Issues around household pharmaceutical waste disposalthrough community pharmacies in Croatia

Danijela Jonjic • Ksenija Vitale

Received: 19 September 2013 / Accepted: 24 March 2014 / Published online: 1 April 2014

� Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie 2014

Abstract Background Croatian regulations mandate

pharmacies to receive unused medicines from households.

Pharmacies are considered as producers and holders of

pharmaceutical waste and are obliged to finance this ser-

vice. Model where pharmacies are responsible for financ-

ing disposal of unused medicines without reimbursement is

not common in Europe. Present service was not tested

before implementation. Objective To investigate the ele-

ments of the pharmaceutical waste disposal service pro-

vided by pharmacies, and to gain insight into the factors

that might influence the effectiveness of the service. Setting

All pharmacies in the city of Zagreb. Method Each phar-

macy was asked to weigh the collected waste from the

public during a period of 30 days, between June 1st and

July 10th of 2011, absent from any media advertisement

and answer a specifically designed questionnaire that was

exploring possible connections between the amount of

collected waste, type of pharmacy ownership, discretion

while disposing, location of the container, appropriate

labeling and to compare the amount of collected waste

between neighborhoods. Main outcome measure Quantity

of collected unused medicines from the public. Results Of

210 pharmacies, 91 participated completing the question-

naire (43 % response rate). The total amount of collected

waste was 505 kg. Pharmacies owned by the city of Zagreb

had higher response rate (74 %) than privately owned

pharmacies (36 %), and collected significantly higher

amount of waste. Anonymity when disposing influenced

collected quantity, while labelling and location of the

container did not. There were differences in the amount of

collected waste between neighborhoods due to the demo-

graphic characteristics and number of pharmacies per

capita. Conclusion The effectiveness of the pharmacy

service of collecting unused medicines in Croatia shows a

number of weaknesses. The amount of collected medicines

is below the European average. Functioning of the service

seems to be negatively influenced by the type of pharmacy

ownership, distribution of pharmacies and lack of ano-

nymity when disposing unused medicines. Additionally,

type of ownership is connected with financial burden for

pharmacies. Governmental bodies should examine current

legislation regulating pharmaceutical waste disposal, par-

ticularly financial responsibility for providing the service,

in order to increase pharmacies’ compliance. Advertising

of the service may increase awareness of the importance of

proper disposal of unused medicines.

Keywords Croatia � Disposal � Household waste �Pharmaceutical waste � Pharmacies � Unused medicines

Impact of the findings on practice

• Involving community pharmacies and their represen-

tatives in creating legislation that regulates pharmacies’

waste management service and having their agreement

on proposed conditions of providing that service is

necessary for its effectiveness.

• Ensuring the public can dispose unused medicines at a

pharmacy with discretion and anonymously greatly

increases effectiveness of the service.

• Existing service of collecting medicines through net-

work of community pharmacies in Croatia needs to be

improved.

D. Jonjic (&) � K. Vitale

School of Medicine, School of Public Health

‘‘Andrija Stampar’’, University of Zagreb, Rockfellerova 4,

10 000 Zagreb, Croatia

e-mail: djonjic0102@gmail.com

123

Int J Clin Pharm (2014) 36:556–563

DOI 10.1007/s11096-014-9936-7

Introduction

As the production and consumption of medicines is

increasing worldwide, so do the pharmaceutical residues

and their metabolites in the environment [1–6]. Along with

environmental pollution through metabolite excretion of

treated humans and animals, improper disposal of unused

medicines adds to the polluting waters and soil-harming

aquatic organisms [7–9]. Additionally, pharmaceutical

residues in the environment may have harmful effects on

human health, primarily contributing to the increase in

antibiotic resistance and interfering with the human hor-

monal system [3–6].

Research in Croatia determined pollution with pharma-

ceutical residues in wastewaters, waters in the vicinity of the

biggest landfill in the country as well as the soil under it,

speculating that a few points of concentrated pharmaceutical

waste could be identified in the landfill itself [10–13]. All

unused and expired medicines, except for cytostatic and

cytotoxic drugs, have been categorized in Croatia as non-

hazardous medical waste [14]. Still they are not allowed to be

disposed as communal waste. Croatian regulations mandate

pharmacies to collect unused medicines that originate from

households in impermeable, sealed, green containers labeled

‘‘pharmaceutical waste’’ [14]. Currently, the size of the

container and where it should be located inside the pharmacy

is not defined. Very little advertisement is being directed to

the public regarding this service, although studies have

shown that the amount of properly disposed medicines could

be increased by clear guidelines for the public and by

advertising the service [15–18]. The main way in which the

public is aware of this service is through the presence of

waste containers in the pharmacies.

According to the Ministry of Environmental and Nature

Protection, the basic principle of environmental protection

in Croatia is ‘‘the polluter pays,’’ polluters being the pro-

ducers and holders of waste [19]. Pharmacies are consid-

ered producers and holders of pharmaceutical waste and

therefore obliged to finance the service of collecting

unused medicines from the public. The costs include con-

tainer price plus the price of takeaway service of a full

container based on its weight in kilograms by a licensed

collecting company. The average price is 13€ for the

container and 5€ per kilogram of waste.

In Croatia, it is commonly held that medicines destined

for disposal should not be touched, so the public is dis-

posing the medication fully packaged. In a previous cam-

paign of pharmaceutical waste gathering from the public,

waste was also disposed fully packaged [20, 21]. The

collecting companies do not advise what to do with the

waste or packaging. It is in their interest to have heavier

containers because they charge for the services based on

weight.

A report from the European Environment Agency states

that Croatia is collecting a very small amount of household

pharmaceutical waste compared to other European coun-

tries despite the fact that pharmacies in Croatia are legally

required to receive unused medicines from the public

[14, 19, 22]. It can therefore be suspected that in Croatia

certain amounts of unused medicines from households are

improperly disposed.

Aim of the study

The aim was to investigate the factors that might influence

the effectiveness of the pharmaceutical waste disposal

service provided by pharmacies using the example of the

city of Zagreb by determining the amount of unused

medicines collected from the public during a specific per-

iod and in the absence of any additional media advertise-

ments. Specific objectives were to explore possible

connections between the amount of collected waste and:

the type of pharmacy ownership, discretion while disposing

the waste, the location of the container, appropriate label-

ing and to compare the amount of collected waste between

neighborhoods.

Method

The study was conducted in 2011 between June 1st and

July 10th in all pharmacies in Zagreb. According to the

2011 census, Zagreb had 790,017 inhabitants, which is

around 20 % of the total Croatian population [23]. There

are 210 registered pharmacies in the city and each was sent

by mail a questionnaire (‘‘Appendix’’) designed for this

study [24]. The questionnaire had two sections: first

determined the facts regarding collection including: dis-

cretion while disposing the waste (anonymous disposal

indicated direct disposing in the container designed as

customer ‘‘drop-off’’ as opposed to the waste being handed

to a pharmacist or pharmacy technician), the location of the

container (the waste container located in the customer area

or behind the counter), the labeling of the container

(according to the regulation, or otherwise) and the amount

of gathered waste in kilograms; the second part collected

data about the type of ownership and the location of the

pharmacy (the population ratio per pharmacy varies from

neighborhood to neighborhood). The types of pharmacy

ownership in Croatia are: privately owned pharmacies (the

owner must be a pharmacist and own only one pharmacy);

private pharmacy chains (a private company consisting of

at least two pharmacies, the owner does not have to be a

pharmacist); leased pharmacies (a pharmacy located within

a health institution whose founder is a county, giving

Int J Clin Pharm (2014) 36:556–563 557

123

tenure to pharmacists who fulfill the conditions prescribed

by the Pharmacy Act); and pharmacies owned by the city

of Zagreb [25].

Pharmacists were asked to collect from the public

unused medicines together with the packaging during any

consecutive 30 days within the indicated period. A forty-

day period was given so they could organize empty con-

tainers (usually owned by a collecting company). After

30 days, they weighed the collected waste and subtracted

the weight of the container, which was obtained through

the data from the producer’s manuals or by weighing the

empty containers before collection. Pharmacists did not

touch the waste itself. According to the total mass of col-

lected weight, duration of the collection, and number of

inhabitants, the average amount of unused medicines per

capita annually was calculated. Analysis of the types of

pharmaceutical waste collected was not the subject of this

study. Completed questionnaires were returned anony-

mously in a self-addressed and postage paid envelope.

Pharmacies did not receive any economic incentive for

participation. In the informal conversations, many phar-

macists supported this study and were happy to participate

because they believed it might help in changing the current

practice of charging them as an intermediary party in the

collection of unused household medicines.

For a description and distribution of the variables,

descriptive statistics was used. For the determination of the

association of categorical variables, v2 test was used with a

determined level of significance as P \ 0.05.

Ethical approval for this study was not required due to

the fact it did not include human participants.

Results

Of the 210 pharmacies operating in the city of Zagreb, 91

pharmacies completed the questionnaire (43 % response

rate). There were 43 private chains at time of survey, but it

was not possible to identify how many chains and how

many pharmacies per chain answered. Pharmacies owned

by the city of Zagreb responded in a much higher per-

centage than the combined response rate of all pharmacies

of private ownership. The minimum amount of unused

medicines collected per pharmacy was 0 kg, and the

maximum 30.00 kg. The total amount of collected waste

was 505 kg. The average amount of unused household

medicines along with packaging was estimated to 7.78

g/capita annually. Table 1 shows the response rate and the

amount of pharmaceutical waste in kilograms based on the

type of pharmacy ownership.

Amount of pharmaceutical waste collected was signif-

icantly different according to the type of pharmacy own-

ership (v2 = 18.277, P \ 0.01). Pharmacies owned by the

city of Zagreb collected significantly higher amounts of

pharmaceutical waste than the combined amounts from all

private and leased pharmacies. Table 2 shows the amount

of pharmaceutical waste collected according to anonymity.

The amount of waste varies considerably due to the

method of collecting. In most pharmacies pharmaceutical

waste was handed over directly to the pharmacist or the

pharmacy technician. However, pharmacies that collected

significantly higher amounts of waste were those that

collected anonymously (v2 = 5.743, P \ 0.01). Although

most of the pharmacies answered that the container was in

the customer area (N = 62), there was no statistically

significant difference in the amount of collected pharma-

ceutical waste regarding the location of the container. The

labeling of the containers varied from: ‘‘wasted pharma-

ceuticals,’’ ‘‘medicines,’’ a triangle with a skull to an

exclamation mark. It was not possible to establish a link

between the specific label and the quantity of collected

waste. Also, there was no statistically significant differ-

ence in the amount of collected waste between neighbor-

hoods. The population data, pharmacy status and collected

waste between neighborhoods are presented in Table 3.

Table 1 Response based on the

type of pharmacy ownership

and the amount of collected

household pharmaceutical waste

based on the type of pharmacy

ownership

Pharmacies by type of ownership N total N response (%) Mass (kg) Mass per pharmacy

(kg/pharmacy) ± SD

Private independently owned 29 15 (52) 40 2.69 ± 3.11

Leased 26 10 (38) 72 7.17 ± 5.23

Private chains 120 40 (33) 124 3.09 ± 2.53

Owned by the city of Zagreb 35 26 (74) 269 10.37 ± 7.10

Total 210 91 (43) 505 5.55 ± 5.75

Table 2 Pharmacy response and the amount of collected household

pharmaceutical waste based on offered anonymity

Provided anonymity N (%) Mass

(kg)

Mass per pharmacy

(kg/pharmacy) ± SD

Anonymity provided 28 (31) 232 8.30 ± 6.38

No anonymity

provided

37 (41) 136 3.68 ± 3.92

Sometimes provided 26 (28) 137 5.26 ± 6.25

Total 91 505 5.55 ± 5.75

558 Int J Clin Pharm (2014) 36:556–563

123

Discussion

When comparing the annual European average of unused

household medicines of 10 g to 100 g/capita (50 g/capita

in Portugal and Spain, 100 g/capita in Sweden), it is

noticeable that amounts collected in Zagreb are below the

European average [22]. Switzerland collects the highest

amounts of unused medicines in Europe (237 g capita/year),

followed by France, Luxembourg, Ireland and Sweden

(above 100 g/capita) [18, 22]. Findings of this study could

explain some of the factors contributing to such low

declared amounts of collected waste. General low phar-

macies’ response rate could indicate that pharmacies did

not want to reveal what they actually do with disposed

waste from households; whether they collect it properly or

dispose it, for example, with communal waste. In a few

cases, it was observed that some pharmacies opt to use

umbrella stands and cardboard boxes as disposing con-

tainers. The reason is unknown: it may be to bridge the cost

of purchasing or renting a container for pharmaceutical

waste, or to mislead the customers. The smaller amounts of

collected waste could be the consequence of that, because

when there is no container or it is not visible, customers are

not passively reminded of the possibility of waste disposal.

The finding that pharmacies belonging to the city had

higher response rate and declared more waste than pri-

vately owned pharmacies could be explained by the fact

that the cost of waste disposal and containers is compen-

sated by the city authorities; containers are regularly pro-

vided and taken away without too much involvement of the

pharmacists. Pharmacists in the city owned pharmacies

have fixed salaries that are not influenced by realized

commerce or the cost of disposal service. On the contrary,

the cost of pharmaceutical waste disposal affects the

overall spending of private pharmacies and consequently

lowers the owner’s income. It may also affect the salary of

the employees if their salary depends on pharmacy profit.

This is visible particularly in pharmacies owned by one

pharmacist who works and manages the business as his/her

single source of income. The income of the pharmacy

chains is affected in the same way and employees act upon

manager’s recommendation. According to the data from

Table 3 Population data, pharmacy response rate according to the pharmacy ownership type, pharmacy distribution, and the amount of collected

waste between neighborhoods [21]

City

neighborhoods

Neighborhood

area (km2)

Population Population

[65 years

N total

population

per pharmacy

Mass

(kg)

N pharmacies

N total/N

respondentes

N privately

owned/N city

owned

N respondents privately

owned/N responded city

owned

Donji Grad 3.02 37.024 10.481 1.543 82 24/10 16/8 4/7

Gornji Grad/

Medvescak

10.19 30.962 7.751 2.815 15 11/2 6/5 0/2

Trnje 7.36 42.282 8.100 3.252 18 13/6 11/2 5/1

Maksimir 14.97 48.902 9.293 2.876 38 17/9 14/3 5/3

Pescenica/

Zitnjak

35.29 56.487 8.537 3.323 44 17/8 14/3 5/3

Novi Zagreb 79.18 117.158 16.099 4.881 79 24/11 22/2 10/1

Tresnjevka/

Sjever

5.81 55.425 9.696 3.079 35 18/6 16/2 4/2

Tresnjevka/

Jug

9.84 66.674 8.615 3.922 56 17/9 16/1 8/1

Crnomerec 24.23 38.546 6.624 3.212 27 12/7 10/2 5/2

Dubrava

Gornja

40.26 61.841 7.338 6.184 34 10/5 9/1 4/1

Dubrava

Donja

10.81 36.363 3.886 4.040 28 9/5 8/1 4/1

Stenjevec 12.18 51.390 3.596 17.130 11 3/3 3/0 3/0

Podsused/

Vrapce

36.16 45.759 5.438 3.520 22 13/3 10/3 2/1

Podsljeme 59.43 19.165 2.620 3.833 10 5/3 4/1 2/1

Sesvete 165.24 70.009 6.240 4.667 6 15/4 14/1 4/0

Brezovica 127.33 12.030 1.666 6.015 0 2/0 2/0 0

Total 641.32 790.017 11.598 3.762 505 210/91 175/35 65/26

Int J Clin Pharm (2014) 36:556–563 559

123

the Croatian Chamber of Pharmacists, in one pharmacy

chain the costs of this service went up to 1300 € in the year

2009 [26]. Additionally, if the pharmacy does not have

proper storage space it has to call the disposal service more

often.

In Croatia, there is a lack of official guidance and any

kind of advertising of this service such as posters, phar-

macy information guides, newspapers or websites. There

are no instructions on outer or inner packaging on how to

dispose unused medicines despite the fact that this is

required by law. Policy makers argue that instructions for

disposal should be noted on the packaging only in the case

when the medication’s environmental risk assessment

indicated the need [27, 28]. On the other hand, literature

demonstrates existence of uncertainty among customers

about unused medicines disposal, so clear instructions on

safe disposal should be noted on the packaging for all

medicines, regardless of its environmental safety classifi-

cation, as suggested by German Advisory Council on

Environment [18, 27]. During 2007, The Zagreb Institute

of Public Health and the pharmaceutical company Pliva

Hrvatska d.o.o. in the city of Zagreb organized a collection

of unused medicines from the public through the network

of primary healthcare centers. This campaign was followed

by strong media advertisement, which could explain why

the amount of collected medicines was 1.6 times more than

in our study [20, 21].

The present study indicates that significantly more waste

is collected if medicines are anonymously disposed into

containers located in the pharmacy rather than handed over

to pharmacists or pharmacy technicians. Previous studies

that may add to the explanation of our results have shown

that people may feel singled out or ashamed when return-

ing unused medicines, especially if they frequently visit the

same pharmacy [16, 29, 30]. In Croatia, pharmacists are

worried that infectious waste, including sharp objects,

blood stained material could be disposed through anony-

mous collections which could be hazardous to health and

increase the weight of the container, so they prefer to see

what is disposed [26]. At the same time, the authors suspect

that in some pharmacies the unused medicines are disposed

together with communal waste in order to diminish the

total cost of disposal. Contrary to our expectations, there

was no significant link between the location of the con-

tainer and the amount of waste collected. The authors

speculate that the pharmacies involved in this study may

have stated that the container was located in the customer

area as ‘‘the desirable response’’ since they are aware of the

legal obligations on waste collection.

Regarding difference between the neighborhoods, we

can observe trend that in historically older neighborhoods

like downtown Zagreb more waste is collected. This could

be explained by the fact that those neighborhoods are

inhabited with predominantly senior demographic group,

which has higher prevalence of chronic diseases, they are

greater medication consumers and visits pharmacies more

often, which in other studies has been shown to be asso-

ciated with a greater likelihood that the unused medicines

will be disposed in appropriate manner [16–18]. Also, older

neighborhoods have more city owned pharmacies than

privately owned pharmacies. The opening of new phar-

macies is regulated by the law which combines the number

of people in the area and the distance between pharmacies,

meaning that two pharmacies can be opened for 8,000

people and every next one for 5,000 people more. In the

downtown area, numerous pharmacies were opened before

the ratification of that law, so today there is one pharmacy

for every 1,600 people [25]. It is interesting to notice that

the downtown area has the highest number of highly edu-

cated inhabitants between ages of 25 and 64, while those

with the lowest (Brezovica and Sesvete) collected the least

amounts of waste [31].

Various studies suggested that patient education is

important for the behavior regarding proper unused medi-

cine disposal [16–18]. There are no data on how much

health professionals (physicians, nurses and pharmacists)

in Croatia advise patients on how to deal with unused

medicines. However, results from the study conducted in

rural Croatia on seniors 65? showed that pharmacists have

been the only educators on proper disposal of unused

medicines for this population [32]. The most viable channel

of educating pharmacists as public educators on safe

unused medicine disposal might be through the national

educational program called ADIVA-Health through

Advice. This program is training pharmacists in providing

pharmacy services for chronic patients and due to its very

high attendance rate might serve as platform for additional

education [33]. Pharmacists in Croatia remain an untapped

resource in providing various health related information

although they are recognized as the most accessible health

professionals both in terms of waiting time and cost [34].

In most European countries, pharmaceutical waste dis-

posal costs are paid or funded by local authorities, health

insurance companies, the pharmaceutical industry or the

government. Moreover, in Great Britain and Denmark,

pharmacies are even recompensed for providing the col-

lecting service. If the cost is borne by the pharmacy, then

the cost is being reimbursed (Czech Republic) or is calcu-

lated within the pharmacy margin (Sweden) [35–37]. In

Spain pharmaceutical companies pay a fee for each pack-

aging of medicine marketed through community pharma-

cies and in France they pay special tax for this purpose [38].

In Luxemburg all pharmacies collect pharmaceutical

waste although they are not obligated to, and the Ministry

of Environment funds the service [37]. Similar to Europe,

pharmacies in Australia and Canada are designated to

560 Int J Clin Pharm (2014) 36:556–563

123

provide this service but also are not required to pay the

costs of waste disposing [15, 39].

The literature indicates that the model where pharmacies

are responsible for financing the disposal of unused med-

icines without some kind of reimbursement or other

incentive is not common in Europe. Despite this, the

present service in Croatia has not been tested before

implementation and this study is the first research on the

topic. The presented results indicate that a different source

of disposal financing should be established. The funding

could come from various levels of government, drug

manufacturers, local authorities or other participants in

medicinal waste management chain [40]. A similar prob-

lem is present in the south east European region that once

belonged to the same model of health care [41].

Our study also brought to attention prescribing medi-

cines and patients’ adherence to therapy. Earlier studies in

Croatia demonstrated that physicians frequently prescribe

medicines on patient demand, and that therapy compliance

is low and does reflect on health care budget [42–45].

Financial value of medicines collected during campaign in

2007 was estimated at 100,000 € [20, 21]. Therefore edu-

cation should go towards all: patients, medical doctors and

pharmacists. In the meantime pharmacies in Croatia are

providing a service of interest to the entire community, so

they should receive encouragement, not the financial bur-

den perceived as punishment.

Drawbacks of the study relate to the fact that the

behavior on proper unused medicines disposal might be

different in big cities and rural areas of Croatia. Studies in

other domains of life have shown cultural, educational and

social differences, so it is reasonable to expect that they

would influence this study as well.

Conclusion

The effectiveness of the pharmacy service of collecting

unused medicines in Croatia shows a number of weak-

nesses. The amounts of collected medicines are below the

European average per capita annually. Our results suggest

that functioning of the service is negatively influenced by

the type of pharmacy ownership, distribution of pharmacies

and lack of anonymity when disposing unused medicines.

Additionally, the type of ownership is connected with

financial burden for pharmacies. In most European coun-

tries it is not common to find a model where pharmacies are

financially responsible for the waste disposal; on the con-

trary, they are rewarded for providing the service. The

authorities should find a way to cover the expenses by

involving all the participants in the medical waste man-

agement chain. The elimination of financial obligations for

pharmacies, advertising and promoting service to the

public may increase the awareness of the importance of

proper disposal of unused medicines in Croatia.

Acknowledgments We thank The Croatian Chamber of Pharma-

cists for assistance in data collection and all pharmacies who partic-

ipated in this study.

Funding The study was funded by the non-governmental organi-

zation ‘‘PIN Partnership-Information-Networking for Health’’,

Zagreb, Croatia.

Conflicts of interest The authors have no conflicts of interest to

declare.

Appendix: Questionnaire

1. Information about the collection of pharmaceutical

waste

Please specify:

• Are citizens providing pharmaceutical waste in the

containers anonymously, or handing over to the phar-

macist or pharmaceutical technician?

• Are the containers for pharmaceutical waste located in

the customer area or behind the counter in the

pharmacist’s area?

• Please indicate what is written as the label for the

pharmaceutical waste containers in your pharmacy.

• The amount of pharmaceutical waste collected from

households during the period from 1st of June 2011 to

10th of July 2011: ____________________________

_________ (kg)

2. Pharmacy neighborhood and ownership type

• Pharmacy neighborhood location (please circle the

appropriate letter):

a. Crnomerec i. Sesvete

b. Tresnjevka North j. Donja Dubrava

c. Tresnjevka South k. Gornja Dubrava

d. Trnje l. Pescenica—Zitnjak

e. Downtown m. New Zagreb—East

f. Uppertown n. New Zagreb—West

g. Podsljeme o. Maksimir

h. Medvescak p. Podsused-Vrapce

s. Stenjevec

• Form of pharmacy ownership (please circle the

appropriate letter):

a. private independent pharmacy

b. leased pharmacy

Int J Clin Pharm (2014) 36:556–563 561

123

c. private pharmacy chain

d. pharmacy owned by the city of Zagreb

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