Prudent Disposal of Unwanted Medications (RxMEDS) Final Report July 13, 2009

Prudent Disposal of Unwanted Medications (RxMEDS)

Today's Date: July 13. 2009 Signature'

Recipient: Area Resources for Community and Human Services (ARCHS)

Agreement Number: CH-83335901

Report Number: Final Report

Recipient Contact Person: Dr. Dianne Benjamin

Principal Investigator/Project Director: Dr. Sterling Hayden

Introduction/Background

The Mississippi and Missouri Rivers supply water to more than 14 million people in the river
basin. Among those drawing water resources from the rivers are the residents of St. Louis,
Missouri and the Metro East Illinois area. St. Louis has received good marks in its traditional
water treatment procedures but new challenges have arisen due to enhanced chemical
identification techniques that are discovering misguided dumping of medications into these
major waterways. The current acceptable and promoted method of disposal of outdated/unused
medications is to flush them down the toilet or deposit in the trash.

The amount of medications going into the rivers and thus flowing past additional millions of
people, who draw their drinking water downstream, is not known. This Regional eXcess
Medication Disposal Sendee (RxMEDS) project provided the EPA with the ability to collect
data on potential medication contamination by tabulating the quantity of expired or excess
medications held by a sample population. In addition the public, especially youth and senior
citizens, learned safe medicine disposal procedures — making their own homes and lives safer.

The RxMEDS project model was conceived following discussions with a family-owned regional
supermarket chain having multiple locations and full-time pharmacies. Their initial reaction
was very positive, in part because they had been considering a similar medication collection
effort. Within a very short time, a diverse regional partnership of pharmacies, disposal services,
senior service agencies, and the St. Louis College of Pharmacy (COP) was created.

Scope of the Project

Duration: The RxMEDS project partnership conducted the medication collection program over
a 24-month period. This time-period was selected to allow for start-up and organizational issues,
program promotion, and planning. It was estimated that since this was a completely new concept
to the region, it would take several months to convince people to take advantage of the
opportunity and to obtain the necessary approvals required from various government and
regulatory agencies.

The actual medication collection period was for 12 months commencing in January 2008 and
ending in December 2008.

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Goals and Objectives/Accomplishments

Regional eXcess Medication Disposal Service (RxMEDS)

Goal: Create an efficient regional model that removes and disposes of unwanted medications
and informs the citizens of related health and environmental issues.

Objectives:

• Identify 25 regional supermarkets
that will serve as collection
centers.

• Establish an environment friendly
methodology to dispose of
unwanted medications.

• Plan and present a major regional
workshop for seniors through our
senior services partners.

• Provide educational programs to
10-20 regional schools on drug
safety, etc. using St. Louis College
of Pharmacy students.

• Conduct relevant research on the
topic, e.g.,

• Demographics of patrons

• Previous disposal methods

• Program's "Best Practices"

Results:

Collection sites reduced to 20 locations
based on mandated staffing
requirements by BNDD and the DEA.

An approved method for collection,
data collection, and disposal of
collected medications was developed.

In cooperation with AARP-Missouri,
RxMEDS participated in a regional
senior conference for 1,000 seniors.

A program was developed and
presented to 15 elementary classrooms
for 387 students and 15 teachers.

58% age 60+

66% female
85% Caucasian
Previous disposal methods

• 37% flushed down toilet

• 21 % threw into trash
296,650 medication doses collected
See section "Overall Conclusions and
Recommendations, pages 17-19.

Status of Objective:

Objective Met: 20 sites
operated for 220 collection
days over 12 months.

Objective Met: See section
"Medications authorized for
collection", page 5.

Objective Met: See section
"Senior workshop", page 8.

Objective Met: Classroom
materials were provided to
numerous interested parties.
Available on request.

Objective Met: Two surveys
were conducted. The Primary
Survey was for those who
returned medications and the
Secondary Survey was for
those who may or may not
have returned medications.
See Appendices for survey
results.

Geographic area served: The RxMEDS pilot project was centered in the St. Louis metro
region. The target communities consisted of five counties and two states: four counties in
Missouri and one in Illinois. The geographic region had a population of 2.7 million people and
was economically and racially diverse. The counties were:

• St. Louis City, MO (considered a county)

• St. Louis County, MO

• St. Charles County, MO

• Jefferson County, MO

• Metro East, IL (many counties merged for statistical purposes)

Selected collection sites: Within this targeted region, Schnuck Markets, Inc. operated 66
community stores. Schnucks identified stores in each county based on customer count, location
within the county, and diversity of the customer base. These locations were designated as
collection points for the RxMEDS project. This method selected locations that were convenient
to the patrons, closely represented the counties' demographics, and offered full-time pharmacies
at each of the sites. The pharmacies operated daily from 9:00 a.m. to 9:00 p.m. The hours of
collection were set from 10:00 a.m. to 1:00 p.m. on the second and fourth Thursdays of each

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month. Ten stores were scheduled for each of the respective days during the month. The original
premise of the grant was to operate at 25 locations; this was not possible due to mandated
changes in the proposed collection method by the U.S. Drug Enforcement Agency (DEA) and
the Missouri Bureau of Narcotics and Dangerous Drugs (BNDD)

Collection site staffing: The original concept was to utilize store pharmacy staff (technicians or
pharmacists) to oversee the collection of medications. The actual collection and recording of data
was the responsibility of sixth year pharmacy students from the St. Louis College of Pharmacy
(COP). These students were registered/licensed pharmacists. They were enrolled in a series of
assignments their last year, one of which was a five-week communi ty outreach assignment. The
number of students enrolled in this assignment was relatively small at any one time, so the idea
was to have one student at each store location, working with that store's technician or pharmacist
to collect the medications.

Collection Day Setup

During our discussions with the various agencies and boards that needed to approve the
RxMEDS project, a major concern was the staffing issue of having only one person, with
support, at the collection sites to review and collect the medications. The concern was the
possibility that with only one person responsible there could be some diversion of drugs
collected, thus jeopardizing the project, the future of the pharmacy student, and the store
pharmacist's license. The approving agencies required that at least two students be assigned to
each location along with the support of a technician or pharmacist to collect and record the
unwanted medications. In order for this to be possible with the number of students available, we
had to reduce the number of locations originally suggested from 25 to 20 to have sufficient
students for each assignment. This was also the reason collection days were held on the second
and fourth Thursday of each month. A pair of students could work both days during the month. If
collections were on the same day, then the RxMEDS project would have been single-staffed and
thus out of compliance with the two student mandate.

Staff training: The RxMEDS project created a policy and procedures manual on collecting,
recording, and processing of unwanted medications. This manual was provided to each location

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and student. It was supplemented with classroom instructions from COP/RxMEDS staff, and a
video and PowerPoint presentation was created to train students as they enrolled in the
community outreach assignment. This allowed for a standardization of the physical locations
and for procedures of uniform medication collection and reporting. Policies and procedures
were adjusted as new issues were encountered and challenges resolved.

Method of collection: The RxMEDS project designated one day a month for the collection of
medications at each of the 20 sites on either the second and fourth Thursday of each month. In
addition to the staffing limitations explained above, we thought this method simplified media
efforts so that information material was prepared in a cost-effective and timely manner.

Patrons brought their medications to the store during collection hours where the College of
Pharmacy students interviewed them, reviewed their medications, and collected the data. The
actual medicines were removed from their plastic containers or packages. These items were
deposited separately and sent for recycling. A form was developed that allowed for the
systematic recording of medications by the students. The interview consisted of:

• A review of all medications with an emphasis on what can safely be kept or disposed

• Information about which medications should not be taken in combination with others

• Listing of all medications brought in for disposal

• Listing of quantity or volume of medication

• Listing of type of medication (pill, patch, capsule, etc.)

• Information from the patron about why medications have not been used

The first form was a combination Excel and Word spreadsheet. Although it allowed for the
collection of data, it was cumbersome and hard to transfer data for analysis. The form was
revised and created in Access which proved to more flexible in the compiling of the information
collected.

It was originally thought that the students would have sufficient time to review the medications
and record the data during a patron visit. This was possible at some of the slower and less active
locations. Most of the students ended up using paper forms, wrote in the information, and later
transferred it to their computer.

One of the quantifiable outputs anticipated was to serve 250-375 patrons per month at the 25
locations. Thus the total anticipated to be served was 3,000-4,500 patrons. This number was not
reached first because of the reduction in sites but also due to such things as: 1) inclement weather
on several collection days, and 2) reluctance of some store patrons who knew about the program
but believed that they could not afford to buy more drugs and should keep drugs in case needed
later. This was particularly true of store patrons in low social economic areas of the project. In
actuality, the collection program interviewed 892 participants through the drug collection phase
and another 675 through a secondary survey.

Even though the number of participants was lower than expected, the amount of drugs collected
exceeded expectations. It was not unusual for a patron to bring in a plastic bag full of
medications, which in some cases took several hours to review and record.

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Entering Collection Day Information

This process was time consuming, but approaching at a very personal level was intended to lead
gain greater trust and create lifelong habits in dealing with medications. If a senior felt that they
had been served honestly and with respect, then perhaps they were the greatest advertisement for
others to participate and even participate again themselves.

Medications authorized for collection: A major hurdle in the approval process for the
RxMEDS project was the collection method that was used to collect or not collect medications
classified as "controlled substances." The original plan was to collect them and a tentative
agreement was reached with the DEA. When the plan was presented to BNDD, we were told
that this was not possible under state law and had to modify our plans. As a compromise, we
decided to revise the collection process, enabling us to record data about any medication that was
presented for disposal but without out taking possession of any medication identified as a
controlled substance. In this manner we collected the necessary information on the drugs
presented but did not violate the state law. The procedure established that the collection site staff
first reviewed all medications presented for disposal. Those identified as a non-controlled
medication were collected, medications removed from their package or container, counted, and
data entered. Controlled substances were not opened or unwrapped. Information about the drug
was recorded and the unopened container was returned to the patron with a brochure (available
upon request) and a demonstration (video available upon request) on how to properly dispose of
the drug so it would have little or no impact on the environment. This process was acceptable to
local, state, and federal agencies that had jurisdiction over medications.

In reality, what was considered a setback actually was a benefit to the collection and disposal
process. Once the stores were identified and we first considered collecting controlled
substances, the plan was to have the cooperation of the local police department to collect the
controlled substances after each collection day and either dispose of them or give them to a
licensed disposal agent for incineration. The concept was to have a law enforcement
representative take possession of these drugs, thus meeting the rule of law. In reality, the 20
stores were located in 14 different police departments. It would have been impossible to get the
cooperation of all, much less some, of these departments to make the collections and disposal
their responsibility for a 12-month period. Following the decision not to collect controlled
substances, all of these police departments were invi ted to attend a meeting to be informed about

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the RxMEDS project and the "who, what, when, where, and how" of the collections. Every
department was very supportive of the program and many even said they would participate by
bringing their medication for disposal. However, none of them wanted to be responsible for the
collection and disposal of the controlled substances.

Collection Day

Tabulation of data collected: Following the collection days, the pharmacy students recorded all
information in the data base. Each student was provided a flash drive that was used to retrieve
the data to the master file for compilation. A COP student was hired to compile and analyze the
preliminary data (see Appendices).

School/community outreach: Fourth year COP students enrolled in Introductory Practice
Experience (IPE) volunteered to present at a drug safety program at elementary schools focused
on the following:

•	What is a pharmacist?

•	Drug safety

•	Appropriate drug disposal

•	Accidental poisoning prevention

•	Harmful effects of illegal drugs

This program was developed by the students and RxMEDS project staff as a part of this grant.
COP faculty and RxMEDS staff coordinated and trained the IPE students and attended the
presentations as needed. In all, 15 programs were presented to a total of 387 students and 15
teachers. A PowerPoint of the elementary school presentation is available upon request.

6

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Waste disposal/recycling: Cintas Corporation provided environmental waste containers for each
collection location. All medications collected were picked up within 24 hours of the collection
period. In addition to the medications, the project sorted the various plastics, paper, and
cardboard for recycling. Over a ton of materials was collected and recycled. All medications
were incinerated. See Appendices for detailed results.

Substantial Involvement of Older Adults

Community need: The geographic area targeted for the RxMEDS pilot project represented the
highest concentration of senior citizens in the State of Missouri. The St. Louis metro region had
2.7 million people and 276,599 (11.4%) seniors over age 65. Although the primary focus of the
project was to inform and educate seniors in regards to a healthier respect and understanding of
their medications, all citizens were encouraged to participate in the program.

Missouri AARP Senior Day

Community involvement: In determining the makeup of the project partnership, it was evident
that a strong presence of organizations representing the senior community was essential.

With this as the goal, two local and two national senior services organizations were asked to
participate in the project. The following community senior service organizations were active
partners:

• American Association of Retired Persons-Missouri (A ARP) - national affiliation

• OASIS-St. Louis Region - national affiliation

• Mid-East Area Agency on Aging (MEEA) - local Missouri agency

• Senior Services Plus - local Illinois agency

These organizations met with the planning team to review the program concepts and make
suggested modifications on how to attract seniors to participate, timing of the pilot program, etc.
They also determined the level of support to provide volunteers and publicity for the project. It
was anticipated that each agency could provide volunteers for the collection days at each site. In
reality this did not happen. Even though these organizations made repeated requests of their
membership only one volunteer was recruited from their ranks during the entire program.

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Senior workshop: The original consensus was to have one large workshop or series of
workshops for all the senior partners based on home hazards, accidental poisonings, and
environmental and safety factors related to the use and disposal of medi cations. It was soon
evident that the various senior partners had their own programs and interests and that one
workshop topic would not meet all their needs.

Several workshops were offered by the COP about the medication disposal program. To meet
this objective, RxMEDS worked with the AARP-Missouri and participated in their annual Senior
Day held at the Missouri Botanical Garden. RxMEDS project staff and COP students and
faculty participated in the event that registered over 1,000 seniors during the day.

Collaborative /Partnership and Leveraged Resources

The RxMEDS partnership secured the participation of seven major businesses and non-profit
organizations in the St. Louis metro area. The following table identifies the project partners.

Partner



Project Role

Schnuck Markets, Inc.

^yftor/riocuJI

Collection points,
pharmacists, public
relations, incentives

Cintas Corporation

ciisnAs

«'¦« mwJ liiraiii i »¦

Waste disposal
equipment, medication
disposal, public relations,
recycling

American Association of
Retired Persons (AARP)-
Missouri Chapter

«AARP

Workshop(s), volunteers,
public relations, planning

OASIS - St. Louis Chapter



Workshop(s), volunteers,
public relations, planning

Mid-East Area Agency on
Aging (MEAAA) *

MEAAtW

MID-EAST AREA AOENCY ON AOINO

Workshop(s), volunteers,
public relations, planning







Senior Services Pius (Illinois
Agency)

ssp

SENIOR SERVICES PLUS

Workshop(s), volunteers,
public relations, planning

St. Louis College of
Pharmacy



Research, education
outreach to schools and
community organizations

Area Resources for
Community & Human
Services (ARCHS)

>
ARCHS

Building Great Partnerships
for the Greater Good of Greater St. Louis

Project coordination,
fiscal management

8

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Partner profiles (based on information current at the time of the project):

Schnuck Markets, Inc. is a St. Louis based company and currently the 11th largest privately
owned grocers in the U.S. and 85th on the list of the nation's largest family-owned and operated
companies. The selected target area for this project includes 66 stores.

Cintas Corporation is headquartered in Cincinnati, Ohio and operates 350 facilities in the U.S.
and Canada, including 14 manufacturing plants and seven distribution centers that employ more
than 32,000 people. It provides ongoing waste disposal services to all Schnucks' stores and
serves over 70,000 other clients in the St. Louis area.

American Association of Retired Persons (AARP) has over 35 million members nationally.
AARP is the leading nonprofit, nonpartisan membership organization for people age 50 and over
in the U.S. They have 160,000 registered members in the Missouri service area.

The Mid-East Area Agency on Aging (MEAAA) is a not-for-profit agency providing programs
and services for older adults at 23 locations. Funding is provided under the amended Older
Americans Act of 1965 and administered by the Missouri Department of Health and Senior
Services. MEAAA programs and services are available to anyone age 60 and older that lives in
the counties of St. Louis, Franklin, Jefferson, and St. Charles.

OASIS is a national nonprofit educational organization designed to enhance the quality of life
for mature adults. OASIS serves nearly 100,000 members in the St. Louis, MO and Alton, IL
areas with a broad range of programs in the arts, humanities, health, technology, and
volunteering.

Senior Services Plus, Inc. serves Madison County, Illinois as the official "Senior Health
Assistance Program" (SHAP) office of the Illinois Department on Aging. Madison County has
the highest percentage of senior citizens of any of the Metro East counties.

St. Louis College of Pharmacy is a private and independent non-sectarian college located in St.
Louis' Central West End medical community. Founded in 1864, the St. Louis College of
Pharmacy is the oldest college of pharmacy west of the Mississippi River. The College's 5,000
living alumni represent 49 states and seven foreign countries. More than 90 percent of the
pharmacists in the St. Louis area are St. Louis College of Pharmacy graduates.

Area Resources for Community and Human Services (ARCHS) serves as the State of
Missouri's Official Community Partnership for the St. Louis region. In this role, ARCHS is an
intermediary, bringing organizations together to enhance the delivery of community and human
services. Since 1998, ARCHS has been credited with positively impacting the lives of more than
1 million area residents by improving access to human services, education, healthcare, and jobs.
ARCHS' resume includes regional partnerships with such organizations as the U.S. EPA, the
U.S. Department of Labor, the U.S. Department of Justice, the State of Missouri, Missouri
Foundation for Health, and the City of St. Louis.

ARCHS is a 501(c) 3 non-profit organization with a $5.4 million operating budget (FY09)
serving St. Louis City, St. Louis County, and St. Charles County. ARCHS secures financial

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services through Leveraged Resource Management, LLC (LRM). LRM provides financial
services to 21 St. Louis area nonprofit organizations with a focus on fiscal agent functions. LRM
manages $30 million in area funds (FY09). LRM is a wholly owned, for-profit subsidiary of
ARCHS. Funding is managed by ARCHS/LRM in compliance with federal rules and regulations.

"Thank You" Reception for RxMEDS Partnership

Project Finances and Cost of Services

Budget: The amount requested for the RxMEDS project from the U.S. EPA was $150,570, but
the project came in under budget because the senior partners declined to invoice for their allotted
advertising expenses. Therefore the entire cost for the RxMEDS project was $137,849. Of this
total, 89% was for the reimbursement of pharmacy personnel, publicity, and collection and
incineration of medications collected. If we base the cost of the project on the number of
participants, then it may seem like a high program cost of $ 155 per participant (based on 892
participants who actually returned medicines). However, if we look at the cost per medications
removed from the participants' homes, then the cost is only $.56 per dose (based on 244,708
doses collected). If the project had been able to collect the estimated 51, 942 doses of controlled
substances recorded but not collected, then the cost per dose would have been even lower.

If we include the elementary school students and teachers, people surveyed who did not turn in
medications, people contacted through various media and public relation efforts who where
informed about the program (402 students and teachers + 547 surveys + 704,300
publications/media + 3,331 community outreach programs = 708,581 total), then the cost is $.20
per contact. The amount of impact the environmental information they received and how it will
affect their future handling of unwanted medications is immeasurable.

Medication costs (estimate): The medications collected were of different dosages, types, etc.
and it would be too laborious to determine the retail value of a single dose of each medication. If
in determining the value of the medications collected we used a conservative estimate of an
average retail value of $5.00 per dose, then over $1,223,540 in drugs were collected and
disposed of in an environmental-friendly program.

Leveraged resources: The partners identified over $400,000 of in-kind services necessary to
make this program successful that represented non-reimbursed labor costs, advertising, volunteer

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time, and office/warehouse facilities. This in-kind funding level represents a 265 % match to the
federal funds requested. In addition, all partners collaborated successfully in obtaining local
news and TV coverage for the program.

Community Outreach and Education Programs

School outreach: As stated earlier, an elementary education component was developed and
implemented as part of the grant's community outreach effort. A copy of the program is
available upon request.

Program summary: The elementary school education component of the RxMEDS program was
executed between February 2008 and May 2008. A total of 15 classrooms were reached
comprising seven schools. Fourth year students, six in total, from the St. Louis College of
Pharmacy gave all but one presentation. In addition to a pair of students giving each
presentation, Dr. Nicole Gattas or Dr. Amy Tiemeier (COP faculty) were present at each
presentation to ensure quality and answer questions. The final presentation was given by
Dr. Tiemeier.

Overall demographics: The table below summarizes the key demographic information of the
school presentations.

RxMEDS Presentations

Participating schools

•

Danforth Intermediate
o 4th grade - 4 classes
o 5th grade - 3 classes



•

Hamilton Elementary
o 4th grade - 1 class
o 5th grade - 1 class



•

Walbridge Elementary
o 5th grade - 1 class
o 6th grade - 1 class



•

Lyons Elementary

o 4th-6th grade - after school program



•

New City School

o 4th grade - 1 class



•

Froebel Elementary
o 5th grade - 1 class



•

Ford Elementary

o 3rd -6th grade - after school program

Grade levels of students involved

4th grade: 115 students
5th grade: 132 students
6th grade: 140 students
Total: 387 students

Evaluations by teachers

Received: 11 of 15

Ratings: for all questions, only three scores of 3
(somewhat agree) were given; all the rest of the
questions were rated as a 4 (strongly agreed)

11

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Lessons learned: We found that the presentation worked best with students (4th or 5th grade)
who were covering or who had recently covered the environment and ecosystems in their science
modules. Letting students know that there would be a game at the end pertaining to the
information really helped the students focus and pay attention. The Jeopardy game concept
(inquiry based learning) was not one that many of the students were aware of and some found it
challenging to remember to phrase their answer in the form of a question. However, as the game
proceeded, many of them improved.

Conclusions and Recommendations

Elementary education program: Overall, we believe the education portion of the RxMEDS
project was a success. Of the evaluations we received, the teachers ranked the program very high
and had positive comments regarding the program and how their students interacted. Having
active learning components, such as the plaster of Paris demonstration and the Jeopardy game at
the end, were key to keeping the students' attention as well as helping to reinforce the key
concepts in the presentation.

Senior services workshop: During the first planning meeting with the senior service providers,
it was evident that creating and holding one major event for all agencies to attend would be
difficult if not impractical. Each of the agencies had multiple events planned that could
incorporate the message of the project without the necessity of adding another event.

In lieu of a single event for the providers, programming and information was provided to any
organization that requested it. The COP made several presentations throughout the tenure of the
project to the senior partners.

The RxMEDS staff and the COP did participate in the annual AARP-Missouri Senior
Conference at which over 1,500 seniors where registered. An information booth and
demonstrations were set up and students, faculty, and staff manned them for the day.

Advertising, Media, Public Relations

Advertising: The major contribution to paid advertising was in the form of ads run in the weekly
newspaper inserts provided as in-kind by Schnucks. These ads were run several times during the
RxMEDS project tenure and reminders were also placed with other health-related promotions.

Media: An attempt was made to utilize all forms of media and resources in the region to
promote the project. This effort was met with mixed success. On the one hand, we were
successful in publicizing through local network television, major radio, several articles in major
and community newspapers, blogs, internet newsletters, City of St. Louis newsletters,
professional journals, local cable television, and numerous community outreach programs.

On the other hand, during the first months of the RxMEDS project it was a struggle to find local
media interested enough to do a story or promote the project. Only after a national Associated
Press article on "drugs in the water" appeared in the local newspaper, did people start checking
to see what safe medication disposal options were available in the St. Louis metro region.

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Ad in Weekly Store Newspaper Insert

Initial contacts were made with the regional water company, electric company, and sewer district
to get them involved. This also met with mixed success. All of them thought it was a great
idea and the medication collection services were needed, but were not initially interested in
providing any assistance. Not until half way through the collection year did the water company
again became interested after a second television network affiliate story on drugs in our water
which highlighted the RxMEDS project as a local solution. Following this program the water
company agreed to send out a flier in their fall billing to promote RxMEDS and other local
environmental efforts. These fliers reached over 380,000 households but came at the end of the
one-year RxMEDS project.

We were approached by a national cable program. They wanted to film the RxMEDS program as
part of a "green living" cable program. The major drawback was that we had to pay them
$50,000 to do the filming. Needless to say, the cable program was not produced by us.

Media materials were developed or obtained to promote the project. A considerable amount of
materials were obtained from local health agencies, poison control centers, etc. that focused on
drug safety in the home. These materials were primarily utilized in the school outreach
presentations. Additional materials such as fliers, store signage, bag staffers, and project logos
where created. The fliers and signage were also translated into Spanish. All of these materials
are available upon request.

Information about the RxMEDS was placed on ARCHS and Schnucks' Web-sites. We also
installed a hotline number that could be called to volunteer or to get more information about the
project. The ARCHS' Web-site and hotline phone number were printed on all brochures, etc.

Public relations and community outreach: RxMEDS partners and additional ARCHS' staff
participated in over 25 various health fairs, community meetings, teacher training conferences,
church and school health programs, environmental workshops, etc. on behalf of the project. Over
3,300 individuals were contacted and information materials on the project's locations and
collections sites were provided.

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Store and Community Signage

Additional project support/interested parties: As the project gained momentum and more
people became aware of its existence, local and national groups sought information and in some
cases offered to assist where possible. The following list represents various organizations that
somehow contributed or promoted the grant activities.

50 PlusStlouis.com
Abbott Laboratories

Alexian Brothers (Hospitals) PACE Adult Care Day Health Center
Brazos County, TX - initiative to create a countywide drug collection program
City of Florissant, Missouri Cable Network
City of St. Louis, Refuse Division

Consumer Healthcare Products Association (CHPA)

East Central District Health Department, Columbus, NE
EMCO Waste Services
Express-Scripts

Fox Television, Channel 2, St. Louis
Grace Hill, Health Camp
GREAT, Family Safety Fair
Human Development Corporation
Living Lands and Waters
Maternal Child and Family Health Coalition
Metropolitan Sewer District of St. Louis
Missouri American Water Company
Missouri Black Expo

Missouri Environmental Education Association (MEEA)

Park Place at Winghaven, Health Fair

14

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• Pattonville School District, Parents as Teachers

• PhRMA

• Ritenour School District Health Fair

• Schnuck Markets, Inc., Weekly Advertisement Section

• South Carolina Pharmacy Association

• St. Clair County Health Department

• St. Francis Xavier College Church, Mission Outreach

• St. Louis Area Agency on Aging

• St. Louis County Waste Management Program

• St. Louis Post-Dispatch Newspaper

• Saint Louis University, "Small Business Week"

• St. Rose Philippine Duchesne Catholic Church

• Union Avenue Christian Church, Community Health Fair

• University City United and Sierra Club of E. Missouri, Community Forum

• U.S. EPA, Region 7

• Wolters Kluwer Health (WK Health)

It is important to note that the project received considerable support from many individuals
and organizations beyond our original partners. There were a few that stood out, as follows:

• Saint Louis University, Dr. Ray Tait: Early on the grant was faced with the
necessity of having the research methodology approved through an Institutional
Review Board (IRB). None of the members of the partnership had this capability
within their organization. Dr. Tait was contacted and volunteered to assist and
sponsor the research through Saint Louis University. He worked with us on the
presentation and "walked" it through to gain approval. Without his efforts and
assistance we would not have been able to continue.

• Wolters Kluwer Health: One of the issues discussed during the approval process
was the method by which sixth year COP students would be able to identify
controlled substances at collection sites. At least two pharmacists or pharmacy
technicians were available on site at each location. In addition, WK Health donated
300 copies of their compact disc software that helped identify medications. Each
student was given a copy of the CD to load on their personal computers to help in the
drug identification process (all students received personal laptops from COP as part
of their school enrollment).

• St. Clair County Health Department: After the announcement of the grant award
by EPA in April 2007, the St. Clair County Health Department called the RxMEDS
project manager and asked about the program and how they could help. St. Clair
County is in Illinois located near Scott Air Force Base. The Health Department and
the community they serve are very environmentally active and eventually became the
largest collection site in terms of number of participants and medications collected.
Ms. Jennings of the Health Department served as a volunteer at every event held at
the store in her county. She also conducted surveys, handed out materials, and
personally placed news stories in the local newspaper to be printed the day before

-------
each collection event was to be held. Ms. Jennings and the Department are models of
how community agencies and individuals should have become involved.

Quantifiable Outputs:

Output:

Measurement/Meth odology:

•

Create and disseminate an effective

•

Number of patrons that participate in the collection program

public relations program to promote the

o 892

project.

•

Number of new partners

•

Continue to recruit additional

o 39

organizations to promote and expand

•

Number of programs and attendance at community awareness

the collection effort.

programs/workshop(s)

•

Utilize community resources in the

o 22 programs with 3,331 attendance

creation, promotion, and operation of

•

Number of programs and attendance presented at schools

the project.

o 15 programs with 387 attendance

•

Collect regional data on unwanted drugs

•

Number of collection site surveys

and their reason for disposal.

o Primary survey, 892

•

Interview and collect medications from

o Secondary survey, 675

250-375 patrons per month.

•

Number of public relations items produced

•

Prepare 4-10 promotional materials to

o 4

advertise project.

•

Extrapolation of information from surveys and data collected

•

Conduct research (program assessment,

o 296,650 doses of medications returned

analysis of drugs collected, patron

o See Appendices

demographics, disposal reasons, etc.)

Sustainability: The RxMEDS pilot was the first step in creating a realistic, effective community
program for the education of the region's citizens and the establishment of an ongoing,
environmentally friendly procedure to dispose of unwanted medications.

For example as part of ARCHS' U.S. EPA Collaborative Problem Solving grant-funded project
"St. Louis Area Communities Against Toxics" (SLACAT), we partnered with neighborhood
stakeholders, Veolia Environmental Services, and COP to provide a one-day take-back and
disposal activity for non-controlled medications at SLACAT's household hazardous waste
(HHW) collection event on May 30, 2009. The event targeted residents of environmental justice
neighborhoods in north St. Louis City, with a population of approximately 60,000 households in
the target area. Veolia estimated they collected 5.6 tons of HHW, including 20 pounds of non-
controlled medications, from the 125 vehicles/households participating in the event. The
successful event will be repeated in spring 2010.

Additional conversations have taken place with the St. Louis County Waste Management
Division about the possibility of collecting non-controlled household medications during their
monthly waste collection events. The COP is interested in continuing the program on a reduced
level and is considering working with the county at four events each year. The drawback to
continuation of the program is creating collection sites, advertising the program, providing
informed individuals who can collect acceptable medications, and the cost of waste disposal. Yet
all these barriers could be overcome with this type of partnership, a partnership not even
considered prior to the RxMEDS program.

There is currently a group in mid-Missouri that is interested in starting a regional collection
program that would include controlled and non-controlled substances. RxMEDS staff have
talked to them several times and told them of the laws, etc. that govern controlled substances. In

-------
March 2009, they received a letter from regional DEA staff clarifying that they can not collected
controlled substances without a law enforcement officer on site to collect them.

In July 2009, ARCHS and COP were interviewed for an in-depth article by the major regional
newspaper about a successful medications collection program in Jefferson County. A
community-based parent organization and law enforcement held a series of seven collection
events at multiple locations. Their primary goal was to prevent teenage drug abuse by removing
medications from homes. As a result of their success, permanent medication collection
opportunities will be available at some law enforcement office sites in Jefferson County.

Success Stories: In 2008 Schnuck Markets, Inc., a major partner in the RxMEDS project who
provided store locations to serve as monthly collection sites, was recognized as "Pharmacy Chain
of the Year," by the trade magazine Drug Topics. One of the major factors emphasized in this
selection was Schnucks' involvement in the RxMEDS project.

Dr. Nicole Gattas, who teaches at COP and during the RxMEDS project was a part-time
pharmacist at Schnucks, received the 2009 American Pharmacists Association (APhA) "Award
in Community and Ambulatory Practice". APhA stated they recognized Dr. Gattas in part for
her contribution to the RxMEDS project.

Mike Juergensmeyer (I), Nicole Gattas, and
Bob Mueller like to lavish patients with
their attention.

(Photo Courtesy of Drug Topics)

Overall Conclusions and Recommendations

Collection locations: In determining the number of locations for a collection the first thing to
consider is the amount of human resources you will have at available to staff the sites. The
RxMEDS project originally anticipated having sufficient collection site staff between the pharmacy

-------
students and volunteers that would be recruited. Our site staff availability was limited by the
students' school schedule, so not all anticipated students were available at all times. In addition,
vacation schedules and academic breaks impacted the site staffing levels and assignment of students.
The lack of someone whose full time job was the recruitment and assignment of community
volunteers greatly hampered the quality and quantity of volunteers actually involved in the year-
long project.

A second thing to consider is the distance between locations and the time involved to collect the
medications efficiently. The waste hauler business responsible for the collection must re-route its
trucks to collect on special days at the various locations, as well as arrive after a collection event has
been completed. The original waste hauler had extreme difficulty in making the adjustments in pick
up schedules and caused multiple duplicate collections during the initial stages of the project. This
waste hauler business was dropped and another waste hauler had to be brought in midway through
the project.

Collection locations should be convenient with ample parking and access. All of our sites were
located in a major supermarket and collections occurred during set hours and advertised days only.

We also found that the collection sites located in low income areas of the region had the least
participation from the community. Low income residents believed that the collections were a good
idea, but were reluctant to dispose of unused medication just in case it might be needed in the future
and be costly to purchase a new prescription or over-the-counter drug.

Medications: It was clear from the way drugs were collected that many participants turned in
quantities reflecting the unused balance of a 30 day supply. It was almost universal that participants
took doses until they felt better and then attempted to save the remainder of the prescription for
future needs.

Our main recommendation to pharmaceutical companies and insurance companies would be to
reduce a standard prescription from 30 to 20 or 21doses. This alone would remove millions of
extra unused medications from the homes and eventually the environment.

We anticipate pharmaceutical companies might view this as too costly an economic concession,
because not selling as many doses per prescription would result in a loss of revenue. Also
prescription insurance companies figure their handling costs, co-pays, and reimbursement rates on a
30-day supply. Even though these parties would have to make the adjustment, it would seem
reasonable that paying for only a 20-day supply rather than a 30-day supply would save up to one-
third the current cost of each prescription.

90-day supplies: Many of the participants turned in the balance of medications remaining from a
90-day supply. These medications generally fell into two categories: 1) medications that were
discontinued due to side effects or 2) medications that were unused by patients after their death and
families did not know safe drug disposal practices.

For example, one RxMEDS participant was an 80 year old white female who brought medications
to a collection site in a low income neighborhood. She returned unused 90-day supplies of six
different types of eye drops, explaining they were tried and discontinued due to side effects. If her
doctor could have given her a sample or limited supply, then it would have significantly reduced the
number of medications in her home and saved her considerable money.

-------
RxMEDS participants who were relatives or friends of deceased family members were all very
concerned about being responsible for the safe disposal of unused medications, many of which were
prescribed to relieve end-of-life pain and suffering. Without being prohibitive, it may be that
doctors providing palliative care for terminal cases, could recommend a 30-day supply with refills to
reduce the unused medications in the home.

Yet another type of example occurred concerning the safe disposal of more than a 12-month supply
of heart medicine from a mail-order company and automatically sent to the patient even though the
doctor had changed the prescription. The family tried to stop the original order but the company
continued to send the medications and the insurance company continued to pay for all the unused
heart medicines.

Also we were approached by a few non-profits and businesses that wanted assistance with safe
disposal of large quantities of medications. For example, we were contacted by a former
pharmaceutical sales representative, a women's shelter, and several nursing homes. We were not
able to resolve their concerns because the RxMEDS project focused on individuals or households
only and did not accept medications from health centers, doctors' offices, or other organizations.
However their dilemmas are real and need to be addressed.

Finally, we support recent initiatives from the federal government under the new White House
administration that is creating mechanisms for collaboration between EPA, DEA, etc., to streamline
policies and procedures for collecting controlled substances. We can already see that this new
approach is trickling down and making a difference in our region and our state. There appears to be
more cooperation from the various regulatory agency staff, rather than just an emphasis on
compliance. This seems especially apparent when comparing our initial startup process in 2007
with nearby community-based medication collection efforts starting up in 2009.

With a few more common sense practices on the part of the prescribing doctors and more flexibility
on the part of insurance companies, millions of dollars can be saved for the consumer and even more
unused medications can be kept out of our homes and the environment.

-------
RxMEDS Appendix 1

Prudent Disposal of Unwanted Medications (RxMEDS)

Primary Survey Results

Introduction:

During 2008, Area Resources for Community and Human Services (ARCHS) implemented the
U.S. EPA project known as Regional eXcess Medication Disposal (RxMEDS). ARCHS' project staff
and partners conducted a bi-state medication collection program through a grocery store chain
in Missouri and Illinois counties in or around St. Louis. A total of 220 collection days were
conducted near the stores' pharmacy counters. The following information, charts, and tables
reflect a summary of the information collected at the 20 store locations as a result of this year-
long effort. The information was collected through a structured brief interview ("primary
survey") conducted by pharmacy students as they collected medications from participants. A
summary of the RxMEDS project's overall results is listed as follows:

• Program cost $137.849 (U.S. EPA grant award $150.050): RxMEDS project costs were
under budget due to senior partners not requesting proposed funds and providing
services as in-kind. Also we modified collection and disposal to reduce this cost.

• Over 2.000 volunteer hours were needed to operate the year-long program.

• 20 collection sites were operated each month. January through October 2008. Only 10
collection sites were operated in November and December due to holidays.

• $289.000 in leveraged funds were reported by the partnership.

39 other local, state, and federal organizations or agencies assisted, provided
information, or requested assistance during the project.

387 elementary students and 15 teachers were presented an educational program on
poison prevention via safe medication handling and disposal.

A secondary survey was conducted with 448 non-participants and 220 participants (7
non responses) for a total of 675 (see Appendix 2).

Over 300 St. Louis College of Pharmacy students participated in the program as
collection agents.

3.331 older adults were educated bv senior partnership programs and community
outreach efforts about safe handling and disposal of medications.

Media/publications reached an estimated 704.300 in the bi-state area.

-------
RxMEDS Appendix 1

Summary of RxMEDS Primary Survey Results:

• 892 participants returned one or more medications.

• 296.650 medications were returned.

o 244. 708 over-the-counter (OTC) and non-controlled prescription individual
capsules, tablets, and suppositories were collected and incinerated.

o 51.942 controlled substances were recorded but not collected from the

participants. This number is an estimate as RxMEDS project guidelines required
collection sites to identify all controlled substances, keep the container closed,
and visually estimate the amount of medication presented for return, and then
give the container back to the participant.

• 10.095 "bottles" were recorded: For this report, a "bottle" is defined as one
prescription or one OTC medication that was recorded on the same line of the survey. A
bottle may include multiple tablets. For instance, a prescription of Lipitor with 30 tablets
would be counted as one bottle. Additionally, a bottle may be a tube of ointment or
inhaler. It is possible that some bottles were recorded on the same survey line, making
this statistic less accurate than the number of tablets returned. For instance, one
student may have recorded "Lipitor #60" on one survey line, even if two bottles were
brought in by the patient.

# of "Bottles"

Description of Type of "Bottle"

473

Controlled prescription bottles attempted to return

6,399

Non-controlled prescription bottles returned

2,536

OTC medication bottles returned

123

Inhalers returned (prescription & OTC)

534

Creams, gels, & ointments returned (prescription & OTC)

Patches returned (prescription & OTC)

10,095

Total "bottles" returned

Most frequent medication returned by category:

• Controlled - Hydrocodone (prescription painkiller, e.g., Oxycontin)

• Non-controlled - Furosemide (prescription diuretic, e.g., Lasix)

• OTC - Aspirin, Acetaminophen, Ibuprofen (painkiller, anti-inflammatory)

-------
RxMEDS Appendix 1

Age of Medications:

In general, prescription medications are considered to expire a maximum of one year after they
are dispensed. Over-the-counter medications generally expire two to three years after
purchase. When medications were returned, the dispensing date was documented for
prescriptions and the expiration date was documented for OTCs. The oldest medication
expired in 1970.

Frequency of Expiration/Dispense Dates of Bottles by Decade

7000
6000
5000
4000
3000
2000
1000
0

2450

525

96

I

1970s	1980s	1990s	2000s	Unknowns

Reasons for Returning Medications:

Participants were asked why they were returning each bottle of medication. Most commonly,
the medications were expired. Many participants returned medications due to the patient
having moved away or having died.

Students commented that many family members returned large quantities of medications after
a death. Often their loved one had died from a medical condition and no instructions had been
given regarding what to do with the medication.

In one instance, a neighbor brought back several boxes of medications. Most were prescription
medications that had never been opened. The participant stated the pharmacy continually
mailed medications that were no longer being prescribed and also continued to mail
medications after the patient died.

See the chart below for a summary of the reasons participants gave regarding why medications
were returned.

3

-------
RxMEDS Appendix 1

Participant Reasons for Return by Category

3550

2503

11167

707

¦ I

407

° 4$

J-

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¦c^

6°

<4> \

Jy- rj- jj.

/ A» ^ ^

#> ^ 6
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-------
RxMEDS Appendix 1
Age of Participants:

Age by Decade and Divided by "Senior" Status

Age by # %
senior status

<65 373 41.9

>65 411 46.1

Unknown 107 12.0

Age by Decade

Ethnicity of Participants:

Overall, the majority of participants were white females age 50 and over.

Anecdotally, the store locations in racially diverse areas tended to be lower income. Pharmacy
students collecting at those locations commonly reported talking with non-participants. Many
responded that they needed to keep their medications in case they needed to take them later

Age by
decade

19-29

2.9

30-39

3.6

40-49

8.1

50-59

136

15.3

60-69

221

24.8

70-79

180

20.2

80-89

104

11.7

>90

1.5

Unknown

107

12.0

-------
RxMEDS Appendix 1

or give them to other family members at a later time. Cost of the medications seemed to be a
concern over safety of keeping medications in the home.

Ethnicity

White/Caucasian

761

85.3

Black/African American

2.7

Asian

0.02

Native American/Alaskan Native

Native Hawiian/Pacific Islander

Hispanic/Latino

0.02

Other

0.07

Not Specified

10.7

Description of Previous Medication Disposal Methods by Participants:

Previous studies report 50% of participants flushing medications down a toilet.* Our findings
show 36.8% previously flushed them down a toilet. We also see that approximately 20% of
participants were keeping their medications in the home. These participants were provided
with future instructions for disposal congruent with recent federal government
recommendations.

*Reference: Seehusen, D.A. and Edwards J. (2006) Patient practices and beliefs concerning
disposal of medications. Journal of the American Board of Family Medicine, 19: 542-7.

-------
RxMEDS Appendix 1

Participants' Previous Disposal Methods

1 didn't/I kept them

176

19.7

Flushed them down

328

36.8

Threw them in trash

190

21.3

Saved them for future use

1.12

Gave them to a friend

0.67

Turned them into a collection program

4.0

Other

6.5

Not Specified

9.8

350
300
250
200
150
100
50
0

328

176

190

„ ¦

I Seriesl

^ ^ -b v' & „i>

^ ^ ^ #° J?

«/" ^ ^ ^ ^
^ e> ^ ^ e> *

^ .<5"

6 ^ ^ x# ^ ^

,«P «

Zip Codes of Participants:

As with the PhRMA secondary survey (see Appendix 2), the analysis of participant zip codes
indicated that the majority of participants came from the same zip code as the collection point.
However no reference or conclusions could be made other than the participants responsed to
the sites that were geographically convenient.

How Participants Heard about the RxMEDS Project:

Anectdotally, pharmacies that were actively promoting the program with their patients had a
larger turnout. We successfully partnered with senior groups; however, when asked how
participants heard about the program, few answered they heard through the senior group.

A major challenge to the program was the year-long continued effort to keep the public aware
of the program. There were no funds for advertising so all efforts basically had to be in-kind.
The program promotion was also difficult because the collections were only held once a month

-------
RxMEDS Appendix 1

at a location. Participants may have heard about the program but forgot about it or missed the
collection day as a result of circumstances.

How Participants Heard

In store promotion

222

24.9

Flyers

Television

4.2

Radio

.78

Newspaper

126

14.1%

Friend/Relative

6.8%

Senior Services Group

.56%

Other

7.7%

Not Specified

284

31.8%

-------
RxMEDS Appendix 2

Prudent Disposal of Unwanted Medications (RxMEDS)

Secondary Survey Results

Background: In 2007 soon after the U.S. EPA awarded the grant for the Regional eXcess
Medication Disposal Service (RxMEDS) project in the St. Louis metro region, the partners
contacted representatives of Pharmaceutical Research and Manufacturers of America (PhRMA)
to discuss the possibility of adding a second survey to function in parallel with the primary survey
activities. Following the 2007 conference presentation in Maine, it was agreed that PhRMA
would develop a one-page survey that would be administered at each collection site for both
participants returning medications and non-participants. In appreciation for this survey, PhRMA
provided a stipend that helped support RxMEDS project costs for purchasing collection site
materials and supplies and for attending the 2008 national conference in Maine. Neither of these
expenses were included in the grant budget.

Level of Participation: The one page survey was administered during the 220 collection days
from January - December 2008 at each of the grocery store chain collection sites, setup near the
pharmacy counters. The survey was conducted by volunteers or the collection site assigned staff
and was administered at all 20 locations over the 12-month collection period. The survey was
conducted only on the days the location was having a collection event. A total of 675 surveys
were completed; some of the survey respondents were collection participants who were
returning medications and other respondents were at the collection site but not returning
medications. All survey respondents voluntarily answered the survey but not all respondents
provided answers to all questions, such as age.

Data Analyst Team: The accompanying data was compiled by the St. Louis College of Pharmacy
(COP) under the direction of Dr. Nicole Gattas. Assisting Dr. Gattas was Dr. Claude Gaebelein and
student pharmacists Emily Svezia and Lynn Ramsey. A special thanks to them for their efforts.

How to Read the Data: The following tables show the frequency of responses. In column 1 are
the different categories of the variable responses. In column 2 are the frequencies of each
category. The "missing system" row indicates a missing value. The next column represents the
percentage of each category to the total (675). The "valid percent" column expresses these
values without counting the missing system values, and the final column represents the
cumulative percentage, which is equal to the percentage of a variable plus the percentages of all
variables that precede it.

-------
RxMEDS Appendix 2

Age and distribution of survey respondents

The focus of the survey was designed to be on seniors and their ideas and perceptions
about safe disposal of unwanted medications. 84% of the survey respondents were in the
50-90+ age range.

Ages of the Respondents in Decades

Age

Frequency

113

132

139

126

656 respondents

(All respondents did not volunteer their age)

Age in Decades

150 i

>¦

t 100

20 30 40 50 60 70 80 90

Age

-------
RxMEDS Appendix 2
Ethnicity

Although collection sites were located in urban and rural areas, the level of response by ethnicity
shows that 78% of the participants were White/Caucasian and 17% were Black/African
American. This result parallels the results of the primary survey in which a vast majority of those
participating in the return program were also white. More minority survey reponders indicated
that economic factors prevented them from returning unused medications, just in case they or a
family member might need the medication in the future.

Ethnicity

Frequency

Percent

Valid
Percent

Cumulative
Percent

Valid White

526

77.9

79.9

Black

112

16.6

17.0

97.0

Asian

1.2

98.2

Native Am

98.8

Hispanic

99.1

Other

99.8

100.0

Total

658

97.5

100.0

Missing System

2.5

Total

675

100.0

Ethnicity

80-

60-

g> 40-

20-

White Black Asian Native Am Hspanic Other 9

Ethnicity

-------
RxMEDS Appendix 2
Gender

Because the collection sites were located at local grocery stores, it could be expected that the
majority of the responders would be female. In fact, 70.5% of the secondary survey responders
were female.

Gender

Frequency

Percent

Valid Percent

Cumulative
Percent

Valid Female

476

70.5

72.6

Male

180

26.7

27.4

100.0

Total

656

97.2

100.0

Missing System

2.8

Total

675

100.0

Gender

80"

60"

» 40"

20"

o-1 1 1—

Female Male

Gender

-------
RxMEDS Appendix 2

Survey Questions and Responses

1. Did you bring unused or unwanted medicines with you to return to the store today for
disposal?

66% of the responders to this survey indicated that they were not at the store to participate in
the monthly collection event.

Did You Return Meds Today?

Frequency

Percent

Valid Percent

Cumulative
Percent

Valid* No

448

66.4

67.1

Yes

220

32.6

32.9

100.0

Total

668

99.0

100.0

Missing System

1.0

675

100.0

• The "valid percent" column ignores missing data

Return Meds?

60"

|40-

20-

(H 1 1—

No Yes

Return Meds?

-------
RxMEDS Appendix 2

a. If you answered no, please tell us the most likely reason why did you not return meds
today.

We used only the two most common combinations, and gathered the rest as "Another
Combination". 60% of the survey responders were not aware of the program.

Reason for Not Returning Meds

Frequency

Percent

Valid
Percent

Cumulative
Percent

Valid Already returned

1.4

Not aware of program

255

37.8

60.3

61.7

Forgot

2.2

3.5

65.2

Inconvenient

66.2

Don't have unwanted

112

16.6

26.5

92.7

meds

Not aware / didn't have

3.0

4.7

97.4

any

Another Combination

1.6

2.6

100.0

Total

423

62.7

100.0

Missing System

252

37.3

Total

675

100.0

meds any

Reason for not returning drugs

The chart above is a Pareto chart, which shows the frequency of responses on the left ordinate
and the cumulative percentage on the right ordinate. It is used to indicate those components

-------
RxMEDS Appendix 2

that contribute most to an effect (like different sources of medication errors). The chart shows
visually that the largest reason for not bringing in meds was a lack of information about the
RxMEDS project. This should be tempered by a realization, however, that almost 25% of those
who did not bring in meds had none at home to return. On the positive side—few found the
program inconvenient!

2. What methods do you currently use to dispose of unused or unwanted medicine?
a. Did you dispose of drugs in the trash?

Of the respondents to this question, 72.5%, nearly three-fourths of those surveyed threw their
unwanted medications in the trash.

Disposed of in Trash

Frequency

Percent

Valid Percent

Cumulative
Percent

Valid Never

112

16.6

27.5

Sometimes

150

22.2

36.9

64.4

Always

145

21.5

35.6

100.0

Total

407

60.3

100.0

Missing 9

268

39.7

Total

675

100.0

Disposed of in trash

40-

30-

Q 20-

10-

0-1 1 1 1

Never Sometimes Always

Disposed of in trash

-------
RxMEDS Appendix 2

b. Flush them in the toilet or down the drain? (Disposed of in the home sewage system?)

Over a third, 36.4%, of the respondents indicated they never dispose of their
medications through their waste water system. However, two-thirds of them do it on a
regular basis.

Disposed of in Toilet/Drain

Frequency

Percent

Valid Percent

Cumulative
Percent

Valid Never

156

23.1

36.4

Sometimes

157

23.3

36.6

73.0

Always

116

17.2

27.0

100.0

Total

429

63.6

100.0

Missing 9

246

36.4

Total

675

100.0

Disposed of in drain

40"

30"

a) 20-
Q.

10"

o-1 1 1 1—

Never Sometimes Always

Disposed of in drain

-------
RxMEDS Appendix 2

c. Disposed of at a household hazardous waste collection program?

Only 16% of the respondents indicated they use household hazardous waste (HHW) collection
programs. This is not surprising as these programs are very infrequent in our area, sometimes
charge a fee to dispose of HHW, and are not in convenient locations for seniors or others with
limited transportation to participate easily.

Disposed of at HHS Programs

Frequency

Percent

Valid Percent

Cumulative
Percent

Valid Never

235

34.8

84.2

Sometimes

4.4

10.8

95.0

Always

2.1

5.0

100.0

Total

279

41.3

100.0

Missing 9

396

58.7

Total

675

100.0

Disposed of as hazardous waste

100"

80"

¦£ 60"

a>
o

a>
a.

40"

20"

o-1 1 1 1—

Never Sometimes Always

Disposed of as hazardous waste

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RxMEDS Appendix 2

d. Returned to pharmacy or collection event?

The respondents indicated that 34% of the time they return medications to their pharmacist or a
collection event. It is not clear if the respondents understood the question as it is illegal to
return them to a pharmacy. As in the previous question, the same barriers of poorly located and
fee-based collection events prevent many from disposing of hazardous waste and medications in
a convenient and timely manner.

Returned to Pharmacy or Collection Event

Frequency

Percent

Valid
Percent

Cumulative
Percent

Valid Never

191

28.3

66.1

Sometimes

7.3

17.0

83.0

Always

7.3

17.0

100.0

Total

289

42.8

100.0

Missing 9

386

57.2

Total

675

100.0

Returned to Pharmacy

60^

!«-

20^

o-J 1 1 1—

Never Sometimes Always

Returned to Pharmacy

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RxMEDS Appendix 2
h. No disposal needed, all the medicine was used?

76.9% of the respondents indicated there is not a need to dispose of any medications. At the
same time 61% of those surveyed indicated they do not use all doses that are prescribed for
them and keep these unused doses on hand.

No Disposal Needed

Frequency

Percent

Valid
Percent

Cumulative
Percent

Valid Never

10.5

23.1

Sometimes

118

17.5

38.3

61.4

Always

119

17.6

38.6

100.0

Total

308

45.6

100.0

Missing 9

System

366

54.2

Total

367

54.4

Total

675

100.0

No disposal needed

40"

30"

c
§

0 20-
Q_

10"

o-1 1 1 1—

Never Sometimes Always

No disposal needed

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RxMEDS Appendix 2

i. Other disposal methods

Although alternate methods of disposal are not described, almost two-thirds of the respondents
indicated they never dispose of medications through means other then those addressed in the
survey. Fewer than 10% of those surveyed responded to this question.

Other Disposal Methods

Frequency

Percent

Valid Percent

Cumulative
Percent

Valid Never

6.2

64.6

Sometimes

1.0

10.8

75.4

Always

2.4

24.6

100.0

Total

9.6

100.0

Missing 9

System

608

90.1

Total

610

90.4

Total

675

100.0

Other

60"

20"

Never

Sometimes

Other

Always

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RxMEDS Appendix 2

3. Which of the following will you consider when deciding to participate in future unwanted
medicine disposal programs? (Check all that apply)

a. Consider what is best for environment?

Over 8 out of 10 participants acknowledged that they would participate in future disposal
programs because they are aware of environmental issues.

Best for Environment

Frequency

Percent

Valid Percent

Cumulative
Percent

Valid No

105

15.6

15.8

Yes

561

83.1

84.2

100.0

Total

666

98.7

100.0

Missing System

1.3

Total

675

100.0

Best for Environment

100"

80"

¦g 60-

a>
o

a>
a.

40-

20-

Best for Environment

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RxMEDS Appendix 2

b. Safe for my Family

A second option was the consideration of home and family safety when properly disposing of
unused medications. 62.4% of the responders think that this is an important issue and a reason
to continue participation in future programs. The unusually large percentage of those saying
"yes" may be indicative of information about youth drug abuse, "Pharming parties" and deaths
associated with improper medication. Just six months after the survey, a community-based
parent organization sponsored seven successful medication collection events at the boundary of
the St. Louis metro region that was not conveniently served by the RxMEDS site locations.

Safe for My Family

Frequency

Percent

Valid Percent

Cumulative
Percent

Valid

250

37.0

37.5

Yes

416

61.6

62.5

100.0

Total

666

98.7

100.0

Missing

System

1.3

Total

675

100.0

Safe for my Family

60"

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RxMEDS Appendix 2
c. Convenient

Surprisingly, the sample indicated 60% of the respondents did not consider convenience as
factor for future participation. Comments received at the collection sites would not have
indicated this result. In many cases participants wanted the collection sites to be expanded both
in location, time of collection, and frequency of collection so it would be more convenient for
them to participate.

Convenience

Frequency

Percent

Valid
Percent

Cumulative
Percent

Valid No

402

59.6

60.4

Yes

264

39.1

39.6

100.0

Total

666

98.7

100.0

Missing System

1.3

Total

675

100.0

Convenience

60-

20"

4. If both methods of disposal of unwanted medications were equally safe for the
environment, which would you be more likely to use more often?

70% of the respondents would prefer, if legally possible, to be able to return unwanted or
unused medications to their pharmacist. They believe that this is a reliable source for obtaining

Convenience

-------
RxMEDS Appendix 2

the medications and that it therefore is a reliable source to dispose of the same medications.
Point-of-purchase collection is gaining momentum for other household hazardous waste
products, for example paint, batteries, tires, appliances and electronics, fluorescent bulbs, etc.

Preferred Disposal Method

Frequency

Percent

Valid
Percent

Cumulative
Percent

Valid a. Return unused

452

67.0

70.2

meds to

pharmacy

b. Dispose of in

192

28.4

29.8

100.0

trash

Total

644

95.4

100.0

Missing 9

1.3

9.0

3.3

Total

4.6

Total

675

100.0

Preferred Disposal Method

80"

60"

q 40"
Q.

20"

o-1 1 1

Return unused meds to pharmacy Dispose of in trash

Preferred Disposal Method

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RxMEDS Appendix 2

Voluntary Unwanted Medicine Disposal Survey

1. Did you bring unused or unwanted medicine with you to return to the store today for disposal?

~ Yes

~ No If you answered no, please select the most likely reason:

~ Returned my unwanted medicine on a past visit

~ Did not know about the program

~ Forgot to bring my unwanted medicine with me

~ Not convenient enough for me to participate

~ I don't have any unwanted medicine

2. What methods do you currently use to dispose of unused or unwanted mec

S
O
M

Please select the option that most closely applies for
each of the options listed below:

Put them in my household trash

Flush them in the toilet or pour them down the drain

Use a household hazardous waste collection program

Return them to the pharmacy or a collection event

No disposal needed, all the medicine was used/taken

Other (please describe):

A
L

W
A
Y
S

E
T
I

M
E
S

icine?

N
E
V
E
R

3. Which of the following will you consider when deciding to participate in future unwanted medicine
disposal programs? Please check all that apply.

Best for the environment ~

Safe for my family ~

Convenient to use ~

4. If both methods for disposal of unwanted medications were equally safe for the environment, which
would you be more likely to use more often?

~ Bring your unused medicine back to the pharmacy for disposal, or

~ Dispose of your unused medicine in your household trash

For data collection purposes, please complete the following information:

Zip Code: Age: Please check if over 90 years of age~

Ethnicity: Q White Q Black/ African American Q Asian I I Native American or Alaskan Native

I I Native Hawaiian or Pacific Islander Q Hispanic Q Other

Gender: Q Male or Q Female

Thank you for your participation.

-------
RxMEDS Appendix 3

Prudent Disposal of Unwanted Medications (RxMEDS)
Recyclable Materials Data

Area Resources for Community and Human Services (ARCHS) implemented the U.S. EPA
funded Regional eXcess Medication Disposal Service (RxMEDS) project in the St. Louis region
from January-December 2008 primarily to collect unwanted medications for incineration.
However, we designed RxMEDS so recycling the medicine's packaging container, such as a bill
bottle, was an integral component. This design allowed for the collection and recycling of
materials such as paper, foil, plastic, cardboard, glass, etc. that were collected along with any
medications collected for disposal.

Each site was supplied with a tamper-proof container for the deposit of non-controlled
mediations that were turned in and with a 64-gallon container for the deposit of recyclable
materials. At each collection site the staff determined which medications could be accepted
(controlled substances could be entered into the data system but must be returned to the owner
for disposal). All information on the medications and participants was recorded and then
collection staff unpacked any medications in plastic bottles, glass, or other packaging. The
medications were deposited into the tamper-proof container and recyclable materials were
placed in the 64-gallon container. These containers were collected by the RxMEDS project
waste hauler and processed for recycling. Containers were collected within 24 hours of the
collection day.

The following table reflects the 20 collection sites and the amount of recyclable materials
collected from each site according to our waste hauler. During the first three months of the
project, the waste hauler provide only a total weight for all collection sites. There were
numerous concerns about the reliability of this first waste hauler company. In July 2008 (six
months into the project) we switched to another waste hauler company.

The weights indicated are in pounds and equal to the weight of the recyclable material only.
Based on the information provided by the two waste hauler companies, RxMEDS collected over
a ton of recyclable materials at the 20 locations during the 12-month project (2,248.4 lbs).

Since the recyclable containers were not tamper-proof, it is possible that other recyclable
materials from the collection site pharmacy may have been tossed into the container prior to its
eventual collection. There is no way to insure that these weights reflect only materials that were
directly related to the medication collection project. However, it is considered a good estimate
of what could be expected in a long-term collection project.

-------
RxMEDS Appendix 3

RxMEDS Recyclable Materials ~ Weight in Pounds from 20 Collection Sites by Day and Month of 2008

SITE

St Louis
St Louis
Lake St Louis
St. Peters
St Louis
St Louis
Ballwin
Florissant
Bridgeton
Granite City
Florissant
St Peters
St Louis
Swansea
Graver
St Louis
St Louis
Godfrey
St Louis
Wentzville

Total 107 84 168 202 179 0 181 77 83 154 194 103 65 77 64 54 101 56 57 139 67 0 36

2,248.4 lbs

11 25 15 29 14 28 11 25 09 23 13 27 11 25 15 29 12 26 10 24 14 28 12
01 01 02 02 03 03 04 04 05 05 06 06 07 07 08 08 09 09 10 10 11 11 12

1.8

7.6

3.9

4.9

7.4

2.3

8.9

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