Assessment of general population knowledge, attitude, and practice on safe unused and expired drugs disposal: a cross-sectional study

Introduction

The proper disposal of medicine is a well-acknowledged challenge that has gained increasing attention in diverse settings.^1,2 A lack of sufficient knowledge regarding the proper methods of disposing of unused medication can lead to significant consequences, such as the accumulation of chemical compounds and dangerous chemicals from the medication in the environment around it, unintentional events of overdose, and the possibility of prescription drug misuse.^3,4 A number of countries have implemented legislation pertaining to the appropriate disposal of unwanted or expired medicine.⁵ Ensuring the effectiveness and safety of pharmaceutical items may be achieved by following the prescribed storage conditions specified on the label and using them prior to their designated expiry date.^6,7 The disposal of pharmaceuticals is often advised by suppliers and certain healthcare organizations, taking into consideration their expiry date.^8,9 This is primarily because outdated medicines could decompose, resulting in a loss of effectiveness or even the manifestation of harmful consequences.¹⁰ Prescribed drugs often remain unused owing to several circumstances, including changes in treatment plans, unpleasant responses, improvements in patients’ well-being, or other contributing factors.^11–14 According to the World Health Organization (WHO), a considerable number of pharmaceuticals has been prescribed or made available for sale improperly, resulting in the buildup of enormous volumes of solid waste consisting of expired and unused medications, hence, there is a notable burden for the environment that is linked to the disposal of these pharmaceutical substances.¹⁵

The Food and Drug Administration (FDA) in the United States has issued guidelines to the general public pertaining to the proper disposal of leftover pharmaceuticals; as per the guidelines provided by the FDA, the optimal approach for disposing of unneeded or expired medications involves depositing them at certified drug take-back locations, these locations are often available at various medical institutions, including retail pharmacies and health centers.¹⁶ Properly disposing of expired, unwanted, or unused drugs by customers is a significant worldwide concern.¹⁷ Numerous developed countries have implemented initiatives to recycle unwanted medications properly. In Australia and Canada, the National Return and Disposal of Unwanted Medicines Project has been implemented with the respective governments and pharmaceutical industries.¹⁸ Drug take-back strategies are prevalent in both the United Kingdom and Sweden.¹⁹

A study conducted in Africa examined the knowledge and perceptions of people regarding the disposal procedures for unused medications. The findings revealed that families lacked knowledge regarding proper disposal procedures. This poor knowledge can be attributed to insufficient public education and promotion campaigns and the failure of healthcare providers to deliver disposal advice at healthcare facilities and drug stores. Additionally, unclear disposal instructions on medicine packages and a disregard for reading these instructions were identified as contributing factors to this issue.²⁰ Despite the existence of international guidelines regarding the appropriate disposal practices for expired and unused drugs,²¹ implementation of these guidelines is often inadequate, and the public has limited access to sometimes conflicting information on this matter.^22,23

Furthermore, it is important to acknowledge that certain medications may be appropriately discarded by flushing them down the toilet, as long as they are included in FDA roster of pharmaceuticals that are deemed safe for such disposal. The list provided includes various opiates such as buprenorphine, morphine, other derivatives of opioids, diazepam, and methylphenidate.²⁴ In contrast, medicines that are not acceptable for disposal by flushing should be mixed with a less appealing substance, such as dirt, cat litter, or recently used coffee grounds; following this, it is recommended that they be securely sealed inside a hermetically sealed plastic bag and appropriately discarded in the designated waste receptacle.²⁵

The existing body of research on the knowledge and attitudes of the general population regarding the disposal of expired and unused medicines has been conducted in various regions worldwide. However, the specific knowledge and attitudes of the Iraqi population regarding the safe removal of expired and unused drugs remain unknown. This lack of understanding is primarily due to the absence of a regulatory authority system in Iraq that addresses the proper handling of expired and unused medicines at the household level. Therefore, this study aimed to evaluate the general population’s knowledge, attitude, and practices about the disposal procedures for expired and unused medications.

Methods

Results

The study recruited 591 participants. The majority of participants were men (64.8%) with average age of 33.5±9.1 years. More than two-thirds (72.9%) were married and 88.7% had university education. Approximately 65% had governmental work with income between 0.5-1.0 million Iraqi Dinars. Although 59.2% had healthcare worker relatives (HCW), 62.9% of them have not received information about how to dispose unused medications (Table 1).

The majority of participants (˃50%) answered four out of eight knowledge questions correctly. More than 84% correctly agreed that improper disposal of unused and expired medication has adverse effects on the environment. In contrast, only one-third (34-36%) answered correctly that the other three items related to the ways of proper/safe disposal of unused medications. In other words, more than two-thirds of the participants believed that disposal of solid and semi-solid medications into garbage is acceptable. In contrast, 68.2% believed that it is not acceptable to dispose needles and syringes into garbage (Table 2 and Figure 1).

Figure 1. The percent of the correct answers for each knowledge item among the participants.

The majority of participants (60-95%) had positive attitudes toward the necessity of proper disposal of unused medications and the pivotal roles of healthcare workers (HCWs) to raise awareness about the safe disposal methods. The majority of participants (60-95%) agreed with two items describing the HCW roles in counseling about improper ways of disposal. The attitude items indicated two suggested methods to enhance the safe disposal of unused medications including via community pharmacies and encouraging patients to return unused/expired medications to community pharmacies to be disposed safely (Table 3).

Although the majority of the participants had a positive attitude toward the safe disposal of unused/expired medications, their actual practice is improper disposal for these medications (Table 4). Approximately 70% of the participants have disposed unused/expired medications into their home trash can. Additionally, 66.3% of them had unused medications in their homes (Table 4).

According to the participants’ gender, there was significant (P-value˂0.05) differences in seven out of eight knowledge items related to disposing of unused/expired medications. In other words, men participants had significantly higher percentages of correct answers in almost all knowledge items compared to women participants (Table 5).

There was significant (P-value˂0.05) difference in the participant attitude toward one item regarding the disposal of unused/expired medications according to the gender. In other words, men participants more likely to believe “if there is monetary incentive for customers to return unused medicines, they would be more likely to do so”. However, there was no other significant (P-value˃0.05) difference according to the participant gender with the other nine attitude items (Table 6).

There were significant (P-value˂0.05) differences in four knowledge items about disposing of unused/expired medications according to the education level as presented in Table 7. In other words, participants with university education had a significantly higher percentage of correct answers to three of the knowledge questions. In contrast, the participants with primary school education had significantly higher percentage of correct answer to one knowledge item: “Incineration is proper environmental way to dispose unwanted medications.

There were significant (P-value˂0.05) differences in three knowledge items about disposing of unused/expired medications according to participant age. In other words, older participants had significantly higher knowledge about the disposing of unused/expired medications compared to younger ones (Table 8).

According to the Chi-square test, the participants with higher income were more likely to have correct answers regarding four knowledge items compared to lower income participants (Table 9). In other words, higher income was associated with better knowledge about disposing unused/expired medications.

Discussion

The increasing availability and use of medicines have resulted in accumulated and inadequate disposal of unwanted, expired drugs inside households, which may give rise to environmental and public health concerns.^32,33 The reduction of this issue may be achieved by the implementation of policies and recommendations for medication disposal,³⁴ as well as by enhancing public knowledge about suitable techniques and procedures for disposing of medicine.³⁵ Hence, the primary objective of this research was to evaluate the general population’s knowledge, attitude, and behavior pertaining to the disposal of unused and expired home medications.

The findings of our study revealed a satisfactory level of knowledge among the general populace about the proper disposal of medications. A majority of the participants correctly answered four out of eight knowledge-based questions related to medicine disposal. Additionally, most of the respondents expressed the belief that it is unacceptable to dispose of needles and syringes in regular rubbish. The present results are consistent with the earlier findings published by A. Althagafi et al. in Saudi Arabi, which recruited 1100 participants,³⁶ however they differ with the findings of research done in Lebanon, which emphasized the limited understanding of the general community about medicine disposal, and where the knowledge score were 24.5%.⁶

Previous research has shown that individuals with intermediate and higher education levels (secondary, university, or postgraduate) and higher incomes had a higher perceived knowledge score, as documented in previous study.³⁷ One reasonable assumption is that those who have higher levels of education and have more financial stability are inclined to exhibit a more intuitive preference towards seeking knowledge and possess a heightened understanding of their environment. In contrast, in line with findings from previous studies, those with lower levels of education are more prone to encountering challenges when attempting to acquire new knowledge and may lack awareness of the potential repercussions of incorrectly disposing of medications.³⁸ The aforementioned findings are consistent with the current study results, indicating that those with a university degree exhibited a statistically significant increase in the proportion of accurate responses to three of the knowledge-based questions.

There was a substantial association seen between gender and knowledge and attitudes, with men exhibiting considerably higher scores in both domains. The results exhibit inconsistency compared to prior research, which indicated that women showed a considerably higher inclination towards using medicine collecting facilities than men in a study conducted between Lebanese and Malaysian populations.^6,39 Additionally, women were found to possess a greater sense of personal accountability towards the proper disposal of medication.⁴⁰

The respondents expressed a belief in the need of consulting healthcare experts on appropriate means of disposal. This finding is consistent with the expectation that health care providers bear primary responsibility for managing medicines and hazardous waste.⁴¹

The present study reveals that 66.3% of the participants had leftover, unutilized, or unwanted medicines, a finding consistent with previous research done in India and Harar city in Ethiopia, where 68% and 66% of the respondents, respectively, retained unused medicines inside their households.^17,42 Furthermore, the findings of research done in Northern Ethiopia by Halefom Kahsay et al. demonstrated a lesser value compared to the information presented in this study, approximately 52.4% of the participants said they had leftover medications stashed inside their households, with analgesics being the most prevalent category, accounting for 41.5% of the reported instances.⁴³

The results from the study indicate that a significant proportion of respondents reported disposing of expired drugs in their home garbage (approximately 70%), in line with previous research that gave insight regarding a number of studies undertaken in different countries around the world.¹⁸ In Busan city, Korea, housewives were seen to dispose of unneeded drugs by using regular rubbish bags.⁴⁴ It was believed that the appropriate approach for disposing of unneeded or expired prescriptions was to flush them down the toilet or drain rather than putting them in the garbage. This was based on the concern that if medications were thrown in the trash, there was a higher likelihood of animals or people coming into contact with them.⁴⁵ A small proportion, about 4.2% of the survey participants, reported disposing of expired prescriptions by flushing them down the toilet or sink. This disposal method aligns with the patterns seen in Kuwait (2%), and much lower than what reported previously in the United States, as it was documented that 35.4% of participants flushed medications down the toilet or sink.^21,46 Notably, this approach is considered the recommended practice for liquid pharmaceuticals.¹⁸ A small portion of the participants in the study engaged in the practice of returning drugs that were unused and had expired to drugstores, but only 1.35%. This behavior has similarities to comparable practices seen in the United States and Malaysia as reported in previous studies.^46,47 The various methods used for the safe disposal of residual pharmaceuticals have a substantial impact on mitigating the entry of these substances into the environment since they have the potential to pose risks to both the environment and individuals.^48,49

Conclusion

The present study conducted among the general population in Iraq provides insights into the actual practices and level of knowledge about the appropriate handling and disposal methods of unused and expired medications. Despite the widespread awareness among the general community of the potential damage and significant risks associated with expired pharmaceuticals, a lack of knowledge was observed on the appropriate methods for disposal and management of such medications. A significant proportion of the participants had positive attitudes about the necessity of appropriately disposing of unneeded drugs. Yet, their current practice involves poor disposal methods for these drugs. The healthcare system and its practitioners must play a pivotal role in providing education and guidance to the general population in this matter. It is recommended that authorities take proactive measures to develop and implement medication take-back campaigns, along with methods aimed at increasing public awareness on this issue. Lastly, all community members must take up the duty and responsibility of protecting the environment and preventing the unethical discharge of chemical substances, such as drugs, that may harm the natural environment.