Australian Drug and Alcohol Review 1989; 8:15-20

Issues in developing a community medication collection: An overview of

medidump projects* Jeffrey Wilks and ChristeUe Withers 2

XKey Centre in Strategic Management, Queensland University of Technology, Brisbane, Queensland

*Apart from public statements previously made by the Queensland Director-General of Health and Medical Services, the views expressed in this paper are those of the authors.

Abstract: Each year hundreds of people are admitted to hospitals as a result of inappropriate ingestion of medications. Non-compliance with prescription directions is a particular problem among the elderly. Young children are also at risk for accidental poisoning, especially when unused and out-of-date medications are not stored safely in the home. Many campaigns encouraging the publ# to dispose of old medications have been run by service clubs, government agencies and pharmades. However, few Australian groups have documented the#projects in any detail and most show little appreciation of the legal and ethical implications of such pro- grams. This paper draws attention to some of the relevant issues involved and offers guidelines for conducting medication collections in thecommunity.

Introduction Many pharmacists and health workers have

expressed concern about drug wastage and the quantity of medication hoarded in family homes. 1-4 Hoard ing can be dangerous in several ways. Firstly, out-of-date medications can be harmful because their active constituents may change over time or they may lose signifi- cant potency. Discussing drug stability, Longmore 5 points out that even in their original containers drugs and medicines have a limited life expectancy. When the containers have been opened, drugs may decompose or progressively become contaminated. In a survey of 111 English households Skinner and his colleagues found that about 9% of the medications inspected showed evidence of deterioration which would make their use either difficult or undesirable, n

Similar findings have been reported in Perth 2 and Canber ra? The small-scale Canberra study revealed that about a third of medications in homes were out-of-date or had deteriorated to such a degree that they could have been dangerous if used again.

A second problem area is the inappropriate use of medication. Frauenfelder and Bungey 7 identify a number of important issues related to the inappropriate use of prescription medicine, including non-compl iance by

patients, adverse drug reactions, and non- therapeutic use of prescription medicines. One reason that unused medication becomes stored or hoarded in family homes is that patients do not comply with instructions given by doctors and pharmacists. T M One recent estimate is that the social cost of non-compliance with prescribed regimens for medicines in Australia may be as high as $700m per year, or approxi- mately 4 % of all health care expenditure in the country during 1987.1~ The issue of non- compliance remains a serious concern for phar- macists and is well discussed in the professional literature.

Using prescribed medications to treat 'similar' conditions over time, or conditions not diagnosed by a doctor, and taking drugs pre- scribed for someone else, are widespread prac- tices which can lead to adverse drug reactions. 5 The elderly appear to be a target group at par- ticular risk for adverse drug reactions. Because of an increase in disease associated with advancing age, elderly people tend to receive more prescribed drugs than younger peo- ple? T M Campbell and his colleagues 15 report on a New Zealand study where 12% of their elderly subjects were taking six or more medica- tions. In this polypharmacy group, there were 15 incidents of duplication of drugs of equivalent action; six incidents of unnecessary

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prescribing; and 10 incidents of the use of drugs whose value was not proven.

Non-compliance also occurs more often in the elderly. This can be attributed, in part, to a lack of understanding of the purpose for taking the drug and an inability to read instruc- tions on labels. Poor labelling is a common pro- blem, ~6 and as much to blame as poor eyesight. At the same time, fear of habituation to drugs, fear of poisoning and difficulty remembering to take medication ~7 remain as important as altered pharmacokinetics in the drug responses of elderly patients.13

It is, of course, necessary to store medica- tions currently in use and certain prescribed drugs for recurring problems such as asthma. Longmore ~ suggests that other items such as small quantities of minor analgesics, cough and cold medications, anti-nausea and anti- diarrhoea mixtures, ointment for insect bites, and Ipecacuanha Syrup and Charcoal for accidental poisoning should be kept in a locked medicine cabinet with an approved first aid kit.

Most Australian homes, however, hoard a range of medications far beyond what could be considered essential. For example, a survey of the medicines stored in 102 randomly selected Perth households revealed a total of 1,18I medicines, with a range of 0-67 medicines per household. The median storage time was 3-6 months, and only 40% of the medicines were said to be in current use? In Brisbane, Fiumara a6 found that cough and cold medica- tions, antihistamines, analgesics and antibiotics were the most commonly hoarded drugs. On average, drugs were hoarded for two years, and 22% of all drugs collected had passed their expiry date.

Added to the problem of hoarding is a par- ticular concern about the way medications are stored in homes. Many drugs are kept in unlocked, easily accessible places, and stored under inappropriate conditions of light, temperature and humidity.~2 Young children are frequently at risk because of these practices. During 1987, 33 children, most under 4 years of age, were admi t t ed to hospi tal in T o o w o o m b a (popu la t ion 80,000) af ter accidental ingestion of medications. A further 17 were admitted .after swallowing other common household cleansers and poisons.

Teenage admissions to hospital for ingestion are usually seen as overdose attempts. It is interesting to note that of 36 admissions of young teenagers to the Toowoomba General

Hospital during 1987, 64% had taken pre- scribed drugs which were unlikely to have been prescribed for the teenager; 15% had used over-the-counter drugs, and 30% had over- dosed on alcohol. Adolescents are known to experiment with substances and are therefore more likely to do so when the substances are readily available. The risk of danger can be reduced if only small quantities of medication are kept at home and if those are in good condition.

Community medication collections In the last ten years many community groups

have become concerned about the dangers of keeping medications in the home. Campaigns encouraging the public to clean out their medicine cupl~ards, and to dispose of any out- of-date or unused drugs, have been run by government departments, pharmacy groups and service clubs throughout Australia. Unfor- tunately, with the exception of some pharmacy projects, most campaigns have been only sketchily researched, evaluated and reported.

Two programmes, Medi-dump in Perth, Western Australian, 2'~ and Medidrop in the Australian Capital Territory, 18 have been reported in some detail giving insight into the process of conducting such projects and their likely results. Queensland programs are a rich source of information but tend to remain unpublished as internal reports. 19-21

Planning a campaign A number of factors need to be considered

in planning a community medication collec- tion. Perhaps the most important consideration is whether a problem with unused medication exists in a particular community and whether local people will support the collection of these drugs. Too often well-meaning health and welfare professionals will impose a program on a community without having first gathered suf- ficient information about actual needs. 2~ In addition, for any community-based program to be successful there has to be a sense of local ownership. 23

Given that a community perceives that there is a problem with unused medication and they are supportive of a collection campaign, then specific planning issues will include: the per- sonnel to be involved, the name, logo and aims of the campaign, collection points, financial support, publicity, analysis of the material col- lected, and disposal or distribution of the drugs.

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As a starting point, the Queensland Director- General of Health and Medical Services has provided a list of requirements for groups intending to conduct drug collections.24 Briefly, a registered medical practitioner or registered pharmacist must be nominated to take respon- sibility for the project. A written application should be made to the Director-General and approval obtained before any collection is made.

Applications for approval must include - - (i) The name of the medical practitioner or pharmacist nominated to accept responsibility; (ii) The place where drugs collected will be stored, sorted and packaged for distribution; (iii) Arrangements for secure storage of drugs at such places; (iv) The missions or organisa- tions to which the drugs will be forwarded.

The first step in meeting these requirements is that the club or organisation undertaking a collection must nominate a registered medical practitioner or a registered pharmacist who would accept responsibility for: a) the quality of the drugs distributed as a

result of the collection drive; b) ensuring that the following drugs were not

distributed: - - drugs prohibited in Queensland under

the provisions of Regulation A5 of The Poisons Regulations of 1973 (e.g., amidopyrine, desomorphine, diacetyl- morphine, thalidomide);

- - dangerous drugs (Schedule 8); - - declared drugs (barbiturates come within

this category); - - drugs which have exceeded the expiry

date or are deteriorated or broken; - - d r u g s in unbranded, unmarked, or

incorrectly labelled containers; - - drugs which have been opened or par-

tially used or which have been stored in open containers;

c) ensuring that all usable drugs are effectively packaged and forwarded to the nominated mission or organisation.

The second specific requirement is for security: a) drugs must not be left unattended on foot-

paths or in vehicles; b) satisfactory arrangements must be made for

the storage of all drugs, particularly dangerous or declared drugs, prior to and after sorting of the drugs collected;

c) persons under 18 years must not take part in collecting or sorting.

Finally, in terms of disposal: a) satisfactory arrangements must be made

with the Director-General for the destruc- tion of collected drugs and poisons not forwarded to the nominated mission or organisation;

b) dangerous drugs, if collected, must be forwarded to the Director-General for destruction.

Th e requ i rement s set down by the Queensland government clearly favour the redistribution of usable drugs to missions or charities. In contrast, the World Health Organisation considers redistribution to be inappropriate and recommends that all drugs collected in community drives be destroyed. The authors support W H O policy and believe supervised destruction should be mandatory for practical, as well as legal and ethical reasons. The purpose of reproducing the requirements set down in Queensland is to alert readers to the types of expectations held by government. On the issue of destroying versus distributing drugs, some negotiation or clarification with state health departments may be required. In other areas, however, responsibilities are very clear. For example, without the Director- General's permission to conduct a drug collec- tion in Queensland, personnel involved can be charged with offences under both the Health Act and the Poisons Regulations.

Steps in p l a n n i n g a c a m p a i g n

i. Forming a working party Formation of a working party allows committed individuals to define goals, identify problems, and develop a planning strategy to guide the campaign. The composition of the working party should be such that it includes individuals with a variety of skills, knowledge and experi- ence. As planning progresses, responsibility for specific tasks and duties should be clearly allocated among working group members.

2. The name The title Medi-Dump has been used in several Australian campaigns. ~'3'5'2~'25 The acronym DUMP (Disposal of Unused Medicines and Pills) was first coined in a 1975 Manchester study 2~ and is often used to generally describe community medication collections. To avoid the implication of dumping medicine any- where, and to promote the idea of dropping into a pharmacy with unwanted medicines, the title Medidrop has been used in Canberra. is

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The choice of a campaign name and any associated logos is a very important one since much of the promotion and profile of medica- tion collections rests on the public being made aware of the campaign. 3. Goals A basic goal of medication collections is to encourage and facilitate action by householders to dispose of unwanted or out-of-date medicines. To do this, some level of public awareness about the dangers of hoarding and the advantages of disposal must be made.

Many collection projects are undertaken as part of a large-scale education and awareness campaign, which may include the distribution of pamphlets and fact sheets, liaison with phar- macists to counsel and advise about medica- tion, and dissemination of information through the media. 5as Irrespective of the size of the campaign, the range and structure of goals must be spelled out early in the planning pro- cess. In the final analysis, however, the scope of the project will invariably be determined by a small number of factors, especially finance and staff. 4. Advertising and promotion As Graham TM correctly observes, the greater the media coverage the greater the chances are of conducting a successful campaign. Radio and television stations will often provide free air time to promote community projects. While this free advertising is generous, it is never enough. Sponsorship and donations will usually be required to finance printing of posters and pamphlets.

In his report of the Townsville campaign, Farr 2~ identified Service Clubs as a valuable source of funds, but a difficulty is that they allocate their money and efforts well in advance. Waiting for funds to become available is a frustrating business, and may disrupt the timeframe for the whole project.

Displaying a colour poster in the windows of local pharmacies is a useful way to reach large sections of the community at relatively little cost; though it is important that media messages alert the public to the existence of such posters and give information about the campaign they represent. Other promotional strategies include specialist interviews on radio and television, 5 fact sheets handed out by phar- macies with each prescription purchase, a letterbox drop of advertising leaflets 18 and novelty items such as magnetic buttons with a

message that can be displayed on the family refrigerator. 5. Information delivery Farr 21 makes some useful observations about the way information should be delivered. Firstly, that there should be two phases to a campaign: (1) something is about to happen, and (2) something is happening, don't miss out. This process creates an air of expectancy and excitement as well as one of local participation. Secondly, the timing of the campaign should not conflict with school holidays or other major local events. In this case, competition is not healthy.

An adequate lead-time is essential for a suc- cessful campaign. While the formal collection period may extend over two weeks, 5as up to several months should be spent planning and promoting the collection period. It is important to mention that the public will probably be telephoning to ask where they can dispose of their medications for several weeks after the formal collection time. Provision must be made to assist these slow respondents.

6. Drug collection A review of documented campaigns reveals that community pharmacies are probably the best collection points for unwanted medications. Pharmacists are already identified by the public as specialists in their role of dispensing and advising about medication. 27 The pharmacy profession highlights the importance of enhanc- ing an educational and counselling role for its members, 2s,~9 as well as recognising the more regular patronage such advise may generate? °

In practical terms, pharmacies are a logical choice to target specific at-risk groups. For example, Fenney and Letts 31 found that 60% of housebound women identified as vulnerable for abuse of prescription medication visited a pharmacy during the two week period of an educational campaign.

Also important is that the problem of untrained people handling large quantities of drugs can be avoided by using pharmacies as collection points.

In addition to collection boxes (a ballot box) being placed in Rockhampton pharmacies, Fitzpatrick 19 reports that collection points were established at a local shopping plaza. These points were manned by Service Club members and a pharmacist or Health Inspector. While provision was made for unwanted medicine to

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be picked up by authorised personnel from citizens who were unable to get to a collection point, very few people availed themselves of this service.

Material collected in pharmacies should be cleared several times during the campaign and stored on secure premises. Some hospitals, especially if their staff are involved in the cam- paign, will provide secure storage for collected drugs.

7. What to do with collected drugs Medicine collections provide an important source of information about prescribing and hoarding habits in a community. For this reason, most campaigns sort, count and categorise the various drugs collected. It should be stressed that this aspect of the campaign must again be supervised by a registered phar- macist or medical practitioner.

It is difficult to know in advance what quan- tity of drugs will be collected. The Perth Medi- dump 2,s project collected 3.5 tonnes of material. Similarly, in excess of 6 cubic metres of old medicines were collected through Medi- drop. is In Rockhampton, 19 2,449 containers were handed in. While differences in the form of reporting restrict comparisons in collection size, it is clearly best to be well prepared for a large amount of material.

Since most drugs collected are likely to be unlabelled, out-of-date or partially used, the decision to destroy them is mandatory 2~ and appropriate. 2~ Drugs are usually destroyed in an incinerator, under supervision. 5,~s.25.2s If the local hospital does not have an incinerator, one can usually be found in the private sector. Burying waste medication is to be discouraged. As a last resort, where collections are under- taken in isolated areas the drugs should be carefully packaged and transported to a larger centre for incineration. In some cases the glass bottles collected can be recycled. 5

8. Evaluating the program Since medication collections are a complex exercise, evaluation procedures need to be built into the program during the planning stage. Rotem and Irvine s2 identify a number of steps and key questions to be addressed in evalua- tion. Their paper is recommended reading for working party members during the early cam- paign planning. Future projects will be assisted considerably by reports on the outcome of earlier collections. In particular, what dif- ficulties were experienced and how they were

overcome; the target groups reached (e.g., the elderly, adolescents); how effective the promo- tion was (e.g., what worked best); a descrip- tion of the drugs collected; and any follow-up to support community awareness or action about drug issues.

Summar~ A successful community medication collec-

tion requires considerable time, money, commitment and planning. Since it will raise community awareness and expectations it should not be undertaken lightly. The first, and perhaps most important consideration, is to determine whether a community perceives that there is a problem or even a reason to collect their unwanted drugs, and whether they will support the collection.

There are usually some legal requirements to be met before beginning the project. Con- tact with State and local authorities will clarify these requirements and avoid any possible legal difficulties later on.

A high media profile is essential for a suc- cessful campaign. Community pharmacies appear to be the best choice as collection points, though Service Club members may be used to assist under supervision.

Drugs collected should be sorted and categorised, again under supervision. After examination the drugs should be destroyed.

Evaluation of the project and the subsequent dissemination of the project report is a profes- sional responsibility.

Acknowledgement The authors wish to thankJo Sherridan for

her contribution in early discussions of the project.

Correspondence and requests for reprints to: Dr Jeffrey Wilks, Key Centre in Strategic Management, QUT, GPO Box 2424, Brisbane, Queensland, 4001.

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