One of the most frequently asked questions by hospice staff and families is what to do with unwanted medications – especially opioids and other controlled substances. The national opioid epidemic only increases the urgency around this question.
Here are the facts fueling this national crisis:
- 2015 National Survey on Drug Use and Health estimated that 3.8 million Americans used opioids for non-medical reasons every month
- In 2016, 46 Americans died every day of a prescription opioid-related overdose
- 64,000 people died of drug overdoses in 2016, an increase of > 22% compared to 2015
- Overdose is the leading cause of deaths for Americans under age 50
This Reference Toolkit helps to clarify the role of home hospice providers in disposing of controlled substances in accordance with federal, state and hospice regulations. It serves as a timely resource for keeping current with requirements related to medication destruction and disposal in hospice and describes ways to properly dispose of medications in hospice home care.
Evolving Federal Regulations
The Secure and Responsible Drug Disposal Act of 2010 (“Disposal Act”), released as an amendment to the Controlled Substances Act (CSA), allows “ultimate users” (i.e., patients or their family members) to deliver unused controlled substances to “appropriate entities” for disposal. It expanded the options to dispose of lawfully prescribed, unused controlled substances through collection receptacles, mail-back packages, and take back events. Importantly, while the DEA encourages hospice staff to assist families in destroying unused medications, this act forbids hospices from taking possession of medications for destruction unless authorized by state law.
In 2018, Congress passed H.R. 6, The Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act. This comprehensive bill includes the Safe Disposal of Unused Medication Act, which authorizes hospice professionals to safely dispose of unused drugs at the time of death. Although it was signed into law by President Trump on October 24, 2018, there is no effective date on this part of the legislation. The law also states the Attorney General may provide guidance on this provision.
Since this statute makes a change to DEA regulations authorized under the Disposal Act, one would expect guidance on how to operationalize this change will come from the DEA. As a result, the authorization of all hospices across the nation to destroy medications at the time of death is not yet in effect.
As previously noted, the Disposal Act prohibits hospice staff from taking possession of medications from patients for disposal unless authorized by state law. In response, many states, including Florida, Kentucky, Louisiana, Maryland, New Jersey, Ohio, Pennsylvania, South Carolina and Virginia have passed laws granting this authorization.
To prevent potential abuse of prescription medications, the Medicare Conditions of Participation (CoPs) require hospices to have:
- Written policies and procedures for managing and disposing of controlled drugs in patient’s home and discussed with patient and family when controlled substance drugs are first ordered
- Documentation in the clinical record that these policies and procedures were provided and discussed
Hospice Medical Disposal Policy
A hospice medication disposal policy should include these components:
Educate patient, family and staff and have policy in place that describes what staff can do in the case of a patient’s caregiver refusal to destroy/dispose of medication.
Dependent on the hospice’s policy and state law, the nurse may assist the family with the collection and disposal of any unused medications. The nurse can provide kitty litter or other substances for the family to use to safely dispose of medication or provide containers for collection centers or utilize other medication destruction products (see below).
Dispose in a manner that does not allow the drug to be unintentionally ingested or easily retrieved. This can include deactivation products, mail-back or take-back programs, or collection receptacles. The family should be the one to dispose of the medication unless state regulations allows the nurse to dispose of meds.
Procedures for documentation should follow state guidelines. When applicable, complete a form that lists medication name, strength and quantity, and provide a copy to the patient’s caregiver. Store drug disposal documentation in the patient’s medical record.
Options for Proper Disposal of Medications
Always follow specific instructions (e.g., fentanyl transdermal patch) and remove drugs from their original containers. Mix/dilute drugs with undesirable but non-toxic substances. Some suggestions include mixing unused medications with coffee grounds or kitty litter and other forms of non-toxic dilution prior to disposal. Seal the drugs in a plastic bag or container, place inside a non-transparent bag or container and place in the garbage. Flush drugs only in certain instances.
Other options include:
Medication Deactivation Products, that render medications unusable:
- Drug Buster
- Element MDS
- Rx Destroyer
Medication Take-Back Programs, where drugs received are incinerated:
- DEA National Take Back days (April and October)
- Police stations
For additional information on these products and programs, we recommend visiting these sites:
Medication Mail-Back Programs
These voluntary programs, conducted by authorized collectors, use packages made available at pharmacies and senior centers. Collectors must be capable of destroying the medications on site or have a relationship with a reverse distributor who has onsite destruction ability.
Safety First and Always
The proper and safe disposal of drugs has always been important but given the nation’s opioid crisis it has become more critical than ever for hospices to follow best practices to prevent drugs from getting into the hands of people who shouldn’t have them and to protect our environment.
For more information and additional resources on medication destruction, contact your Enclara Pharmacia Account Manager.