Expand Prescription Drug Take-Back and Disposal Programs
Most opioid abuse prevention strategies include some sort of prescription drug take-back or disposal program. This is a step in the right direction, but most communities have significant opportunities to expand and enhance these efforts to reach more people and reduce the ability of people to misuse these medications or give them to others who may misuse them. This objective focuses on practical ways to make improvements to existing efforts and to add new options for communities.
Why Safe Disposal is Important
- A majority of abused prescription drugs are obtained from family and friends, including from the home medicine cabinet.
- SAMHSA’s 2009 National Survey on Drug Use and Health found that over 70 percent of people who used prescription pain relievers non-medically got them from friends or relatives, while approximately 5 percent got them from a drug dealer or from the Internet.
- Nearly 80 percent of heroin users reported using prescription opioids prior to heroin. 
- Prescription drugs involved in overdoses are almost all originally prescribed by physicians but are used by individuals other than the patient prescribed the drugs.
- When medicines are no longer needed or have expired, it is important to properly dispose of them to reduce harm from accidental exposure or intentional misuse. Throwing drugs in the garbage is a bad idea, because they can accidentally be taken by kids or pets.
- Some people propose flushing or pouring unused medications down the drain, however, medications flushed into the waste stream can end up in water supplies.
- Since the drugs in take-back programs are incinerated, take-back programs are the safest way to get rid of the chemicals and to stop them from getting into drinking water and watersheds.
- Innovative mail-back options provide a convenient way for people to have excess medications disposed of through incineration. (Details further down on this page.)
To Flush or Not to Flush
If no take-back programs are readily available, it is still important to dispose of the medications quickly and appropriately. Some prescriptions include instructions on how to dispose of the drug. The U.S. Food & Drug Administration (FDA) provides guidance on the safest ways of disposing of these medications at home.  The FDA also recommends that certain drugs be flushed immediately, such as fentanyl patches, Oxycontin, and Percocet, and publishes a full list of pharmaceuticals that are safe to flush.  Other experts strongly recommend not flushing medications down the toilet.
The bottom line is that the best options are bringing your medications to a take-back day, putting them into a drug disposal kiosk, or using a mail-based program to send in the medications for proper disposal. But, if you don't have access to these options, flushing unused medications that are on the "flush list" is better than keeping them around.
- Senior Citizens -- Senior citizens have a disproportionate number of medications in their homes. Helping seniors understand how to properly dispose of medications can make a big difference in the success of your program.
- Nursing Homes One study estimated the nation’s nursing homes discard anywhere from $73 million to $378 million worth of drugs a year. Some are incinerated, but many are flushed. Nursing homes could be provided with information and tools (or services) for more appropriate disposal options that are better for the environment and that minimize the likelihood of diversion of these medications.
- Hospice Programs and Funeral Homes -- Hospice programs can help family members understand how to properly handle the medications they inherit when a loved one passes away. Funeral homes may pass out a brochure to remind people to make sure that any prescription drugs that were being taken by a loved one are properly disposed of. People in the late stages of life may have been getting prescription opioids to deal with pain. Hospice and funeral homes could be provided with disposal options.
Increasing the Number of Drug Drop-Boxes in your Community
Disposing of unneeded medications via a drug drop box is considered the best disposal option. So, it is important for communities to increase the number of drop boxes that are available and to promote awareness of them as a disposal option. Drop boxes have resulted in multiple cities and communities being safer and reducing the risk of opioid addiction. Boxes are often located in close proximity to law enforcement agencies, so that the drugs are secure. However, many pharmacies are now providing drop boxes as well. The Product Stewardship Institute provides detailed guidance for expanding and improving a pharmacy-based collection program.
There are three primary categories of in-home disposal — deactivation powders that are poured into prescription bottles, deactivation pouches that prescriptions can be poured, and medication mail-back envelopes. An example of a vendors that provide each of these are listed in the “Available Tools and Resources” section below. All three approaches have the benefit of being a low-cost solution to disposal. Powder packets offer a level of simplicity in distribution, because they can be easily attached to prescriptions by the pharmacist. All three in-home disposal approaches are useful as give-aways in campaigns to increase awareness of medication safety. All three methods support the environmental concerns discussed above and decrease the possibility of accidental exposure or intentional misuse.
Extended Producer Responsibility (EPR), also known as product stewardship, describes a system where the life cycle costs of a product become part of the cost of manufacturing. EPR is a proven method to sustainably fund the recycling or disposal of a variety of products that have disposal concerns, such as paint and fluorescent lights. This holds promise for a change in responsibility for pharmaceutical disposal. The Product Stewardship Institute documents two successful cases: 
- In France, the pharmaceutical EPR collects on average over 16,000 tons per year, at a cost of just $0.0022 per box. "In a recent survey, 77% of French residents claimed to have disposed of unwanted medication via these take-back sites, while 70% said they always dispose of pharmaceuticals in this way."
- In British Columbia the pharmaceutical industry has been funding the entire cost of their drug take-back program since 2004.
Impactful Federal, State, and Local Policies
- Drug Take-Back Programs -- Several West Coast counties, the city of San Francisco, and the state of Massachusetts have issued legislation that require drug companies to fund drug take-back programs. The Product Stewardship Institute, a nonprofit that supports drug take-back programs, calculated that at least a dozen other local governments around the country are considering similar legislation. On a national level, however, only 2.5 percent of eligible take-back organizations are participating, according to the Government Accountability Office.  The primary barrier seems to be financial: Maintaining secure prescription drop-off container, training staff to follow the relevant regulations, and destroying the returned medication costs money. As a potential solution, writing a policy that mandates opioid manufacturers to pay patients for their returned bottles of pills, along with subsidizing drop-off location operators, could offset the costs and be what is needed to make returning leftover medication an automatic habit for consumers.
- State Legislation Requiring Disposal Kits be Given with Prescriptions -- In 2018 Kentucky passed a bill that amended KRS 218A.170 -- requiring "a practitioner or a pharmacist to sell or distribute a nontoxic composition, which permanently captures the controlled substance, for the sequestration or deactivation and disposal of unused, unwanted, or expired controlled substances anytime a controlled substance is sold or distributed." . Kentucky was the first state to pass such a bill.
Available Tools and Resources
DEA National Drug Take-Back Day Initiative
The National Prescription Drug Take Back Day Initiative addresses a crucial public safety and public health issue by providing an opportunity for Americans to prevent drug addiction and overdose deaths. Since September 2010, the DEA has been promoting two national take-back days each year in April and October. An ongoing inventory of success cases is documented at the DEA website. Nationally, hundreds of tons are collected on each take-back day, and thousands of tons of prescription drugs have been collected through this initiative. To promote your local Rx Take Back Day, the DEA provides a partnership toolkit featuring promotional materials for associated partners  and a variety of on-line take-back resources and ideas on how to implement a local take-back day.
State Level Drug Take-Back Programs
See below for inspiration and ideas to replicate from current state efforts:
Medication Disposal Locators
The National Association of Drug Diversion Investigators (NADDI) provides an online resource to find locations of drop boxes, to buy boxes, apply for grants, and other information about drop boxes. 
Use the following links to find drug disposal locations
- DEA's Disposal Locator - Find locations in your ZIP code. These collectors are registered with the DEA and pass unused medicine on to the agency to disposed.
- Rx Drop Box
- Dispose My Meds
- National Association of Boards of Pharmacy
- The American Medicine Chest Challenge
In-Home Disposal Products
- Stericycle -- "Prescription Drug Seal & Send Pouches" provide an option for unused prescription drugs to be mailed to Stericycle in an unmarked mailing pouch. The pills are then incinerated.
- Deterra Drug Disposal System-- Verde Technologies offers a product which deactivates prescription drugs. Each patented pouch contains a water-soluble inner pod containing activated carbon. Once the pharmaceuticals are placed in the pouch, warm water is then added, which dissolves the inner pod releasing the activated carbon. The warm water also dissolves prescription pills, patches, and liquids, allowing them to be absorbed by the carbon, rendering them inert and non-retrievable. .
- DisposeRx is a powdered blend of solidifying materials that provides a solution for the safe disposal of unwanted or expired prescription drugs. Prescription drugs can be rendered safe for disposal (and impossible to misuse) by adding water and powder from the packet directly into the pill bottle and shaking the bottle. 
The Colorado Consortium for Prescription Drug Abuse Prevention has developed a successful program for reaching people age 65+ 
Efforts to Promote In-Home Disposal
- The State of Pennsylvania has a goal of distributing Deterra® Drug Deactivation and Disposal pouches alongside 10% of all opioid prescriptions. In 2017, Attorney General Shapiro unveiled a plan to distribute 300,000 drug disposal pouches in 12 counties.
- The Inspira Health Network (New Jersey) distributed the Deterra® pouch throughout their network.
- In Minnesota, the Mallinckrodt pharmaceutical company donated 30,000 disposal pouch systems to be distributed.
- Walmart is providing DisposeRx powder packets with its pharmacy prescriptions. 
- Muhuri PK, Gfroerer JC, Davies MC; Substance Abuse and Mental Health Services Administration. Associations of nonmedical pain reliever use and initiation of heroin use in the United States. CBHSQ Data Review. Published August 2013.
- Minnesota Pollution Control Agency https://www.pca.state.mn.us/featured/dont-flush-medicines-down-drain
- http://www.njtvonline.org/news/video/inspira-health-network-battles-opioid-crisis-proper-drug-disposal/ Case Study]