IOWA CITY – When a patient emerges from anesthesia after surgery, his nurse wants to make sure he doesn’t feel pain.
She gets a 1 milliliter syringe of hydromorphone, a generic form of Dilaudid, from a secure drug cabinet. She plans to give her patient .2 milliliter. Even patients with open hysterectomies – some of the most painful procedures – need just .4 milliliter.
She squirts the rest of the drug down the drain, where it can’t be abused by addicts but can pollute drinking water.
UI nurses disposed of an average 70 percent of each of 47,000 hydromorphone 1 milliliter syringes with waste in fiscal 2013.
Portions of nearly 250,000 doses of prescription medication were flushed down the drain or returned to the UI Hospitals and Clinics pharmacy to be wasted in the past two years, despite U.S. Environmental Protection Agency guidelines against flushing drugs.
The UI Hospitals disposed of another 100,000 units of drugs worth nearly $1.5 million in the last two years because the drugs were expired, recalled or not stored properly.
But the UI doesn’t know how many drugs are wasted overall because records aren’t stored in one place, and some hospital units still use paper to track prescriptions.
Drug waste common, not benchmarked
Drug waste is inevitable at any hospital, especially one such as UI Hospitals, which dispenses 5 million doses of medication to inpatients each year and stocks 4,000 combinations of 1,200 drugs. The 700-bed hospital deals with more unique ailments and more serious cases than any other hospital in the state.
Hospitals aren’t benchmarking drug waste, so it’s impossible to know how the UI Hospitals compares.
Some of the reasons for waste, such as pharmaceutical companies selling drugs in too-large containers, are out of the hospital’s hands.
But the drugs wasted at the UI Hospitals and across the nation create a disposal nightmare. Prescription drugs found in waterways can make animals and humans sick. Tossing life-saving drugs also adds to the ballooning cost of American health care.
“There is a lot of opportunity to address the environmental concerns and identify opportunities for cost savings,” said Janet Howard, director of facility engagement for Practice Greenhealth, a not-for-profit organization based in Virginia that helps hospitals seek environmental solutions. “The challenge is it takes time.”
Keeping drugs away from addicts
Only about 5 percent of drugs prescribed in a hospital are controlled substances, which are governed by the U.S. Drug Enforcement Agency. A 1970 law requires drug manufacturers, distributors and dispensers to track drugs from production to dispensing or destruction.
“It’s sort of like cradle to grave for drugs,” said Scott Collier, diversion program manager for the DEA’s St. Louis division.
The goal is to prevent diversion of drugs to addicts. But this doesn’t always work.
A Minnesota nurse was charged in 2011 with skimming drugs off a patient before he had surgery for kidney stones. The man claimed Sarah May Casareto told him he would need to “man up” because they couldn’t give him much painkiller, according to the Minneapolis Star Tribune.
He was left writhing in pain because Casareto took his fentanyl, the newspaper reported. Casareto pleaded guilty to fifth-degree drug possession.
UI Hospitals tracks drugs from the moment they arrive at the loading dock to when they are dispensed or wasted. To avoid overstocking, pharmacists assign a value to each drug that indicates at which point it should be reordered.
The hospitals’ precautions to avoid drug theft include witnesses verifying each drug transfer, fingerprint access to secure drug cabinets and even a drug vault with bullet-proof windows, a steel door and reinforced walls.
UI drug data not centralized
Despite meticulous drug security, UI Hospitals does not have centralized records for drug tracking and does not examine drug waste as a whole.
The best data UI officials could provide to show drug waste came from EXP Pharmaceuticals, a California-based company that picks up wasted drugs every three weeks at UI Hospitals. EXP is a reverse distributor also used by UnityPoint Health-St. Luke’s Hospital and Mercy Medical Center in Cedar Rapids.
A Gazette analysis of the UI’s EXP data from fiscal 2012 and fiscal 2013 shows:
- EXP picked up 105,471 units of wasted drugs worth $1.47 million from UI Hospitals during that time. More than $800,000 worth of these drugs was eligible for return to manufacturers. EXP destroys the rest, likely by incineration.
- About 20 percent of the drugs make up 80 percent of the waste. Painkillers, anesthetics and anti-anxiety medicines are high-use drugs, which equates to high waste.
- Several of the UI’s high-waste drugs have been included on shortage lists by the Food and Drug Administration.
- Although wasted in smaller quantities, some ultra-expensive drugs were tossed at UI Hospitals. These include two Gliadel wafers worth a total $38,000 used to implant in the brain to kill cancer cells, and four doses of snakebite antidote Crofab valued at a combined $11,800.
Drugs wasted at the bedside, such as the hydromorphone washed down the drain, are tracked through AcuDose-Rx machines used throughout the hospital.
These secure medicine cabinets require nurses to scan their fingerprint and enter a password before gaining entry and then recording what is dispensed and how much is left. Another nurse must witness waste going down the drain.
The problem with this data is that not all hospital units have AcuDose machines. The operating room, which handles about 75 surgeries a day, still uses paper slips to record each anesthetic or painkiller prescribed for a procedure.
The UI Hospitals charged The Gazette $525 for two years’ worth of waste records from the AcuDose machines. Those records showed 248,246 drug transactions that resulted in waste.
Because the data did not include how much was prescribed or administered, it was difficult to tell how much was wasted.
The Gazette was able to determine that when UI employees wasted portions of 1 milliliter hydromorphone syringes in fiscal 2013 – which was 47,000 times – the average waste was .7 milliliters, or 70 percent of each syringe.
Packaging contributes to waste
Pharmaceutical companies contribute to drug waste by packaging drugs in units that are too large for a single dose, UI officials said.
The 1 milliliter hydromorphone syringes contain more than twice as much medicine as most patients need in a single dose and the extra can’t be saved because of drug control laws.
Hospira, one of the world’s largest suppliers of generic drugs, also makes a .5 milliliter syringe of hydromorphone. But it is more expensive than the larger syringe and oddly shaped, so it’s hard to stock in the AcuDose machines, said UI Pharmacy Manager Becky Triplett.
Another example is Acyclovir, an antiviral medication that can be used to treat infections in children. The one-gram vials available on the market are too large, even for adults, Triplett said.
“Why do they sell it that way?” she said. “I don’t know.”
And yet, UI pharmacy officials have not asked drug manufacturers make smaller containers, said Mike Brownlee, UI associate director and chief pharmacy officer.
“Because of drug shortages, we have been focused on just acquiring the drug let alone getting it in a different package size,” he said.
The UI Hospitals are part of the University HealthSystem Consortium, a Chicago-based alliance of 120 academic medical centers and 299 affiliated hospitals. Doug Smith, senior director of supply chain services for the organization, has heard other hospital officials complain about drugs being packaged in oversized containers – particularly for children.
“Most of the manufacturers have created strengths and vial size based on adult doses,” Smith said. “If they want to make a product at a smaller dose, they must go to the FDA for approval.”
Despite the UHC’s size and clout, Smith doesn’t think the organization could convince pharmaceutical companies to change their ways. He recalled asking the industry in the 1980s to produce 12 new formulas so that pharmacists wouldn’t have to dilute existing medications.
None of the changes were made.
“They have limited capacity in what they came make,” Smith said. “Adding another vial is another product line. Some of it is an economic decision they have to make.”
Drugs in the water
A 1999-2000 survey by the U.S. Geological Survey showed 80 percent of 139 streams across the nation had traces of prescription drugs, including antibiotics, antidepressants and hormones. Most of these drugs enter the water supply from human consumption and excretion. But drugs flushed down hospital sinks contribute to the flow.
Even small amounts of prescription drugs in water can harm animals.
Estrogen in some lakes and streams in different parts of the country has caused fish to develop both male and female sex characteristics, according to USGS research.
In another study, male fathead minnows exposed to antidepressants at low levels showed decreased attention to females. The male fish, when exposed to higher levels of fluoxetine, the active ingredient in Prozac, became aggressive to females, even killing them, said Rebecca Klaper, an associate professor at the University of Wisconsin-Milwaukee’s School of Freshwater Sciences.
Prescription drugs in water could also affect humans, but it’s harder to study.
“We still do not know if there are long-term problems, especially for sensitive populations like children,” said Dana Kolpin, an Iowa City-based USGS researcher who has studied the effects of prescription drugs on white sucker fish in central Iowa.
Research such as this spurred the EPA to study drug disposal practices at U.S. hospitals. The agency visited 12 health care facilities, reviewed disposal records of 20 facilities and talked with about 700 people from hospitals, government agencies and drug-management companies to come up with best practices released in 2010.
“EPA’s goal is to keep pharmaceuticals out of U.S. waters,” the report said.
The EPA recommends hospitals track every drug dispensed for several weeks to discover waste patterns.
The UI Hospitals uses several of the EPA’s best practices, such as refusing drug samples, rotating stock and segregating waste, but officials have not done a waste inventory, Brownlee said.
“A deeper dive may reveal something, it may not,” Brownlee said.
Examining waste data
Researchers with the Albany, N.Y., Medical Center received a two-year EPA grant in 2007 to collect and sort pharmaceutical waste in some areas of the 630-bed academic medical center.
When the team sorted more than a year’s worth of waste from eight operating rooms, they found propofol, a common anesthetic, made up 45 percent.
“They were opening a bunch of bottles and wasting 90 percent of it,” said Russell Mankes, a retired associate professor in Albany’s Center for Neuropharmacology & Neuroscience.
As propofol doesn’t degrade in nature, accumulates in body fat and is toxic to aquatic life, the team looked for ways to reduce the waste, Mankes said.
By removing 50 milliliter and 100 milliliter vials of propofol from the pharmacy and keeping only the 20 milliliter vials, Albany practitioners wasted less, the study showed. The savings were estimated at $100,000 a year.
Many hospitals are struggling to do the right thing, said Howard, from Project Greenhealth. Some hospitals want to hire a reverse distributor, but they can’t afford it or there are no approved companies nearby, she said.
Health care centers can’t donate pharmaceuticals because of the risk of liability if the drugs aren’t used properly or before expiration.
But examining waste data can lead to easy solutions, such as switching prescribing patterns or stocking a different strength of medicine, Mankes said.“You may have some real opportunities there to reduce waste, improve the bottom line and stop poisoning the fish and people around you,” he said.