A RUM deal for unwanted medicines

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Hi, I'm Jo Cheah, your host for this episode of the Australian Prescriber podcast. Today I'd like to welcome Amanda Wheeler who is a professor of mental health at Griffith University in Brisbane. Together with her team, Amanda has written the article ‘Returning unwanted medicines to pharmacies: prescribing to reduce waste’ in the June edition of the Australian Prescriber. Amanda welcome and thanks for taking the time to speak with me today.

Thanks Jo.

So Amanda, could you perhaps just tell us briefly about the RUM Project and what it actually stands?

The RUM Project stands for Return Unwanted Medicines. Some other people call it the ‘yellow bin project’. Basically, it's a project that's been available in Australia since around 1998. It's an initiative that's been funded by the Federal Government and it provides everyone in Australia who is living here with a free and convenient way to dispose of their unwanted medicines. That includes things that’ve expired, packets they've opened that they don’t need anymore, any kind of medicines that they just don't need to have in the house anymore they can take them to their pharmacy and that community pharmacy will organise for safe collection of that. They put them all into a big yellow storage bin and they're collected, and they're disposed of in a way that's environmentally safe.

So that's a really good introduction to the topic. So why is the RUM project important and what made you interested in the RUM project to start with?

I think most of us have medicines that we no longer need or that have expired and we don't realise they've sort of accumulated in our bathroom cabinets and our kitchen cupboards and we don't sort of think about it but I think storing our modern medicines in the home, we know it can actually be dangerous, so keeping expired medicines, medicines that may no longer be effective and in some cases they may be toxic or harmful to use such as eyedrops. And if medicines end up in the wrong hands they can cause harm from accidental ingestion. So, I suppose we think logically of you know worrying about children but also pets if they consume them accidently.

So, for people who don't know, why can't we throw out our medication in the bin or pour the liquids down the sink? I think a lot of people do do that just naturally without knowing the consequences.

If we put medicines into our general household rubbish or flush them down the toilet they actually end up in landfill and or straight away into the waterways, so they can actually damage the environment. And then there’s been research to show that they can have an effect on plant and animal life and there's the potential there, although we don't have all the evidence, but there's potential there that they may harm human lives as well.

So that's really interesting because I don't think a lot of people would necessarily think about the environmental impact of throwing their tablets in the bin and so it's good for you to clear that up for us. So what kind of medicines are being returned and the most common ones that you've mentioned in your article, why do you think these are the ones that are being returned?

Well I'll just go back when we at Griffith University were asked to do an evaluation of the contents of the bins to see what was actually being returned. So we actually looked at 423 bins that had been collected from pharmacies all around Australia and there were more than 30,000 different medicine items in those bins. Most of those medicines were prescription medicines that are being prescribed by a doctor. There was a smaller amount of medicines that you could buy in a pharmacy and medicines that had been dispensed in blister packs or dose administration aids. And when we looked at those medicines and the most common medicines being prescribed were also being discarded when they were unwanted or expired. But the actual top three returned medicines were for the treatment of acute conditions so they were things like paracetamol for as an analgesic, salbutamol for asthma attacks and glyceryl trinitrate for angina attacks. So they were things being used for short-term conditions.

OK, so the RUM project is a subsidised national scheme and in your article you've written that the cost of waste and medicines discarded by the RUM project is approximately $11.6 million a year. So is this figure a good figure, is the project working, and do you have any comments about that?

Yeah, look, I think it's always hard to… what's the cost of waste? How do we reduce waste? And I think there's been a lot of work done in the UK to look at how to reduce waste but realistically there's never going to be a situation when there are no wasted medicines. I mean people are not going to tolerate some medicines, people sometimes need to have them at home in case of an emergency but then they'll go out of date, and the right thing is that they've got them there and they discard them once they've gone out of date. So we're always going to have wasted medicines and in fact probably the better thing to focus on is getting people to clean out their medicine cabinets regularly and return their unwanted medicines via the RUM project and we want people to use the service. And I think that's everyone's responsibility not just pharmacists to remind people. I think we kind of think it's logical that pharmacists would play a primary role in raising awareness but I think it's every health professional’s responsibility especially if they know they're changing someone's medicines, if they're being discharged from hospital and lots of medicines are being stopped, or perhaps even when someone's passed away.

Yeah, that's a really good point, especially, you know, if patients are going into hospitals there's a lot of medication changes we do often say ‘Do you want us to hold onto these medicines and actually discard them for you?’ Sometimes we get patients or families saying ‘Oh, actually, I want to hold onto that just in case.’ Yeah so I mean that's quite a common thing that happens.

It comes back to education. I think we need to talk to people when they understand why we're trying to minimise accumulation. I think it's a role of education for health professionals. I think also having said there is a role for everyone, and that’s health professionals but also consumers, to really be aware of what medicines are actually needed, especially you know regular medicines and if-required medicines, so that means when we're prescribing medicines, when medicines are being dispensed and when consumers are actually requesting repeats.

So are there any tips or strategies that you'd have for doctors or pharmacists in their you know daily practice to reduce waste or in anything we should be saying to patients in particular?

Well I think raising some of those things so, before a doctor goes to write out a repeat prescription or send a repeat prescription perhaps after someone's rung to request it, actually prompting and saying ‘Have you checked which ones you actually need? I see you've got three that are regular and obviously they're really important. We don't want to…’ It's that hard balance between making sure that people have got access to the medicines they need when they need them but not actually having a lot so that they do start accumulating. And I think that’s probably, particularly for if-required medicines, that doctors need to ask before they're prescribing how much does someone actually need, pharmacists need to check if if-required medicines are needed. So it comes back to education and the sort of counselling role but also remembering just to ask I think.

And you've made a good point in regards to the when-needed medicines. Often in hospitals we see opioids are prescribed following surgery. These are prescribed on discharge and the pharmacists dispense it, but then your article said that actually a lot of patients aren't using these opioids following surgery.

I mean I think especially with your opioid medicines, things that are potentially dangerous to have in the home for accidental ingestion, but they're also a safety issue as well. There have been cases of people being targeted because they know they have been provided with a large amount of an opioid medicine. So I think that research that came out of the United States found that up to 70% of opioids that were prescribed or dispensed after surgery actually went unused and if they're needing something for more than that time that's longer than the prescriber would expect then they have a follow-up appointment.

Yeah that's a good point. So the doctor’s actually prescribing appropriately, pharmacist’s reviewing the prescription making sure that it looks appropriate based on what the patient's had in hospital, for example, and then giving them enough and then booking in a review so that if they did need further supply they could get some more from their prescriber.

Yeah absolutely.

Yeah, so the RUM project, I read in your article, it doesn't accept sharps or cytotoxic agents and in some states Schedule 8 items, so where should we be referring our patients to in regards to how they should be disposing of these items safely?

Well it's really hard. Unfortunately in Australia there's no definitive consistent scheme that's nationwide available for consumers for dealing with sharps and cytotoxic agents so we recommend that people, often these are prescribed at a hospital level or whether obtaining them to actually ask what other systems or mechanisms might be in place. And, whilst it would seem that it's just logical that it gets addressed by the RUM project, but at the moment the RUM project, I understand that have had their funding extended for another four years, but at the same rate, so they can't sort of increase their capacity to deal with sharps and such toxic agents. But a lot of those people it’s at a specialist level and so I think it's going back to the hospital at the moment and asking where they can dispose of those safely.

Yeah that's a good point. So it's more it could be a facility-based wastage or something like that. We do obviously at hospital have cytotoxic bins and sharps bins. I guess to wrap things up a little bit, so for health practitioners working in primary care areas so what are the main points that you want them to take away in regards to the RUM project?

I think really raising awareness. I think what we knew from the other part of the project was that we surveyed sort of almost four and a half thousand Australians about the awareness of the RUM project and more than 80% we surveyed were completely unaware of how to dispose of their unwanted medicines safely and appropriately. Most of them had actually disposed of them in the household rubbish or into the toilet or drain. So I think, on a positive note, those people said to us that, once they knew about the free service that they could access at a community pharmacy, more than 90% of them said they'd use it in the future.

So basically raising awareness and then just reminding your patients, you know, have a look at where you're storing your medications and then maybe a couple of times you bring it all down to the pharmacy and we can have a look at it for you. So, Amanda, thank you so much. It's been a pleasure having you on.

Thanks Joe, it’s been a pleasure speaking to you today.

Professor Wheeler’s full article is available online at nps.org.au. The views of the host and their guests on the podcast are their own and may not represent Australian Prescriber or NPS MedicineWise. I'm Jo Cheah and thanks for listening.