Disposal of Leftover Drugs in Ghana

Asian J. Pharm. Res. 2014; Vol. 4: Issue 2, Pg 84-91

ISSN- 2231–5683 (Print) ISSN- 2231–5691 (Online)

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www.asianpharmaonline.org

RESEARCH ARTICLE

Disposal of Leftover Drugs in Ghana Aboagye, V. S.1* and Kyei, K. A.2 1

2

Family Health Hospital, P. O. Box 669, Teshie-Accra, Ghana. University of Ghana, School of Allied Health Sciences, College of Health Sciences, P.O. Box KB 143, Korle-Bu, Accra, Ghana *Corresponding Author E-mail: [email protected]; [email protected]

ABSTRACT: The handling of drugs has become an issue of great concern in recent times. This study was conducted in Ghana to find out how leftover drugs are disposed of or otherwise handled. Two hundred questionnaires were randomly distributed and completed by individuals from the ages of 15 years and above. The responses were then collected and analyzed using Statistical for Social Sciences (SPSS), version 16. The survey revealed that majority of the people living at the study site do not dispose of leftover drugs but rather leave them for future use either for themselves or for family members and friends when the need arises. The result of these actions lead to self medication, drug abuse and toxicity when unknown expired or deteriorated drugs are taken in. The study suggested several provision that could be made at the various pharmacies or healthcare centres where leftover drugs may be properly disposed off. The general public were also counselled to desist from hoarding leftover drugs at home.

KEY WORDS: Leftover; Medication; Proper disposal; Prescribing. INTRODUCTION: In Ghana, medicines are given by the medical doctors and/or the pharmacists for various ailments. The intent of prescribing and dispensing drugs is for the remedy of a particular disease or sickness. Prescribers and dispensers for that matter do consider the required amount of medicines needed to relieve the patient of the disease. The patient is therefore expected to finish the entire course of medication given. However, several studies have shown that most people do not finish taking their prescribed drugs but discontinue the use of the medicines, once they feel better1-3.

Received on 02.06.2014 Accepted on 18.06.2014 © Asian Pharma Press All Right Reserved

Leftover drugs include drugs that remain when people do not comply with prescriptions given them by the doctor, the pharmacist or the chemical seller. These drugs may be suspensions, tablets, capsules, syrups and other formulations. Some patients are not able to finish their medication as a result of unwanted/unbearable adverse effects or generally for the dislike of the drug(s). One particular source of drug accumulation is those drugs that become "orphaned" by the death of a consumer. These products (medicines) are frequently purchased in excess or not fully consumed as directed (e.g., patient noncompliance), leading to the accumulation of unwanted, leftover drugs4, 5. Drugs may also remain unused when patients feel better and therefore discontinue its use. Leftover drugs also include drugs that remain as a result of change of medications by doctors. Changes from one drug to another (brand wise or generic wise) without any provision made for retrieving the old ones, leave the patient with no option than hoard these drugs.

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POSSIBLE DANGERS OF KEEPING LEFTOVERS Potential source of abuse: Some of these medications can be addictive or have potential for abuse. Taking leftover drugs by mistake can potentially harm older adults who have difficulty keeping track of how much medicines they are ingesting. Excessive drug intake could cause dizziness or other problems that might result in falls or injuries 6. Self-medication: There is the tendency for patients to self diagnose themselves and therefore self -medicate based on a previous experience or foreknowledge of a disease condition. Self-medication as a means of self-care through the purchase of over-the-counter (OTC) medicines is, and always has been common in the society for a wide variety of minor ailments, such as headaches, colds and indigestion 7.

(Prozac) and other anti-depressants on fish development. Other work is focused on the effects of atorvastatin (Lipitor), a cholesterol lowering drug, on fish reproduction 10 . So far no known study or similar studies have been carried out in Ghana but the possibility of unearthing such truth is high. Disposal of leftover or unused drugs is an issue of great concern. Improper disposal of leftover drugs pose a great challenge to both environmental and health workers globally. Unused pharmaceuticals do not only pose exposure risks for both the environment and humans, they also reflect lost opportunities for proper therapeutic treatment and wasted healthcare resources11. In many Ghanaian homes, there is continual usage of left over drugs in one way or the other, consciously or unconsciously. A study conducted in Ghana on the disposal of unused drugs revealed that a great majority of Ghanaians in Accra have a museum of leftover drugs in their homes 12. There is no known outlet for the proper disposal of these unused drugs to the general public, hence the various alarming consequences. This has led to the introduction of Disposal of Unused Medicines Programme (DUMP); a programme designed to retrieve all unused medicines at some special Hospitals in Ghana 12.

Though the literacy rate of Ghana was 57.9% as at 2006, it is not known how many Ghanaians have been well informed about self-medication and the possible consequences when not carried out appropriately. Likely outcomes of inadequate education on self-medication may include: incorrect diagnosis, absence of knowledge of alternative treatments, irrational use of drugs and neglecting side effects and drug interactions. Without consulting a doctor, a patient may expose him or herself to unforeseen complications. Though self- medication is allowed it must be done with caution, mostly for common ailments. This study therefore focuses on the handling of leftover drugs, whether they are disposed off or otherwise kept for Possible intake of deteriorated drugs: The longer leftover whatever use patients or individuals, may deem appropriate. drugs are left around the higher the likelihood for them to The objectives of the study sought to identify factors that lose their potency under poor storage conditions or pass lead to leftover drugs at the study site and which drugs their expiry dates. These medicines may be taken (mostly) constitute leftover drugs. The study also sought to accidentally or purposely. In many homes today, left over identify ways/means of disposing leftover drugs by or unused drugs are found kept in a medicine cabinet, a first individuals at the study site and to suggest proper ways to aid box or some other storage place. Some of these dispose of leftover drugs. medicines have long passed their expiry dates or are stored under poor conditions, rendering them as a toxic form of METHODOLOGY: household hazardous waste. The study was conducted over selected areas in Ghana. Questionnaires were randomly issued out from the 13th to Hoarding of drugs at home is causing many to self diagnose the 20th of December, 2009. The target group included themselves at home without seeking for the advice of a people of 15 years and above. The main instrument used in health professional1 and the environmental hazard that the collection of the data in this study was questionnaires irresponsible disposal of leftover drugs may cause is which were administered by an interviewer randomly to something to worry about. Studies done in the United States people living in these selected areas. Two hundred (200) revealed that, drugs can kill helpful bacteria in septic questionnaires were sent out and the number obtained for systems and pass largely untouched through sewage the analysis was an hundred and eighty (180). The treatment plants. It further stated that children and animals questionnaire was first designed and pre-tested after which can get into drugs tossed in the trash can, and once in modifications were made. Prior to distribution of landfills, drugs can trickle into groundwater 8. questionnaires, the purpose of the study was explained to the respondents and time allowed for the completion of the In another study, water from 139 streams in 30 states questionnaires, thus ensuring a high turnover. The data revealed that, 80% contained traces of pharmaceuticals 9. obtained was analyzed using SPSS (Statistical for Social The effect that those traces of pharmaceuticals may have on Sciences, version 16). the environment, plants, and marine life is unknown. This situation has created a research opportunity, which has been seized by scientists at the Great Lakes Water Institute. Studies are ongoing to determine the effects of fluoxetine

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be taken (especially those with long term diseases), and Out of the 200 questionnaires sent out, 180 were retrieved dislike of the drugs. and analyzed. The majority of the respondents were between the ages of 21 – 40 years, recording as high as Table 2: Reasons given for choosing to obtain medicines from sources other than a health care centre, Kumasi Metro. 2009. 62.8% (113/180) of the total) and the minority being 10 Frequency Percent individuals above 61years, representing 5.6% of the Easy access/ availability 105 58.3 respondents. A total of 99 (55%) of the respondents were Effectiveness of drug 8 9.3 males with a corresponding 81(45%) being females Lack of money 3 4.0 (Table 1). First aid/quick relief 19 22.7

RESULTS:

Lack of confidence in orthodox medicine From previous experience Total

Table 1: Socio-demographic characteristics of respondents, Kumasi Metropolis, 2009 N % Characteristics Age/ years 15-20 21-40 41-60 60+ Sex Male Female Highest Level of education attained No education Primary level Junior High School(JHS) Senior High School/Vocational Tertiary level Occupation Student Professional Artisan/traders Unemployed Self employed Retired

27 113 30 10

15.0 62.80 16.70 5.6

99 81

55 45

9 3 48 67 53

5.0 1.7 26.7 37.2 24.0

63 12 80 17 4 4

35.0 6.7 44.4 9.4 2.2 2.2

2

2.7

3 180

4.0 100.0

The study also showed that exactly 85% of the respondents got well after taking the first course of their medicines, the rest did not. In all, 148(82.2%) of the respondents did not suffer a rebound of their ailment after taking their medication. For 32(17.8%) of the respondents who suffered a rebound, 68.8% went back for the same drug they took previously and out of these, 3(13.6%) got these medicines from a chemical seller, 6(27.3%) from the pharmacy, 7(31.8%) from leftovers at home and 6(27.3%) from the hospital. Table 3: Leftover medicines Drug Paracetamol tablets Amoxycillin capsules Aspirin tablets Metronidazole tablets F-PAC (Parcetamol/Aspirin/Caffeine) Vit.B.Complex tablets Multi-vitamins tablets Diclofenac tablets Magnesium Trisillicate tablets Ibuprofen tablets Others/Unidentified Do not remember

Frequency 27 12 4 5 3 7 7 3 3 5 45 1

Students formed the majority (35%) of the study participants followed by traders (21.1%) (Table1). Paracetamol (20.6%) and anti- malarial (15.0%) drugs were the frequent medicines taken by clients (Table 3). Among the 180 respondents, 110 had taken medicine within the past one month, 35 had done so within the past two to three months, whereas 12,2,10 and 11 had taken medicines within 4 –6 months, 7 -9 months 9 -12 months and over 12 When asked about respondents’ first point of call when months , respectively, as at the time of the study (Figure 1). sick, it was found out that 7.2% of the respondents sought for first aid at home whereas 14.4% visited a chemical shop In all, 42.8% of the respondents generally obtained their close by their vicinity. Majority of them (49.4%) however medicines from the hospital, 34.4% from the pharmacy, sought for their help at the hospital, 28.9% reported at the 18.3% from chemical sellers, 2.8% from relatives and 0.7% pharmacy (Figure 3). from other sources which was not disclosed (Figure 2). Other sources of medication used other than health care centres were; 46.7% from friends and relatives. 40.5% of the participants from left over drugs at home and a little over 40% from herbal and mobile drug sellers (Figure 5).

83(46.1%) of the respondents said they had taken medicines without going to a chemical shop, pharmacy or a hospital at some point in time. Out of these, 44.1% had resorted to leftovers at home and 40.6% took medicines from relatives or friends, 10.2% from herbal medicine sellers and 5.1% The most pronounced (58.3%) reason given for obtaining from mobile drug sellers. medicines from sources other than a health care centre was accessibility (Table 2). Some of the reasons participants Reasons given for obtaining medicines other than the above gave for not completing the course given them included, mentioned places (chemical shop, pharmacy, or a hospital) feeling better after a few days of drug consumption, the included, accessibility (58.3%), immediate relief/first aid unpleasant side effects of the medicines, too many drugs to (22.7%), effectiveness (9.3%), lack of money (4%), lack of

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confidence in orthodox medicines (2.7%) and fore knowledge of the medicine (4%) (Table 2). 17.3% were going to dispose them away into the dust bins. 8.6% were going to give it out to friends or relatives and The following were means of disposal of leftover drugs by 2.5% said they did not know what they were going to do respondents: 72.7% threw medicines into dust bins and with them (Figure 5). 0.7% kept them in a First Aid Box. A majority of the respondents, (71.6%), who had leftovers said, they were keeping them for future use.

Fig. 1: A bar graph showing recent intake of medicines by respondents, Kumasi Metro. 2009.

Fig. 2: A pie chart showing the source of medicines taken in recently, Kumasi Metro. 2009.

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DISCUSSION:

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Disposal of medicines into trash cans has strongly been discouraged. Introduction of Active Pharmaceutical Ingredients (APIS) to sewerage and trash, have been found to enter the environment as contaminants, thus posing as exposure risks for both the environment and humans. Children may easily have access to unused or leftover drugs that are thrown into the trash can, left uncovered. Most medicines look like candies and this can serve as an open invitation to children and other individuals, and this may accidentally and/or purposefully lead to poisonings of infants, children, adults, and pets.

A total of 45% of the 180 respondents who participated in the study had leftover drugs. The majority (71.6%) indicated that they were keeping them for later use, but 17.3% stated they were of going to dispose/throw them away soon. However, 8.6% said they were going to give them out to friends or relatives where as 2.5% did not know what they were going to do with them, they had no plans whatsoever. It is worthy of note that majority of the respondents (71.6%), who had leftover medicines were actually keeping the medicines for future use. Left over drugs are meant to be disposed of and not kept. They were It is clear that in Ghana much education or awareness has to be taken, only after the advice of a health professional. not been created about responsible disposal of medicines. In Leftover drugs represent wasted healthcare resources and Ghana, all refuse go to a given dump site and there is no lost opportunities for medical treatment 13. The most likely sorting out of expired or unused medicines deposited from factor leading to leftover drugs may be that, patients are not trash bins. Some hospitals however, burn unwanted drugs in efficiently counselled about appropriate use of their an open air only under the supervision of authorized medication. Another likely reason may be the lack and or persons from the Food and Drugs Board. Ghana, like most inadequate patient counselling thus leading to non- third world countries do not have incineration facilities, compliance. Unused medicines not only pose exposure risks equipped with adequate emission control, which are mainly for both the environment and humans, they also reflect lost found in the industrialized countries. opportunities for proper therapeutic treatment and wasted It would be best if there are no leftovers at all (or reduced healthcare resources. drastically) so that the need for disposal would not be an The study revealed that after drug usage, 73% of the awesome responsibility for us all. It is time that all health respondents throw the left over medicines into dust bins, workers and consumers take their stand to curb the possible 17.6% leave them anywhere deemed suitable, 2.8% put fatal consequences of having leftover drugs at home and them in carrier bags and keep them on the table or in irresponsible disposal of such drugs into the environment. containers, 2.3% flushed them down the water closet or The study also revealed that as many as 17.2% of the wash them down the drains, 1.7% left them on respondents left their leftover medicines anywhere, not tables/shelves, 1.7% kept them in the fridge, and 0.7% kept noting exactly where they left them. This is quite alarming; children could just take them without the knowledge of the them in a first Aid Box (Figure 5). parents or guardians. It is also not advisable to take medicines without seeking the advice of a qualified health professional as this may lead to serious complications.

Fig. 3: A bar graph showing respondent’s first point of call when sick, Kumasi Metro. 2009.

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Figure 4: A pie chart showing sources of medicines taken without going to a health care centre, Kumasi Metro. 2009.

Fig. 5: A pie chart showing means of disposal of medicines by respondents, Kumasi Metro. 2009.

Figure 6: A bar graph showing what respondents intend doing with left over medicines, Kumasi Metro. 2009.

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Leaving these leftover medicines anywhere also suggests that, these drugs may not be kept under ideal conditions consequently causing degradation of the active ingredients and therefore reducing their potency. Especially in Ghana, where exposure to sunlight and high temperatures are very common, medicines may undergo photochemical reactions that may compromise the potency or appearance of the drugs if not stored properly. Again, except for reconstituted suspensions and other formulations that may require storage in the fridge, it is not ideal for medicines to be kept in the fridge where exposure to moisture especially for tablets may cause deterioration. The possibility of taking expired drugs is also an issue of great concern. From the study, it was realized that 26.1% of the total number of respondents did not check for the expiry date of their medicines before taking them and 8.3% admitted having taken an expired drug before. The issue here is that if patients do not check for expiry dates then they may actually be taking in degraded drugs which may be toxic and therefore harmful to their health especially if the drugs taken are leftover drugs which may have long passed their expiry date. In Ghana some medicines are dispensed in loose form in dispensing envelopes without any written information about the expiry date, so that the longer they are kept the likelihood of them going bad without one knowing. This is likely to occur if all the medicines are not taken as prescribed and taken at a later date. The information gathered from the study also showed that majority of the respondents are students (of school going age) or have had some formal education of some sort and are therefore expected to have a fair idea as to what medicines they were taking in. However this did not deter them from being culprit of keeping leftover medicines and using them at a later date. It therefore suggests that patient education and counselling may not have been enough to be translated into improved compliance and or responsible consumption of medicines.

practices within the healthcare communities, along with improving communication with patients to promote adherence to medication regimes. These outcomes, by reducing leftover medications, would lessen the consequent need for disposal, and possibly improve healthcare outcomes. For 32 (17.8%) of the respondents who suffered a relapse, 22(68.8%) went back for the same drug they took previously and out of these 3(13.6%) got these medicines from a chemical seller, 6 (27.3%) from the pharmacy, 7(31.8%) from leftovers at home and 6(27.3%) from the hospital. It is clear from here that, more of the respondents resort to leftover medicines at home as compared to those obtained from the pharmacies and hospitals. This may be attributed to easy access and lack of money. This underscores the occurrence of self- medication (rationally or irrationally) because the medicines are within reach. In a study conducted in other parts of the country (Wassa West and the Kassena Nankana districts), two of the six sentinel districts involved in chloroquine efficacy studies in Ghana between 1998 and 2001, Two hundred and four households in the Wassa West district kept a cumulative total of 248 drugs, whereas 228 households in the Kassena Nankana district kept a cumulative total of 410 drugs. One hundred and ninety-nine (80.2%) of the drugs kept in the Wassa West district and 181 (44.2%) of drugs kept in the Kassena Nankana district were antimalarials. Reasons given for keeping antimalarials were mainly “leftover after previous treatment” 14 .The above study actually confirms that Ghanaians do possess and rely on leftover drugs.

This present study revealed that 83(46.1%) of the respondents had taken medicines without going to any of the health care centres(hospital/clinic, pharmacy, chemical seller) at some point in time. Out of this, 44.1% had resorted to leftovers at home and 40.6% took medicines from relatives or friends, 10.2% from herbal sellers and 5.1% from mobile drug sellers. Reasons given by respondents for obtaining medicines from the above places include availability (57.3%), quick relief/first aid (22.7%), It is interesting to note that most pain killers (33.6%) were effectiveness (9.3%), and lack of money (4%). named as the most frequent of the leftover medicines. For instance, paracetamol alone accounted for as much as Obviously top on the list is availability, which is likely to 22.1% of the total leftover drugs with Amoxicillin as the lead to self- medication and possible abuse of drugs. There second highest recorded (9.8%). It is worth noting that in a is the need to educate patients and the whole society at large study carried out at the Cocoa Clinic in Accra, 17% of the about prudent self-medication so as to prevent these medicines returned in response to their retrieval of unused undesirable consequences. medicines programme were antibiotics 12. This buttresses the point that many individuals actually do have leftover The survey also sought to find out if patients with chronic drugs and especially where antibiotics are involved it raises diseases were those culpable of harboring leftover drugs as a lot of concern about the possible drug abuse and resultant they may grow tired of taking the same drugs over a long drug resistance. period of time or may have to change one medication for another (without discarding the former). The DUMP carried These findings underscore possible indicators of which out at Cocoa Clinic indicated that 20% of the returned drugs drugs experience high non-compliance and could help were antihypertensive 12. This study however did not bring foster the optimization of prescribing and dispensing out this revelation. Most respondents interviewed were not

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within this category of patients. A more specific study 3. could be carried out in the future on such patients to gather 4. a substantial amount of information. It is also obvious from this study that majority of the respondents do not actually discard their left over drugs but rather keep them for future use (71.6%). This suggests the danger of persons who use leftover antimicrobial drugs, being repeatedly at greater risk for colonization and infection with drug resistant organism. Speaking to respondents, on a one-on-one interview, it became known that most people did not regard paracetamol as a medicine or a potential for drug abuse. Most of the participants were actually taking paracetamol at the slightest headache. Majority of the respondents said, they had not been sick for a long time but upon further probing, they admitted having taken a pain killer, paracetamol tablets for that matter a day before or that very day for body ache and pains. This is a notable finding in that, Paracetamol may actually be irrationally utililized among this group under study.

CONCLUSION: The study has shown that some of the inhabitants of the Ghanaian populace have leftover medicines at home, majority of which are Amoxycillin (9.8%) and pain killers (33.6%) particularly paracetamol (22.1%). Almost 72% indicated that they were keeping these leftover drugs for future use. The main method or means of disposal of leftover or unused medicines was disposal into rubbish bins (71.1%).

RECOMMENDATION: The following recommendation may prove useful:  Patient counselling on the need to comply with prescriptions must be intensified.  The public must be educated about rational use of drugs and the dangers or implications associated with keeping leftover drugs at home.  Introduction of ‘take back’ of unused or leftover medicines programme at hospitals and pharmacies or at collection points could be launched to retrieve unused/left over or old medications for proper disposal by the Food and Drugs Authority.  A National Policy about the safe disposal of unused medicines could be introduced, where disposal points could be branded at accredited healthcare facility after a massive national education on the safe disposal of unused medicines. The Food and Drugs Board, health workers and the general public would have to work together to make this possible.

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