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Pill puzzle: flush or crush?

By Christine Jordan Sexton
3/20/2009 © Florida Health News

A curious ritual occurs once a month at Palm Gardens nursing home in Tampa. 

Administrator Scott Allen, a pharmacist and the supervisor of nursing sort through drawers where painkillers, anti-depressants and other drugs are stored when patients die or leave. Usually they come up with about $5,000 worth.

It takes them about three hours to find all the leftover drugs, remove them from the packaging and fill out the paperwork. Then they dispose of them down the toilet.

“All three of us witness the flush,” Allen said.

For years, nursing homes around the state have done the same thing. Now two state agencies are pushing “Trash Don’t Flush” to keep drugs from contaminating the water supply and yet make them unavailable to addicts and dealers.

The departments of Health and Environmental Protection propose crushing the pills, mixing them with wet kitty litter, and taking them to the dump.

That idea is meeting mixed reviews. One clinical chief at a nursing home chain called it “ridiculous.”

Unlike hospitals and pharmacy chains, nursing homes don’t stock controlled substances. Instead, drugs are packaged at a pharmacy and sent to the nursing home specifically for each patient. So when the patient goes, so must the drugs.

The Board of Pharmacy rule requires only that the nursing home destroy the drugs, fill out the proper paperwork and have it witnessed and signed by the pharmacist, director of nursing, and nursing home administrator. The board doesn’t say how the drug should be destroyed.

Nursing homes are inspected by the Agency for Health Care Administration at least every 15 months to ensure they are meeting minimum requirements for patient care and safety. AHCA checks paperwork but doesn’t care how the drugs were destroyed, administrators say.

DEP and DOH launched the “Trash Don’t Flush” campaign a year ago. Wastewater filtration systems aren’t designed to deal with medications, they say, so worrisome amounts of the drugs are showing up in drinking water and harming aquatic organisms.

The campaign suggests grinding up pills and mixing the powder with wet kitty litter or some other inedible substance. The drug slurry should be placed in a plastic-lined container that can be sealed, such as a coffee or paint can. DEP wants the cans tossed in the garbage where they will end up in a landfill.

DEP has no authority over nursing homes, so the kitty litter mix is optional. Nonetheless the idea is gaining momentum and worrying nursing homes, said Florida Health Care Association lobbyist Peggy Rigsby.

The DEP/DOH process is too “labor-intensive” and would take six hours, protests Palm Gardens’ Allen. “Every pill has to be popped out of packing and then ground up somehow,” he said. The coating that makes tablets easier to swallow makes them difficult to crush, he said.

“The drugs still end up in landfills (and) eventually leech out into the water system,” he said.

Next month, his nursing home will participate in Operation Medicine Cabinet, sponsored by the Hillsborough County sheriff’s department. Deputies will transport the drugs to a hospital for incineration – an alternative method of destruction that makes more sense to Allen.

Another skeptic is Patches Bryan, chief clinical officer for Greystone HCM, which owns 29 long-term-care and assisted-living facilities, mostly in Florida. She allows her nursing homes to destroy the pills with whichever method they prefer.

Until and unless AHCA or the Board of Pharmacy requires the kitty litter alternative, she said, she won’t require it. She said, “I thought it was ridiculous, personally, but that was me.” 

--Contact Christine Jordan Sexton