Petition 2014/15 of Anthony Roberts and 40 others Report of the Health Committee Contents Recommendation 2 Background 2 The petitioner s concerns 3 Best practice and international benchmarks 4 Ministry of Health s response 5 Our response 6 Appendix 8
Petition 2014/15 of Anthony Roberts and 40 others Recommendation The Health Committee has considered Petition 2014/15 of Anthony Roberts and 40 others, and we recommend to the Government that it investigate introducing a nationally consistent process, and reimbursement to pharmacies, for collecting and disposing of pharmaceutical waste. The petition requests: That the House of Representatives implement a national solution to pharmaceutical waste management. Background Common pharmaceutical waste There is currently no nationally consistent programme for the collection and disposal of pharmaceutical waste. There is also no consistent approach for reimbursing costs to pharmacies for providing these collection and disposal services. Pharmacies dispense a range of medicines, including some that pose risks to people and the environment if disposed of inappropriately. All medicines require careful disposal, particularly those that are hazardous substances or involve needles/syringes. The most common pharmaceutical waste is unused courses of medication. Without local disposal facilities or the awareness of these services, people discard medicines with other household waste. Retaining medicines in the home also poses a risk for others who may use expired or inappropriate medicines. There are risks associated with needles/syringes, or sharps, because they can injure or infect. They are single-use and used regularly by some people, such as diabetics, who need proper collection and disposal services. The untreated disposal of antibiotics, hormones, and cytotoxics is also concerning. Cytotoxics are medicines that contain chemicals toxic to cells, preventing their replication or growth, and are used to treat cancer. Community pharmacies now provide more cytotoxic medicines than they used to. Dilution of these substances can reduce the potential contamination of people and the environment, except for a few that remain active at extremely low concentrations. Different types of pharmaceutical waste need to be separated when they are collected, and treated differently. Sharps, cytotoxics, controlled drugs, and other pharmaceutical waste should be separated. 2
Agencies involved in collecting and disposing of pharmaceutical waste Collecting pharmaceutical waste involves central and local government as well as businesses. The Ministry of Health sets expectations and directions for the district health boards (DHBs) to provide services. However, DHBs make decisions about how best to allocate their resources and what services they provide. DHBs have service agreements with pharmacies about the services they provide, including collecting pharmaceutical waste. Most DHBs directly fund and contract waste management service providers to collect waste from pharmacies. A private firm, Interwaste, disposes of that pharmaceutical waste. Interwaste is the only national provider of medical and clinical waste disposal services in New Zealand. Interwaste works with seven DHBs, operates two informal collection schemes, and has been contracted to introduce pharmaceutical waste disposal schemes for three Aucklandbased DHBs. Several DHBs also run intermittent collection campaigns, including MidCentral s Safe and Efficient Disposal of Unused Medicines (SEDUM) project and Nelson Marlborough s Disposal of Unwanted Medicines through Pharmacies (DUMP) scheme. These campaigns increase public awareness of how to dispose of such waste. The petitioner s concerns The petitioner told us that the nationally inconsistent practices for disposing of pharmaceutical waste increase risk to the public and the environment. The petitioner told us that people retaining surplus medication could cause medical emergencies, and increased admissions to hospitals. He told us that vulnerable people, including children and residents of aged care facilities, would be particularly at risk of poisoning. The petitioner believes that more people are keeping medication because of Pharmac s decision to implement stat dispensing. In 2002, Pharmac increased the dispensing limit from one month s worth of medication to a 90-day supply (often referred to as all-at-once or stat dispensing). Pharmac projected that, by partially reintroducing stat dispensing, it could reduce DHB s spending on dispensing fees paid to pharmacists by $132 million over five years. We heard that pharmacies are unable to resell returned medicines because they cannot guarantee its integrity or the expiry of medication. The ministry told us that it is common for general practitioners to prescribe quantities of medication smaller than the quantity of medicine available in a pharmacy s package. Pharmacies are unable to sell part-packs (packs of partially used medication) to another pharmacy without a wholesalers licence. Pharmacies are also unable to sell part-packs back to the wholesaler. The petitioner told us this practice contributes to unnecessary and expensive wastage, especially of uncommonly prescribed medicines. The petitioner told us that Pharmac should consider wastage when deciding on the most appropriate size of packaging for medicines. Not all DHBs have implemented measures and given funding to local pharmacies to ensure that unused medicines are disposed of safely and consistently. Some pharmacies are also not reimbursed by DHBs for providing collection and disposal services. The petitioner told 3
us that some pharmacies have resorted to dumping pharmaceutical waste in skip bins or charged the consumer for disposal because they were unable to cover the cost. The petitioner told us that the environmental risk is highlighted in a 2009 Auckland Council study that identified evidence of 21 of 46 pharmaceuticals tested for in the Auckland estuarine environment. Any pharmaceuticals disposed of down a drain are not treated or denatured at sewage facilities and flow freely into waterways. However, the Parliamentary Commissioner for the Environment told us that dilution will render most pharmaceutical waste harmless to the environment. The Pharmacy Guild of New Zealand informed us of an exception. Hormones with endocrine disruptors are detrimental to development and can affect humans and aquatic species because they are active at extremely low concentrations. Not all landfills in New Zealand use a protective lining to ensure that pharmaceutical waste does not leach into waterways. The petitioner told us that this inconsistent practice of disposal contributes to the contamination of waterways. The petitioner told us that he believes New Zealand is not following best practice and should enable the use of high-temperature incineration for pharmaceutical waste. Incinerators have been largely phased out since the Resource Management Act 1991, but Interwaste still sends cytotoxics to Australia for incineration. The petitioner requests: consistent nationwide funding for disposing of all forms of pharmaceutical waste regular public promotion of how to dispose of unwanted medicines (DUMP campaigns) to improve public safety the formal development of national policy on how to dispose of unused and unwanted medicines, taking into consideration international best practice and environmental protection. The petitioner believes that consistency in collecting and disposing of pharmaceutical waste requires the Ministry of Health to direct DHBs to change current arrangements. The petitioner s concerns are supported by the Pharmaceutical Society of New Zealand and the Pharmacy Guild of New Zealand. They are also supported by Green Cross Health, a primary healthcare provider that represents 338 community pharmacists and 46 medical centres. Best practice and international benchmarks There are countries that nationally fund their collection programmes, such as the Australian Return of Unwanted Medicines Project funded by the Department of Health as part of Australia s National Medicinal Drug Policy. In some European countries, pharmaceutical manufacturers fund national collection systems. Green Cross Health told us that it supports an industry-led approach that includes DHBs and the ministry. Other countries, such as the United Kingdom, prioritise pharmacies ability to dispense medications in part-packs. The Pharmaceutical Society of New Zealand told us that 4
allowing pharmacies to sell to other pharmacies in New Zealand could be an effective solution to the restrictions on part-packs. The ministry told us that there are New Zealand guidelines for the Management of Healthcare Waste (NZS 4304:2002) but that they are 15 years old and are unlikely to represent good practice. The World Health Organization issued guidelines in 2011 that recommended the use of high-temperature incineration of pharmaceutical waste. Interwaste told us that it considers the incineration of all pharmaceutical waste unnecessary because current sterilisation and disposal practices follow international best practice. Interwaste told us that, although incineration is a preferable method for disposing of pharmaceutical waste and a necessary treatment for cytotoxics, it is not required for infectious waste. Interwaste told us that treating (denaturing/autoclaving) current waste and disposing of the residual non-hazardous waste by deep burial in Grade 1 landfills and immediately covering it would prevent leaching or contamination of waterways. All Grade 1 landfills have protective lining to prevent the leaching of contaminants but the majority of landfills in New Zealand do not have adequate protective linings. Ministry of Health s response The ministry told us that it agrees with the petitioner and expects all DHBs to fund a sharps disposal service for people using needles and syringes in the community, at no cost to the patient. The ministry told us that they updated their national coverage schedule to include an expectation that DHBs provide buckets and systems to retrieve sharps waste. Interwaste told us that diabetics are still using unsafe containers, such as coke bottles, to collect sharps waste. Pharmacies and medical practitioners are responsible for collecting the sharps they dispense, and DHBs are responsible for disposing of them. The ministry sets out the obligations of pharmacies in its Service Coverage Schedule and in the standard Community Pharmacy Services Agreement between DHBs and individual providers of community pharmacy services. The ministry told us that retaining pharmaceutical waste in the home can increase the risk of accidental poisoning, but discredited the petitioner s reference to a child poisoning study. The ministry claimed that the study s data on poisonings showed no link between rates of pharmaceutical dispensing and the risk of poisoning by prescription drugs. The ministry told us that it believes that Medsafe takes adequate safety steps, including warning labels and child-proof packaging on potentially dangerous medicines. The ministry agrees that there is a need for more careful prescription and dispensing practices to mitigate the increased quantities patients are collecting because of stat dispensing. Pharmac recently changed dispensing rules to help pharmacies reduce wastage and manage stock. It has also widened the wastage rule to allow pharmacists to claim recompense for the remainder of partly-dispensed packs if the remaining stock is unable to be dispensed. 5
The ministry told us that nationwide solutions will require it to work with agencies responsible for regulating environmental risk and waste management matters, including the Ministry for the Environment, the Environmental Protection Authority, and local authorities. The requirements for disposal of unwanted medicines into sewage systems or landfills are governed by local authority bylaws and resource management consents, including landfill acceptance criteria. Under the Resource Management Act 1991 no new high-temperature incineration facilities can be granted resource consent. An exemption was granted for three incineration facilities in Auckland, Christchurch and New Plymouth. Two have closed but the New Plymouth facility remains active. Addressing pharmaceutical waste The ministry informed us of some of its work to address some of the issues the petitioner raised. This includes: preparing the introduction of the Therapeutic Products Bill, which could include solutions to the problem of disposing of pharmaceutical waste working with the Ministry for the Environment on a proposal to accommodate incineration needs under the Ministry for the Environment s Contestable Waste Minimisation Fund investigating options to reduce the opportunity cost of unused medicines and the environmental effects of medicines waste by implementing the Medicines New Zealand 2015 2020 medicines strategy. The strategy involves working with Pharmac, the Health Quality and Safety Commission, DHBs, and pharmacists. The ministry recognises that it could do more and told us that it could extend its Service Coverage Schedule to include the disposal of cytotoxics and other hazardous medicines and set clearer national expectations. The ministry would need to specify what functions DHBs are required to deliver with respect to pharmacy services, the government policy settings for co-payments, and other charges that may be levied on the consumer. The new obligations of pharmacies would need to be set out in the Schedule and in the standard Community Pharmacy Services Agreement between DHBs and individual providers of community pharmacy services. Our response We thank the petitioner Anthony Roberts for bringing this matter to our attention. We agree there is a need to develop a national policy on how to dispose of unused and unwanted medicines. We note that there are New Zealand guidelines for the management of healthcare waste, but are concerned that the ministry believes that these 15-year-old guidelines no longer reflect best practice. We are pleased to hear that the ministry is considering options to address issues with disposing of pharmaceutical waste. We agree with the petitioner that the ministry should 6
continue to direct such services to follow international best practice and place importance on environmental protection. We request that the ministry update the committee on progress in this area in a year. We agree there should be consistent nationwide funding for disposing of all forms of pharmaceutical waste. We are concerned that there is no consistent nationwide collection service and that it is left to individual DHBs to decide how to resource it. Therefore, we recommend to the Government that it investigate introducing a nationally consistent process, and reimbursement to pharmacies, for collecting and disposing of pharmaceutical waste. We commend Pharmac s efforts to reduce the expense of part-packs for pharmacies and encourage less wastage. Pharmacies can now claim the remainder of partly-dispensed packs if the remaining stock is unable to be dispensed. Pharmacies are also encouraged to dispense smaller quantities of medicines if the difference is negligible but reduces waste. We believe there is merit in the Government investigating further options to address the question of pharmaceutical waste, including wastage of unsaleable part-packs, by examining all aspects of the supply chain to identify potential causes of waste. Pharmacies can now recover the cost of part-packs but are unable to trade them with other pharmacies. Partpacks that are safe for use are unable to be dispensed or supplied to pharmacies that may require them and results in unnecessary pharmaceutical waste. We agree that promoting awareness of collection services and campaigns such as DUMP and SEDUM are of value to the public. We support the DHBs continued use of these campaigns to minimise pharmaceutical waste in their communities. 7
Appendix Committee procedure Petition 2014/15 of Anthony Roberts and 40 others was referred to the committee on 16 June 2015. We received written evidence from the petitioner, the Environmental Protection Authority, Green Cross Health, Interwaste, the Ministry of Health, the Parliamentary Commissioner for the Environment, the Pharmaceutical Society of New Zealand, and the Pharmacy Guild of New Zealand. We heard oral evidence from the petitioner, Green Cross Health, Interwaste, the Ministry of Health, the Pharmaceutical Society of New Zealand, and the Pharmacy Guild of New Zealand. Read the evidence that the committee received on this petition (this link will take you to the relevant page on the Parliament website). Committee members Simon O Connor (Chairperson) Dr David Clark Sarah Dowie Julie Anne Genter Barbara Kuriger Melissa Lee Dr Shane Reti Barbara Stewart Poto Williams 8