International Journal of

Environmental Research
and Public Health

Review
Household Pharmaceutical Waste Disposal as a Global
Problem—A Review
Justyna Rogowska * and Agnieszka Zimmermann

Division of Medical and Pharmacy Law, Department of Social Medicine, Faculty of Health Sciences,
Medical University of Gdańsk, Tuwima Str. 15, 80-210 Gdańsk, Poland
* Correspondence: [email protected]

Abstract: The negative effect of the pharmaceuticals presence (persistence?) in various components
of the environment is a global problem today. These compounds are released into the environment as
a result of, inter alia, their use and improper disposal. Therefore, it is important to reduce excessive
drug consumption and to develop a system for the collection of unused/expired pharmaceuticals.
The effectiveness of actions in this area is inextricably linked with the need to educate society on how
to deal properly with unwanted medications. The aim of the study was to show that the inappropriate
handling of unused/expired drugs by society is an important problem in waste management systems,
and it impacts the state of the environment. Forty-eight scientific articles published between 2012
and 2021 were taken into account that discussed the systems in various countries for the collection of
unused/expired pharmaceuticals. This literature review shows that the main method of disposing
of unused/expired medications, according to respondents from different countries, is either by
disposing of them in household waste or flushing them into the sewage system. This is also the case
in countries with systems or programs for the return of redundant drugs, which indicates that these
systems are not sufficiently effective. This may be influenced by many factors, including the lack or
ineffective education of the society.
Citation: Rogowska, J.;
Zimmermann, A. Household
Keywords: household waste; pharmaceutical waste; disposal of pharmaceutical waste; management
Pharmaceutical Waste Disposal as a
of pharmaceutical waste; consumer behavior
Global Problem—A Review. Int. J.
Environ. Res. Public Health 2022, 19,
15798. https://doi.org/10.3390/
ijerph192315798
1. Introduction
Academic Editor: Paul B.
Tchounwou
Developments in technology and progress in medicine have resulted in an increase
in life expectancy. According to World Health Organization (WHO) data, life expectancy
Received: 19 October 2022 increased from 66.79 to 73.31 during 2000–2019 [1], and from 1900 to 2019, the global
Accepted: 24 November 2022 average life expectancy more than doubled [2]. On the other hand, social, economic and
Published: 27 November 2022 cultural changes have influenced the development of civilization diseases such as obesity,
Publisher’s Note: MDPI stays neutral diabetes, cardiovascular diseases, cancer and autoimmune diseases, which is reflected in
with regard to jurisdictional claims in the statistics of the consumption of specific categories of pharmaceuticals. According to
published maps and institutional affil- data of the Organization for Economic Co-operation and Development (OECD), in the
iations. years 2000–2017, the consumption of antihypertensive drugs increased by 70% on average,
cholesterol-lowering agents threefold and the consumption of antidiabetic drugs double, as
with antidepressants [3]. An increase in the use of ‘over-the-counter’ (OTC) medicines was
also observed. This is due to the fact that OTC drugs are easily available and affordable [4].
Copyright: © 2022 by the authors. A survey conducted by Hedendrud et al. (2019) in Sweden showed that, in total, 87%
Licensee MDPI, Basel, Switzerland. of respondents reported the use of OTC drugs in the prior 6-month period [5]. Similar data
This article is an open access article
were obtained by Vatovec et al. (2021) in a study conducted among 421 respondents from
distributed under the terms and
the US in which 85% of respondents had obtained OTC drugs in the previous 12 months [6].
conditions of the Creative Commons
In turn, in a study carried out in 2008–2011 on a group of 7091 people in Germany, 40.2% of
Attribution (CC BY) license (https://
respondents admitted that in the 7 days preceding the survey, they had used medicines or
creativecommons.org/licenses/by/
dietary supplements such as vitamins or minerals [7]. Research conducted by Rogowska
4.0/).

Int. J. Environ. Res. Public Health 2022, 19, 15798. https://doi.org/10.3390/ijerph192315798 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2022, 19, 15798 2 of 29

et al. (2019) showed that almost 60% of respondents buy OTC pharmaceuticals before
they are needed. The same study indicated that analgesics are the most used OTCs (71.8%
of respondents) [8]. Similar results were presented by Zorpas et al. (2018). Among
184 respondents living in the district of Nicosia (Cyprus), 65.8% of them most often used
painkillers [9].
Furthermore, the COVID-19 pandemic has caused an increase in the consumption
of some OTCs (for example, ivermectin is sold as an OTC drug in some countries), and
thereby self-medication has become a serious problem [10]. An online survey study was
conducted by Quispe-Cañari et al. (2021) [11] on a group of 3792 respondents from Peru.
Their objective was to investigate the prevalence of self-medication drugs used for respira-
tory symptoms in the prevention of COVID-19. The survey showed that the majority of
respondents self-medicated with acetaminophen and ibuprofen in the case of preventive
use, in the presence of symptoms and for confirmed cases [11].
Antibiotics are a group of pharmaceuticals the excessive consumption of which is of
concern. These drugs are used for human and animal disease treatment, growth promotion
and prophylaxis [12]. The global consumption of antibiotics increased by 65% between
2000 and 2015 [13]. The effect of the increased consumption of these drugs is increases in
their presence in the environment, which may affect the survival, reproduction, metabolism
and population of organisms and change the community structure and ecological function
of the ecosystem, including biomass production and biodiversity [14]. Furthermore, the
overuse of antibiotics is a major driver of antibiotics resistance. Some antibiotics are easily
degraded, such as penicillin, whereas others are considerably more persistent, such as
fluoroquinolones and tetracyclines; thus, they prevail for a longer time in the environment,
spreading to larger distances and accumulating in higher concentrations [15].
The presence of pharmaceuticals in the environment is a consequence of both their
usage and disposal. The main source of pharmaceuticals is the excretion of active substances
consumed by humans and animals via urine and feces (between 30 and 90% of the orally
administered dose is excreted as active substances in the urine of humans and animals) and
the incorrect disposal of unused medical products into toilets and sinks or incorrect disposal
via solid waste [16]. By limiting the excessive consumption of drugs, especially OTCs, or by
placing emphasis on the development of more effective methods of wastewater treatment,
the release of pharmaceutical residues (unaltered or as metabolites) that pass through the
body into the sewage systems may be reduced. Moreover, the incorrect disposal of unused
medical products can be minimized through the development and/or improvement of
take-back schemes and awareness-raising amongst the public.
However, it seems that there is no global strategy for limiting the production and
disposal of pharmaceutical waste. On the other hand, the problem of the improper handling
of unnecessary drugs by common people is a very important issue. For example, according
to the report published by UNESCO/HELCOM (United Nations Educational, Scientific and
Cultural Organization/Baltic Marine Environment Protection Commission), wastewater
is the main source of pollution of the Baltic Sea with pharmaceuticals [17]. At the same
time, wastewater treatment plants located around the Baltic Sea are not designed to remove
micro-pollutants, and their modernization will be a long and costly process. Therefore, the
proper disposal of unnecessary drugs by the inhabitants of the Baltic Sea region is crucial
to reduce pharmaceutical content in the Baltic Sea environment. Moreover, both in the
European Union and within HELCOM, it has been indicated that one of the activities aimed
at limiting pharmaceuticals in the environment is to improve unnecessary drug collection
systems within the society and increase public awareness of these systems, including
their purpose and environmental effects resulting from improper drug handling. These
actions were included in the European Union Strategic Approach to Pharmaceuticals in the
Environment, a European One Health Action Plan against Antimicrobial Resistance and
the updated Baltic Sea Action Plan [18–20].
In the view of the above, the aim of the study is to show that the inappropriate handling
of unused/expired drugs by society is an important problem in waste management systems,
Int. J. Environ. Res. Public Health 2022, 19, 15798 3 of 29

and it impacts the state of the environment. The publication also focuses on the actions
taken to reduce the impact of pharmaceutical waste on the environment, which are already
implemented in various countries.

2. Methods
This review was based on 48 articles published between 2012 and 2021, obtained
from databases such as Scopus, Google Scholar and PubMed, and the references con-
tained in these articles. In order to retrieve articles from databases, keywords (and their
combinations) such as ‘disposal of pharmaceutical waste’, ‘drug disposal’ and ‘house-
hold medical waste’ were entered in the search field. This period of time was selected
to include in the review countries from different continents and with different levels of
socioeconomic development.

3. Pharmaceutical Waste
Around the world, the definition of waste is different in the legal systems of individual
countries [21]. In the EU, according to Directive 2008/98/EC of the European Parliament
and of the Council of 19 November 2008 on waste, and repealing certain Directives (OJ
L 312 22.11.2008, p. 3), ‘waste’ means any substance or object that the holder discards or
intends or is required to discard. Pharmaceutical waste seems to be both expired drugs and
unused drugs. Unused drugs might be used by other patients; however, in view of safety
reasons (there is a worldwide problem with falsified drugs), such drugs can be offered only
by a licensed pharmacy. The main reasons why a drug becomes unwanted by a patient or
eventually remains unused are:
- Changing the dosage of the drug or changing the drug;
- The death of the patient;
- The noncompletion of therapy or inappropriate use of drugs by the patient
(especially antibiotics);
- The discontinuation of therapy due to side effects [22].
Sasu et al. (2012) showed that more than half (59%) of the respondents from Ghana
finished their medication, and the remaining respondents stopped taking medicines when
they thought they felt better [23]. Ayele and Mamu (2018) indicated that the reasons
given by Ethiopian respondents for no longer using drugs were mostly due to recovery
from/improvement in the disease or symptoms (53.3%) and forgetting to take the drugs
(16.7%) [24]. Respondents from Malaysia admitted that they had unused medicines due
to the fact that they stopped taking medicines when they felt better (76.9%), their doctor
changed their treatment (50.3%), they experienced unwanted side effects (49%), they did
not take the medicines as instructed/prescribed (47.2%) and they did not feel better after
taking the medicines (46%) [25]. Another survey, carried out by Hassali and Shakeel (2020),
indicated that the main reasons why the respondents keep unused medications at home
were that their treatment was changed by their doctor (28.6%) and they felt better (25.1%).
Furthermore, respondents kept unused medications for future use (23.9%) [26]. The main
reasons why respondents from Tanzania stopped taking medications were, above all,
recovering from their illness prior to completing treatment (82.2%), intolerable side effects
of the medications (8.3%), a change in the treatment regime (6.2%) and forgetting to take
the medications (3.3%) [27]. Similar results were obtained in studies conducted among the
inhabitants of Indonesia. The majority of the respondents revealed that the reason they were
no longer taking the drug was because their health had improved (82.7%, 97%, depending
on the study). Other reasons were: a change in medication by a doctor, no therapeutic
effects according to the respondents, alterations in the prescription, experiencing side
effects and a switch to herbal remedies [28,29]. Research by Vatovec et al. (2017) on a
group of American students indicated one more important reason for having leftover OTC
drugs—too many in the package in relation to needs [30].
Int. J. Environ. Res. Public Health 2022, 19, 15798 4 of 29

4. Collection System of Unused/Expired Pharmaceuticals

Methods for residents to dispose of unused/expired medications depend on socioeco-
nomic culture as well as legal regulations and regulatory guidelines [31]. In many countries,
there are no legal powers indicating the entities responsible for collecting unwanted drugs
from residential areas. The provisions mainly concern unused or expired drugs from
health care institutions and pharmacies but not from households. Collection systems are
organized at national, regional or local levels; the system costs may be concentrated on
one entity or spread between different entities [16]. Pharmacies operating in such systems,
on a mandatory or voluntary basis, play an important role in the collection of unwanted
medicines from patients.

4.1. Low and Middle-Income Countries

In low- and middle-income countries, there are often no guidelines regarding the
disposal of medications by the public. In Ethiopia, there is no national policy that aims to
control the safe disposal of unused/expired medicines or raise public awareness of this
issue [24]. Similarly, in Tanzania, the only existing guideline established by the Tanzania
Medicines and Medical Devices Authority (TMDA) is for the disposal of expired or unused
medications in drug dispensing units, health centers and hospitals [27]. It is the same
case in Malaysia, where there are laws only regarding hazardous waste from health care
facilities and pharmaceutical companies. According to the law, a waste producer is obliged
to appoint a licensed contractor who will collect the waste for disposal at scheduled
waste incinerators or secure landfills [32]. Unfortunately, these provisions do not apply
to household pharmaceutical waste, which, in effect, results in pharmaceuticals that are
discarded in household waste being disposed of at landfills. However, in Malaysia, there
is a voluntary medicine take-back program [32]. In India, unused and expired antibiotics
are categorized as hazardous waste, and they should be collected separately from other
household waste, but this is not adhered to, and in general, the public is not aware of these
rules and regulations [33]. In Brazil, despite the fact that the regulations on the handling
of medical waste appeared in the 1990s, it was only in 2020 that regulations regarding the
collection of unnecessary drugs from residents appeared. In 1993, regulations (CONAMA
Resolution No. 5) were implemented in Brazil according to which drug residues were
classified as group B, which may not only pose a threat to the environment but also to
public health [34]. Then, in 2004, we implemented a Waste Management Plan of Health
Services that related to the management, treatment and final disposal of waste but only
in the health services [34,35]. Introduced in 2010, the National Solid Waste Policy did
not regulate household pharmaceuticals. In 2020, Decree N◦ 10.388 was implemented,
which provides a return system for expired or unused household medicines intended for
human use only, where, after disposal by consumers, they are processed along with their
packaging. Pursuant to these regulations, drugstores and pharmacies, which are collection
points for unused/expired drugs, are obliged to purchase, provide and maintain containers
for the collection of unwanted pharmaceuticals in their facilities in a proportion of at least
one fixed collection point for every ten thousand inhabitants [36]. However, it should be
noted that these regulations apply only to medicines intended for humans. Moreover, only
pharmacies located in cities of more than one hundred thousand inhabitants are obliged to
participate in the above-mentioned system [35].

4.2. High Income Countries

In Kuwait, there are no guidelines for the acceptance and disposal of medicines
returned from households. There is only a guideline issued by the Ministry of Health that
pharmacies are required to return unwanted medications generated from their stock, for any
reason such as expiry or overstock, to the Central Medical Stores [37]. Moreover, in Saudi
Arabia, no official state guidelines have been issued by the Ministry of Health or protocols
for the disposal of unwanted and unused medications or medical waste [38]. However, it is
possible to return such drugs to a pharmacy [39]. A survey conducted by Alhomoud et al.
Int. J. Environ. Res. Public Health 2022, 19, 15798 5 of 29

(2021) [38] among undergraduate or postgraduate students of pharmacy indicated that

pharmacies are the best place to return unused medications (67% of respondents). Moreover,
according to respondents, the authorities responsible for the safe disposal of medications
should be the Food and Drug Administration (90%) and pharmaceutical companies (87%),
followed by pharmacies (81.5%) [38]. There are no regulations in Israel regarding the
collection of pharmaceutical household waste. However, in 2001, the Ministry of Health
published a circular that instructed health maintenance organization pharmacies to receive
unused medications from any individual [40].
In the European Union, the obligation to implement appropriate collection systems
of medicinal products that are unused or have expired results from Art. 127b, Directive
2004/27/EC of the European Parliament and of the Council of 31 March 2004, amending
Directive 2001/83/EC on the Community code, relating to medicinal products for human
use (OJ L 136, 30.4.2004, p. 34–57). In most European countries, the collection system
includes either take-back to the pharmacy or drop-off at waste collection points, depending
on the policy and strategy implemented in each country or region. Some pharmacies take
part in the process on a voluntary basis, while some are obliged by law to participate in
a take-back scheme. Croatia is an example of a country where pharmacies are obliged
to accept unused/expired medicines from patients. By law, pharmacies are considered
producers and holders of drugs and therefore are obliged (in accordance with the ‘polluter
pays’ principle) both to receive drugs from patients and bear the costs associated with
it [41]. Additionally in Serbia, pharmacies are obliged to offer unnecessary pharmaceuticals
to patients and then transfer them to manufacturers, return them to wholesalers or transfer
them to specialized companies for destruction [42].
In France, by Law No. 2007–248 of 26 February 2007, pharmacies are required to
accept unwanted medications from patients [43]. The collection of unused medicinal
drugs functions within Cyclamed, which is a nonprofit organization, in operation since
1993, in which dispensing pharmacists, wholesale distributors and drug companies are
involved and whose purpose is to collect expired and nonexpired unused drugs that pa-
tients bring back to pharmacies for disposal [44]. In this system, wholesale distributors are
responsible for delivering empty containers to pharmacies and picking up filled containers,
while pharmacies are responsible for the free-of-charge collection of unused medicines
from patients. Medical waste disposal is financed by Cyclamed through contributions
from pharmaceutical companies [45]. Cyclamed succeeds in collecting 62% of unused
medications [46].
The current legislation in Romania is designated by the National Public Health Insti-
tute as the authority responsible for approving on-site collection by the separation of waste
accumulated from medical activities. However, the legislation covers only, for example,
pharmacies, drug stores, distributors of medicines and pharmaceutical products, produc-
tion units, the warehousing and storage of medicines and biological products or research
institutes, while expired medicines derived from the population should be submitted to
the nearest pharmacy or pharmaceutical point [47]. However, in the case of medicinal
waste collected from the population, the law is not sufficiently explicit with regard to
on what basis such waste is to be collected from patients and who will bear the costs
of the disposal of medicines handed over to pharmacies: manufacturers, pharmacies or
local authorities [48]. In a study concerning the opinions of pharmacists on the legislation
and the procedure for collecting medical waste, just over 65% said they were dissatisfied
with the current procedure, more than 40% of the investigated pharmacists considered
current legislation to be incomplete and about 20% considered the law to be ambiguous,
while almost 13% believed the law to be clear and easy to apply [48]. Furthermore, over
92% of respondents thought that the costs of the disposal of returned medicines should
not be borne by pharmacies but by patients, local authorities, the Ministry of Health, the
Ministry of the Environment and other entities (government, manufacturer or supplier,
drug-issuing pharmacy, authorized ecological unit) [48]. At the same time, it should be
noted that the regulations indicating that expired medicines derived from the population
Int. J. Environ. Res. Public Health 2022, 19, 15798 6 of 29

should be submitted to the nearest pharmacy or pharmaceutical point were introduced only
in 2014 [47]. Poland is an example of a country that lacks clear legal provisions regarding
the collection of unnecessary drugs from residents. On the one hand, municipalities are
responsible for organizing a system of collecting municipal solid waste from residents;
on the other hand, there are no precise regulations that would impose an obligation to
segregate pharmaceutical waste. [8]. Therefore, the system is based on the principle of the
voluntary participation of entities such as pharmacies or health centers. [49]. In Portugal,
the disposal of household pharmaceutical waste is regulated by the National Environment
Agency, but the national entity responsible for the collection and treatment of unused
pharmaceutical products is Valormed, a nonprofit society created by the pharmaceutical
sector (industry, distributors and pharmacies). It provides pharmacies with special boxes to
collect pharmaceuticals returned by the public. Then, pharmaceutical waste is transported
to sorting facilities, from where it may be sent for incineration [50]. In 2002, an integrated
system for the collection and management of unused and expired drugs, called SIGRE
(Sistema Integrado de Gestión y Recogida de Envases—Integrated Packaging Management
and Collection System), was developed by the Spanish National Association of the Phar-
maceutical Industry [51]. The pharmaceutical industry finances the work of SIGRE, which
is responsible for the management of pharmaceutical waste and for the implementation of
ecological campaigns [45]. The pharmacies with SIGRE collection points play a major role
in the system [52]. However, wholesale distributors are responsible for the collection of
pharmaceutical waste from pharmacies and its storage until disposal [45].
In the US, in 2007, the Food and Drug Administration and the White House Office
developed and published, under the National Drug Control Policy, the first guidelines
for consumers on drug disposal, which indicated that the proper way to dispose of drugs
was to throw them into the garbage [53]. The Safe and Secure Drug Disposal Act, enacted
in 2010 in the US, mandated the Drug Enforcement Administration (DEA) to develop
and implement legislation that specifies methods for transferring unused or unwanted
controlled pharmaceutical substances to authorized entities for disposal [54]. The DEA
promulgated the Final Rule on the Disposal of Controlled Substances in 2014, which gives
patients the opportunity to return unused drugs through a take-back event, dropping
them at authorized points (for example, hospitals, pharmacies) or sending substances to
authorized collectors in mail-back envelopes that meet the criteria of the DEA rule [55].
If, however, the drug take-back or collection program is not available, the guidelines
issued by the Environmental Protection Agency (EPA) are to be followed. According to
these guidelines, drugs should be removed from their original containers, placed into a
disposable container or into a sealable bag, mixed with an undesirable substance such as
cat litter or used coffee grounds and disposed of in the garbage [56].

5. Methods of Disposal of Unused/Expired Pharmaceuticals

In order to answer the question of how residents of various countries deal with
unused/expired pharmaceuticals, 48 scientific articles published from 2012 to 2021 from
different sources were analyzed (Figures 1 and 2).
The analysis of literature shows that the main way to dispose of unwanted drugs is
by throwing them into the garbage (Table 1). The inhabitants of both highly developed
and low- and middle-income countries admit to this method of disposing of unwanted
drugs. Indeed, in many countries, especially in Africa and Asia, throwing medications
into the trash or pouring them down the sink or toilet is the only way to dispose of
them (Table 1). Some respondents, especially from Tanzania, Uganda, Ghana, Indonesia,
Malaysia and Saudi Arabia, give unused medications to family, acquaintances, friends
or neighbors [25,27,29,38,57,58]. The reuse of unused pharmaceuticals is against the law
in many countries, e.g., Poland or the UK, and taking such donated drugs may have
negative effects on health, due to the conditions of their storage or the fact that they may be
inappropriate [57,59]).
n. Res. Public Health 2022, 19, x

Int. J. Environ.
Int. J. Environ. Res. Public
Res. Public Health
Health 2022,
2022, 19,19,x15798 7 of 29

Figure
Figure 1. Thenumber
1. The number of articles
of articles fromfrom different
different sources.sources.

Figure 1. The number of articles from different sources.

Figure 2. The number of articles in particular years.

Figure 2. The number of articles in particular years.
The reasons why respondents use improper methods of disposal are primarily:
− AThe analysis
lack of education oforliterature
inadequateshows thatinthe
education this main
field; way to dispose of unwanted d
by− throwing
A lack of an them into the
appropriate garbage
system (Table
or program 1). return
for the The inhabitants of both highly deve
of unused drugs;
− Getting used to certain behaviors;
and low‐ and middle‐income countries admit to this method of disposing of unw
− Convenience;
drugs. Indeed, in many countries, especially in Africa and Asia, throwing medic
− A lack of punishment (no responsibility).
into the trash or pouring them down the sink or toilet is the only way to dispose o
(Table 1). Some respondents, especially from Tanzania, Uganda, Ghana, Indonesi
laysia
Figure 2. and
TheSaudi
number Arabia, give unused
of articles medications
in particular to family, acquaintances, frie
years.
neighbors [25,27,29,38,57,58]. The reuse of unused pharmaceuticals is against the
many countries, e.g., Poland or the UK, and taking such donated drugs may have ne
Theon
effects analysis
health, due oftoliterature shows
the conditions of their that theormain
storage way
the fact to dispos
that they may be
propriate [57,59]).
by throwing them into the garbage (Table 1). The inhabitants of
and low‐ and middle‐income countries admit to this method of
drugs. Indeed, in many countries, especially in Africa and Asia
into the trash or pouring them down the sink or toilet is the only
Int. J. Environ. Res. Public Health 2022, 19, 15798 8 of 29

Table 1. The way of dealing with unused/expired medicines by respondents around the world.

Procedure Dealing with Unused/Expired Drugs by Respondents

State or Type of The Method of Research
Region Country Years of Return to Pharmacy/Pharmaceutical
City Respondents Conducting the Group Throwing in the Toilet or Sink Reference
Research Distributor/Health Facility/to Drug Other [%]
Research Garbage [%] Discharge [%]
Take-Back Program [%]
Cook Household
6.0—give to
County, 2009 members over Phone interview 445 16.0 59.0 31.0 [53]
someone else
Illinois the age of 18
Southern Campus Web-based 11.2—pharmacy 18—toilet
2011 238 62.7 8.0 [60]
California community survey 1.8—physician’s office 4.3—sink
North
USA
America University
An online
Vermont 2014 students from 358 2.0 25.0 1.0 - [30]
survey
Burlington
Vermont
Telephone
Vermont 2016 residents over 252 37.0 32.0 12.0 - [6]
polling
the age of 18
1.0—burn
8.9—give to
someone else
Residents of two 30.2—keep at
districts of Lages home (unused)
South Face-to-face 15.3 (unused) 39.6 (unused) 5.0 (unused)
Brazil Lages 2018 over the age of 309 2.8—burn [61]
America interviews 8.7 (expired) 69.6 (expired) 11.1 (expired)
18 who had a 0.5—give to
fixed residence someone else
4.6—keep at
home
(expired)
Literate and
semi-literate
participants
filled out the
questionnaires
Residents of themselves, 38.0—bury
Ashanti Konongo– while illiterate 21.0—give to
Africa Ghana 2012–2013 500 1.0 29.0 4.0 [58]
region Odumasi over respondents someone else
the age of 18 were taken 7.0—burn
through
structured
personal
interviews in the
local dialect.
Int. J. Environ. Res. Public Health 2022, 19, 15798 9 of 29

Table 1. Cont.

Procedure Dealing with Unused/Expired Drugs by Respondents

State or Type of The Method of Research
Region Country Years of Return to Pharmacy/Pharmaceutical
City Respondents Conducting the Group Throwing in the Toilet or Sink Reference
Research Distributor/Health Facility/to Drug Other [%]
Research Garbage [%] Discharge [%]
Take-Back Program [%]
One resident
from each
The Greater household, from
Face-to-face 18.8—
Ghana Accra 2014 Ga South 600 - 80.2 - [62]
interviews burn/bury/others
Region Municipal
Assembly over
the age of 18
The
respondents
answered the
questionnaires
either by
themselves or
with the
Residents of assistance of the
less
Ghana All country no data Ghana over the researcher. no date more than 75 - - [23]
than 4
age of 18 Some of the
respondents
needed
assistance
because they
could
neither read nor
write.
2.2—burn
1.9—give to
One resident someone else
Harar city
from each Face-to-face 1.9—donate to
Ethiopia (eastern 2018 694 1.0 53.2 23.9 [24]
household over interviews hospital
Ethiopia)
the age of 18 16.0—keep at
home until
expired
Populations of
two distinctive
groups of
households:
within the
Nairobi formal Face-to-face 4.9—take-back programs 9.8—burn
Kenya No date 164 28.7 25.0 [63]
City settlement interviews 17.7—special garbage bins 14.0—bury
(middle-class)
and informal
settlement
(lower-class)
areas
Int. J. Environ. Res. Public Health 2022, 19, 15798 10 of 29

Table 1. Cont.

Procedure Dealing with Unused/Expired Drugs by Respondents

State or Type of The Method of Research
Region Country Years of Return to Pharmacy/Pharmaceutical
City Respondents Conducting the Group Throwing in the Toilet or Sink Reference
Research Distributor/Health Facility/to Drug Other [%]
Research Garbage [%] Discharge [%]
Take-Back Program [%]
Questionnaire
survey and key
informant
interview. The
103 community questionnaire 24.7–34.1 *—pharmaceutical
Anambra
pharmacies in was distributed distributors
State
Nigeria 2016–2017 the three in community 77 29.6–36.1 *—the National Agency for 9.6–23.9 * 1.2–7.1 * 4.7–9.6 *—burn [64]
(southeast
senatorial zones pharmacies. Food and Drug Administration
Nigeria)
in the state Pharmacists and Control bin
received, filled
out and
returned their
questionnaires.
One resident 8.4—burn
Mwanza from each Face-to-face 0.3—bury
Tanzania 2015 359 - 59.1 12.5 [27]
City household over interviews 17.9—give to
the age of 18 someone else
Northern
Uganda
(four
districts
including
One resident 33.0—give to
Gulu,
from each Face-to-face someone else
Uganda Nwoya 2012 260 0.8 10.8 - [57]
household over interviews 55.4—keep for
(Acholi
the age of 18 future use
sub-region),
Lira and
Dokolo
(Lango
sub-region)
Students from
three higher Face-to-face
Zambia Lusaka 2019 385 4.4 60 33.3 2.3—burn/bury [65]
learning interviews
institution
1.3—give to
someone else
9.6—donate to
hospital
Residents of 52.2—keep at
Asia/East, Face-to-face 21.3 (unused) 14.3 (unused) 1.3 (unused)
Afghanistan Kabul 2016 Kabul over the 301 home until [66]
South Asia interviews 7.3 (expired) 77.7 (expire) 12.0 (expire)
age of 18 expired
(unused)
1.3—give to
someone else
(expired)
Int. J. Environ. Res. Public Health 2022, 19, 15798 11 of 29

Table 1. Cont.

Procedure Dealing with Unused/Expired Drugs by Respondents

State or Type of The Method of Research
Region Country Years of Return to Pharmacy/Pharmaceutical
City Respondents Conducting the Group Throwing in the Toilet or Sink Reference
Research Distributor/Health Facility/to Drug Other [%]
Research Garbage [%] Discharge [%]
Take-Back Program [%]
New Respondents
0.5—burn
Territories, from seven sites
In-street 3.1—give to
Hong Kong in the Hong 4.1—toilet
China 2015–2016 questionnaire 1837 0.9 53.9 someone else [67]
Island, Kong Special 1.3—sink
surveys 0.6—sell to
Kowloon Administrative
others
Peninsular Region
Students from
The participants
Wuhan
completed the
University of 365 0.6 84.0 - -
questionnaire
Science and
themselves.
Technology
China Wuhan 2018 [68]
The participants
Residents in provided their
retirement responses 206 5.3 94.0 - -
homes marked by the
researchers.
Dental students Descriptive
from second, cross-sectional
third and fourth survey based on
12.0—toilet
India North India No date academic a 236 3.0 94.0 - [69]
32.0—sink
years aged structured
between 18–25 questionnaire
years format
Students from
the faculty of
science of the An online 14.6—keep for
196 48.0 -
university survey future use
and college (a
literate group)
Haryana [33]
India 2018–2019 Residents 22.0
State The participants
of nearby
were assisted in
villages between 32.9—keep for
filling out the 491 85.0 -
18 and 50 years future use
questionnaires
(an illiterate
offline.
group)
4.4—give to
someone else
0.4—donate to
Bandung the hospital
Residents over 29.0 (unused) 1.8 (unused)
Indonesia (West Java 2017–2018 Interviews 497 0.2 (expired) (unused) [28]
the age of 18 82.1 (expire) 5.3 (expire)
Province) 4.0—burn
0.4—give to
someone else
(expired)
Int. J. Environ. Res. Public Health 2022, 19, 15798 12 of 29

Table 1. Cont.

Procedure Dealing with Unused/Expired Drugs by Respondents

State or Type of The Method of Research
Region Country Years of Return to Pharmacy/Pharmaceutical
City Respondents Conducting the Group Throwing in the Toilet or Sink Reference
Research Distributor/Health Facility/to Drug Other [%]
Research Garbage [%] Discharge [%]
Take-Back Program [%]
Yogyakarta
Province
(three One resident
districts: from each 23.2—give to
Indonesia 2018 Interviews 324 3.1 71.6 17.3 [29]
Sleman, household over someone else
Bantul and the age of 18
city of
Yogyakarta)
Patients of the
health center
(Gombak
campus,
The
Selangor) and
questionnaire
medical college
was handed out 27.0 (liquid)
of the 6.0 (liquid) 62.0 (liquid)
Selangor, in person, and 65.0 (solid)
Malaysia 2011 International 885 8.0 (solid) 1.0 (ointments - [70]
Pahang the question 83.0 (ointments
Islamic 12.0 (ointments and creams) and creams)
sheet was and creams)
University
collected with
Malaysia
their answers.
(Kuantan
campus,
Pahang), over
the age of 18
Households in a
residential Face-to-face 2.9—toilet 3.8—burn
Malaysia Selangor 2018 103 25.2 63.1 [32]
area in Hulu interviews 8.8—sink 3.8—bury
Langat
7.2—donate to
hospital/charity
Face-to-face 11.5—give to
Residents of 5.8 (unused)
interviews with 8.2 (unused) 47.4 (unused) someone else
Malaysia Selangor 2019 Selangor over 426 12.4 [26]
people in public 1.1 (expired) 84.9 (expire) 16.1—keep at
the age of 18 (expire)
places home until
expired
(unused)
15.7 (liquid)
20.7 (liquid)
The participants 31.5 (solid)
17.0 (liquid) 8.5 (solid)
could choose to 22.8 (ointments
28.0 (solid) 2.5 (ointments
use a web-based and creams)
13.3 (ointments and creams)—return to 54.7 (liquid) and
Residents of (Google Forms) -give to someone
pharmacy 76.0 (solid) creams)—toilet
Malaysia All country 2019 Malaysia over or a paper-based 483 else [25]
15.5 (liquid) 61.1 (ointments 42.9 (liquid)
the age of 18 survey (all 3.7 (liquid)
17.6 (solid) and creams) 2.1 (solid)
potential public 11.4 (solid)
12.8 (ointments and creams)—dispose 3.7 (ointments
places across 4.6 (ointments
in biomedical waste bin and
Malaysia). and
creams)—sink
creams)—burn
Int. J. Environ. Res. Public Health 2022, 19, 15798 13 of 29

Table 1. Cont.

Procedure Dealing with Unused/Expired Drugs by Respondents

State or Type of The Method of Research
Region Country Years of Return to Pharmacy/Pharmaceutical
City Respondents Conducting the Group Throwing in the Toilet or Sink Reference
Research Distributor/Health Facility/to Drug Other [%]
Research Garbage [%] Discharge [%]
Take-Back Program [%]
Undergraduate
An online [71] Jha
Nepal Lalitpur 2020 medical and 441 9.3 38.5 4.1 3.4-burn
survey et al., 2021
dental students
Khon Kaen 64.6 (liquid) 1.6 (solid)
The survey was
City (Ban Face-to-face 81.4 (solid) 0.6 (ointments
Thailand 2009–2010 conducted by 311 1.0 (solid) 7.4 (liquid) [72]
Ped interviews 66.6 (ointments and
Thai villagers
subdistri) and creams) creams)—bury
0.5—burn
District of Residents over Convenience
Cyprus no date 184 - 92.4 24.5 8.2—give to [9]
Nicosia the age of 18 sampling
someone else
Poll by the
Residents over
Israel All country 2014–2015 Central Bureau 7000 10.7–18.6 (depends on region) more than 85 - - [40]
the age of 20
of Statistics
The
questionnaire
was filled out by
7.6—give to
Residents over the patient or 9.3—toilet
Jordan All country 2019 1092 11.8 62.4 someone else [73]
the age of 18 was completed 12.0—sink
Asia/ 1.8—others
with assistance
Western
from the
Asia/
pharmacist.
Middle East
The
questionnaire
was handed out
Pharmacists in person. The
10.0—return to Ministry’s Central
working in the authors waited
Drug Store 9.0—toilet 20.0—give to
Kuwait All country 2009 six government until the 144 73.0 [37]
6.0—disposed with hospital 32.0—sink someone else
hospitals and in participants
medical waste
the polyclinics filled out the
questionnaire
and handed
it back.
Int. J. Environ. Res. Public Health 2022, 19, 15798 14 of 29

Table 1. Cont.

Procedure Dealing with Unused/Expired Drugs by Respondents

State or Type of The Method of Research
Region Country Years of Return to Pharmacy/Pharmaceutical
City Respondents Conducting the Group Throwing in the Toilet or Sink Reference
Research Distributor/Health Facility/to Drug Other [%]
Research Garbage [%] Discharge [%]
Take-Back Program [%]
The
questionnaires
were distributed
to selected
houses in each
4.4 (liquid)
residential zone.
8.5 (solid)
Only residential
2.5 (ointments
buildings 17.0
and
Residents of (apartments and 72.6 (liquid) (liquid)
1.5 (liquid) creams)—give to
13 zones of standalone 78.3 (solid) 6.0 (solid)
Lebanon Beirut Area 2014 300 3.6 (solid) someone else [74]
Administrative houses) were 86.9 (ointments 5.5
0.7 (ointments and creams) 4.4 (liquid)
Beirut Area included in the and creams) (ointments and
3.6 (solid)
random sample creams)
4.4 ointments
selection
and
process;
creams)—other
commercial
buildings were
excluded
from the study
sample.
Patients of
several primary
The survey was
Nablus City and secondary
distributed to
Palestine (North of 2011 care institutions 250 13.6 66.4 10.8 - [75]
patients and
Palestine) as well as local
pharmacists.
community
pharmacies
The
Patients and questionnaire
personnel of was handed out
King Khalid in person. The 1.7—return to physician 1.6—give to
Saudi
Riyadh City 2015 University respondents 1057 1.7—return it to pharmacy 79.2 7.0 someone else [76]
Arabia
Hospital filled out 3.7—hazardous waste collection 0.6—other
and King Saud the
University questionnaire
and returned it.
Patients, family
members and
The survey was 2.6—give to
Saudi working staff of
Jeddah City no date distributed 1171 13.6 72.8 4.6 someone else [77]
Arabia King Abdulaziz
in person. 1.1—burn
over the age
of 16
Int. J. Environ. Res. Public Health 2022, 19, 15798 15 of 29

Table 1. Cont.

Procedure Dealing with Unused/Expired Drugs by Respondents

State or Type of The Method of Research
Region Country Years of Return to Pharmacy/Pharmaceutical
City Respondents Conducting the Group Throwing in the Toilet or Sink Reference
Research Distributor/Health Facility/to Drug Other [%]
Research Garbage [%] Discharge [%]
Take-Back Program [%]
The
questionnaire
Saudi Residents over was sent to 1.4—physician 9.1—give to
All country 2017 767 62.9 16.6 [78]
Arabia the age of 18 respondents 6.5—pharmacy someone else
across the
country.
8.7
(unused)—give
Residents of An
to someone else
Saudi Qassim Qassim Province observational 5.0 (unused)—pharmacy 28.5 (unused)
2017 302 75.8 (expire) 57.7 [79]
Arabia Province over the age cross-sectional 5.0 (expired)—medical store 9.0 (expire)
(unused)—keep
of 18 survey
at home until
expired
Pharmacy
Saudi undergraduate An online 22.0—give to
All country 2018–2019 464 15.0 89.0 - [38]
Arabia or postgraduate website survey someone else
students
4.4 (liquid)
73.3 (liquid)
1.9 (solid)
75.3 (solid)
2.8 (ointments
74.2 (ointments and creams)—return to 1.1 (liquid)
1.7 (liquid) and
The survey was pharmaceutical distributor 1.4 (solid)
Saudi Community 3.6 (solid) creams)—toilet
Riyadh City 2019 distributed 360 15.5 (liquid) 1.1 (ointments [39]
Arabia pharmacists 3.3 (ointments 3.6 (liquid)
in person. 16.1 (solid) and
and creams) 1.1 (solid)
16.7 (ointments and creams) creams)—other
1.4 (ointments
-putting in
and
the medicines’ bin
creams)—sink
7.0 (OTC)
6.0
Participants
(POM)—donate
Saudi from An online 6.0 (OTC) 45.0 (OTC) 6.0 (OTC)
All country 2020 924 to charity [80]
Arabia all areas of website survey 10.0 (POM) 42.0 (POM) 7.0 (POM)
18 (OTC)
Saudi Arabia
14 (POM)—give
to someone else
TGB company
employees
32.9—bring to
representing An online
Turkey All country 2016 1121 34.0 33.9 company’s [81]
almost each survey
drug-box
geographic
region of Turkey
Int. J. Environ. Res. Public Health 2022, 19, 15798 16 of 29

Table 1. Cont.

Procedure Dealing with Unused/Expired Drugs by Respondents

State or Type of The Method of Research
Region Country Years of Return to Pharmacy/Pharmaceutical
City Respondents Conducting the Group Throwing in the Toilet or Sink Reference
Research Distributor/Health Facility/to Drug Other [%]
Research Garbage [%] Discharge [%]
Take-Back Program [%]
Residents of
Interview with
Galway, Galway and 14.0—toilet
Ireland 2010–2011 people in the 398 28.0 51.0 6.0—other [82]
Cork Cork over the 29.0—sink
streets
age of 18
Respondents An online
All country 450 30.0 68.0 -
from all country survey
The
Poland 2015 Clients of the questionnaires [8]
Pomeranian
pharmacies over were distributed 635 35.7 35.0 -
district
the age of 18 to clients by
pharmacists.
Household 1.0—recycling
Face-to-face
Portugal All country 2014 members over 244 69.0 25.0 2.0 depot [49]
interviews
the age of 18 3.0—other
Europe Clients of the
five pharmacies The
(three urban and questionnaires 4.0—throw
Bihor
Romania 2014–2015 two rural were distributed 771 0.7 95.3 - away to other [46]
Country
pharmacies) to clients by places
over the age of pharmacists.
18
The South Household 6.6—burn
Face-to-face
Serbia Backa 2010 members, over 230 4.5 80.3 7.6 1.0—give to [42]
interviews
District the age of 18 someone else
1.8—burn
Residents of 0.8—store
Novi Sad Face-to-face
Serbia 2011–2012 Novi Sad over 383 4.4 82.8 2.9 7.3—keep at [83]
city interviews
the age of 18 home until
expired
3.0—burn
Residents over An online
Australia Australia All country 2016 4302 22.5 64.9 23.2 6.0—bury [84]
the age of 18 survey
1.0—other
* depending on the dosage forms and class of the pharmaceuticals. OTC—Over-the-Counter. POM—Prescription Only Medicines.
Int. J. Environ. Res. Public Health 2022, 19, 15798 17 of 29

In Tanzania, 91.4% of respondents were not aware of the existence of proper medicine
disposal methods [27]. This is due to the fact that patients are not educated in this area or
the methods of education are ineffective. For example, Yu et al. (2019) indicated that 79% of
young adults and 88% of elderly people in China had not received advice on how to deal
with unused medicines [68]. Similar results were obtained in studies conducted among
residents of Saudi Arabia (73% and 80%, respectively) [77,78]. This problem also concerns
specific categories of drugs, such as opioids. Among 300 adult cancer out-patients receiving
opioids in Texas (USA), 223 (74%) were unaware of proper opioid disposal methods, and
138 (46%) had unused opioids at home [85].
On the other hand, most patients are aware that throwing unwanted medications
into the trash or pouring them into the sewage system has a negative impact on the
environment and health. For example, in Jordan, 72.5% of participants said they knew
that the improper disposal of medications could harmfully affect the environment and
health [73], and 0.86% of households in the US said that flushing unwanted medications
down the toilet or sink may result in medications contaminating the water supply or
negatively impacting the environment [53]. These results are comparable with the results
obtained for the populations of Ethiopia, Malaysia, Afghanistan and Portugal [24–26,50,66].
Respondents indicate that it should be the responsibility of health care professionals
and pharmacists to provide information on the handling of household pharmaceutical
waste [73,86]. Providing appropriate guidance, in the opinion of respondents, could
control or minimize medication wastage [26]. At the same time, people who receive
instructions regarding proper disposal are more likely to return unused pharmaceuticals
to a pharmacy [78]. This means that pharmacies play an important role in the system, not
only as places for collecting unused pharmaceuticals but also in the field of environmental
education. However, in order to provide adequate information, providers must have this
knowledge themselves. A survey conducted in the Kingdom of Saudi Arabia among
undergraduate or postgraduate pharmacy students indicated that more than half (60%)
had never received any information during their studies or training on how to store or
dispose of medications. Moreover, 89% reported previously disposing of unused medicines
mainly in household garbage [38]. On the other hand, between 73.3 and 75.3% (depending
on the dosage form) of community pharmacists in Saudi Arabia returned unused drugs
to the pharmaceutical distributors, and only between 1.1 and 4.4% poured them down
the sink or toilet [39]. These results are similar to the results obtained in Nigeria. A study
conducted among community pharmacies in Anambra State in Nigeria indicated that the
most common method of drug disposal was via the National Agency for Food and Drug
Administration and Control or drug distributors (above 60%). However, about 20% of drug
disposal was via rubbish bins [64]. In contrast, most pharmacists in Kuwait disposed of
pharmaceuticals by throwing them in the trash (73%) or pouring them down the toilet or
sink (9% and 32%, respectively). At the same time, over 80% of these pharmacists are aware
that this method of disposing of pharmaceuticals can cause damage to the environment [37].
A phone and online survey by Bungau et al. (2018) carried out on a group of 521 pharmacists
from Romania indicated that 53.6% consider themselves sufficiently informed about the
waste disposal legislation, only 19.3% consider themselves highly informed and almost 9%
believe they are little or not at all informed [48]. Only 15.9% of pharmacists from California
(US) correctly selected all of the appropriate methods of medication disposal that could
be recommended to patients in their communities for non-controlled substances, and only
10.1% were able to recognize all of the appropriate methods of disposal for controlled
substance medications [87].
Accordingly, it is important to properly educate pharmacy students, pharmacists
and health care staff in this field. In the aforementioned survey, Alhomond et al. (2021)
showed that among the students who received information on the appropriate disposal of
medicines, 85% did not dispose of unused or expired medications in household garbage
(while 15% did), and of those who had never received such information, 91% did (9%
did not) dispose of medications in household garbage [38]. Of the people in Ireland
Int. J. Environ. Res. Public Health 2022, 19, 15798 18 of 29

who obtained advice from a health care professional regarding disposal, 75% chose an
appropriate method compared with 25% who did not [82]. Tabash et al. (2016), in their
research, assessed the impact of an educational program on the knowledge, attitude and
practice of health care staff regarding pharmaceutical waste management. The survey
was carried out among various health care staff working in five governmental hospitals
in Gaza before, after and six months following the implementation of the educational
program. It was found that the educational program led to a significant improvement in
the knowledge, attitude and practice of health care staff regarding pharmaceutical waste
management. Knowledge and practice levels increased from 50 to 75% [88]. In addition
to information obtained from pharmacists, doctors and other health care professionals,
patients obtain knowledge about the appropriate disposal methods of unused drugs from
books, the media, the Internet, family members and friends. Yu et al. (2019) noticed that
for young adults and aged people, family members such as parents and children appeared
to be the main advisors on the disposal of medications [68]. In a different study, 54% of
respondents in the US reported having looked for drug disposal information, with the
Internet being the primary source of information [6], whereas 56.1% of patients from Jordan
reported that social media was the preferred method of education regarding the disposal of
unused or expired medications [73]. Electronic media are, according to respondents among
the Ethiopian community, the best source of ecological information (49.6%), with doctors
also a good source (24.5%), whereas, only 8.5% of the participants in this study indicated
pharmacists [24].
One source of information is educational campaigns and programs carried out by
national and local governmental bodies as well as environmental organizations and private
institutions. Public education campaigns on pharmaceutical waste management in the
Bihor county (Romania) population resulted in a significant increase, from 1.1% to 87.3% in
6 months, in the number of patients who returned expired and/or unused drugs to phar-
macies [47]. The implementation of an educational program in a private communication
company in Turkey contributing to the proper storage, use and disposal of pharmaceuticals
resulted in a positive change in the drug disposal behavior of 46.5% of the employees
who participated in the program [81]. In Spain, one of the components of the SIGRE
system, beyond receiving leftover medication from patients, is educational campaigns.
For example, in 2018, a campaign under the slogan “Thanks for lending us a hand” was
launched. The goal of this campaign was a more responsible use of drugs and encouraging
the return of unwanted drugs, especially antibiotics, to SIGRE collection points located in
pharmacies [52].
The International Pharmaceutical Federation (FIP), in 2015, prepared the document:
“Green pharmacy practice—Taking responsibility for the environmental impact of medicines”,
in order to provide pharmacists’ associations with useful information in this field. This
reference document proposes solutions for developing green pharmacy policies, such as:
creating an adequate legal framework at the national level, establishing effective pharma-
ceutical waste disposal practices, organizing continuous training programs for pharmacists
and other health professionals and running informational and educational campaigns for
patients in order to reduce and properly dispose of pharmaceutical waste [89].
In Australia, in 1998, the Return Unwanted Medicines (RUM) project was introduced
by the government. This program provides the free option for the public to return un-
wanted and expired medicines to community pharmacies [90,91]. Returned medicines are
deposited in bins situated within any community pharmacy, which are then collected by
pharmaceutical wholesalers, transported to registered incineration sites and disposed of
by high-temperature incineration [90,92]. Although in the years 2000–2018, there was an
increase in the amount of unwanted medicines collected in pharmacies, from 19.6 to 66.4%
per month, a 2016 survey of 4302 Australian adults found that only 17.6% of them had
heard of the RUM project [84,93].
A return or take-back voluntary program was also implemented in Malaysia. Under
this national program, patients can return unused drugs to pharmacies, hospitals and
Int. J. Environ. Res. Public Health 2022, 19, 15798 19 of 29

health clinics that are subordinate to the Ministry of Health Malaysia [32]. Although this
program has functioned in Malaysia since 2010, the analysis of patient behavior indicates
that still, the main method of disposing of unwanted drugs is by discarding them in the
trash (Table 1).
Canada is one of the countries that started introducing unused drug return programs
by consumers in the 1990s. In 1996, the EnviRX program introduced in British Columbia
was aimed at the possibility of returning unused/expired drugs by patients [93]. Residents
can also return unused/expired prescription or OTC drugs in Canada for free. Due to
the fact that Canada consists of various provinces and territories, there is a mixture of
guidelines, regulations and programs for the appropriate disposal of pharmaceuticals [43].
For example, in British Columbia, Manitoba, Ontario and Prince Edward Island, the
Medications Return Program was implemented. This program is operated by the Health
Products Stewardship Association (HPSA). The HPSA represents producers of health
products in Canada, and it is financed by them [94]. As part of the program, since the
beginning of its operation, 3,783,069 kg of medications have been collected [93]. Alberta,
Saskatchewan and Nova Scotia have voluntary programs, administered and monitored by
their respective pharmacy associations [43]. The effect of the take back programs introduced
in the 1990s is the large (compared and other analyzed countries) participation of patients
in the system of drug return to pharmacies. A survey conducted by the Canadian statistical
office as part of the Canadian Environmental Sustainability Indicators program in 2011
showed that over 63% of citizens return medicines to the supplier, retailer, pharmacy or
doctor, while 21% throw them into the garbage, and 5% pour them into the sink or toilet [95].
In September of 2010, the US Drug Enforcement Administration (DEA) established a
nationwide program called the National Take-Back Initiative [96]. As part of the program,
a biannual series of National Prescription Drug Take-Back Days are organized [97]. The
aim of the program is to provide the opportunity to donate unwanted drugs and educate
the public about not abusing drugs and about the proper way to dispose of them. During
Take-Back Days, collection points for unwanted drugs are organized in cities throughout
the United States. For example, during April 2021, the 20th National Take-Back Days
managed to collect 420 tons of unwanted drugs at 5060 points across the country [98].
As reasons for the inappropriate disposal of unused drugs, residents also indicate
convenience or habit. Patients from Portugal indicated that in order to increase the amount
of medications returned to pharmacies, it would be important for the number of collection
points to be increased, thus reducing the distance to them [50]. More than half of the
respondents who declared their willingness to participate in Take-Back Days in Texas (US)
admitted that they would not take part in this initiative if they had to travel more than 5
miles to do so [96]. On the other hand, among the survey participants in Saudi Arabia who
were unwilling to properly dispose of medications, above 50% said they had no specific
reason for this [38].
Some researchers have reported that sociodemographic factors such as education,
income level, household size and gender influence a household’s environmental behav-
ior [99–101]. The analysis of literature reports shows that in some studies, such relationships
occur, while in others, age, gender and education do not affect the method of disposal of
unwanted drugs. Shaaban et al. (2018) and Hassali and Shakeel (2020) indicated that highly
educated respondents are more likely to return medications to a pharmacy and are more
likely to be cognizant of the detrimental consequences of inappropriate waste disposal than
those of lower educational levels [26,78]. The analysis of the behavior of pharmacy students
in Saudi Arabia showed that the percentage of female students found to throw unused or
expired drugs into the household garbage was significantly higher compared with the male
students [38]. On the other hand, Akkici et al. (2018), in studies conducted among respon-
dents in Turkey, observed that a higher percentage of women declared having changed
their unused drug handling practice (49.9%) than men (38.5%) [81], whereas age, gender or
education did not affect the environmental behavior of the respondents in Romania, the
USA, Thailand or Ireland with regard to the handling of unused drugs [6,47,60,72,80].
Int. J. Environ. Res. Public Health 2022, 19, 15798 20 of 29

An important issue that should be given attention is keeping unused medicines at

home for various reasons. In Tanzania, the majority of households (96%) kept unused or
expired medications [27]. More than 85% of respondents in Indonesia reported storing
unused medications in their homes [29]. In Malaysia, 70.6% of respondents claimed to have
some bought medications that remained unused in their homes [26]. Almost all residents
of Ghana (98%), in a study by Abruquah et al. (2014), declared that they had unwanted
medications in the home that they wished to dispose of [58]. Keeping unused or expired
drugs is not something that concerns residents of developing countries. According to
the studies of Wieczorkiewicz et al. (2013), a quarter of respondents had expired drugs,
both prescription and nonprescription, in their households. In one study, 61.8% of the
residents of Cook County (Illinois, USA) indicated that the longest time that they had ever
stored expired medications was less than 1 year, and 2% stated that they had stored expired
medications for longer than 10 years [53]. Moreover, Vatovec et al. (2017) showed that
drug expiration was not the main reason for disposing of medications (1% prescription,
8% OTC) [30]. In the case of households in Serbia, drugs that were no longer used were
still kept by about 95% of residents [42]. Unused medicines were kept in the home by 88%
of respondents in Ireland [82], and 44.4% of Serbian households indicated that they had
expired medications [83]. Residents of Cyprus also indicated that they kept quantities of
unused drugs remaining after their medical treatment (76.8%) [9]. At the same time, some
studies indicate that elderly people rather than younger people prefer to keep unused
medicines at home, and more women kept unused drugs at home than men [68,81].
Unused pharmaceuticals were kept at home for several reasons. The first is the belief
that they may be useful in the future. This was the main reason for residents of Malaysia
(70.4%), Portugal (43%), Cyprus (93.4%), Uganda (55.4%) and Ireland (57%) to keep unused
medicines at home [9,25,50,57,82]. Another reason is that the drugs have not yet expired.
For instance, 33% of Portuguese residents used this reason to keep unused drugs, even if
they assumed that they would not use these drugs in the future [50]. Massoud et al. (2016)
indicated that 67% of residents of the Beirut area disposed of unused drugs due to the
expiration of the medication [74]. Moreover, a study in Malaysia showed that drugs are
disposed of after not being stored correctly and medicines turned bad (74.4%) or when
medicines smelled bad, tasted bad or looked bad (72.9%) [25]. Other reasons residents keep
unused medications include: giving to friends or someone in your family who may use
them [50,57] or fear that they will not be able to find the same drug on the market [9]. A
further reason that people keep unused/expired medicines at home is that they are unsure
of how to dispose of them. More than half of the respondents indicated this reason in
research conducted by Azad et al. (2012), Yu et al. (2019) and Ong et al. (2019) [25,68,70].

6. Environmental Impacts of Improper Disposal of Unused/Expired Pharmaceuticals

Pouring unwanted drugs into toilets or sinks causes them to be transported through
the municipal sewage system to municipal wastewater treatment plants. Wastewater treat-
ment plants, both in undeveloped countries (if they exist) and in developed countries,
focus mainly on treating wastewater with regard to nitrogen and phosphorus compounds
or suspended solids. In the European Union countries, there are no regulations obliging
member states to use technologies that enable the removal of micropollutants, including
pharmaceuticals, from wastewater. According to Council Directive 91/271/EEC of 21 May
1991 concerning urban wastewater treatment (OJ L 135 30.5.1991, p. 40), member states
shall ensure that the treated wastewater released into water meets the requirements for
biochemical and chemical oxygen demand and total suspended solids, and in the case of
emissions, it is sensitive to specific nitrogen and phosphorus contents. In effect, microp-
ollutants, including pharmaceuticals and their metabolites, end up in water reservoirs,
such as seas or rivers, which may pose a threat to organisms living in them. For example,
according to information contained in the UNESCO/HELCOM report, the main pathway
of pharmaceuticals into the freshwater and marine environment in the area of the Baltic
Sea is via the discharges of municipal wastewater treatment plant effluents [16].
Int. J. Environ. Res. Public Health 2022, 19, 15798 21 of 29

The disposal of pharmaceuticals in conventional wastewater treatment plants using

mechanical, biological and chemical processes depends on the two processes of sorption
and biodegradation [102]. For example, inter alia, carbamazepine, diclofenac, metoprolol,
tramadol and rosuvastatin display low sorption on sludge [103]. In effect, these compounds
may pass into the liquid phase. Therefore, only about 30% of diclofenac is removed, while
for example paracetamol is removed up to 100% [104]. In addition, the degradation process
may result in higher concentrations of some compounds, such as carbamazepine, being
observed in the effluent than in the influent [105]. Moreover, compounds present in
wastewater can undergo degradation processes and react with other compounds in the
environment. As a result, compounds with higher toxicity than the original compounds
can be formed [106]. An even greater environmental problem occurs when there are
no sewage systems and no wastewater treatment systems. Large portions of African
communities do not even have proper sanitation systems and modern ablution facilities
that can be flushed with fresh water to direct human waste into WTP [107,108]. As a
result, pharmaceuticals and their metabolites enter directly into water and soil. The threat
to water (including groundwater) and soil also results from throwing unused/expired
pharmaceuticals into household rubbish bins or directly into the environment. Household
waste is disposed of in landfills. In a study by Lu et al. (2016), 15 compounds, among others,
atenolol, ibuprofen, ketoprofen, diclofenac, gemfibrozil, benzophenone, carbamazepine
erythromycin, amphetamine, methamphetamine, ketamine, ephedrine, flunitrazepam
and codeine were found in leachate from municipal landfills [109]. Carbamazepine and
primidone were detected in all tested leachate samples from five landfills in the USA [110].
Pharmaceuticals are designed to elicit a biological response in organisms even at
low concentrations. Accordingly, those in the aquatic environment might also produce a
biological response in nonspecific organisms [111]. Many of these compounds are toxic
to aquatic organisms. For example, acetaminophen exhibits low toxicity to the bacteria
Allivibrio fischeri, whereas its toxicity to Daphnia magna is high [112,113]. Moreover, meto-
prolol exhibited a negative chronotropic effect on the heart of Daphnia magna at a high
concentration exposure, and, among analgesics, the most toxic effect was reported of EC50
below 100 mg L−1 , while phytoplankton is highly sensitive to metoprolol in acute and
high-level exposure with EC50 of 14.5 mg L−1 at 96 h post exposure. Diclofenac also causes
gill alterations in trout fish [114]. In addition, it should be noted that the ecotoxicological
effects of pharmaceuticals are still unknown [115], e.g., 88% of human pharmaceuticals do
not have comprehensive environmental toxicity data [116]. At the same time, pharmaceuti-
cals and their transformation products are present in a mixture, and therefore it is difficult
to clearly define their negative impacts on organisms.
In recent years especially, the problem related to the release of antibiotics into the
environment has intensified, causing the development of antibiotic-resistant bacteria and
the environmental occurrence of antibiotic-resistant genes [117]. This phenomenon results
in resistant bacteria that are able to survive in the presence of an antimicrobial in concen-
tration that is usually sufficient to inhibit or kill microorganisms of the same species [118].
The human health risk of ARGs is due to the fact that antibiotic resistance can be trans-
ferred from environmental components to drinking water sources [119]. In Europe, 75%
of inhabitants use groundwater as their source of potable water [120]. At the same time,
both in Europe and in other parts of the world, pharmaceuticals are detected both in
groundwater and drinking water. For example, in groundwater samples in Barcelona, the
most frequently detected compounds were antibiotics, which were present at concentra-
tions reaching 1000 ng L−1 [121]. On the other hand, analyses of tap water samples taken
in Northern Kunming (China) showed that out of 17 examined antibiotics, 9 antibiotics,
inter alia, trimethoprim, sulfamethoxazole, oxytetracycline, metronidazole, dimetridazole,
azithromycin, clarithromycin and roxithromycin were detected in over 80% of all samples.
The average concentration of total antibiotics in tap water was 10 ng L−1 [122].
Accordingly, in 2015, the WHO adopted a global action plan on antimicrobial resis-
tance, including antibiotic resistance. The aim of the plan was, among others, to increase
Int. J. Environ. Res. Public Health 2022, 19, 15798 22 of 29

the knowledge and awareness of antimicrobial resistance and to conduct activities related
to optimizing the consumption of antibiotics [123]. Moreover, the European Union, in the
EC Communication from 29 June 2017, announced the European One Health Action Plan
against Antimicrobial Resistance [18].
At the same time, it should be noted that the COVID-19 pandemic resulted in an
increase in the consumption of certain drugs, including antibiotics, and thus an increase
in their amounts in the sewage stream [124]. Due to the lack of drugs that were dedicated
to the fight against the SARS-CoV-2 virus, drugs from various therapeutic groups were
tested, i.e., antiviral drugs used in AIDS, antimalarial drugs (e.g., chloroquine and hydrox-
ychloroquine), antibiotics (e.g., azithromycin), painkillers and combinations of these drugs
(e.g., hydroxychloroquine and azithromycin) [125]. Literature research by Morales-Paredes
et al. (2022) indicated that the concentrations of most drugs used in COVID-19 therapy
in the aquatic environment increased during the pandemic (e.g., azithromycin concen-
trations in surface waters from 4.3 ng L−1 before the pandemic to 935 ng L−1 during the
pandemic) [126].

7. Recommendations
Reducing the amount of drugs in the environment, and thus their negative impact, is a
multistage process and includes, inter alia, the rational prescription of drugs, the limitation
of drug consumption, legitimate self-medication and proper disposal. Social awareness of
the problem plays a key role in each stage of the process.

7.1. Prescribing and Purchasing Pharmaceuticals

Prescribing excessive amounts of drugs increases their consumption and storage.
Storing medicines at home and their consumption by a person other than the person for
whom they are prescribed can increase the risk of adverse effects. The accidental intake
of drugs by children may be a problem. In addition, the storage of drugs means that
consumers will, most likely, eventually dispose of them when they have expired. In a
survey conducted by Naser et al. (2020), Jordanian respondents indicated that from their
perspective, the best way to reduce drug waste was by dispensing medications only as
required (42.4%), prescribing medications rationally (35.4%) and giving proper advice to
consumers (33.5%) [73]. Similar conclusions were obtained in the research by Hassali and
Shakeel (2020). Respondents from Malaysia suggested that the provision of appropriate
directions by health care professionals (73.2%) and prescribing medications in quantities
for a duration that ensures patient adherence (26.7%) could control or minimize medication
wastage [26]. Therefore, an important role in the process of limiting the amount of drugs
in the environment is played by health care workers authorized to prescribe drugs and
pharmacists who advise patients to buy OTCs. At the same time, pharmacists should
also be educated because they interact greatly with patients and can change inappropriate
consumer habits. This is especially important in the case of the currently very common
problem of self-medication. The effect of self-medication is not only the purchase of large
amounts of drugs by patients, their subsequent storage and then their disposal but also
negative consequences for the health of patients resulting from, for example, interactions
between drugs or the risk of side effects. Despite the fact that the regulations for the
promotion of pharmaceuticals, especially in the EU, point to the importance of monitoring
drug advertisements to ensure compliance with laws and regulations and using adequate
sanctions to prevent violations, the legislation consists of bans on public advertisements of
prescription-only drugs. However, the legal rules still do not reduce the patients’ needs,
and raising social awareness is a key point for a sustainable pharmacy market.
The COVID-19 pandemic has resulted in an increase in demand for the purchase and
storage of drugs, especially those for chronic diseases. The phenomenon of “panic buying”
was particularly visible in richer geographical areas [127,128]. Elek et al. (2021) reported
that in Hungary, the duration of therapy with regard to pharmaceutical purchases increased
by more than 30% in the month when major lockdown measures were announced, and
Int. J. Environ. Res. Public Health 2022, 19, 15798 23 of 29

this refers to almost all categories of pharmaceuticals [128]. Lockdowns and restricted
access to doctors were also associated with an increase in the problem of self-medication
among patients.

7.2. Disposal of Pharmaceutical Products

There is no doubt that the ways in which society wrongly disposes of unused/expired
drugs have a negative impact on the environment. Accordingly, safe drug return systems
and programs need to be established and developed. Pharmacies play an important role in
such systems as the points of return of pharmaceuticals, due to their general availability
and number. In some countries, they are obliged to be included in the system of collecting
unused/expired medicines from households (e.g., Croatia, France), whereas in others, they
operate on a voluntary basis (e.g., Poland). The next stage is to educate the public on
the proper handling of unwanted drugs, including collection systems and drug take-back
programs. For example, although the RUM project in Australia was launched in 1998,
a survey conducted in 2016 showed that less than 18% of Australian respondents had
heard of it. On the other hand, 91.7% of respondents who were previously unaware of the
scheme stated they would now use it [91]. At the same time, attention should be paid to
adjusting educational tools to the target group and national specificity. In the case of older
people, in our opinion, the participation of pharmacists in the education process will be
important, while in the case of young people, electronic media and social networks may
prove effective.
The COVID-19 pandemic and blockades, and thus limits on the possibility of move-
ment in different countries and patients’ fear of getting sick, could reduce the willingness
and actions of patients in the pharmaceutical waste collection system [129]. In the USA,
Drug Take Back Day, which was planned for April 2020, was canceled due to the pan-
demic [130].
Pharmacy reuse (sometimes referred to as recycling) is a complex issue, facing concern,
especially regarding safety and liability. The controlled reuse of drugs can be a way to
reduce their negative environmental impact. Reuse can also help reduce the accumulation
of drugs in society. However, the problems that appear in this case arise from the storage
methods of medications in households, including poor storage conditions such as humidity
and temperature, which are not regulated. Research conducted in the Netherlands and
Great Britain showed that over 50% of respondents were willing to use medications returned
unused to the pharmacy by another patient as long as the quality of these medicines
was verified [131,132]. In addition, an experiment by Lam et al. (2021) in Great Britain
showed that the integration of sensors that measure and track the interaction of the storage
conditions (e.g., temperature, light, humidity) on drug packaging, and the guarantee that
the quality of drugs will be visually assessed by the pharmacist, meant that the respondents
would be more willing to participate in a system for the reuse of medications [59].
Despite these repository programs, the collection and redistribution of unadulterated
prescription drugs are not allowed by dispensing laws in EU countries. The reuse of
still-usable drugs in modern, tamper-evident packaging is still dangerous with regard to
unknown storage conditions.

7.3. Waste Management and Wastewater Treatment

Because the main methods of disposing of unused/expired drugs by respondents
from various countries include throwing them into the garbage and pouring them into the
sink/toilet, waste management and wastewater treatment from pharmaceutical residues
should be developed at the same time. On the one hand, some countries (e.g., Switzerland,
Germany) started introducing additional methods of wastewater treatment (e.g., ozone,
granulated activated carbon) in wastewater treatment plants to remove micro-pollutants
such as pharmaceuticals and their metabolites. In other countries, however, wastewater
treatment systems are completely lacking. For example, in Ghana and India, only 7.9%
and 30.7%, respectively, of the wastewaters are treated, which results in the presence of
Int. J. Environ. Res. Public Health 2022, 19, 15798 24 of 29

pharmaceutical residues in the aquatic environment [104]. This same situation occurs in the
case of household waste. Incineration is the main method of waste management in some
countries, such as Germany and Sweden, and in other countries such as Malaysia, Poland
and Romania, landfilling is the leading practice in the management of solid waste [25].
An important area in the field of wastewater treatment seems to be the development
of new, more effective and low-cost methods of the elimination of pharmaceutical residues
from wastewaters. Among the treatment methods, photocatalytic methods play a special
role and have been recognized as one of the most promising methods for the elimination of
organic pollutants in environmental matrices [133]. Although TiO2 is the most frequently
used photocatalyst, other such semiconductors show good elimination of organic pollu-
tants. For example, meso-tetra (4-carboxyphenyl) porphyrin (TCPP)/Bi12 O17 Cl2 shows
photodegradation efficiency of 79.4% for tetracycline [134]. In the case of tetracycline, an
effective level of degradation can be obtained by also using the combination of Cd0.5 Zn0.5 S
nanoparticles and Bi2 WO6 microspheres [135].

8. Limitations of the Study

This study had some limitations. The selected period (2012–2021) from which the
publications were analyzed allows data to be shown only from selected countries. Published
studies from particular countries may not be representative of the entire population of
the country because they are conducted, for example, on a specific, selected group of
respondents, such as students or residents of large cities. In addition, some research was
conducted using online surveys, which may also affect the results (e.g., the tendency to
behave differently on the Internet compared with the real world, access to the survey only
for people who have and use IT tools).

9. Conclusions
The conducted review showed that the basic way for patients in different countries to
deal with unused/expired drugs is to throw them into the garbage and/or pour them down
the sink. This happens even despite the fact that many countries have systems for collecting
unnecessary medications from patients. In view of the above, investigating the reasons why
expired/unused pharmaceutical products become waste plays a key role in reducing the
problem. There is a need for more research to explore this problem. It seems that a global
system based on the obligatory collection of unused/expired medicines from households is
needed. Simultaneously, with the development of this system, it is necessary to effectively
educate societies about the impacts of improper drug disposal on the environment. It is
equally important to conduct research on developing new or modifying existing methods
of wastewater treatment from hazardous compounds, especially now that the problem of
microbial resistance is becoming more and more serious.

Author Contributions: J.R.—concept of the manuscript; J.R., A.Z.—concept of the conclusion; J.R.,
A.Z.—writing the article; J.R., A.Z.—final proofreading and approval for publication; A.Z.—language
review of the manuscript, J.R.—revision and response. All authors have read and agreed to the
published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Conflicts of Interest: The authors declare no conflict of interest.
Int. J. Environ. Res. Public Health 2022, 19, 15798 25 of 29

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