The drug take-back program (DTP), despite being eco-friendly strategy to manage the UUE medications, is underutilized in many countries . The study aimed to evaluate the willingness of the community people, residing at different locations of five districts of Nepal, towards the safe disposal of the UUE medicines to track the feasibility of the implementation of take-back program in their communities. 400 participants responded to the study, most of whom were youth (30.3%) from the age group 16-25. Previously, Owens et al. reported that habit of throwing medications in household garbage was decreased with the increasing age . Males were more inclined to dispose UUE medicines in the present research, which was contrast to that reported by Owens et al., who reported that more females flushed UUE medications down the toilet or sink . Whatever be the gender, there is rising tendency of disposal of pharmaceuticals in garbage and sewer is in many countries .
The present research revealed that community people were discarding their UUE medicines with the household rubbish (78.5%), down the sink (12%), return to pharmacy (3.5%), down the toilet (2.5%), giving others (2.3%). Similarly, 10% respondents flushed expired medicines down the toilet or sink in Afghanistan, Kuwait, Kenya, Ethiopia, UK and USA [7-11]. More than two-third respondents threw the UUE medicines in garbage (37.5%) and dumping site (33%). Abruquah et al. also found that 29% residents of Konongo-Odumasi in the Ashanti region of Ghana also threw such medicines into waste bin. Also, 38% buried in the ground, 4% flushed them down the toilet or sink and 21% had the intentions to transfer them to their relatives and friends . El-Hamamsy found that 97% people out of 316 in 20 community pharmacies in Cairo, Egypt had some pharmaceuticals in their houses, 22.78% kept them till expiration date, 11.39% did not dispose them, 26.27% discarded them in household waste, 12% returned the UUE medications to the pharmacy and 11.39% flushed them in the toilet. The researcher suggested that community pharmacies have provision of adequate experts and storage area to collect and store unused medicines .
There was lack of dissemination of sufficient information regarding proper disposal techniques from the healthcare professionals to the community people. This was in line with the findings of Tong et al. who reported that community people had lack of knowledge and awareness regarding proper disposal of unused medicines and adverse effects of improper disposal method to the environment (Tong et al., 2011).Unsafe drug storage and disposal habits may pose the community people at risk of accidental poisoning, drug abuse, financial burden, improper recommendation and donation to neighbors, as well as environmental impact causing soil, water pollution affecting aquatic animals [5, 8, 11, 12, 27]. Renal failure may occur among vultures following the ingestion of carcass from cattle treated with diclofenac. Similarly, antibiotics in water may lead to antibiotic resistance, genetic alterations in humans and marine life on long-term basis [7, 9]. Kinobe et al. reported that more than one-fourth of the respondents preferred mass media as the best source of improving awareness about disposal technique and implementing medicine take-back concept at Rawang, Malaysia .
A survey conducted in Ghana showed that 21% respondents passed the unwanted and unused medications to their close relatives and friends for future use thinking that they might be of use to them . Results from the present study also revealed that 9.8% respondents passed the UUE medicines to their relatives and friends. Such results might be due to the lack of information regarding the negative impact of these to their health.
Results from this study revealed that 97.8% people were interested to support the medicine take-back programs, if implemented in their community. Lystlund et al. conducted a research at University of Oklahoma Family Medicine Department and found that 61% of patients reported interests on drug take-back programs. They found that the common UUE medicines handling activities were disposing in garbage (53.2%) or sewer (29%) and home storage (17.7%). They concluded that the program would be more successful, if offered to the patients free of cost . Previously, local residents were allowed to drop off UUE medicines free of cost in the Unwanted Medications Take Back Program initiated by Clark County (Washington) in 2003, provided that the medicine was not a controlled drug, was in the original and sealed container without breakage and leakage. This program was supported by 70 local pharmacies to safely dispose of unwanted or expired medicines and provided service daily and could collect 23 pounds of controlled drugs till 2006 .
Provision of adequate collection bags was perceived by the community people to be one of the major initiatives for the successful implementation of the take-back programs [3, 17, 29]. In Saudi Arabia, Ministry of Health issued an act in 1999 and the Gulf Countries Council (GCC) in 2001 regulated the management of the medical waste including unwanted pharmaceuticals. However, these acts could not optimize the proper disposal of leftover and expired medications due to the absence of medicine take-back programs. Therefore, urgency in improving general public knowledge and practice toward discarding medicine and assessing the level of awareness about the environmental risk through inappropriate medicine disposal was realized .
Feasibility of implementation
Extended Producer Responsibility campaign was proposed in Sweden in 1990 to make the pharmaceutical manufacturers responsible for the safe disposal of the environmentally harmful products. However, manufacturers were continually demanding that whole supply chain be tracked to trap the safe disposal. Later on, the US Supreme Court also mandated the industry-funded take-back programs for pharmaceuticals in the USA. However, the take-back programs got materialized into real practice only since 2016, although some efforts were already underway . The present research found that the community people were interested to support the medicine take-back concept, if implemented in their community. However, main constraint was the budget and there was no data related to cost (both direct and indirect) of waste disposal via different technique based on the nature of the UUE medicines. Relying on the World Bank data, estimated cost of solid waste management was USD 1.5 billion in 2010 and would be increased to USD 7.7 billion in 2025. The estimated cost for collection and disposal with waste generation rate of 0.22 ton per year and collection efficiency of 43% was 20-50 USD per ton, 10-30 USD per ton for sanitary landfill, 2-8 USD per ton for open dumping and 5-30 USD per ton for composting in low income countries . Previously, the city of Chicago had started its take-back program in 2003 on annual one-day collection basis at 25 locations and collected 7,000 pounds of waste medicines till the end of 2009. The program was financed with USD 50,000 by the state . Unfortunately, neither the Federal Government nor the Provincial Governments in Nepal have yet allocated budget for the implementation of the medicine take-back in Nepal. These all showed that the take-back concept could be initiated and implemented on the funding of the government or other external sources or from fund-raising from within the community members.
Economic implications and sustainability of implementation of take-back concept:
Viability of medicine take-back concept are far more compromised due to the rising cost of the returned medicines along with their procedural or administrative, and inventory holding costs, as well as due to the rising cost incurred in their safe disposal. Introducing of new concept including take-back or brown bag system itself demands some investment, and more than this, its sustainable operation demands a lot dedication, commitment from the concerned health care providers and policy makers. Bearing sustainability is mind, New Zealand introduced the copayment mechanism whereby each patient pays NZD $0 or $3 per item returned depending on his/her socioeconomic and health status, and number of items collected annually .