Exploring Household medicine waste in Iraq

doi:10.21203/rs.3.rs-1613875/v1

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Exploring Household medicine waste in Iraq

https://doi.org/10.21203/rs.3.rs-1613875/v1

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Purpose: This study aims to explore household medicine wastes and their storage and disposal behavior in Iraq. This is a cross-sectional study conducted through an online questionnaire.

Method: This is a cross-sectional study using an online form. The study collected data on the demographic of precipitants, the quantity and class of medication wastes, and the method of eliminating and discarding behaviors in Iraq.

Results: A total of 742 house reports were included. There were 22,072 waste items in total. Paracetamol was the highest medication wasted (10.7%) product. The overall number of expired medications was 5332, with anti-infectives accounting for the biggest share (10.4 %). The majority of the expired drugs (78.1 %) were discarded in the garbage, whereas (61.7 %) of non-expired wastes are retained for future use. Among the various potential factors evaluated as a source of waste and expired drugs, 21.9 % were attributed to patient improvement. Regarding the storage sites, the refrigerator was the primary location.

Conclusion: In conclusion, there is a large volume of domestic pharmaceutical waste which discarded in unplanned and harmful ways.

Household medicine wastes

Expired medicines

medicine storage

drug disposal

Medicines are manufactured and consumed in increasing amounts every year. (Global Overview: Drug Demand Drug Supply 2021) Certain people have a tendency to stockpile medications, and large quantities go unused or expire. The presence of expired medications in households has, in the last decades, received attention due to its impact on patients, the well-being of society, healthcare costs, and environmental safety in which unsafe storage of expired medications at home leads to increased risk of toxicity, suicide, and accidental childhood poisoning.(Jafarzadeh et al. 2021) Unfortunately, the vast majority of kids who are poisoned by medicines gain access to the medications at home.(Franklin and Rodgers 2008; Alruwaili et al. 2019; Santos et al. 2019) For instance, the “Food and Drug Administration” (FDA) has reported death cases, in children, as a result of accidental exposure to unused medicine.(FDA 2021) In Iraq, there is widespread self-medication; including the abuse of the recent generations of antibiotics as, most of the medicines, including the Prescription Only Medicines (POM), can be bought from the community pharmacies without a legitimate prescription.(Jassim 2010; Al-Zidan et al. 2020) Consequently, the consumption, storage, risk of exposure to expired medicines, accidental childhood poisoning, and the economic burden could be higher than in other parts of the world.

Medication quality and efficacy are affected by storage conditions so to ensure proper medications activity, they should be stored according to labeling.(Bajaj et al.) The extreme summer temperatures in Iraq significantly decrease the stability of many medicines maintained at room temperature without refrigeration.(Pau et al. 2005)

Another aspect of this dilemma is the disposal of unused or expired medications. Unfortunately, traces of pharmaceutical residues have consistently been detected in effluents from sewerage facilities, surface water, and drinking water.(Tixier et al. 2003; Kasprzyk-Hordern et al. 2008; Vulliet et al. 2011; López-Serna et al. 2013; Patrolecco et al. 2015) Inappropriate antibiotic disposal, could lead to the development of Multidrug-resistant microbial strains such as the dangerous Methicillin-Resistant Staphylococcus Aureus (MRSA).(Kumar et al. 2019) Moreover, numerous cases were documented regarding the negative impact of the inappropriate disposal of medicines on animals and wildlife. (Länge et al. 2001; Green et al. 2006; Parolini 2020) Therefore, legislation, in different countries around the globe, regarding the management of pharmaceutical waste has been endorsed to protect human health and the environment. (European Environment Agency 2010) For example, in Australia, Sweden, Austria, Serbia, and Lithuania unused medicines are returned to pharmacies. The returned medicines are then usually transported to specially designated incineration stations where they are subsequently burned at high temperatures and the emitted gas is purified before releasing into the air.(Persson et al. 2009; Kruopienė and Dvarionienė 2010; Bergen et al. 2015) Unfortunately, there is neither an adequate level of public awareness nor firm governmental measures to safely dispose of unused medicines in Iraq.

Aims And Objectives:

Explore the quantity and type of household medication wastes in addition to the storage and disposal behavior of medicines.

This is a cross-sectional study conducted between the 3rd of March – the 15th of June 2021 using an online questionnaire uploaded and distributed through social [Facebook and Telegram] to health care colleges students (Medicine, Dentistry, and Pharmacy) in Iraq to fill the survey on behalf of their families, relatives, and neighbors. Health care college students were targeted as they could recognize the medications and their classes. To encourage participants a lottery for three medical books was arranged. The questionnaire was adopted from different previous studies.(Abou-Auda 2003; Jassim 2010; Foroutan and Foroutan 2014; West et al. 2014; Mahara et al. 2021) Sample size was calculated through the Raosoft® sample size online calculator which was 385 for the Iraq population with a 95% confidence level. (Raosoft, Inc. 2022).

Following ethical approval from the scientific committee of the University of Al-Kafeel -College of Pharmacy, the validity of the study questionnaire was assessed via peer review of relevant experts. The feedback from experts and some students were used to develop the final version of the questionnaire.

The survey includes five sections, in the first section, the demographic data were collected (governorate, family size, number of children in the family, members aged ≥ 65 years old, presence of members with chronic disease, presence of health care providers among family members, the household head and his/her age, education level of the household head, and the estimated monthly income in USD). The second section collects the data regarding the number and class of medication wastes. The term medication waste was used to refer to any medication not in current use whether it was expired or not. Classes of medications were listed based on British National Formulary BNF-81. The third section investigated the elimination of waste medication and the method of discarding them. The fourth section investigated the potential causes of medication waste. Whereas the fifth section examined the storage places of the household medication and the accessibility of children to them.

Statistical analysis:

Invalid or duplicated data were excluded. The data were analyzed by Microsoft Excel 2019 and Statistical Package for the Social Sciences (SPSS) version 25. While For figures, GraphPad Prism version 8 was used. Descriptive statistics (means, standard deviation, median, frequencies, and percentages) for the survey items were performed Parametric (t-test, ANOVA) and non-parametric tests (Kruskal-Wallis H test or Mann-Whitney U test) done when applicable. The level of P < 0.05 was considered to be significant.

A total of 792 feedbacks were collected and after excluding the duplicated and invalid data, 742 house reports were included in the study. Characteristics of the participants showed in Table 1. Participants from Baghdad had the highest contribution with 30.2% followed by Nineveh with 21.7%. Nearly three-quarters of the houses were in the city centers. The average responders’ family size was found to be 6.5 ± 2.04. More than half of the houses report having a member suffer from a chronic disease. less than half of the participant houses report having a health care provider in their family. Father was head of the household in the majority of the houses with the average age of the head of household being 53.18 ± 9.35. The majority of them had a diploma or college degree. The income of the family was questioned and the highest income was $400-$700 (28.7%) followed by $ 700-$ 1000 (24.9%). Two third of the households reported having expired medicines in their houses.

Table 1

Characteristics of the participants
Characteristics		No. (n = 742)	Percentage
Governorate	Baghdad	224	30.2
	Nineveh	161	21.7
	Najaf	133	17.9
	Others	107	14.4
	Diyala	61	8.2
	Qadisiya	35	4.7
	Babylon	21	2.8
Living Site in the Governorate	Center	538	72.5
Living Site in the Governorate	Peripheral	204	27.5
Number of Family Members (Family size)	Mean, SD	6.50	2.04
Is any one of the family members have a chronic disease?	No	345	46.5
Is any one of the family members have a chronic disease?	Yes	397	53.5
Is anyone of the family members in the house, Health care provider?	No	421	56.7
	Yes	321	43.3
Who is the Head of the household	father	617	83.2
	mother	95	12.8
	others	30	4.0
Age of the Head of the household	Mean, SD	53.18	9.35
Education of the Head of the household	Diploma and College	469	63.2
	High school	169	22.7
	Primary school	79	10.6
	Illiterate	25	3.4
Estimated monthly Family Income (USD $)	less than 400	124	16.7
	400–700	213	28.7
	700–1000	185	24.9
	1000–1500	129	17.4
	More than 1500	91	12.3
Having Expired medications	No	246	33.2
Having Expired medications	Yes	496	66.8

There were 22,072 waste items in total. Across 742 houses, Paracetamol was the highest medication wasted at 10.7% (2351 products, mean 3.2 ± 2.5) followed by skin medications at 10.6% (2341 products, mean 3.2 ± 2.6). Nervous system medication showed to be the lowest waste medication at 3.3% (738 products 1 ± 1.7). Nervous system medications had the highest percent of expired medication among the discovered wastes (40%) with a mean of 0.4 ± 1.4 followed by endocrine medicines (32%) with a mean of 0.3 ± 1.2. The total number of expired medications was 5332. The lowest percentage of expired medication class was for the endocrine medications (4.6%), and the highest percentage was for anti-infectives (10.4%); as shown in Table 2 and Fig. 1.

Table 2

The number of total medications and the expired ones.
Class of medication	Expired wastes				Non expired wastes				total wastes
Class of medication	n	% Column	% row	median	n	% Column	% row	median	n	% column	Median
Nervous system	292	5.48	39.57	0	446	2.66	60.43	0	738	3.34	0
Endocrine	245	4.59	32.36	0	512	3.06	67.64	0	757	3.43	0
Genito-urinary	274	5.14	31.46	0	597	3.57	68.54	0	871	3.95	0
Herbal	260	4.88	24.19	0	815	4.87	75.81	0	1075	4.87	1
Ear, Nose, Oropharynx	380	7.13	29.87	0	892	5.33	70.13	1	1272	5.76	1
Cardiovascular	282	5.29	22.03	0	998	5.96	77.97	2	1280	5.80	1
Eye medications	407	7.63	31.31	0	893	5.33	68.69	1	1300	5.89	1
Musculoskeletal & NSAIDs	451	8.46	24.03	2	1426	8.52	75.97	2	1877	8.50	2
Gastro-intestinal	422	7.91	22.38	0	1464	8.75	77.62	2	1886	8.54	2
Anti-infective	553	10.37	27.66	0	1446	8.64	72.34	2	1999	9.06	2
Respiratory	467	8.76	23.35	0	1533	9.16	76.65	2	2000	9.06	2
Vitamins and nutrition	368	6.90	15.83	0	1957	11.69	84.17	2	2325	10.53	3
Skin medications	504	9.45	21.53	0	1837	10.97	78.47	2	2341	10.61	3
Paracetamol	427	8.01	18.16	0	1924	11.49	81.84	2	2351	10.65	2
Total	5332	100%			16740				22072	100%
* NSAID: nonsteroid anti-inflammatory drugs

The survey was also investigating the disposal behaviors of waste medications, as shown in Fig. 2. The majority of the expired medications were thrown into the trash bin (78.1%), followed by (9% of) those who reported keeping the medications, and only 4.9% reported taking those medications to the pharmacy. On the other hand, regarding non-expired wastes, 61.7% keep the medication for future use, and 17.4% will pass them to other family members or a friend. Only 4.9% reported taking back the medication to the pharmacy. Finally, more than half were discarding the medications as they are in the original pack (53.6%).

Among different potential causes investigated to be sources of the waste and expire medication, 21.9% were due to improvement of the patients followed by keeping the medicines for future use 19.4%. Whereas, 11.3% reported that their physician changed the prescription, and 8.4% was due to a high number of medicines prescribed and supplied by the pharmacist. Furthermore, 9.9% forgot to use the medicines, and 11% stopped using the medicines because no improvement was seen. Likewise, 5.3% stopped using the medicine because of adverse events occurrence. Finally, inconvenient routes of administration, mortality, high medicine cost, and lost confidence in medicine, were the potential causes (1.3%,1.8%,1.8%, and 2.3%), respectively. As shown in Fig. 3.

Concerning the storage of medications in the houses, as demonstrated in Fig. 4, the refrigerator was the main storing site for liquids (60.6%), injections (55.5%), and topically used medicines (43.9%). Whereas, the solid dosage forms are stored mostly in the home pharmacy (39%) and refrigerator (26%). The bathroom was the last place to store medications, as clarified in Fig. 3.

Lastly, concerning the accessibility of medicines by children, as well as the possibility of overdose and toxicity, 40.4% and 25.6% of respondents stated that the medications are kept and stored in locations that are difficult and very difficult for children to reach, respectively. Medications were easily accessible for the children, according to 9.6% of respondents. As shown in Fig. 5.

Increasing consumption, storage, and inappropriate disposal of unused and /or expired household medicines are leading to public substantial health and environmental problems. Interestingly this problem can be reduced by implementing medicine disposal guidelines and policy as well as improving awareness of the public on appropriate medicine disposal methods and practices.(Haughey et al. 2019)

In the current study, about 66.8% of the respondents have unused or expired medication (Table.1). This is not per other studies conducted in Pakistan (35.3%) (Shamim 2018) and Ethiopia (29%) (Wondimu et al. 2015) which could be due to the differences in medicine or information access across these studies. (Gidey et al. 2020) Successive changes in the prescription and/or dispensing errors of medications result in the accumulation and the subsequent expiration of drugs in the households.(Insani et al. 2020)

Interestingly, most of the unused medicines were those used for treating nervous system diseases followed by medications used with endocrine disorders. Surprisingly, paracetamol and anti-infective medications represented the smallest proportion of the unused medications (Fig. 1). This differs from the findings of Quadra et al. who stated that most of the disposable drugs were analgesics followed by vitamins, anti-allergic and anti-inflammatory drugs,(Quadra et al. 2019) and Abahussain et al., (Abahussain and Ball 2007) that cough and cold medication were the major disposal drugs.

Most of the household drugs (expired drugs) were eliminated in the garbage (78.1%) followed by keeping them (9%), sewer (7.7%), or tacking back to Pharmacy (4.9%). Whereas most of the household drugs (non-expired drugs) were kept to be used in the future (61.7%), or to be given to others (family members, friends) (17.4%), or returning them to the pharmacy (4.9%) (Fig. 2). The disposable behavior of expired drugs is in agreement with Alnahas et al.,(Alnahas et al. 2020) who stated that most of the disposable drugs were thrown in the garbage, followed by flushing in the toilet. Throwing drugs in the garbage may affect the environment because these pharmaceuticals may contain estrogen, antibiotics, antineoplastic and immunosuppressant agents that may generate toxic byproducts and cause mutagenic, teratogenic, and carcinogenic effects in animal and human populations.(Constantino et al. 2020) The disposal behavior of non-expired drugs is in accordance with Dias-Ferreira et al.,(Dias-Ferreira et al. 2016) Braund et al.,(Braund et al. 2009) and Persson et al., (Persson et al. 2009) who found that most expired drugs have been returned to healthcare facilities or pharmacies because of economic costs and avoid waste of money. This may belong to the nature of Iraqi culture and their living style which favors being social and donating different things to each other and lack of awareness on how to deal with disposable drugs. Unfortunately, giving drugs to siblings or friends may increase the risk of developing a negative impact on health and wellbeing. For instance, there is an increase in developing antimicrobial resistance with the inappropriate use of antibiotics.(Bergen et al. 2015; Al-Zidan et al. 2019; Nepal et al. 2020)

The current study showed that patient improvement, polypharmacy, or frequent changes in the treatment regimen are the major factors of drug accumulation (Fig. 3), which is in accordance with the studies of Kristina et al.,(Kristina 2018)] Kahsay et al.,(Kahsay et al. 2020) and Marwa et al.(Marwa et al. 2021). Regarding the storage, the majority of the respondents asserted that household medications are stored in the refrigerator followed by the home pharmacy, kitchen, and bathroom for different dosage forms: liquid, injections, topical, and solid (Fig. 4). This is in accordance with Gracia-Vásquez et al., that the solid dosage form is the major pharmaceutical dosage form of the unused storage drugs in Mexican.(Gracia-Vásquez et al. 2015)

The majority of the participants in this study said they were aware of the dangers of the accessibility of medications to children (Fig. 5) which is in accordance with the findings of Yanovitzky et al.(Yanovitzky 2016) Keeping the medications in the upper and closed containers is an essential step to prevent accidental poisoning by young children and inappropriate self-medication drug practice.

All in all, taking the medications as per the prescriber’s instructions and handing in unused and expired medications to designated collection points such as pharmacies, clinics, and hospitals.(Abou-Auda 2003; Makki et al. 2019) Also, people should be aware of disposable unused or expired household medications. Likewise, the Iraqi ministry of health and environment should start an initiative with a clear protocol for retrieving expired and/or unused medicines from the people. The authors suggest a collaboration between the private pharmacies as collection posts, which are widely distributed all over the country, and the Iraqi ministry of health and environment will collect and dispose of these medicines most properly.

The present study has a minor limitation regarding the diversity of the included subjects. Therefore, it is recommended that future studies include participants with more diverse backgrounds to get a more comprehensive overview of household medications across the nation in addition to an onsite survey. Survey through house visits by the researchers were difficult to apply and inconvenient due to the COVID-19 pandemic situation.

There is a massive amount of household medication waste of which the majority were paracetamol, with nervous system medications accounting for the biggest percentage of expired medications. The vast majority of people discard the waste medicines in their original packaging in the garbage. The improvement of the patient and keeping them for future use is regarded as the most important of the several waste reasons. In general, the refrigerator is the most popular area for medicines to be kept and there is a potential for children to reach. There is a large volume of domestic pharmaceutical waste, and in the absence of a dedicated program, significant expenditures are paid, in addition to environmental and patient harm.

On behalf of all authors, the corresponding author states that there is no conflict of interest.

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No competing interests reported.

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Exploring Household medicine waste in Iraq

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