Medication Disposal in the Hospital

Full update March 2020

Imagine the pharmaceutical waste you encounter during your shifts: partially used vials of injectable meds that have passed their beyond-use date, prepped infusions returned to the pharmacy that were discontinued before they were used, etc. This should make it easy to see how healthcare facilities have been implicated in flushing around 250 million pounds of med waste into sewer systems each year. Results of water testing all over the U.S. have revealed the impact of improper med disposal. For example, samples have shown that our water supply contains multiple types of meds including blood pressure meds, hormones, and NSAIDs. Med disposal is serious business. Corporate fines can reach tens of thousands of dollars per day when federal regulations for med disposal are not followed. This technician tutorial covers the basics of pharmaceutical waste disposal. Keep in mind that the specifics will vary depending on additional factors such as your state and local laws, and hospital policies.

What determines the proper disposal method for a med?

The properties of a med are the main determinants of its proper disposal method. Most med waste will need to be incinerated (completely burned) and/or placed in a landfill. (Processes such as incineration can help reduce the dangerous properties of med waste.) But the type of incineration and the type of landfill (and the need for any additional steps prior to incineration) can differ depending on the risks associated with waste. That’s why separation of med waste is important in the hospital setting. Fortunately, there’s guidance on how this should be done.

First, the Resource Conservation and Recovery Act (RCRA) is a federal regulation that lays out specific meds that are considered hazardous waste, in addition to characteristics that lead to a med being considered hazardous waste. These meds can be harmful to human health and the environment when not managed properly.

Some meds specified as hazardous waste by RCRA may be referred to as “listed” meds. This is because RCRA includes four different lists of hazardous substances, two of which contain medications. Here are some examples:

  • P-listed or “acutely toxic” (Examples: arsenic trioxide [Trisenox], nicotine inhalers and nasal sprays, physostigmine, warfarin)
  • U-listed or “toxic” (Examples: cyclophosphamide, lindane, selenium)

Additional characteristics that can lead to a med being considered hazardous waste under RCRA include:

  • Corrosive (Examples: solutions with pH of 2 or less, or 12.5 or more)
  • Ignitable or flammable (Examples: aerosol inhalers, flexible collodion)
  • Toxic (Examples: chromium, selenium, silver)

Keep in mind that RCRA is not specific to healthcare. It covers all sorts of businesses and organizations (e.g., construction, laboratories, manufacturing, etc), and many substances other than medications.

The National Institute of Occupational Safety and Health (NIOSH) maintains a list of hazardous meds called Antineoplastic and Other Hazardous Drugs in the Healthcare Setting. It’s updated about every two years. This list categorizes meds based on the following properties:

  • Carcinogenic, or cancer-causing (Examples: lomustine, melphalan, tamoxifen)
  • Genotoxic, or capable of damaging genetic information (Examples: abacavir)
  • Organotoxic, or capable of harming organs such as the kidneys or liver (Examples: leflunomide)
  • Reproductive toxic, or capable of interfering with normal reproduction (Examples: ambrisentan, dronedarone, misoprostol)
  • Teratogenic, or capable of causing harm to an unborn baby (Examples: colchicine, liraglutide, zonisamide)

Special disposal of NIOSH-listed hazardous meds is not enforced on a federal level (unless they’re RCRA meds, too). This list was actually created to prevent exposure in the healthcare setting. However, special disposal of these meds might be required on a state, local, or institutional level. (For more on avoiding exposure to these meds due to handling, go to our technician tutorial, Hazardous Meds 101.)

Regulated medical waste, also called biohazardous or infectious, includes items contaminated with blood and even some meds such as albumin or immune globulin (IVIG), depending on your state laws. An example of regulated medical waste is a needle used to inject a patient. The catch with this type of waste is that it usually must undergo a process to kill all the germs prior to disposal, such as autoclaving or microwaving.

According to federal law, in order to prevent diversion of controlled drugs (e.g., narcotics, etc) they should be disposed of in a way so that no one can retrieve or use them.

Who regulates and enforces proper med disposal?

The Environmental Protection Agency (EPA) enforces RCRA. EPA inspectors will periodically look at your entire facility for disposal of all sorts of hazardous waste, not just med waste. They’ll want to see that hazardous waste is properly identified, stored, disposed of, etc.

Interestingly, many regulations governing med waste are at the state level. Most state regulations are fashioned after RCRA. However, they can vary from state to state. For example, some states may discourage or prohibit the placement of med waste in a sewer system.

Although recommendations from organizations such as CDC (e.g., infection control) and NIOSH (e.g., hazardous meds) may not be actual federal regulations, they may be incorporated into state or local law, or hospital policies.

Keep in mind that the Joint Commission looks at proper disposal of hazardous med waste, as part of their “Environment of Care” standards.

What are typical disposal rules for different types of med waste?

Color-coded bins are usually the trick to knowing where to dispose of med waste. These are used to segregate waste that will require different types of treatment. There aren’t hard-and-fast rules on the colors that must be used for disposing of the different types of waste, but some colors are most commonly used. We’ll talk about those here. Other indicators that can help guide you include labeling on the outside of the bins. In addition, keep in mind that there may be differences in disposal rules depending on your state and local laws and hospital policies, and the company that your hospital contracts with to dispose of waste.

Hazardous med waste. RCRA meds should typically be segregated in black bins. Some organizations also recommend disposing of “bulk” amounts (i.e., quantities of drug that are pourable from a container) of non-RCRA hazardous meds (e.g., chemotherapy agents) in these bins.

A hitch with RCRA is that it has not been kept up to date in terms of adding new meds. So there are a number of hazardous drugs that are not technically “listed.” As such, these should be managed as hazardous waste on an organizational level until federal regulations catch up.

Non-RCRA hazardous meds, such as chemotherapy agents, should typically be disposed of in yellow “chemo” bins. In addition, “trace” amounts of some RCRA meds (i.e., containers with less than 3% by weight of the original quantity of a drug such as needles, empty vials, used syringes, etc) may be able to be disposed of in yellow bins. According to guidance such as USP Chapter <800>, personal protective equipment worn when handling hazardous drugs should be considered, at minimum, to be contaminated with trace amounts of hazardous drugs, and as such, disposed of in yellow bins.

Non-hazardous med waste. Non-hazardous med waste, which is the majority of meds, can typically be disposed of in designated bins, often blue or white, or in regular trash if it will be incinerated. If the meds themselves must go in designated bins, the outer packaging may still be able to be disposed of in regular trash.

In some cases, meds can be poured down the drain, or “sewered.” This may be limited to IV fluids (e.g., lactated Ringers, dextrose, saline), lipids, and electrolytes (e.g., magnesium sulfate, potassium chloride, etc), and will depend on your state and local law and hospital policy.

You may also be able to pour liquid controlled meds (e.g., narcotics, etc) down the drain to prevent diversion. As mentioned, this practice might be prohibited or discouraged by state or local law or hospital policy. (And it’s starting to be frowned upon on a national level as well.) If this is the case, follow hospital policy to make sure the drug is unable to be retrieved and used. In addition, keep in mind that any controlled drugs that are also hazardous (e.g., phenobarbital) should be disposed of accordingly.

Biohazardous waste. Biohazardous waste should be placed in bins marked with the word “biohazard” or with the biohazard symbol. These bins are usually red or orange.

You may be thinking that sharps generated in the pharmacy, such as for med prep (e.g., used needles, broken ampules) are not contaminated with blood and are not technically biohazardous. However, institutions may treat contaminated AND uncontaminated sharps as biohazardous in order to streamline handling.

Sharps contaminated with hazardous meds should not be placed in sharps bins meant for biohazardous waste, unless the bins are explicitly marked for biohazardous AND hazardous waste. Vendors who handle biohazardous waste may not be licensed to handle hazardous waste. In addition, the disinfection process for biohazardous waste could lead to aerosolization of hazardous meds (i.e., small particles of the med get into the air), which could be harmful to waste plant workers. Instead, place these sharps in yellow chemo bins or other designated bins according to your hospital’s policy.

Perhaps most importantly, do not dispose of sharps in containers that could be punctured, such as plastic bags. To reduce the risk of sharps-related workplace injuries, only dispose of them in rigid containers, and do not overfill the containers.

Keep in mind, disposal of hazardous meds is more expensive than disposal of non-hazardous meds; think dollars compared to pennies per pound. Placing unnecessary items in disposal bins for hazardous meds can really add up.

What are some helpful tips that can be used to prevent improper med disposal?

Three of the most common mishaps with hazardous med waste in hospitals are:

  • Improper disposal of chemotherapy meds,
  • Pouring hazardous med waste into a drain, and
  • Failure to properly determine what type of hazardous med waste is being disposed of.

In addition to these potential issues, consider what other questions you or your colleagues most often have about disposal of med waste. What would be a helpful strategy for answering these questions? Would lists near disposal bins help, or badge cards with reminders? Work with your pharmacy team to find ways to get everyone up to speed on proper med disposal. Some institutions use special labeling or packaging, or information on computer-generated labels, to indicate special disposal requirements. When new drugs are added to your hospital’s formulary, or when non-formulary meds are brought or ordered in, be sure you’re clear on their disposal requirements as well.

Don’t be surprised if your hospital requires you to take additional training on disposal of hazardous med waste, to stay in compliance with federal regulations.

What about disposing of patient information, such as med labels that include patient names?

If med waste has protected health information (PHI) attached, such as a label with the patient’s name, the information should generally be removed or covered prior to disposal of the med waste. If the information is removed, it should be disposed of in a bin designated for disposal of confidential information.

How can I help reduce med waste?

For starters, avoid placing non-med waste such as paper, food waste, cardboard, etc, in containers meant for med waste. Med waste can cost significantly more to dispose of than non-med waste.

Here are some additional tips to help reduce the need for disposing of med waste:

  • Use the most appropriate vial sizes to prep doses, to prevent the need for disposing of unused, leftover drug.
  • Dispense patient-specific doses of liquid meds rather than prepackaged doses when possible, to prevent the need to waste extra drug from a unit-dose container.
  • Double check that meds with short-stability haven’t already been discontinued before you prep them, especially if there’s a slim chance they can be reissued for another patient.
  • Manage inventory in order to minimize expired meds.
  • If your hospital allows, send remaining, properly labeled, bulk meds home with patients.

Using a reverse distributor is another option for reducing the need for disposing of med waste in-house. Meds eligible to be sent to a reverse distributor must be unused, potentially usable meds that can be returned to the manufacturer for credit.

Project Leader in preparation of this technician tutorial (360381): Stacy A. Hester, R.Ph., BCPS, Associate Editor

Cite this document as follows: Technician Tutorial, Medication Disposal in the Hospital. Pharmacist’s Letter/Pharmacy Technician’s Letter. March 2020.

─Continue for a “Cheat Sheet” for disposing of meds in the hospital─

“Cheat Sheet” for Medication Disposal in the Hospital

Proper disposal of medication in the hospital is regulated on multiple levels. This is why the specifics can differ from institution to institution. But, there are some general principles to keep in mind. Use these tips to help ensure you dispose of medications properly.

What determines the proper disposal method for a med?

The properties of a med are the main thing that determines proper disposal. Some of the different categories of waste that impact method for disposal include:

  • Hazardous
  • Infectious, or biohazardous
  • Controlled substance

Who regulates and enforces proper med disposal?

  • The Environmental Protection Agency (EPA) regulates disposal of hazardous med waste on a federal level.
  • State and local law also regulate disposal of hazardous med waste.
  • The Centers for Disease Control (CDC) and the National Institute for Occupational Safety and Health (NIOSH) may influence regulations on proper med disposal.
  • Regulatory agencies such as the Joint Commission may also look for proper med disposal.

What are typical disposal rules for different types of med waste?

Meds usually will need to be disposed of in a specific color of bin. Check your hospital policies to make sure you comply, and are aware of the nuances. Here are some of the most common and general scenarios:

  • Hazardous waste – black bin
  • Chemo waste – yellow bin
  • Non-hazardous med waste – blue or white bin
  • Biohazardous waste – red or orange bin

What are some helpful tips to prevent improper med disposal?

  • Make sure you dispose of chemo waste and hazardous waste properly.
  • Avoid sewering meds, or pouring them into a drain, in most cases. There may be exceptions to this rule in your institution, but hospitals are likely to move away from this practice.
  • If you aren’t sure if a med is considered hazardous waste or requires special disposal, double check before you dispose of the med.
  • If needed, refer to a resource, such as by posting your hospital’s list of hazardous med waste in your work area.

What about disposing of patient information, such as med labels that include patient names?

  • Remove protected health information (PHI) prior to disposal of med waste. Any removed PHI (e.g., label with patient’s name) should be placed in a bin designated for disposal of confidential information.

[March 2020; 360381]

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