MPH, is Assistant
Professor of Pharmacy Practice, Matthew Silva, PharmD,
BCPS, is Associate Professor of Pharmacy Practice, and
Karyn M. Sullivan, BPharm, MPH, is Assistant Professor of
Pharmacy Practice, School of PharmacyWorcester/Man-
chester, Massachusetts College of Pharmacy and Health Sci-
ences, Worcester.
Correspondence: Courtney I. Jarvis, PharmD, Massachu-
setts College of Pharmacy and Health Sciences, 19 Foster St.,
Worcester, MA 01608-1715. Fax: 508-756-8715. E-mail: court-
ney.jarvis@mcphs.edu
Disclosure: The authors declare no conicts of interest or -
nancial interests in any product or service mentioned in this
article, including grants, employment, gifts, stock holdings,
or honoraria.
Acknowledgment: To Holly Baker for clerical support.
Funding: By the Massachusetts College of Pharmacy and
Health Sciences Faculty Development Grant Program.
Previous presentations: At the American Society of Health-
Systems Pharmacists Midyear Clinical Meeting, Las Vegas,
NV, December 48, 2005, and the American Public Health As-
sociation Annual Meeting, Boston, November 48, 2006.
H
ealth professionals have been recommending for many
years that all unused or expired medications be disposed
by ushing them down the toilet. In fact, most written pa-
tient education materials about safe medication disposal still in-
clude this recommendation. A survey of 301 patients conducted
in an outpatient pharmacy showed that more than one-half had
disposed of unused or expired medications by ushing down
the toilet and less than 20% had ever received advice regarding
proper disposal by a health professional.
1
The problem with im-
proper disposal is that medications become potential pollutants
of ecosystem surface, subsurface, and drinking water.
28
Most
data concerning documented environmental effects have been
related to antibiotics, estrogens, and antidepressants. Antibiot-
ic-resistant bacteria has been found in birds and rivers.
3
Low
levels of estrogen have had a feminization effect on male sh
and may have the ability to alter reproduction in affected spe-
cies.
3
Antidepressants in the environment have been shown to
delay the development of sh and frogs and affect the spawning
behavior of shellsh.
9,10
Adverse health effects in humans have
not been established. Hypothesized effects from continuous ex-
posure include reproductive organ tissue cancers.
3

To reduce the entry of medicinal pollutants into the environ-
ment, guidelines on proper disposal of prescription drugs were
released in February 2007 by the White House Ofce of National
J o u r n a l o f t h e Ame r i c a n Ph a r ma c i s t s As s o c i a t i o n www. j apha . org 66 - JAPhA 4u. ! - JAN/ FEB 2009
RESEARCH NOTES
Table 1. Demographics of respondents to pre- and postsur-
vey assessing pharmacists attitudes toward and knowl-
edge of medication disposal
Respondent characteristic No. respondents (%)
n 158
Age (years)
<25 4 (2.53)
2635 34 (21.52)
3645 32 (20.25)
4655 64 (40.51)
>55 24 (15.19)
Gender
Women 70 (44.30)
Men 88 (55.70)
States represented
Massachusetts 93 (58.86)
California 15 (9.49)
New Hampshire 9 (5.70)
Florida 4 (2.53)
Rhode Island 4 (2.53)
Maryland 4 (2.53)
New York 4 (2.53)
Other 25 (15.82)
Pharmacy practice environment
a
Community chain 64 (37.87)
Community independent 14 (7.66)
Managed care 6 (3.40)
Hospital pharmacy 58 (34.04)
Other 24 (17.02)
Licensed pharmacy experience (years)
<5 9 (5.70)
610 29 (18.35)
1115 20 (12.66)
1620 13 (8.23)
>20 87 (55.06)
a
Some respondents practice in more than one practice environment.
Drug Control Policy, the Department of Health and Human Ser-
vices, and the Environmental Protection Agency.
11
At the same
time, the American Pharmacists Association published guide-
lines on proper disposal techniques.
12
In summary, the guide-
lines recommend that unused or expired prescription drugs be
taken out of their original container and thrown in the trash, un-
less the prescribing information specically states ushing the
drug down the toilet or sink. Furthermore, the guidelines suggest
mixing prescription drugs with undesirable substances such as
used coffee grounds or kitty litter and placement in impermeable
containers will reduce drug diversion.
11,12

Pharmacists are a well-established and important commu-
nity resource for drug information, including answering routine
questions about unused or expired medication disposal. It is
imperative that pharmacists are aware of the updated federal
guidelines for proper medication disposal as well as the environ-
mental impact from improper disposal.
Objective
The objective of this study was to assess the effect of a brief
educational intervention on pharmacists attitudes and knowl-
edge with regard to medication disposal and the potential envi-
ronmental effects of inappropriate disposal.
Methods
This study was approved by the Massachusetts College of
Pharmacy and Health Sciences (MCPHS) Institutional Review
Board, and informed consent was obtained before the study was
conducted. In September 2005, a survey (Appendix 1 in the elec-
tronic version of this article, available online at www.japha.org)
designed to assess the attitudes and knowledge of medication
disposal practices was mailed to 488 registered pharmacists
who serve as experiential education preceptors to MCPHS stu-
dents in 27 states throughout the country. Mailing of this survey
occurred 2 months before an educational intervention. An identi-
cal postsurvey was mailed to the 223 respondents to the pre-
survey 3 months after the intervention (in February 2006). The
intervention consisted of a newsletter containing an article on
the proper disposal of medication and the environmental conse-
quences of inappropriate disposal, as well as other issues rele-
vant to current pharmacy practice. Ten days after the postsurvey
was mailed, a reminder postcard was mailed. Pharmacists who
returned both the pre- and postsurvey received a gift card for
$10 to a national retailer as an incentive for participation.
Responses were calculated for collected demographic in-
formation. A comparison of the responses between the pre- and
postsurveys was conducted using Fishers exact test for propor-
tions, with a predened signicance of P 0.05.
Results
A total of 223 pharmacists (47% response rate) completed
the presurvey. A total of 158 pharmacists (32% response rate)
completed both the pre- and postsurveys. The demographics of
respondents are provided in Table 1. In general, most respon-
dents were Massachusetts pharmacists in hospital or commu-
nity practice with considerable professional experience (55%
with >20 years experience). The results of each survey item are
provided in Table 2. Before the educational intervention, 47%
of pharmacists perceived inappropriate medication disposal to
be an environmental problem. This increased to 57% after the
intervention (P = 0.03). When asked about medication disposal
by patients, 10% correctly indicated that patients could arrange
for hazardous waste pick up during the presurvey. This propor-
tion increased to 20% postintervention (P < 0.01). Conversely,
before the educational intervention, 19% incorrectly indicated
that patients should wash the medication down the sink. This
signicantly decreased to 5.6% after the intervention (P < 0.01).
Similarly, 27% incorrectly indicated on the presurvey that medi-
cation should be ushed down the toilet before the intervention.
The postintervention decrease approached signicance at 22%
(P = 0.08).
Discussion
Pharmacists are a well-respected source of drug information
and are often asked by patients for advice, including methods for
disposal of unused or expired medication. The purpose of this
study was to evaluate knowledge and attitudes about medication
disposal before and after a brief educational intervention. The
J o u r n a l o f t h e Ame r i c a n Ph a r ma c i s t s As s o c i a t i o n www. j apha . org JAN IIB 2uuu - 4u. ! - JAPhA 67
RESEARCH NOTES
results of this interaction suggest that acceptance or learning of
some key medication disposal messages occurred, with room for
continued education, exposure, and awareness in regard to dis-
posal practices. Our brief educational intervention in the form of
a newsletter sent to pharmacy experiential education preceptors
improved knowledge and changed some attitudes of pharmacists
regarding proper disposal. Other potential strategies include
incorporating proper medication disposal practices into phar-
macy education curricula and continuing education programs. It
is imperative that pharmacists are aware of proper medication
disposal, especially in light of the new federal recommendations
designed to protect patients and the environment.
Although disposal of medication in household trash is cur-
rently recommended for most drugs, experts agree that this is not
the best long-term solution.
6,11
Federal guidelines advise the use
of community-based pharmaceutical take-back programs.
11
The
purpose of take-back programs are twofold: control the amount
of pharmaceuticals entering the environment and reduce the
number of prescription medications available for diversion by al-
lowing consumers to return expired or unwanted medications.
13

Several successful take-back programs have emerged outside of
the United States, in Australia, British Columbia, and Sweden. Pi-
lot programs have been initiated in the United States in Washing-
ton, Maine, Florida, Indiana, and California.
14
Existing programs
vary; some consist of annual collections at hazardous waste
facilities, 1-day drop-off events involving pharmacies and local
sheriffs departments, or ongoing programs with collection bins
at participating pharmacies. Australias government-nanced
program has been active since 1998. Since its inception, this
program has collected more than 227,000 kg or 413 million solid
oral dosage forms.
14
Successful single-day take-back programs
have taken place in several states as a partnership between law
enforcement ofcials and pharmacies. Because regulations pro-
hibit the disposal of controlled substances without a waiver from
the Drug Enforcement Administration (DEA) or the presence of
a law enforcement ofcial, these partnerships are encouraged to
allow for disposal of all unwanted medications.
14,15
Maine hopes
to implement a mail-back program once funding is available; the
program would allow patients to use prepaid envelopes, which
would be readily available at physicians ofces, pharmacies,
and post ofces, to send their expired or unwanted pharmaceu-
ticals to the Maine DEA ofce.
14
Similarly, Washingtons pilot
program, Pharmaceuticals from Households: A Return Mecha-
nism (PH:ARM), aims to collect 41,000 kg or 74 million solid
oral dosage forms.
14
The program uses secure containers at des-
ignated sites (pharmacies, nursing homes, and sheriffs depart-
ments) for the collection of unwanted/expired medications. The
returned pharmaceuticals are transported from the collection
sites for witnessed incineration and are tracked from collection
to destruction. Programs that provide continuous drop-off loca-
tions at community pharmacies, health department clinics, re,
police, and sheriffs departments, as well as hazardous waste
facilities, not only benet patients who wish to dispose of phar-
maceuticals but also allow nursing homes, schools, and public
health departments that generate minimal quantities of waste to
dispose of pharmaceuticals properly.
14
Federal recommendations to ush controlled substances
with well-established abuse potential should be questioned.
These recommendations are benecial in that diversion is im-
mediately halted, but this solution may actually contribute to
the problem, as these compounds leach into the ground and
water and create environmental toxicity. More environmentally
safe practices include incinerating these compounds or mixing
them with refuse solids such as kitty litter or coffee grounds and
disposing in impermeable containers, as is recommended with
most other medications.
Table 2. Survey respondents perceptions regarding medi-
cation disposal
Survey item
Presurvey
%
Postsurvey
% P
a
Perception of inappropriate
disposal as public health
problem
Major problem 40.36 46.20 0.89
Minor problem 47.09 46.84 0.52
Not a problem 9.42 5.06 0.08
Undecided 3.14 1.90 0.34
Perception of inappropriate
disposal as environmental
problem
Major problem 46.64 56.96 0.03
b
Minor problem 44.84 40.51 0.23
Not a problem 6.28 1.27 0.01
b
Undecided 2.24 1.27 0.39
Pharmacists are good
resources for information
regarding proper disposal
Strongly agree 41.26 45.57 0.83
Agree 43.95 39.87 0.25
Undecided 10.31 8.86 0.39
Disagree 4.04 3.80 0.56
Strongly disagree 0.45 1.90 0.20
Pharmacist recommendation
for unused or expired medication
Dispose of in trash 12.76 15.67 0.71
Return to pharmacy 21.35 25.75 0.62
Flush down toilet 27.08 22.01 0.56
Wash down sink drain 19.01 5.60 0.01
b
Arrange for hazardous
waste pickup
9.90 20.15 0.09
Other 9.90 10.82 0.99
How often are pharmacists
asked about medication disposal?
Never been asked 17.04 13.29 0.62
Rarely 66.82 73.42 0.64
Several times per month 14.90 12.03 0.73
Several times per week 1.35 1.27 0.57
Where did you learn about
medication disposal?
Never learned about proper disposal 36.32 34.81 0.42
Pharmacy school 19.28 15.19 0.19
Continuing education program 11.21 15.82 0.12
Pharmacy literature 22.87 27.85 0.89
Other 28.25 24.05 0.21
a
Fishers exact test for proportions with a predened signicance of P 0.05.
b
Signicantly different between pre- and postsurveys.
J o u r n a l o f t h e Ame r i c a n Ph a r ma c i s t s As s o c i a t i o n www. j apha . org 68 - JAPhA 4u. ! - JAN/ FEB 2009
RESEARCH NOTES
Until a national plan for the incineration of unused and ex-
pired medications can be developed and implemented, individual
states and communities are encouraged to develop take-back
programs similar to those previously discussed to protect the
public and the environment against improper disposal practices.
Where programs are not available, pharmacists must continue
to counsel patients on proper medication disposal techniques,
using the 2007 federal guidelines.
11

Limitations
The nature of the intervention used in this study may be con-
sidered a limitation. The Industrial Audio Visual Association re-
ports that people tend to remember 10% of what they read, 20%
of what they hear, 30% of what they see, and 50% of what they
both see and hear.
16,17
Therefore, a newsletter may not result
in sustained retention of information. In addition, the postsur-
vey was sent only 3 months after the newsletter, assessing only
short-term changes in knowledge and attitudes about medication
disposal. Also, the positive ndings of our study may be attrib-
uted to other events or experiences that generated knowledge
between the intervention and the 3-month follow-up survey. Par-
ticipants may have gained knowledge on proper medication dis-
posal from medical journals, educational programs, newspaper
articles, or even television programs. Selection bias may have
played a role in our results because those who responded may
have been more interested in medication disposal techniques
than nonresponders. Demographic information was only col-
lected from survey respondents, thereby prohibiting comparison
of responders and nonresponders. Nonresponse bias therefore
cannot be ruled out. In addition, the pre- and postsurveys were
sent before the release of the 2007 federal guidelines. Pharma-
cist knowledge about proper disposal techniques has probably
improved since these data were collected as a result of the new
guidelines receiving publicity in the pharmacy literature. Reas-
sessment of knowledge and attitudes would be benecial for
comparison.
Conclusion
A brief educational intervention in the form of a newsletter
is effective at changing pharmacists attitudes and knowledge of
inappropriate and environmentally unsafe medication disposal
practices. Pharmacists receiving the educational intervention
were more likely to report that they would recommend appropri-
ate methods of medication disposal. Further educational efforts
are necessary for improving pharmacists knowledge regarding
safe medication disposal practices, especially in light of recent
federal guidelines regarding disposal practices.
References
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Appendix 1. Survey assessing effect of an educational intervention on pharmacists attitudes
and knowledge about medication disposal

Please check the appropriate answer(s):
1. What is your age?
< 25
26 to 35
36 to 45
46 to 55
> 55
2. Gender
Female
Male
3. In what state do you work?____________________
4. In what type of pharmacy do you work? (check all that apply)
Chain retail pharmacy
Independent retail pharmacy
Managed care pharmacy
Hospital pharmacy
Other (please specify): _________________
5. How long have you been a licensed pharmacist?
Less than 5 years
6-10 years
11-15 years
16-20 years
Greater than 20 years
For each of the statements below, please indicate the extent of your agreement or disagreement by
placing a check in the appropriate box.
6. To what extent do you perceive the inappropriate disposal of medicine as a public health
problem?
Significant problem Minor problem Not a problem Undecided


7. To what extent do you perceive the inappropriate disposal of medicine to be an environmental
problem?
Significant problem Minor problem Not a problem Undecided


8. To what extent do you agree that pharmacists are a good resource to patients for information
about the proper disposal of medicine?
Strongly agree Agree Undecided Disagree Strongly
disagree


9. If asked by a patient how to dispose of expired or unused medicine, which of the following
statements describes how you would suggest they appropriately dispose of their medicine?
(Check all answers that apply)
Dispose of medicine in household trash
Return medicine to community pharmacy
Flush medicine down the toilet
Wash medicine down the sink drain
Arrange for hazardous waste trash pickup
Other, please specify______________________________________

10. How often do patients ask you about proper disposal of their unused or expired medicine?
Ive never been asked about disposal
I get asked about disposal only rarely
I get asked about disposal several times per month
I get asked about disposal several times per week

11. Where did you learn about the proper disposal of medicine?
I never learned about proper medicine disposal
Pharmacy school
Continuing education program
Pharmacy literature
Other (please specify):____________________________