Historically, efforts to minimize environmental impact have been tied to the economy. Initiatives such as batch production to reduce IV waste deliver tangible economic impacts, and as such tend to receive support from administration. But all too often, green initiatives—from working with vendors to minimize excessive packaging to ensuring all medication waste is disposed in a manner that prevents it from entering our water system—are seen as positive, but non-essential, programs that tend to fall by the wayside when resources become tight.   

Survey Design
Given the complexity of waste management regulations, for the fourth year in a row, PP&P polled a random nationwide sampling of health-system pharmacy directors in the fourth quarter of 2012. Responses were submitted via email, with pharmacy directors from 416 facilities responding, yielding a confidence interval of 4.63% (95% +/-4.63) based on the total population of pharmacy directors nationwide. 

We intentionally surveyed a random sampling of pharmacy directors, not just readers of PP&P, to ensure our data reflects trends across the whole of hospital pharmacy practice. Thus we were pleased to learn that 73% of pharmacy directors use PP&P as a resource for information on pharmacy waste management. 


Regulatory Action Drives Compliance
Regulations are often the impetus driving compliance efforts. 2012 saw an increase in inspections for environmental practices from multiple regulators, including accreditors, state boards, CMS, and health departments. Notably, inspectors are now highly likely to query hazardous drug waste practices and RCRA compliance. As a result, facilities receiving recommendations regarding their waste practices during these inspections are also on the upswing. 

Simultaneously, hospitals continue to upgrade their compliance efforts with a special emphasis on RCRA-characteristic waste management. In 2009, just over one third of pharmacy directors were confident in their compliance with RCRA. By 2012, self-reported compliance had grown to 54% of facilities and actual practices confirm this number. Three years ago, it was not uncommon for facilities to dispose of warfarin in the regular trash; this year saw 71% of hospitals managing their warfarin waste as RCRA-hazardous. Waste management programs focusing on RCRA waste are now the norm in most hospitals, and the use of EPA-approved RCRA containers is nearing universal acceptance. Nonetheless, the need for additional progress is evidenced by the fact that although an increasing number of facilities have dedicated onsite, long-term storage areas for hazardous waste, these facilities still remain in the minority. Without full logistical support from the organization, pharmacy’s commitment to compliance can be difficult to actualize. 

Given the challenges in managing these complex and often conflicting regulations, a growing number of facilities are turning to outside vendors to manage much of their medication waste. Pharmacy directors often rely on these vendors to manage much of the waste process, from formulary reviews to identify hazardous materials to collection and disposal services.

Mixed Signals Continue for Controlled Substances
While compliance rates are progressing for most categories of medication waste including RCRA-hazardous, non-hazardous, and chemotherapy waste, compliance rates have dropped for controlled substances. Some state environmental agencies have taken the lead in banning the disposal of medications via the sewer system, while the DEA and EPA have been woefully inadequate in addressing this issue. Given that the fear of regulatory citations can inspire defensive action, perhaps it should not be surprising that the practice of sewering products such as fentanyl patches and morphine waste has increased over the past few years. Acknowledging this conundrum, pharmacy directors now are less likely to declare their controlled substance waste practices compliant. 



Waiting for clear federal guidance on this issue may equate to a Sisyphean task; therefore, it is incumbent upon pharmacy to embrace cradle-to-grave management of all medications in their facility and explore every option to ensure waste is disposed of safely. Environmentally appropriate waste management is not a luxury to engage in when resources are plentiful. Rather, pharmacy should explore current options from expanding the in-house definition of hazardous drugs to reviewing new products and services on the market.