ISE19/20-21

• Over prescription by medical practitioners, non-adherence to therapy by patients and stockpiling from retail purchase are common factors of accumulating medicines at homes.^{1Legend symbol denoting According to the estimate of the World Health Organization, more than half of all medicines are prescribed, dispensed or sold inappropriately, and that half of all patients fail to take them correctly. See World Health Organization (2021).} Storage of these expired/residual medicines ("unwanted medicines") can be dangerous to one's health with accidental ingestion. On the other hand, inappropriate disposal practices such as flushing unwanted medicines down toilets/sinks and discarding them in household waste, are often a significant contributor of pharmaceuticals found in environmental media (e.g. surface water and landfill leachate), according to the World Health Organization ("WHO").^{2Legend symbol denoting See World Health Organization (2011).} To minimize the introduction of pharmaceuticals into the environment, WHO recommends governments to take a combination of preventive measures, including ensuring optimal supply of medicines to patients, and providing a pharmaceutical take-back arrangement.
• In Hong Kong, the Government does not regulate the disposal of unwanted medicines arising from households and does not provide household residual medicines collection services. Under the current policy, household residual medicines (and injections) are handled together with general domestic solid wastes.^{3Legend symbol denoting See GovHK (2017a).} However, a study conducted by the Hong Kong Baptist University has found that leachate from the landfills contained human antibiotics. Following the recommendation of Audit Commission in 2016 about the reduction of drug wastage, the Hospital Authority ("HA") has been launching a pilot programme in some hospitals to split patients' prescriptions into smaller quantities with a view to reducing the risks of storing excess drugs at homes.^{4Legend symbol denoting See Food and Health Bureau (2016) and Hospital Authority (2021).}
• In Australia, apart from efforts to avoid excessive medicines being kept by households, it has notably put in place a national drug take-back programme to address the safe disposal of unwanted medicines. Established in 1998, the programme enables the public to return their unwanted medicines to the local community pharmacies for centralized treatment, which helps prevent inappropriate disposal of medicines on one hand, and avoids adverse health consequences resulting from accumulation of unwanted medicines on the other. This issue of Essentials begins with an overview on handling of unwanted medicines arising from households in Hong Kong, which is followed by a discussion of the initiatives and experiences in Australia to reduce and handle unwanted medicines from households.

Hong Kong

• In Hong Kong, the Government regulates the disposal of expired/unserviceable medicines of healthcare institutions such as hospitals and clinics, but it does not regulate the disposal of medicines arising from households. In accordance with the Waste Disposal Ordinance (Cap. 354), unwanted or waste medicines (and injections) generated by healthcare institutions are classified as chemical waste. The storage, collection, transport and disposal of such chemical waste of these healthcare institutions are required to comply with the Waste Disposal Ordinance and the Waste Disposal (Chemical Waste) (General) Regulation (Cap. 354C). These control measures do not apply to the disposal of medicines arising from households.
• In replying to a Legislative Council Question in 2017 on use and disposal of drugs, the Government stated that given the generally small quantities of household residual medicine (and injections), they were being handled together with general domestic solid wastes.^{5Legend symbol denoting See GovHK (2017a).} In replying to another Legislative Council Question in 2019 about disposal of waste medicine from households, the Government stated that the concentrations of antibiotics detected in river waters of Hong Kong were generally low according to some local academic studies. It therefore had no plans to provide household residual medicine collection services.^{6Legend symbol denoting See GovHK (2019c).} As advised by HA, patients can simply handle the residual medicines together with general domestic wastes, without the necessity of returning them to the hospitals.^{7Legend symbol denoting See 醫院管理局(2016年).}
• Having said that, the Department of Biology of the Hong Kong Baptist University conducted a study in September 2018 with a focus on the environmental impact of medications discarded by households. The study has found that leachate collected from landfills in Hong Kong contained human antibiotics with quantities that could result in the possible development of antibiotics-resistant micro-organisms.^{8Legend symbol denoting See Hong Kong Baptist University (2018).} Meanwhile, there are media reports from time to time about medical wastes (including unwanted medicines) being found in some beaches of Hong Kong.^{9Legend symbol denoting See 東網(2017年) and 香港01(2018年).}
• To reduce unwanted medicines from households, the Secretary for the Environment had suggested introducing measures at source so as to reduce the generation of residual or surplus pharmaceutical materials requiring disposal.^{10Legend symbol denoting See GovHK (2013).} Indeed, in the Director of Audit's Report published by the Audit Commission in 2016, it found that HA had dispensed a huge quantity of drugs to patients.^{11Legend symbol denoting See Audit Commission (2016).} The Audit Commission recommended HA to regularly assess the extent of drug wastage and to take appropriate measures to tackle the problem. Accordingly, HA has been launching the "E-FILL" Drug Refill Services Pilot Programme in selected hospitals since December 2017 to split prescriptions into smaller and manageable quantities for certain elderly patients attending specialist outpatient clinics.^{12Legend symbol denoting The target patients are aged 60 or above attending Medical specialist outpatient clinics; taking multiple drugs with medical consultation interval of 16 weeks or longer; and having multiple medical consultations or hospital admissions in between appointments.} Under the scheme, patients will collect medicines in phases. Hospital pharmacists will review patients' clinical conditions. If the conditions of the patients remain stable,^{13Legend symbol denoting For patients who have episodes of medical consultations or hospital admissions with changes in medications or having drug-related issues, pharmacists will review patients' drug profiles and perform medication review and reconciliation. They may arrange telephone call follow-up or face-to-face consultation if necessary.} the patients (or their carers) will just need to present their refill slip to collect drug refill at the designated counters of the hospital's pharmacy department.^{14Legend symbol denoting See GovHK (2018).}
• As at end-2020, the pilot programme covered nine public hospitals^{15Legend symbol denoting They are Prince of Wales Hospital, Tuen Mun Hospital, Pamela Youde Nethersole Eastern Hospital, North District Hospital, Alice Ho Miu Ling Nethersole Hospital, Ruttonjee Hospital, Tseung Kwan O Hospital, Pok Oi Hospital and Tin Shui Wai Hospital.} with a total number of about 38 700 patients.^{16Legend symbol denoting Information is based on the email reply from the Hospital Authority at the request of the Research Office.} Since it is a pilot programme, the scale remains small. On the other hand, for the HA patients aged 65 or above attending specialist outpatient clinics with prescribed medications, the overall average period of time covered by a prescription was still over three months (105 days) in 2020.^{17Legend symbol denoting Ibid.} As pointed out in the Director of Audit's Report, prescribing large quantities of drugs for a long period of time could lead to drugs being unused and wasted.

Australia

• Different from Hong Kong where drug dispensing activities normally take place in public hospitals and clinics,^{18Legend symbol denoting See GovHK (2007)., 19Legend symbol denoting During the coronavirus pandemic, community pharmacies have offered to help refill patient prescriptions of some hospitals of HA. See News.gov.hk (2020).} in Australia, provision of medication dispensing services lies in community pharmacies. It has around 5 700 community pharmacies in the country and most people have a pharmacy less than 10 minutes away from their home.^{20Legend symbol denoting See the Pharmacy Guild of Australia (2018) and the National Return & Disposal of Unwanted Medicines Limited (2021c).} With such a widely distributed network, community pharmacies have been an integral part of the primary health care system.^{21Legend symbol denoting The Australian government has been providing funding to the community pharmacies for the provision of the services though the Community Pharmacy Agreement. See Department of Health and Ageing (2011).}
• While community pharmacies are bound to adhere to the guidelines to avoid multiple repeat prescriptions at one time, they also play a role under the support of the government to strengthen patients' knowledge or ability to manage their medicines. For example, the initiative of "Dose Administration Aids" assists patients with long term conditions in organizing medicines into individual doses according to the prescribed dose schedule through a device (e.g. compartmentalized box or medication pack).^{22Legend symbol denoting It can be either one single type of medicine per compartment or different types of medicines per compartment. See NPS MedicineWise (2014).} Where requested by the doctor, the community pharmacy will supply medicine to patients in periodic instalments such as on a daily or weekly basis. All these not just improve the health outcomes of patients, but also avoid the accumulation of unwanted medicines at homes, requiring disposal finally.
• Despite the above arrangements, people in Australia are still free to buy non-prescription medicines in pharmacies. During the outbreak of the coronavirus pandemic, there was panic buying, which reportedly resulted in pharmacies' and wholesalers' numerous product lines being out of stock.^{23Legend symbol denoting See Department of Health (2020c).} Although its government has subsequently imposed a limit on sales of certain non-prescribed medicines^{24Legend symbol denoting They included adrenaline auto-injector and salbutamol (for asthma).} for every purchase, stockpiling is likely to result in disposal at the end. In fact, since 1998, the Australian government has put in place a national programme "Return Unwanted Medicines" ("RUM") to facilitate the safe disposal of medicines in the community.^{25Legend symbol denoting Apart from Australia, various other places such as the United States, South Korea and Taiwan have been launching similar collection programmes. The one in Australia is one of the oldest programmes being launched at the national level.}

National drug take-back programme

• Having been established for over two decades, RUM aims to provide a safe, free and convenient means for the public to return unwanted and expired medicines. Under RUM, pharmacists of community pharmacies are responsible for collecting unwanted medicines from the public and keep them in designated containers (known as "RUM bins"). The operation is as follows:
  
  

  (a)	Types of medicines to be collected: Medicines that can be returned include oral medicines, eye and ear drops, creams and gels, and Chinese/herbal medicines, excluding syringes and needles. Medicines for pets can also be returned. Medicines can be taken to any pharmacy for disposal. It is not necessary to return them to the pharmacy from which they were originally purchased;
  (b)	Operation: returned medicines are placed in the RUM bin stored in a secure area of the pharmacy. There are collection protocols for pharmacies to follow.26Legend symbol denoting See the National Return & Disposal of Unwanted Medicines Limited (2021d). Generally speaking, they should remove the medicines from any outer packaging and place them in the containers, which are placed in a visible position in the pharmacy but out of reach of the public. During the collection process, community pharmacists can take the opportunity to review the clinical conditions of relevant individuals to determine if further counselling or consultation is required. When handling certain controlled medicines such as morphine and methadone, they are required to adopt additional measures (e.g. recording the return and crushing the tablets before disposal, depending on the state's collection protocol).27Legend symbol denoting See the National Return & Disposal of Unwanted Medicines Limited (2021b). Once full, the collected medicines will be transported to the warehouse of pharmaceutical wholesaler and be disposed of by high-temperature incineration;28Legend symbol denoting In Australia, over half of all waste was sent for recycling while a quarter was sent to landfill for disposal. See Australian Bureau of Statistics (2020). and
  (c)	Funding: community pharmacies collect these medicines at no cost to the public. The programme is monitored by a national not-for-profit company. All costs are borne by the government, including the manufacture of RUM bins, transport and storage costs, incineration, and the management of these arrangements. For the years between 2018-2019 and 2021-2022, a total funding of AUS$15.1 million (HK$80.9 million) is reserved for the project.29Legend symbol denoting See GrantConnect (2018). This is equivalent to a budgeted cost of about HK$3 per capita over a four-year period.

• Since the commencement of the programme, over 10 million kilograms of unwanted medicines were collected and incinerated, equivalent to a total of four Olympic-sized swimming pools being filled up with the medicines.^{30Legend symbol denoting See the National Return & Disposal of Unwanted Medicines Limited (2019).} In 2016, a national audit was carried out which found that over 60% of survey respondents disposed of unwanted medicines because they had expired.^{31Legend symbol denoting See Griffith University (2016).} However, since only about one-fifth of survey respondents had heard about the programme, the government considered necessary to increase public awareness. Different awareness initiatives were therefore rolled out. For instance, an online lucky draw was launched in 2017 and winners were required to return their unwanted medicines to the pharmacy before collecting their prizes.^{32Legend symbol denoting See the National Return & Disposal of Unwanted Medicines Limited (2017a and 2017b).} More recently, in Mackellar of New South Wales, it has been reported that additional 20% of unwanted medicines were collected following the distribution of paper bags to encourage the community to return any unwanted medicines to pharmacies.^{33Legend symbol denoting See the National Return & Disposal of Unwanted Medicines Limited (2021a).}

Concluding remarks

• Accumulation of unwanted medicines at homes can cause accidental poisoning and bring adverse impacts to the environment. Reducing the generation and improper disposal of them are therefore crucial. In Hong Kong, the Government does not regulate the disposal of unwanted medicines arising from households and does not provide household residual medicines collection services. However, it has rolled out initiatives (e.g. E-FILL Drug Refill Service) to help patients better manage their medicines and reduce the generation of unwanted medicines at homes. In Australia, apart from the efforts to strengthen patients' ability to manage medicines (e.g. dose administration aids), it has also engaged community pharmacies to provide a safe, free and convenient means for the public to return unwanted medicines under the national drug take-back programme. In operation for over 20 years, the programme has handled over 10 million kilograms of unwanted medicines, which would otherwise have been discarded together with household waste or flushed, causing an impact to the environment.

Prepared by Kent CHUNG
Research Office
Information Services Division
Legislative Council Secretariat
29 April 2021