Efforts to Manage Unneeded and Unwanted Medicine in the Granite State www.nh.gov/medsafety

Brandon Kernen New Hampshire Department of Environmental Services Brandon.Kernen@des.nh.gov (603)271-0660

Emerging Substances of Concern

•  Global Organic Contaminants •  Pharmaceuticals and Personal Care

Products •  Endocrine Modulating Chemicals •  Nanoparticles •  Industrial Chemicals (new and recently

recognized)

•  Includes prescription and over-the-counter (OTC) medications, cleaning agents, cosmetics, nutritional supplements, & skin care products

• Produced and used in larger volumes yearly

• Released via small quantity generators

• Biologically active

• Commercial labs cannot analyze

Pharmaceuticals and Personal Care Products (PPCPs)

PPCPs – DES Program Interest

•  Drinking Water •  Wastewater - Surface Water Discharges •  Wastewater - Groundwater Discharges •  Wastewater - Pretreatment •  Watershed Management – Ecological Impacts •  Residuals Management •  Solid Waste Management •  Air – Incineration of Solid Waste •  Household Hazardous Waste Management •  Hazardous Waste Management •  Environmental Health Program

NHDES Interests in PPCPs •  Assessing Occurrence (overcoming analytical lab issues) •  Fate & Transport •  Human Health/Ecological Health •  Source Characterization (individual use & disposal, vet/

livestock, manufacturing) •  Treatment (wastewater/drinking water) •  Pollution Prevention (green chemistry, life cycle analysis, take

back programs, public education, behavior modification) •  Risk Communication/Perspective – See Factsheet •  Public Education •  Policy/Regulation (fed/state reg, policy, liability, nonreg)

NH Drug Deaths 1995-2009

From Dr. Andrew, Chief Medical Examiner

Drug Deaths 2000-2009 by Age

From Dr. Andrew, Chief Medical Examiner

Drug Deaths 2000-2009 by Sex

From Dr. Andrew, Chief Medical Examiner

Leading Agents in NH Drug Deaths

From Dr. Andrew, Chief Medical Examiner

NH Top Ten 2004-2009

2004 Methadone Cocaine Oxycodone “Heroin” Fentanyl Diazepam Hydrocodone Alprazolam Quetiapine Amitriptyline

2005 Methadone Cocaine Oxycodone Diazepam “Heroin” Quetiapine Hydrocodone Citalopram Fentanyl Alprazolam

2006 Methadone Cocaine Oxycodone Diazepam Fentanyl Venlafaxine “Heroin” Clonazepam Acetaminophen Alprazolam

2007 Methadone Cocaine Oxycodone Diazepam Morphine Fentanyl “Heroin” Alprazolam Tramadol Hydrocodone

2008 Methadone Oxycodone Cocaine “Heroin” Diazepam Morphine Fentanyl Alprazolam Hydrocodone Citalopram

2009 Methadone Oxycodone Cocaine “Heroin” Citalopram Morphine Alprazolam Fentanyl Clonazepam Diazepam

From Dr. Andrew, Chief Medical Examiner

Single Agent Deaths 2005-2008 2005

61/151(40%) Methadone "Opiates“ Heroin Oxycodone Cocaine Fentanyl Methamphetamine Clozapine Tramadol Propoxyphene Lithium Citalopram Morphine Acetaminophen Benzos (NOS) Hydrocodone Clonazepam Venalfaxine

2006 44/138 (32%) "Opiates“ Methadone Cocaine Heroin Acetaminophen Oxycodone Fentanyl Olanzepine Barbiturate Valproic acid Buprenorphine Morphine Diphenhydramine Venlafaxine Temazepam

2007 61/168 (36%) Methadone "Opiates“ Cocaine Heroin Oxycodone Fentanyl Morphine Aspirin Diphenhydramine Tramadol Nortriptyline

2008 45/117 (38%) Heroin Methadone Cocaine Fentanyl Oxycodone Tramadol Fluoxetine Carisoprodol "Opiates“ Morphine Aspirin Acetaminophen Buprenorphine Diazepam

2009 53/164 (32%) Methadone Heroin Oxycodone Fentanyl Morphine Cocaine Acetaminophen Insulin Amitriptyline Carisoprodol Clozapine Lithium Pentobarbital Quetiapine Sertraline

Source of Drug 2008 2009

Prescribed 48 83

Illicitly obtained 45 63

Illicit/prescribed 12 6

Over-the-counter 4 4

OTC/prescribed 3 3

Undetermined 3 1

NH Drug Deaths vs. Traffic Deaths1995-2009

Concentrations PPCPs are generally detected in water resources

Ongoing Studies in NH •  Fish Tissue and Water in the Connecticut and

Merrimack River (EPA) •  PPCP loading in the Merrimack River

Watershed (UNH) •  Squam Lake Association/Squam Lake •  Wastewater at a County Nursing Home/

Prison •  Water pre and post treatment from a

reservoir •  Leach field site at a nursing homes •  Testing of some NH water systems in a few

years

USEPA Candidate Contaminant List 3 For the first time includes 10 pharmaceuticals: • Erythromycin • 17 alpha-estradiol • 17 beta-estradiol • Equilenin • Equilin • Estriol • Estrone • ethinyl estradiol • Mestranol • Norethindrone

Antibiotic

Hormones

Reducing pharmaceuticals in the environment would require changes in:

1)  When and how medicine is prescribed and used;

2)  How pharmaceuticals are designed and engineered so they do not persist once released in the environment;

3)  Wastewater and drinking water treatment technologies; and

4)  How unused medicines are disposed of (probably 5%-15% of the problem).

NH Initiatives 1)  Encouraging the use of green chemistry and

life cycle environmental analysis of products (letter from NE states to government agencies)

2)  Encouraging refinement of USDEA controlled drug disposal regulations

3)  Conducting environmental sampling 4)  Developing and promoting medicine

collection and disposal policies. 5)  Removing state regulatory barriers for safe

medicine disposal

Assessment of Medicine Disposal Options White Paper Developed by DES

Summarizes •  Medicine use trends in the United States •  Other considerations (drug abuse and poisoning) •  Legal issues affecting how unused medicines may be

collected and disposed •  Potential health and environmental issues associated

with releasing medicines to solid waste facilities and wastewater disposal systems

•  Typical unused residential medicine disposal and reuse practices in New Hampshire

•  Options for managing unused medicine in NH

Understanding Current Medicine Disposal Practices in NH

Professional poll of 500 adults was conducted by the University of NH Survey Center Survey results are analyzed by:

• All results • Political affiliation • Religion • Education

• Income • Region of the state • Age • Households with and without children

How does your household typically get rid of unused or expired medicines?

What is your best estimate of the total number of containers of medicine currently in your house?

Approximately what proportion of all prescription medicine in your home are household members using or planning to use in the next 6 months?

Thinking about any unused prescription medicine you have in the home, why is this medicine not likely to be used in the

next six months?

Thinking about any unused prescription medicine you have in the home, why have you not disposed of it?

Have you seen the State of New Hampshire's guidance about how to properly dispose of unused medicines?

When you think about the disposal of unused medicines, both prescription and over-the-counter, do you worry

about any of the following…….

NH Medicine Disposal Workgroup

•  Stakeholder meeting in January 2009 (approx 80 people)

•  Formed working groups to develop medicine disposal policies for various settings (homes, school nurses, veterinarians, hospice, long-term health care, farms)

DES Medicine Disposal Policies Developed to Date

•  Residential medicine disposal policy •  Medicine collection and disposal SOP •  Medicine disposal policies for school

nurses •  Medicine disposal policy for hospice

Work will occur on guidance for long-term health care facilities.

NH’s Household Medicine Disposal Message Help Prevent Pollution, Poisonings and Drug Abuse!

Dispose of your Unneeded Medication 6 Steps to Safety

1) Pour medicine into a sealable plastic bag. 2) If the medicine is a solid, add a small amount of water to dissolve it. 3) Add any undesirable substance (such as dirt, coffee grounds or kitty litter)

to the liquid medicine in the plastic bag. 4) Seal the bag and immediately dispose of it in the trash for regular pick-up. 5) Use marker to black out any personal contact information on the empty

medicine container prior to disposing of it in the trash. 6) For more information, consult www.nh.gov/medsafety.

Medicine collection events staffed by law enforcement, if readily available, are also good options for safely disposing of unwanted medicine.

Do NOT flush medicine down the toilet unless accompanying product information instructs that it is safe to do so. Don't keep unneeded medications in the home. For more information or in case of an accidental poisoning, call the poison center at 1-800-222-1222.

Medicine Disposal as Solid Waste •  Addresses environmental, drug abuse and drug

poisoning concerns •  Solid Waste in NH

–  15% Incinerated –  85% in Landfills (almost all landfills are lined and capped)

•  Most medicine disposed of in a landfill will be retained by solids or break down through chemical processes

•  Leachate at lined landfills is collected and can be treated.

•  Solid waste disposal is readily available to households.

•  Does require additional financial resources •  Readily available disposal option to all

Marketing of the Residential Disposal Message

•  New state website (www.nh.gov/medsafety) •  News articles will be published by various

organizations •  Look for opportunities with utilities •  Press release •  Post cards have been sent to licensed health

care workers (16,000 people) •  Posters are available to interested

organizations •  Stakeholder e-mail list

Removing Regulatory Barriers

•  Fixing state law to clarify that law enforcement can collect unwanted medicine (HB 607 will be introduced in 2011)

•  Amending hazardous waste regulations to enable law enforcement to collect and dispose of collected medicine without substantially complying with hazardous waste regulations.

Challenges •  Decentralized efforts among stakeholders •  Maintaining a message aligned with other

stakeholders is very difficult •  Lack of legal understanding among

stakeholders •  New initiatives cancel/dilute ongoing

initiatives – Efforts should always be integrated