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1 Review Article ISSN: Patel Denis Pankajkumar et al. / Journal of Pharmacy Research 2016,10(5), Available online through Storage and Disposal of Medicines in Home -A Review Patel Denis Pankajkumar, Sneha Chacko, Bhatt Sandipkumar Prakashkumar* Department of Pharmacology and Clinical Pharmacy, K.B. Institute of Pharmaceutical Education and Research, Gh-6, Sector -23, Gandhinagar, Gujarat. Received on: ; Revised on: ; Accepted on: ABSTRACT Appropriate household storage and use of drug products reduce drug wastage and unnecessary hazards. Rational use of drug also focuses on the storage and disposal of drugs irrespective of both Over the Counter (OTC) and prescription drugs. At present, pharmacy practice is in developing stage and focuses on drug related issues. Therefore, the awareness and importance of storage and disposal of drugs among consumers remained/s underreported and less focused topic. Pharmacist has prime responsibility to make aware people regarding storage and disposal of medicine. KEYWORDS: Storage, Disposal, Over the counter (OTC), Drug related issues, Pharmacy practices INTRODUCTION: Proper storage of medicine is essential for two reasons: 1) To maintain the stability and integrity of formulated medicine. 2) To prevent accidental injury and waste of medicines. Former will be well verse with pharmaceutical company and health care stake holder while the later reason necessitates careful handling and storage of medicine at home. Most of the medicines are available in child resistant containers. However, major needs proper labeling direction like keep out reach of children. Manufacture of the medicine follows the standard for the minimum labeling condition require for the medicine. It has been found that industry labels a wide variety of storage conditions on the medicines. In India, National drug expenditure as a proportion of total health expenditure in developing countries varies from 7 to 66%. Rational use of drugs is, therefore, important and essential to acquire proper medicines and dispense them in public health care systems. In recent years, the cost and expenditure on drugs have increased enormously. It is essential, therefore, to ensure that the drug used should match the burden of diseases and essential needs 1. There are quite a few storage instructions given on labels that are neither friendly to pharmacist nor to the consumer. However, all the attempts by the by the profession and pharmaceutical manufactures will fail if the public, 1) remove or transfer the medicine into another more convenient container but not necessary for stability point of view 2) incorrectly and/or unsafely store 3) disposed of medicines in the home. Home-stocked drugs may lose potency due to poor storage, because of exposure to heat, light, humidity and air. Drug storage at the home promotes self-medication and lead to exposure of factors those accelerates deterioration of drug quality and increase the contribution to wastage. Although this problem seems universal, it is of particular importance in developing countries where many people are deprived of basic primary health care 2-8. Looking from the use, development and complexities in medicine development, regulatory authorities of the developed countries have laid down guideline for safe handling, storage and disposal of medicine. While in India, medicine deregulation and improper utilization are common. Numbers of factors are prevailing viz: lack of public awareness, underutilization of pharmacist as health care provider, lack of pertinent policy and procedures etc... the occurrence of improper disposal and storage medicines was very common. Fig 1 evident improper removal, throw and store of medicine. *Corresponding author. Bhatt Sandipkumar Prakashkumar Department of Pharmacology and Clinical Pharmacy, K.B. Institute of Pharmaceutical Education and Research, Fig 1: A, B, drug disposal C, D: Improper storage: Improper storage Gh-6, Sector -23, Gandhinagar, Gujarat, , India. and disposal of medicines in our settings. A C B D

2 Patel Denis Pankajkumar et al. / Journal of Pharmacy Research 2016,10(5), Pharmacists are the medicine expert by their knowledge, education and experience and role in health care system. They are in a unique position to influence the use of medications at patient level. Pharmacist can directly contribute by disseminating information and counseling about storage and disposal of drugs 13. STORAGE Medication storage defines medication location, such as the drug cabinet, automated dispensing cabinet (ADC), refrigerator, or medication cart, as well as proper methods for storing medications 9. Proper storage of medications ensures optimum efficacy, stability and safety. (10) Prescott J and colleague states that people store their medications in the bathroom which is worst places to keep medicine. Bathroom cabinets tend to be warm and humid, an environment that speeds up a drug s (especially tablets and capsules) breakdown process. Being exposed to heat and moisture can make medicines less potent before their expiration date. Numbers of medicines are affected by environmental factor. As per instance a warm, muggy environment can cause aspirin tablets to break down aspirin into acetic acid (vinegar) and salicylic acid, which can irritate the stomach Storage errors with dramatic consequences have been reported: color change, spillage, leaching, taste change, particulate matter, softening of material/denaturation 9. Such drug incompatabity and points explores the importance of storage. The exhaustive literature review reveals and emphasizes on following points:- Importance of storage Sharing of medicines Factors affecting drug consumption Common places of storage Drug abuse Self-medication Accidental ingestion Medicine cabinet management Temperature or climate affecting storage. Importance of storage For positive therapeutic outcome, patients must receive medications appropriate to their clinical needs, in doses that meet their own requirements, for an adequate period of time, and at the lowest cost to them and their community. Such medicines must be esthetic, stored appropriately with active ingredient. Unfortunately, use of medicines is limited only to consumption but not its safe storage and disposal at home. Unnecessary prescription of drugs, OTC medicines, and irrational use is accountable for improper drug storage and disposal 14. Each medicine is unique chemistry and blend of specific substances. Numbers of environmental factors affects this chemistry that affects its composition and active potency. Beyond certain limits and criteria, medicine will not be a medicine that may leads to harm or loss to patient. Factors affecting drug consumption Cost and convenience seem to be major factors in determining whether, given the choice, patients purchase a medicine over the counter or obtain it on prescription 3,5. The factors influencing drug usage and therefore pharmaceutical wastage and accumulation are in figure 2. Identifying and assessing these parameters is an important step in recognizing the points where pollution prevention efforts could be designed and implemented 15. Self-medication Self-medication, defined as the administration of a therapeutic agent without a physician s prescription, can contribute to the inappropriate use of drugs without clinical indication. Leen De Bolle states drugs are often stored at the patient s home, and leftover medication may latter be considered for self-medication. Researcher found that in one third of the cases drug storage was unsafe and 1 in 5 medications especially OTC and drugs of unknown indication had passed the expiration date. The regular lack of safe storage for medicines and the frequent occurrence of drug containers without package insert raise concern Accidental ingestion Published literature reveals that the drugs consumed were mainly analgesics, anticonvulsants, antihistamines, antibiotics, oral contraceptives, ayurvedic, homeopathic preparations, corticosteroids etc. Enough pharmacoepidemiological evidences from India and overseas explores maximum cases of accidental ingestion due to household products especially leftover drugs or drugs in medicine cabinet. The cases of accidental ingestion were mainly seen in children Drug abuse Intentional drug consumption causes drug abuse or drug dependence. This phenomenon is common among adolescents and youth. (20,22) The drug abuse due to common OTC drugs especially pain killers are common among college students. The majority of students obtained prescription pain medication for illicit use from peers and the second leading source was family members 23. Sharing of medicines Medication sharing is relatively common. Up to certain extent this is true in adult/ neighbors. A medicine consumer who receives a medication by sharing does not receive the appropriate information about safe storage, storage condition and other relevant medicine information 24. Common places of storage at home Several studies reported kitchen, bedroom, and bathroom and store room as a common storage place at home. N Kheir et al reported that medicines for everyday use are often kept in places where they can be seen, such as the kitchen bench, while the when required medicines are usually kept out of the way in a bathroom cabinet. Storage of medicines in homes under damp and humid conditions, as well as exposure to light or high temperatures, can cause medicines to degrade more quickly than expected 19,22,25.

3 Patel Denis Pankajkumar et al. / Journal of Pharmacy Research 2016,10(5), Factors influencing drug consumption Pharmaceutical sale Prescribing Dispensing Non adherence and non Increased consumer wastage Detailing Sampling Promotional Manufacturers and distributors Increased consumer acquisition Drugs prescribed based on patient requests Drugs with complicated instructions Drugs prescribed to treat side effects Lack of knowledge Drugs prescribed as prn Off label prescribing Patient hand offs (hospital) Changes in treatment Education meetings and events for physician CME linked to marketing Medical journal advertising Virtual detailing e-sampling and e-vouchers Behind the counter drug expansion Non-standardized labels Prescribing pharmacists Free/low cost medication Extended quantities Inaccessible, unused residues in containers and patches Internet patient forums Abandoned and lost drugs Purchase of excessive quantities of OTC drugs Doctor shopping polypharmacy Increased marketing of human drugs for pets Diseases state or death Inappropriate and unusable charitable contributions Drugs with complicated delivery systems Patient confusion; lack of incentives Psychosocial factors Ineffective Stockpiling for future use Deliberate under-dosing Poor perception of disease severity; imagined improvement Complicated treatment regimens Adverse drug reactions Sensory aversions Small quantities trials Medication reuse Concordance Installment dispensing Abuse and addiction prevention Fig 2: Factors influencing drug consumption. Medicine cabinet management Exclusive cabinet to keep medicine safe is nearly impossible in our setting. A suitable place and racks, places are entitled as medicine cabinet. It is wise and important to check Medicine cabinet routinely for remaining doses of drugs, expiration dates, denaturation of the drugs in medicine cabinets for its potency. Drugs should be kept in the bottle or container as they are brought in. The original container will have sufficient protection, measures, expiration date, dose, and any instructions 26. DISPOSAL The disposal of unwanted medications has been a concern in many countries, as pharmaceutical waste enters the ecosystem, ultimately having an effect on human health and environment. Often, people with unused or expired medications are unsure of what the golden standard for disposal is. Therefore, it is essential to dealt with. Numbers of policy and procedures are laid down for safe disposal of medicine in the developed country. Drug wastage is defined as Any drug product either dispensed by prescription or purchased over the counter, that is never fully consumed, Improper wastage and disposal can lead to delay intreatment, disease progression, treatment of ensuring complications that include exacerbation or prolongation of illness, uncontrolled chronic disease, hospitalization, disability and death adding to overall increase in cost of treatment. Pharmaceuticals have been widely

4 Patel Denis Pankajkumar et al. / Journal of Pharmacy Research 2016,10(5), detected in the environment and in some cases can lead to detrimental effects on wildlife. Traces of pharmaceuticals have consistently been detected in effluents from sewage facilities, surface water and drinking water 12. Improper disposal of medicines increase chances of the drug resistance, infertility, cancer etc 27. The following points during our literature review find essential and important:- Public perception on disposal of drugs Economic impact Presence of most commonly used OTC drugs and prescription drugs in water and landfills Presence of API s in drinking water Occurrence of antibiotic resistance, cancer and infertility due to improper disposal of drugs Safe disposal methods guidelines Urgent needs of pharmacy take-back programs. Public perception on disposal of drugs Usually patients may not use all the medications dispensed to them because of many reasons: they may be avoiding unpleasant side effects, the symptoms have been relived, forgetfulness, dosage changes, side effects intolerance, or medications reaching the expiration date. Unused and expired medications are likely managed in a wide variety of ways. Methods of disposal of unwanted medications are by rinsing them down a sink, flushing them down a toilet, or throwing them in the trash. Another method also is to return to pharmacy. However a few pharmacists will take unused medication back to facilitate proper disposal of them, the majority will not. There are economic burden and environmental effects of unused medications 28. Economic impact Medication use and its costs have increased over the last several years. As the average age of the population increases, the number of prescriptions per patient will inevitably increase also. Medication waste is a factor of changes in prescribing policies, noncompliance (intentional and unintentional), and drug and dosing changes Presence of API s in drinking water The presence of pharmaceuticals in the environment, especially in water resources, has been confirmed by several reports; UK s wastewater treatment plant s (WWTP s) source waters were analyzed, and 10 pharmaceutical compounds including ibuprofen, mefenamic acid, diclofenac, propranolol, dextropropoxyphene, erythromycin, trimethoprim, tamoxifen, sulfamethoxazole, and acetyl sulfamethoxazole were identified. Unwanted medications can arise from households or from healthcare activities and, therefore, there are different factors that contribute to their generation. Active pharmaceutical ingredients enter the water supply through numerous pathways (Fig. 3): Excretion after ingestion, injection, or infusion Removal of topical medications during bathing and Disposal of unused or unwanted pharmaceuticals Domestic Household Disposal Usage Chemical and biologic degradation plus leachate treatment Pharmacy Household Wastage Sink/Toilet Body Landfill Toilet Metabolism (e.g., conjugation and hydroxylation) Leaching to Groundwater WWTW Biologic and chemical degradation removed as sludge Treated leachate discharged at river Surface Water Bio-solids Spread on land Fig 3: Pathway of drugs from domestic households to the environment (WWTW: Wastewater treatment works) 32

5 Patel Denis Pankajkumar et al. / Journal of Pharmacy Research 2016,10(5), Presence of most commonly used OTC drugs and prescription drugs in water and landfills Over the last few decades, the occurrence of micro pollutants in the aquatic environment has become a worldwide issue of increasing environmental concern. Micro pollutants, also termed as emerging contaminants, consist of a vast and expanding array of anthropogenic as well as natural substances. These include pharmaceuticals, personal care products, steroid hormones, industrial chemicals, pesticides and many other emerging compounds. The occurrence of micro pollutants in the aquatic environment have been frequently associated with a number of negative effects, including short-term and long-term toxicity, endocrine disrupting effects and antibiotic resistance of microorganisms 33. Research studies have explored that endocrine functions of certain aquatic organisms have been adversely impacted by chronic exposure to trace levels of medicine in surface water 34. to influence the use of medications drug disposal and safe storage at home. Following points should be emphasized by pharmacist for safe storage and disposal of medicine:- Counsel patient of safe storage and disposal of drugs Educate patient regarding identification of drugs, temperature of storage and disposal of medication Preparation of education material like patient information leaflet (PIL), flyers, brochure, pamphlet etc.. Indicate patient that any change in physical properties of medications may be due to degradation of that medicine Instruct parents or guardians to keep medication out of reach of children Information should be provided to school student which would be effective in preventing drug abuse and to inculcate drug abuse education in school curriculum in order to prevent drug abuse Safe disposal methods guidelines Significant environmental risk because of the improper drug disposal was first discovered around 35 years ago. Different studies have proved the presence of trace amount of drugs especially NSAIDS, antihypertensive, antibiotics etc. in water system. As a result, several guidelines are developed by developed and developing countries for proper disposal of medicine. Literature evidence of guidelines and practice guidelines are available. It will be another quantum of work to look in detail. Rather than focusing on those guidelines, it necessary to emphasize in our practice. Urgent needs of Pharmacy take-back programs. In India, there are no governing policies for safe disposal of medicine. Therefore, policy makers have to frame government programs or policies. As per instance, one of the programs over the globe is pharmacy take back program. Medicines returned to medical store are another method of proper drug disposal. Published studies have shown that the take back programs are beneficial in community settings. Returned medicines can help in reducing the environmental hazards and promote safe drug utilization. Unused medicines are regarded as a problem in many countries because of the economic value they represent as well as the consequences of non-adherence to prescribed treatment and environmental hazards. Therefore, minimizing the quantity of unused medicines generated and ensuring the safe disposal of unavoidable unused medicines is an important public health concern 35,36. ROLE OF PHARMACIST Pharmacists have the greatest interaction with consumers and overthe-counter medications. Therefore, they are in an excellent position CONCLUSION The current behavior of consumer and practices of the pharmacist for the collection, storage and disposal of medicine are not optimal. An organized method of collecting unused medication needs to be introduced. More research is needed, particularly on the reasons why patients store, dispose and stop a therapy and which measures are most appropriate to improve it. In the meantime, pharmacists should encouraged to continue playing a major role in the communication and counseling of patients in order to promote a more rational use of medicines and a proper discharge of medicines. ACKNOWLEDGMENTS: Articles based on this project study are supported by K.B. Institute of Pharmaceutical Education and Research (K.B.I.P.E.R) and Information and Library Network (INFLIBNET). REFERENCES: 1. Krishnaswamy K, Kumar BD. 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