Publication Number S QG-RR-6(11/02) rev. 4/03 April 2003



# Final Report



# Pharmaceutical Waste Survey

Debra Oliver Local Hazardous Waste Management Program in King County Interagency Resource for Achieving Cooperation Pharmaceutical Workgroup



## Alice I. Chapman, P.E. Local Hazardous Waste Management Program in King County Interagency Resource for Achieving Cooperation Pharmaceutical Workgroup

## This report was prepared by the Local H azardous Waste Management Program in King County, Washington. The program seeks to reduce hazardous waste from households and small quantity generator businesses in King County by providing information and technical assistance to protect human health and the environment.

For more information or to order addi tional copies of th is report contact:

130 Nickerson Street, Suite 100 Seattle, WA 98109 206-263-3050 TTY Relay: 711
Fax 206-263-3070 www.govlink.org/hazwaste/

Publication Number SQG-RR-6(11/02) rev. 4/03



### Oliver, Debra and Chapman, Alice. Pharmaceutical Waste Survey, Final Report. Seattle, WA: Local Hazardous Waste Management Program in King County, 2003.



# Alternate Formats Available

Voice: 206-263-3050 or TTY Relay: 711

PharmaceuticalWasteSurvey.doc Prin ted on Recycled PaperKing County – Pharmaceutical Waste Survey i 

# CONTENTS

Acknowledgements ............................................................................................................... ...............................................1

Introduction and Objectives .................................................................................................... ............................................2

Survey Objectives.............................................................................................................. .............................................2 Survey Data Limitations........................................................................................................ ..........................................3

Methodology.................................................................................................................... ......................................................4

Findings....................................................................................................................... ..........................................................5

Who was Surveyed?.............................................................................................................. .........................................5 Nature of the Waste and Quantity Information ................................................................................... ............................7

Quantity Data by Wastestream................................................................................................... ............................7

Physical State................................................................................................................. ......................................10

Active Ingredient Data ......................................................................................................... .................................13 Current Management Practices................................................................................................... .................................14

Process Flow Diagrams.......................................................................................................... ..............................14

Disposal of Drug Wastes ........................................................................................................ ..............................14

Qualitative Data on Disposal Methods ........................................................................................... ......................15

Confusing Concepts: Hazardous, Biohaz ardous and Reverse Distributors .........................................................15 Awareness of Federal Hazardous Waste Regulations ............................................................................... ..................16 Preferred Waste Management Options ............................................................................................. ...........................17
Other General Considerations................................................................................................... ...................................18

Summary and Conclusions........................................................................................................ ........................................19

Appendix A Survey Form........................................................................................................ ..........................................23

Appendix B Survey Protocol .................................................................................................... ........................................29

Project........................................................................................................................ ...................................................31 Background..................................................................................................................... ..............................................31 For your information only...................................................................................................... ........................................31 Suggestion for an Opening ...................................................................................................... .....................................32 Differences between medical industry and other industries we have visited:..................................................... ..........32 Vocabulary/Jargon.............................................................................................................. ..........................................32 Survey form info............................................................................................................... .............................................33 Special Information in Doctor s’ Offices Regarding Samples: ..................................................................... ..................34

Appendix C Survey Plan and Considerations..................................................................................... ............................35

Appendix D Process Flow Diagrams by Business Type............................................................................. ...................39

Appendix E Waste Quantity Data by Business Type ............................................................................... ......................51

Appendix F Where are Drug Wastes Disposed? .................................................................................... ........................67

Bibliography................................................................................................................... .....................................................89ii King County – Pharma ceutical Waste Survey 

# Tables

Table 1. Total Surveys Completed .............................................................................................. .5 Table 2. Incomplete Surveys from Randomly Generated List .....................................................5 Table 3. Completed Surv eys, by Business Type ..........................................................................6

Table 4. Waste Ca tegory Descriptions .........................................................................................7 Table 5. Annual Quantity Generated by Business Type...............................................................8 Table 6. Waste Categor ies by Business Type...............................................................................9 Table 7. Physical State of Single-Phased Waste Streams...........................................................10 Table 8. Waste Categories and Quantity Generated...................................................................11 Table 9. Disposition of Wastes by Category and Quantities Disposed ......................................12 Table 10. Drug Active Ingredient Data ........................................................................................13 Table 11. Disposition of Wastes a nd Quantities Disposed Per Year............................................14 Table 12. Knowledge of RCRA Regulations ...............................................................................16

Table 13. Maintain Records on Waste Pharmaceuticals ..............................................................17 Table 14. Drug Waste Disposal Options That Would Work Best for Facility .............................18 Table 15. Extrapolation of Waste Generated Statewide...............................................................20 Table 16. Patient Contact per Day per Business Type .................................................................21 Table 17. Average Quantity of Waste per Business.....................................................................22King County - Pharmaceutical Waste Survey 1 

# ACKNOWLEDGEMENTS

The information offered in this report is due to the combined efforts of many people. Thanks to the following for developing the st udy, questionnaire, data analysis and report: Alice Chapman, Technical Assistance Polluti on Prevention team, Local Hazardous Waste Management Program in King County; Cheri Grasso, On-Site Consultation team, Local Hazardous Waste Management Program in King County; Stan Jeppesen,Washington Department of Health Board of Pharmacy ; and Debra Oliver, Interagency Regulatory Analysis Committee. Thanks also to Bill Rowe and Doug Gallucci, University of Washington data gatherers; Tom Georgianna , statistician, King County Environmental Lab; Brian Westra, librarian, Local Hazar dous Waste Management Program in King County; Sue Hamilton, Lisa Niehaus, Ann P eacock and Emmanuel Rivera, field staff; and Gail Savina, editor, Local Hazardous Wa ste Management Program in King County.

The Interagency Regulatory Analysis Committee, or IRAC, was formed to address issues of regulatory conflict and to improve coordi nation between regulatory agencies. It is a

forum where the mutual concerns of different agencies or jurisdicti ons can be addressed.

IRAC’s mission is “ to create a more effective and ef ficient means of protecting public health and safety through coor dination of regulatory agencies .” To learn more about IRAC or become a member, write us at 130 Nickerson St, #100, Seattle, WA 98109, call us at (206) 263-3087, or visit our website at http://www.govlink.org/irac/



## .
IRAC Pharmaceutical Workgroup members in clude representatives of the Local Hazardous Waste Management Program in King County, King County Industrial Waste, Public Health – Seattle & King County, Spokane Regional Solid Waste System, Washington Board of Pharm acy, Washington Department of Ecology, Washington State Pharmacists Association, Washington State Un iversity, United States Drug Enforcement Administration, University of Washington, United States Environmental Protection Agency, and the following private and not-for-p rofit organizations: Alan B. Jones, PhD., Full Circle Environmental; In terpretive Consultations, Inc., PharmEcology Inc.; and P.S. Industries, Inc.

Special thanks to the Washington Board of Ph armacy for their support in this research.

And finally, thanks to the medi cal care facilities and docto r’s offices that assisted by providing data.2 King County - Pharmaceutical Waste Survey 

# INTRODUCTION AND OBJECTIVES

The IRAC Pharmaceutical Workgroup was esta blished at the request of the Medical Industry Roundtable 1 

## (MIRT) to examine existing regulations affecting the management of drug wastes. While several proposals were made to improve drug waste management practices and associated regula tions, discussions were hamper ed by a lack of data about drug waste generation, current management practices and input from the regulated community about feasible options. A literature review [Chapman] located limited data on these issues, and the workgroup completed th e following survey to address remaining data gaps.



# Survey Objectives

1. Gather local (King County) da ta that can be extrapolat ed to Washington State drug
waste generators.

2. Gather data from a variety of potential drug waste generators.

3. Characterize potentially hazardous drug wa stes according to the following:

• types of wastes and potentially useful descriptive categories

• physical state (solid, liquid, etc.)

• quantities generated and how often, and

• progress of drug through the f acility (from product to wa ste, using a process flow diagram).

4. Gather data on current drug waste mana gement practices, including disposition, collection containers, reco rdkeeping, and commercial disposal services.

5. Measure awareness of the federal Re source Conservation Recovery Act.

6. Gather data on generators’ pref erred waste management options.

1 

### See the MIRT web site http://dnr.metrokc.gov/swd/bizprog/waste_pre/medical.htm for more information

about this roundtable.King County - Pharmaceutical Waste Survey 3 

# Survey Data Limitations

The survey was developed and conducted with in a short timeframe (about one month) to meet a public comment period deadline. For this reason, schedule demands and survey completion were a higher priority in study desi gn than statistically-b ased representative sampling, and survey results should be view ed as descriptive da ta about drug waste management by respondents rather than data that can be generalized beyond those surveyed.

In survey development, we expected that surveyors would talk w ith nurses in hospital units, where we believed that most drug wa ste was generated. Because nursing staff are so short-handed and busy taking care of patients, interruptions by surveyors were typically not possible. Instea d, we surveyed those people who had some time to spend answering questions, from office managers to doctors. Gathering data about drug waste quantity was the priority, and other questions were asked if time permitted. For this reason most surveys are incomplete.

The records kept by most facilities do not allow for ready comparison to Washington’s Dangerous Waste Regulations (Chapter 173-303). Thus, much of the quantity data on drug wastes were estimates from those persons generating the wastes, ra ther than facility data. Larger generators, such as some hos pitals, maintained drug waste records on a pharmaceutical computer system called Pyxis. Th is system provides the quantity of active ingredient, but not the total weight of the drug, including inert ingr edients and packaging.4 King County - Pharmaceutical Waste Survey 

# METHODOLOGY

A survey form was developed, field tested at two sites and revised to meet study objectives (see Appendix A). Su rvey protocols (see Appendix B) were written and staff were trained on study objectives and protocols. Those data collected by the Board of Pharmacy were summarized in a spreadsheet ra ther than on the survey form because they focused primarily on drug waste quantities.

Using North American Industry Classificati on System (NAICS) codes [United States], potential drug waste generators were iden tified. Because the commercial business list source [info USA] uses the Standard Industr ial Classification (SIC ) code system, the NAICS codes were converted to SIC codes [http://www.census.gov/epcd/ naics/NAICS63.htm]. The infoUSA, Board of Pharmacy data [Morrison], and Department of Social and Health Services (DSH S) license data were used to find the total number of businesses in King County and in Washington State within each classification.

To determine the number of surveys needed in each classification, weightings were assigned to the classifications based on expected relative amounts of waste generated (compared to the other classifications), relati ve variability within the classification, and time constraints of the project. Appendix C provides the list of NAICS codes, number of each to survey, and other survey planning considerations.

After all surveys were completed, the classifications were modified to better reflect the primary function of the sites within the cl assification. For example, the classification “specialty outpatient clinic with doctors’ o ffices” was changed to “specialty outpatient” to more accurately describe th e activities at the site.

Eighty-nine businesses were ra ndomly selected from InfoUS A lists and Department of

Social and Health Services license information. Research Randomizer (see http://www.randomizer.org/ ), an on-line calculator, was used to generate the random

numbers. An additional 25 businesses were se lected by the Board of Pharmacy. These 25 were surveyed for quantity data only.

In-person surveys were conducted at some bus inesses, especially major medical centers. Most surveys were conducte d via telephone. Surveys took fro m 5-10 minutes up to half an hour to complete. Survey data were entered into a Microsoft Access database for analysis.King County - Pharmaceutical Waste Survey 5 

# FINDINGS

Who was Surveyed?

Tables 1, 2 and 3 below provide summary information about the surveys conducted.

Table 1. Total Surveys Completed

Source of respondents Number
Attempted Number Completed 2

Field tests 2 2

Randomly generated list 90 36

Selected by Board of Pharmacy 25 22 3

Total 117 60



### Table 2. Incomplete Surveys from Randomly Generated List

Reason Incomplete Number

Call not returned 16

Incorrectly classified as non-hospital site. When found to be a hospital, site dropped (a sufficient number of hospitals had already been surveyed) 10

Share practice with previously surveyed site 9

Failed to contact site 7

No longer in business or phone disconnected 6

Refused interview 5

Outside King County 1

Total 54

2 

### Number completed includes partially complete surveys.
3 

### One pharmacy surveyed collected drug wastes from 54 locations statewide.6 King County - Pharmaceutical Waste Survey 

### Table 3. Completed Surveys, by Business Type

SIC Code 4 Business Type Comments Surveyed Est. # in

WA

8011 doctors office included general practitioners, pediatrics, family practice, psychiatry 16 10,000

8093 specialty outpatient included occupational health, drug & alcohol center, women’s clinic, cosmetic & plastic surgery, urology, c ancer, oral surgery, cardiology 12 see 8011 5

0742 veterinary all were small animal vet clinics, 4 of 7 were the largest clinics in Washington 7 1361 6

8062A ambulatory/surgical

center excluded hospitals 6 50

8062 hospital excluded ambulatory/surgical centers 5 110

5912 pharmacy - retail one pharmacy surveyed collected drug

wastes from 54 locations statewide 5 1068

8051 nursing/boarding home 4 900

8043 podiatrist 2 see 8011

RD reverse distributor manages legend drugs and DEA controlled

substances 1 1

8092 dialysis center 1 see 8011

8721 other accounting billing center for diagnostic imaging 1 NA

Total 60

4 

### SIC Codes were modified slightly to meet study needs (see comments).

5 

### Per Morrison, there are 10,000 practitioner offices/c linics in Washington, assumed to include doctors office, specialty outpatient, podiatrist and dialysis center.
6 

### Per infoUSA there are 1361 small animal veterinary clinics in Washington.King County - Pharmaceutical Waste Survey 7 

# Nature of the Waste a nd Quantity Information

Quantity Data by Wastestream



## Waste stream names (as reported by survey resp ondents) were review ed and standardized into fourteen waste categories. The categories and types of wastes included in each waste category are described in Table 4 below.

Table 4. Waste Category Descriptions

Waste Category Category Includes:

chemotherapy debris/liquid IV bags, tubing, gloves, gowns and other debris with some chemotherapy drug residuals remaining; AND vials of expired or partially used chemotherapy drug concentrate

chemotherapy IV liquid unused IV preparations (chemother apy drug concentrate mixed with other fluids for IV administration); AND vials of expired or partially used chemotherapy drug concentrate

cough syrup unusable cough syrup, expired cough syrup samples

debris IV bags, tubing, gloves, gowns, plastic and other debris not associated with chemotherapy.

disinfectant absorbed onto wipes, gauze, or surgical scrubs

empty syringe used syringes with no residual liquids (excludes partial injections)

inhaler expired or unusable inhalers

injectable liquids DEA controlled substances, Ketamine/valium 99+%, fentanyl, demerol, versed, morphine, propofol, lidocaine, marcaine, antibiotics, hormones, anesthetics, diuretics, heparin, iron, vaccines and others. These may be expired or partial injection residuals. This category description overlaps narcotics and IV liquids. However, the quantities are not duplicated.

IV liquids IV preparations other than chemotherapy. Includes some drugs (e.g., blood pressure regulators), but quantity is primarily hydrations, total parenteral nutrition, and normal saline solutions. Vials of leftover or expired drug concentrates also included.

mercury thermometer broken thermometer

Mixed used for wastestreams described as “all medications”, “all wastes” or listing multiple drug forms (pills, tablets, patches, liquids, ointments, etc.)

Narcotics DEA controlled substances, including Class II

Ointment outdated ointment samples

Pills outdated samples of tablets or pills , packaged in bingo cards or in bottles, antibiotics, birth control p ills, allergy pills, over-the-counter and prescription drugs; expired, unused, partial and full8 King County - Pharmaceutical Waste Survey 

## A total of 121 pharmaceutical waste streams from 55 sites 7 

## were identified. An additional

five sites had no identified waste streams. Of these, two had no drugs on site, two were serviced by a pharmacy, and one respondent co uldn’t provide accurat e information about the site. Quantity data were recorded for 89 waste streams from 47 sites (see Table 5 below). For more detail about specific wa ste streams, see Appendix E for a database report of survey data by business type.

Table 5. Annual Quantity Generated by Business Type

Business Type Waste
measured in

ml Waste
measured

in lbs Waste
measured

as pills Waste
measured as
items/other Total #

waste

streams generated Ambulatory/surgical

center 11,742 0 34 2,500 8 8

Dialysis center 5,475 0 0 0 1

Doctor office 9 15,801 0 0 6,758 0 26

Hospital 12,565,908 1,953 0 0 11

Nursing/boarding home 0 0 6,500 0 1

Pharmacy – retail 10 0 292 300 0 4

Podiatrist 2,842 0 245 0 3

Reverse distributor 0 1,733 0 0 4

Specialty outpatient 12,546 0 80 114 11 16

Veterinary 4,218 4 6 2 12 15

TOTALS 12,618,532 ml 3,982 lbs 13,923 pills 2,616 items 89



## Hospitals, ambulatory/surgical care centers, a nd specialty outpatient clinics were more likely than other facilities to administer intravenous (IV) fluids, and they generated higher amounts of liquid wastes. IV fluids th at provide hydration or total parenteral nutrition (TPN) without an a dditional “drug” added may not designate as dangerous waste since they consist primarily of norma l saline, vitamins and minerals, dextrose, amino acids or enzymes. They may also be acceptable for sewer disposal with authorization from publicly owned treatment works.

Survey respondents often provided quantity data in units of “pills.” Pills are packaged in blister packs or bingo cards and sometimes in bottles. The pharmaceutical waste stream therefore contains much packaging not accounted for by this survey.

7 

### For this section of the report, the pharmacy that collects waste from 54 sites is counted as one site.
8 

### Includes empty syringes generated during flu season.
9 

### 6757 ml of this quantity is cough syrup.
10 

### One pharmacy surveyed collected drug wastes from 54 pharmacies statewide, but is counted as one

waste stream.
11 

### Debris (intravenous tubing, syringes or gloves)

12 

### Broken mercury thermometersKing County - Pharmaceutical Waste Survey 9 

## In a separate study, the University of Wa shington Environmental Health Services conducted a box survey 13 

## of a cubic yard bin (650 pounds – converts to 3.2 pounds/gallon) of waste pharmaceuticals after cont rolled substances and items for reverse distributors were removed. The box typically takes three to five weeks to fill. The following packaging information was recorded:

Volume: 37% by volume was pills and bottles of liquids 63% by volume was packaging (not bottles) Weight: 72% by weight was pi lls and bottles of liquids 28% by weight was packaging (not bottles)

Table 6 below identifies the t ypes of businesses generating each category of waste and the amount of waste generated. Blank lines i ndicate those waste streams lacking quantity

data.

Table 6. Waste Categories by Business Type

Waste CategoryAmbulatory /surgicalcenterDialysiscenterDoctorsofficeHospitalNursing orboardinghomePharmacy –retailPodiatristReversedistributorSpecialtyoutpatientVeterinary

Total # of Waste
Streams

Generated 14 10 2 30 22 1 6 4 4 21 20

Chemotherapy debris/liquid 1,873 lbs 1 NoQty 4 NoQty

Chemotherapy IV liquid 1,968,408 ml

Cough syrup 6,757 ml

Debris 1 NoQty 1 NoQty 96 ea

Disinfectant 1 NoQty 4 lbs Empty syringe 2,500 ea

Inhaler 100 ml Injectable liquids 11,612 ml 2 NoQty 5,475 ml 52 ml 18 ea 12,392 ml 1 NoQty 4,218 ml

IV liquids 10,597,500 ml 3 NoQty 50 ml

Mercury
thermometers 2 ea

Mixed 8,992 ml 1 NoQty 237 lbs

Narcotics 130 ml 1 NoQty 0.2 lbs 6 NoQty 1,496 lbs 4 ml 1 NoQty Ointment 2,842

ml

Pills 34 ea 6,758 ea 1 NoQty 80 lbs 2 NoQty 6,500

ea 292 lbs 15

300 ea 1 NoQty 245 ea 80 ea 3 NoQty 6 ea 1 NoQty

13 

### Bill Rowe, University of Washington Environmental Health and Safety Box Survey, reported in IRAC Pharmaceutical Workgroup mee ting notes dated 10/22/2002.

14 

### Although 121 waste streams were identified, no da ta was available pertaining to the waste stream generated by the accounting firm, su rveyed because of its confusing SI C category. This waste stream was assumed not to be pharmaceutical in na ture, so is not included in Table 6; therefore the total waste streams

detailed in Table 6 is 120.10 King County - Pharmaceutical Waste Survey 

### Physical State



## Physical state data was available for 118 wast e streams and not available for three waste streams. Of the 118 waste streams, 100 (85 %) were single-phased and 18 (15%) were multiphased. Multiphased wastes typically contained bags/tubing with residual liquids, ampoules/vials with residual liquids, syringes with residual liquids or liquids in vials mixed with oral solids/pills. The physical states of the single-phased waste streams are

described in Table 7.

Table 7. Physical State of Single-Phased Waste Streams

Physical State # of Waste

Streams Comments

Liquid 48 primarily intravenous solutions or injectables

Powder or pill 38 nearly all are pills

Debris 12 IV tubing or bags, mercury thermometer

Other - describe 1 empty syringe

Ointment/lotion 1 podiatrist waste

Total single-phased

waste streams 100King County - Pharmaceutical Waste Survey 11 

## Table 8 below lists each waste category, the amount of waste generated for that category, and the number of waste streams surveyed in that category. Blank lin es indicate the waste stream was not reported with those units.

Table 8. Waste Categories and Quantity Generated

Units Reported Waste Category

lbs ml each # Waste
Streams w/ Quantity Data # Waste
Streams w/o Quantity Data

Chemotherapy debris/liquid 1,873 3 5 Chemotherapy IV liquid 1,968,408 1 Cough syrup 6,757 3

Debris 96 3 2

Disinfectant 4 1 1 Empty syringe 2,500 1

Inhaler 100 1 Injectable liquids 33,749 18 28 3 IV liquids 10,597,550 5 3 Mercury thermometers 2 1 Mixed 237 8,992 4 1 Narcotics 1,496 134 6 8

No data 1 Ointment 2,842 1

Pills 372 15 13,923 31 8

TOTALS 3,982 lbs 12,618,532 ml 16,539 pills
or items 121 total waste streams



## Table 9 identifies the current disposal met hod for each category of waste, number of waste streams and amount disposed per category. Chemotherapy wastes were being disposed primarily through hazardous waste vendors, although some went to

biohazardous waste containe rs. The “mixed” and “narcotic” wastes going to the hazardous waste vendor were reported by one re verse distributor. Otherwise, most drug wastes are going into the sewer system, in to the garbage and into biohazardous waste

containers.

15 

### One pharmacy surveyed collected dr ug wastes from 54 locations statewide, but is counted as one

wastestream.12 King County - Pharmaceutical Waste Survey 

### Table 9. Disposition of Wastes by Category and Quantities Disposed

Disposition by Category Waste
measured in
lbs Waste
measured in
ml Pills counted individually Other waste
measured as
items Total # of

waste streams reported # of waste

streams not

quantified
BACK TO PHARMACY Cough syrup 340 1 Injectable liquids 15 1 Total to pharmacy 355 ml 2
DOWN THE DRAIN Cough syrup 12 1 Injectable liquids 11,581 11 1 IV liquids 10,597,500 6 2

Mixed 1,421 1

Narcotics 130 3 1

Pills 6,188 6

Total down the drain 10,610,644 ml 6,188 pills 28 4
HW VENDOR

Chemotherapy debris/liquid 1,873 3

Chemotherapy IV liquid 1,968,408 1

Mixed 237 2

Narcotics 1,496 2

Total to HW vendor 3,606 lbs 1,968,408 ml 8

ACCUMULATED IN COLLECTION BIN

Pills 30 1

Total accumulated 30 pills 1
GARBAGE Chemotherapy

debris/liquid 1 1

Debris 36 1

Disinfectant 4 2 1

Narcotics 4 1

Pills 36 93 5 Total in garbage 40 lbs 4 ml 93 pills 36 items 10 2
BIOHAZARD CONTAINER Chemotherapy

debris/liquid 4 4

Cough syrup 6,405 1

Debris 60 4 2 Empty syringe 2,500 1 Injectable liquids 22,143 17 2 Mercury
thermometers 2 1

Mixed 7,571 1

Ointment 2,842 1

Pills 80 517 8 2

Total in biohazards 80 lbs 38,961 ml 517 pills 2,562 items 38 10 NO DISPOSITION OR QUANTITY DA TA PROVIDED BY GENERATORS IV liquids 1 1

Narcotics 4 4

No Data 1 1 Total with no quantity 6 6
OTHER CREATIVE METHODS

Inhaler 100 1 Injectable liquids 10 18 2 IV liquids 50 1

Narcotics 1 1

Pills 595 12 2

Total other methods 160 ml 595 pills 18 items 17 3
REVERSE DISTRIBUTOR

Mixed 1 1

Narcotics 0.2 3 2

Pills 256 6,500 7 4

Total to reverse distributor 256 lbs 6,500 pills 11 7 GRAND
TOTALS: 3,982 lbs 12,618,532 ml 13,923 pills 2,616 items 121 32King County - Pharmaceutical Waste Survey 13 

### Active Ingredient Data



## Two sites, a hospital and an ambulatory/ surgical center, used a computerized pharmaceutical tracking system called Pyxis. For drug products and wastes tracked on Pyxis, quantity data were limited to active ingredients. See Table 10 below. Pyxis does not track waste disposal.

Table 10. Drug Active Ingredient Data

Waste Description Active Ingredient

Quantity Data Disposition Total Waste Quantity

injectables fentanyl, demerol, versed,
morphine - controlled
substances; propofol,

lidocaine, marcaine 42 patients over 7 days, average
205 patients/month, with (a very
close estimate) 3117 mg active
ingredients - calculates to 50 cc
solution per week Down the

drain 2,600 ml

Hydrations normal saline, dextrosebased solutions, not likely to
designate as dangerous

waste contact obtained data from Pyxis
system, 189.3 liters over 13
days Down the

drain 5,315,000 ml

TPN total parenteral nutrition,
patient receives nutrients
through IV, may not
designate as hazardous,
contains amino acids,
dextrose, enzymes, vitamins
(K &C), potassium, calcium,

sodium and saline solution contact compiled data from Pyxis
computer system, 28.4 liters
over 13 days Down the

drain No data

Narcotics -
injectables DEA controlled substances contact checked Pyxis system
for quantity data; 448 mg
disposed No data No data

Narcotics -

solution

based DEA controlled substances contact checked Pyxis system
for quantity data; 15 mls
disposed No data No data

Narcotics -

other misc. DEA controlled substances contact checked Pyxis system
for quantity data; 1015 mgs
disposed No data No data

Narcotics -
tabs/caps DEA controlled substances
in solid tablets or caplets. contact compiled data from Pyxis
computer system; 8765 mg
active ingredient, timeframe? No data No data14 King County - Pharmaceutical Waste Survey 

# Current Management Practices

Process Flow Diagrams



## Process flow diagrams were completed for ten surveyed facilitie s. See Appendix D.

Disposal of Drug Wastes



## About ten different methods were used to dispose of pharmaceutical wastes, including giving them to charitable organizations, putting them down the drain, using the reverse distribution process and disposing of them with biohazardous waste.

Data on disposal were gathered for 115 of the 121 waste streams surveyed. Of these 115 waste streams, 89 also had waste quantity da ta (summarized in Table 11 below), while 26 did not have quantity data. (Of the 26 wastes without quantity data, four were put down the drain, two went in the garbage, ten went into the biohazardous waste container, seven went to a reverse distributor, and three were categorized as “other”.)

Disposal methods categorized as “other ” include giving wast es to charitable organizations, giving them to DEA-licensed ve ndors for incineration, returning them to the sales representative and putting them in the sharps container.

For more detail about disposal of sp ecific waste streams, see Appendix F.

Table 11. Disposition of Wastes and Quantities Disposed Per Year

Disposition

(# Waste streams = 89) ml lbs pills each

Accumulate and Wait (1) 30

Biohazard Container (28) 38,961 80 517 2,562

Down the Drain (24) 10,610,644 6,188

Garbage (8) 4 40 93 36

Hazardous Waste Vendor (8) 1,968,408 3,606

Other (14) 160 595 18

Pharmacy (2) 355

Reverse Distributor (4) 256 6,500

Total (89) 12,618,532 3,982 13,923 2,616King County - Pharmaceutical Waste Survey 15 

### Qualitative Data on Disposal Methods



## Qualitative data on current disposal pract ices were gleaned from two open-ended questions: Do you have additional comments? and Do you have any other thoughts?

Several respondents donate expired pharm aceuticals to free clinics, missionary organizations, or directly to medical doctors working overseas.

“Wasting Narcotics .” For respondents, the preferred (a nd by some considered the safest) way to destroy controlled substances and stay in compliance with Drug Enforcement Administration (DEA) regulations is by wasting them down the drain, that is, both destroying and disposing of them at once by putting them down the drain. (In one case the respondent injected leftover narcotics into dirty linens that would later be laundered).

Of the thirteen respondents that had narcotic s on site, methods varied for identifying and keeping these controlled substa nces separated from other dr ugs. Six respondents use only one or two narcotics regularly and were familia r with these drugs. Four keep narcotics in a locked box. Two respondents check their list s for which drugs are narcotics, and one facility labels syringes that contain narcotics.

Vendors . In some cases vendors may be a source of misinformation and may add to a facility’s waste problems. In one facility, for example, the vendor routinely cleans out the sample closet, tossing all expired medications and ointments into th e trash and replacing them with new samples. In another facilit y, staff – under the direc tion of a drug company representative – clean out the medicine cupboard quarterly, dis posing of old antiinflammatories and antibiotics to the bioh azard bag. Before receiving this instruction, staff had popped pills from blister pack s and flushed them down the toilet.

Containers for Drug Wastes . Respondents were asked thr ee questions about storage of drug waste: Do you have containers for drug wastes? Where are they kept? How are they

labeled? Of the 30 respondents, eighteen, or 60 percent, answered “yes” to having containers for drug wastes. Their containers we re kept in a variety of places, including under the radiation table; in the x-ray process ro om, the store room, the pharmacy tech area, the IV prep room; in a locked box in the operating room; and in the lab area by the autoclave. Most were labeled “biohazardous;” one was labeled “expired.” One facility kept containers labeled “Sch edule #” and “Waste Chemo.”

Confusing Concepts: Hazardous, Biohazardous and Reverse Distributors



## Many respondents confused hazardous (s ome expired meds) with biohazardous (potentially infectious). For example, when asked about hazardous waste disposal for waste drugs, one associate hospital noted that a courier from the main facility picked up its full biohazardous waste containers on a daily basis.

The term ‘reverse distributor’ is often understood to mean any vendor who picks up a waste from a health care facility. For exampl e, one respondent who claimed to be using a reverse distributor actually put pharmaceuticals with the biohazardous waste and sent16 King County - Pharmaceutical Waste Survey 

## them to Stericycle. Another respondent claimi ng to use a reverse dist ributor stated that they “collect drug waste for revers e distributor in the red bag.”

Drug store chains and supermarket drug st ores manage their pharmaceutical returns through their central office. One pharmacy stated they send even the dropped (and therefore unusable and not returnable) tablets back to their reverse distributor.



# Awareness of Federal Hazardous Waste Regulations

Of the 33 respondents asked about federal Hazardous Waste regulations, 31 respondents – or 94 percent – stated that they di d not have knowledge about the Resource Conservation and Recovery Act (RCRA), while two respondents stated that they knew about federal regulations. See Table 12 below.

Table 12. Knowledge of RCRA Regulations

Facility Description Knowledge of RCRA Regulations No knowledge of RCRA Regulations

Ambulatory/ surgical center

N = 3 3

Doctors Office (includes podiatrist) N = 12 12

Hospital N = 2 1 1

Reverse Distributor N = 1 1

Specialty Outpatient N = 9 9

Veterinary N = 6 6



## Detailed logs are required by the Board of Pharmacy and Drug Enforcement

Administration to account for the witnessed de struction of controlled substances. Of 34 respondents asked about recordkeeping, 23 respo ndents, or two-thirds , stated that they kept no records of drug disposal and 11, or one-t hird, stated that they did keep records (in one case records were actually kept by the vendor). See Table 13 below.King County - Pharmaceutical Waste Survey 17 

### Table 13. Maintain Records on Waste Pharmaceuticals

Facility Description Maintain records on waste pharmaceuticals Do not maintain records on waste pharmaceuticals

Ambulatory/ surgical center

N = 4 3 1

Doctors Office (includes podiatrist) N = 10 3 7

Hospital N = 3 3

Nursing/Boarding Home

N = 1 1

Reverse Distributor N = 1 1

Specialty Outpatient N = 9 1 8

Veterinary N = 6 6



# Preferred Waste Management Options

29 respondents provided information about which waste management options they preferred. See Table 14 below. Eight responde nts (27%) preferred to drop off drug waste at a pharmacy. Seven (25%) preferred to ha ve a vendor pick up waste drugs. Seven (25%) preferred the reverse distributor choi ce. (Four of these were pharmacies, already serviced by reverse distribut ors.) Finally, six (20%) preferred using an associated hospital’s disposal service.

The current practice of wasting controlled substances down the drain to comply with Drug Enforcement Administration regulations to prevent their abuse and diversion was the preferred option among those who employed it. Two options, drop-off at another site and a mail-away service, were not among the services chosen by any of the respondents.

Another idea suggested by some respondents wa s to use an inventory control system to use up medications before they expire. And finally, several respondents complained of being over-regulated and felt that any collec tion and disposal of wastes – even to controlled combustion facility and without th e designation process – is too much burden. One facility stated simply, “it must be convenient, cheap and easy.”18 King County - Pharmaceutical Waste Survey 

### Table 14. Drug Waste Disposal Options That Would Work Best for Facility

Service Requested Respondent

associated hospital’s disposal service 6 doctors office -2
specialty outpatient -4

drop off drug waste at a pharmac y 8 ambulatory/surgical center -1
doctors office; outpatient -5
nursing/boarding home-2

other (What I’m doing now works.) 1 ambulatory/surgical center -1

reverse distributo r 7 doctors office

– 1
nursing/boarding home -1

pharmacy – retail -4

veterinary -1

vendor pick-up at my site 7 doctors office -3
hospital -1

specialty outpatient -1

pharmacy – retail -1

veterinary -1

other site drop-off 0

mail-away service 0

Total 29



# Other General Considerations

Respondents typically refer to biohazardous waste as “hazar dous waste.” This led to confusion when discussing waste disposal and needs to be addressed when planning

outreach efforts.

Tracking systems in the health care industry are based on quantities of active ingredient in the drug; not total quantity of the drug (i nert ingredients plus active ingredient).

Medically trained staff are accustomed to hand ling even minutely infectious materials as biohazardous waste. They are also aware th at chemotherapy drugs may have an adverse

health effect at low concentr ations and treat them with the utmost of care. It is conceivable that with this background, health care industry staff ma y tend to consider materials that may have only potentially co ntacted drugs to be hazardous wastes (as materials that have only pot entially contacted anything infectious are considered biohazardous), unaware that there are thresh olds and limitations. This needs to be

addressed in outreach efforts.

The reported quantities of most pharmaceutical wastes are small. Some of the largest numbers reported are IV fluids – typically nutritional substa nces such as TPN, saline, dextrose, etc. Unless some medications are adde d to IV fluids, the fl uids are not expected to designate as Washington state-only dange rous waste. Removing IV fluids without drugs from this survey could re duce the totals even further.King County - Pharmaceutical Waste Survey 19 

# SUMMARY AND CONCLUSIONS

With a few exceptions (mostly large hospitals , pharmacies and those using chemotherapy drugs), the health care industr y has been unaware of its re sponsibility to meet both federal and state hazardous waste regulations . Lacking clear guidance and proper disposal options, individuals within the industry have come up with a variety of creative methods to manage drug wastes. These include drains, bins, biohazard contai ners, trash cans, and

linens.

Outside of the regulation of controlled substances by the Drug Enforcement Administration, no checks exist in the system. Aware of the importance of preventing the

diversion of narcotics and other controlled substances, the industry destroys them immediately (usually down the drain). There is similar awareness about the importance of managing biohazardous waste to prevent the sp read of infection. These waste handling methods are often applied to waste pharmaceu ticals as well, resulting in the improper management of both federal and state wastes.

The health care industry itself, through th e Medical Industry Roundt able, requested that the IRAC Pharmaceuticals Workgroup be formed to help find ways to manage a problematical waste stream. The survey found that some facilities were so concerned with the lack of waste management options that they simply stored up their wastes, waiting.

The goal of the IRAC Pharmaceutical workgrou p’s survey was to provide data to the Department of Ecology about the size and nature of pharmaceutical waste streams generated by the health care industry. Despite time limitations due to the public comment deadline and the lack of recorded waste dispos al information available, a large amount of data has been collected and organized.

Since the data were collected only in King County facilities, extrapolation statewide is necessary. Due to the limitations discussed on page 3, extrapolations, like the survey results, should be viewed only as descrip tive data about drug waste management. Table 15, Extrapolation of Waste Generated Statew ide, on the following page, offers one of several possible methods to do this. The ex trapolation in Table 15 is based on the information in Table 16, Patient Contact pe r Day per Business Type, and Table 17, and Average Quantity of Waste per Business. Additionally, the qualitative information regarding barriers to proper disposal of pha rmaceuticals that was provided by the industry in this survey is useful statewide.20 King County - Pharmaceutical Waste Survey 

### Table 15. Extrapolation of Waste Generated Statewide

Facility Description Average Pounds

Pharmaceutical Waste/Facility/Year Estimated # Facilities in Washington State 16 Extrapolated Quantity

of HW Generated
per Year

Ambulatory/ surgical

centers 5 50 250 lbs

Dialysis centers 12 12 144 lbs

Doctors offices

(includes podiatrist) 3 5,800 17,400 lbs

Hospitals (IV Fluids) 6,900 110 759,000 lbs

Hospitals (Other wastes) 490 110 53,900 lbs

Nursing/boarding

homes 8 900 7,200 lbs

Pharmacy – retail 17 5 1068 5,340 lbs

Specialty Outpatient 42 3,900 163,800 lbs

Veterinary – small

animal 1 1361 1,361 lbs

Pharmaceutical waste generated in Washington state each year by health care industry. 759,000 lbs (75 percent) of this amount consists

of IV fluids that are not expected to designate as dangerous in WA. 1,008,395 lbs

Pharmaceutical waste generated in Washington state each year by the health care industry, not including IV fluids. 249,395 lbs

16 

### Numbers for practitioner offices/clinics and hospitals are per Morrison. Numbers for pharmacies from Stan Jeppesen, WA Board of Pharmacy. Number of dialysis centers is from infoUSA.
17 

### One pharmacy surveyed collected dr ug wastes from 54 locations statewide, but was counted as one pharmacy in N=5.King County - Pharmaceutical Waste Survey 21 

### Table 16. Patient Contact per Day per Business Type

Facility Description Average # Patient Contact / Day / Facility Estimated # Facilities in Washington State 18 Estimated Contact / Day / Facilities in WA

Ambulatory/ surgical

center

N = 6 72 patients/day 50 3,600 patients

Doctors Office

(includes podiatrist, dialysis, specialty outpatient clinics) 43 patients/day 10,00 0 43,000 patients

Hospital

N = 5 382 beds/facility 110 42,020 beds

Nursing/boarding

home

N = 4 111 beds/facility 900 99,000 beds

Pharmacy – retail 19

N = 5 220 Rx filled/day 1068 234,960 Rx

Veterinary – small

animal 34 patients/day 1361 46,274 patients

18 

### Numbers for practitioner offices/clinics and hospitals are per Morrison. Numbers for pharmacies from Stan Jeppesen, WA Board of Pharmacy.
19 

### One pharmacy surveyed collected dr ug wastes from 54 locations statewide, but was counted as one pharmacy in N=5.22 King County - Pharmaceutical Waste Survey 

## The quantity and facility data was reviewed to see if estimates of the pounds of waste per facility could be developed. The data has ga ps; for example one facility may not have quantity data for all waste streams. However, table 15 below summarizes those averages that could be computed. To convert the quantities reported into pounds, milliliters were converted assuming the density of water (1 g/ml ), pills were determined to average 0.55 g

each 20 

## , debris was assumed to be 1 gallon each, and syringes were assumed to average 2 g each. For pills, the conversion to pounds is for the pill only, and does not include the amount of packaging discarded with the pill. Again, the table demonstrates the influence of high-density IV fluids (27,650 pounds of the total generated by hospitals) on the quantities generated per facility. Those IV fluids containing drugs, and those without drugs, could not be separated out from the data provided.

Table 17. Average Quantity of Waste per Business

Total Amount

Generated Average Amount Generated per Facility
per Year Business Type Number of

Facilities with Quantity Data Number of

Wastestreams with Quantity

Data In Units of Pounds

ambulatory/ surgical center 5 7 26 5

dialysis center 1 1 12 12

doctors office 14 24 43 3

hospital – IV

fluids 4 8 27,650 6,900

hospital –other 4 2 1,950 490

nursing/ boarding home 1 1 8 8

pharmacy –

retail 21 56 56 292 5

podiatrist 2 3 6 3

specialty outpatient 8 12 335 42

veterinary 7 13 9 1

Total 102 127 30,331

20 

### On 11/12/02 Bill Rowe, with the University of Wash ington, weighed a random assortment of 50 pills of varying sizes, shapes and drug active ingredient. The total weight was 27.6 g for an average of 0.55 g/pill.

21 

### These wastes were sent to reverse distributors.King County - Pharmaceutical Waste Survey 23 

# APPENDIX A

SURVEY FORM24 King County - Pharmaceutical Waste SurveyKing County - Pharmaceutical Waste Survey 2526 King County - Pharmaceutical Waste SurveyKing County - Pharmaceutical Waste Survey 2728 King County - Pharmaceutical Waste SurveyKing County - Pharmaceutical Waste Survey 29 

# APPENDIX B

SURVEY PROTOCOL30 King County - Pharmaceutical Waste SurveyKing County - Pharmaceutical Waste Survey 31 

# Project

IRAC’s Pharmaceutical Workgroup is conducting a survey and needs data from 84 health

care facilities within th e next two weeks. The following wonderful people have agreed to conduct up to twelve surveys, either by visiti ng in person or by telephoning the facilities:

Ann Peacock, Sue Hamilton, Emmanuel Rivera, Lisa Niehaus

Alice Chapman, Cheri Grasso and Debra Oliver are also doing the surv ey and are part of the IRAC workgroup. They can answer (or try to) the questions you may have and provide guidance, although they’ve visited as many of these facilities as you have!



# Background

The Washington State Board of Pharmacy, in collaboration with the Interagency Regulatory Analysis Committee, is interested in learning about the quantities, types, disposal and fate of pharmaceutical wastes. We are in the process of collecting data to evaluate the best disposal options availa ble to keep toxic drug wastes out of the environment, inaccessible to diversion and to comply with laws governing their disposal. The range of wastes we are inte rested in is all-inclusive:

Prescription drugs (like n itroglycerine), over-the-c ounter drugs (cold meds, vitamins, diuretics, etc.), controlled substances (e.g., morphine), chemotherapy drugs and materials (like IV tubing, gl oves and gowns), doctor’s-order drugs (from the leftovers in a syringe to spi lled aspirin), and cont rast media and dyes used for diagnosis.

We need your help to learn more about pha rmaceutical wastes and appreciate your time answering questions for us.



# For your information only

The IRAC Workgroup is testifying at Ecology ’s public hearing on October 29 and needs preliminary data to suppor t the proposed language that will conditionally exclude controlled substances and legend drugs fr om the Dangerous Waste Regulations. The

condition is that these substances are destr oyed in a specific type of combustion unit – not a medical incinerator, but a state-of-the art waste-to-energy unit that burns for a longer time and at a temperature that does not cr eate furans or dioxins . As the regulations stand now, the health care industry must de signate and properly manage their waste pharmaceuticals.32 King County - Pharmaceutical Waste Survey 

# Suggestion for an Opening

I am _________________ with King County. We are working with the Board of Pharmacy on a study of how waste or unus able pharmaceuticals are disposed of – how, where and how much – and we need your help. [Or Who would be the best person to talk to about this for 15 –20 minutes...] Would you be willing to allow me to spend about 15-20 minutes with you at your facility to help me with the questionnaire? Or, if you and they are able to do this over the phone, go ahead.



# Differences between medical industry and other industries we
have visited:

Categories are different. Medications are categorized according to their use (antibiotic, nutrient, psychotropic, narcotic, etc.) or thei r state (tab, solution, t opical); but have not been categorized according to hazard, ingredients, or chem ical classification. The active ingredients in pharmaceuticals do not have the type of toxicity data that the DW regulations require in order to designate them. Some RCRA-regulated drugs have been designated, but it is unlikely th at it is widely known or understood among the facilities we will survey.



# Vocabulary/Jargon

Reverse Distributors are businesses that “buy back” unused/expired pharmaceuticals

from medical facilities. Th e facility sends their expi red or unusable pharmaceutical products to a reverse distri butor (RD). The RD sorts a nd destroys (via a RCRA/HW incinerator) expired or unsold drugs that it cannot return to the manufacturer for credit. The RD sends products that fit manufacturer’s criteria for credit to the manufacturer and keeps a percentage of the credit the faci lity would have received. The medical community assumes the drugs they receive credit for are being reused by the manufacturer or “recycled.”

This service came about when manufacturers, in order to encourage pharmacies and medical clinics to try their new drugs, offered a money-back guarantee for unused drugs they agreed to try. RDs capital ized on the credit. This servi ce is usually only available to hospitals or other large medical facilitie s. Common reverse distributors are MedTurn, Easy Returns, and Capital Returns. Th e EPA has written that those unusable pharmaceuticals in the reverse distribution sy stem are considered product until declared waste by the RD or manufacturer.

Hazardous in their eyes means biohazardous. Red bags are not always red.

Destroyed often means a drug has been put into the garbage disposal or down the sink

drain.

Tabs/Caps – Tablets and capsules, pills, oral solids, PO. We expect to find more of this type of medication than any other. Include s aspirin, blood pressure medicine, etc.King County - Pharmaceutical Waste Survey 33 

## Bingo Cards – These are also called “blister packs.” They are packages of single doses of medications, usually four or five units ac ross by four or five units down. A molded plastic cover seals the individua l tablets or capsules to a foil-covered card, through which one pushes the tablet or capsule.

Solutions – This includes antibiotics, cough syrups, etc.

Injectables – Insulin, vaccines, flu shots, etc. Le ftovers are sometimes “wasted” down a

drain.

Chemo – This is short for “chemotherapy” or ch emical therapy and involves the use of a lot of drugs – often via IV. We have often confused it with Radiation Therapy, but it has nothing to do with that, except that both therapies are used in fighting cancer.

Contrast Media – These include dyes that are used in radiology to provide contrast in xrays and other tools for diagnosis. This incl udes some radioactive materials, but they’re regulated separately. We don’t know a lot about this category.

Debris – This is our word, on the form where we are asking for the nature of the waste. By debris we mean the paraphernalia associat ed with the medications that may have been contaminated and now needs to be dispos ed of – paper cups, syringes, etc. In chemotherapy, the patient consumes most of the medication. What is waste is usually handled properly; however, in addition to the wasted medicine are the gloves, gowns, IV tubing, etc., that may have been exposed to the medication.

TPN and IVP – total parenteral nutrients and intrave nous parenterals. These are IV bags with fluids (water, dextrose, saline, electro lytes, etc.) given to someone who can’t eat (right after surgery). Don’t in clude these unless they contai n medication. We don’t expect

to see them outside of hospitals and nursing homes.

Legend drugs – These are drugs that require a prescription. The “legend” is the statement that appears on every container of pr escription drugs that says it is unlawful to transfer to anyone other than the pa tient for whom it was prescribed.

Controlled substances a/k/a “narcs ,” controls, or scheduled drugs – These are tightly regulated by the Drug Enforcement Administra tion due to their like lihood for diversion and abuse. These must be destroyed in front of a witness. The most common form of destruction we expect to find is down the drain. We also expect that facilities will have paperwork for all their controlled substances but not for legend drugs.

PO – Short for the Latin phrase per oss , which means “by mouth” and will in some cases refer to pills taken orally. Thes e are also called oral solids.



# Survey form info

Starting with the optional questions may help you build rapport and ease any discomfort with the survey. On the first not-optional pa ge of the questionnaire the first question, “ Do you keep records ....” is your key to an easier time of it! Ask to see their records!34 King County - Pharmaceutical Waste Survey 

## We will have to get their best estimates on volumes, numbers, fre quencies, etc. In one clinic, Alice sat the waste drug box on her survey sheet and traced its height, width and depth to figure out its volume back in the office. Do whatever it takes!

Also, take advantage of the process flow page if you get some good information on the life cycle of some type of drug. This is something Ecology wants.

The numbers of patients served per unit of time (week, month, whatever) is extremely important because we will extrapolate our data across the state using that constant. The

number of RNs may be used in the same way, please don’t forget that one!



# Special Information in Doctors ’ Offices Regarding Samples:

For samples in doctors’ offices, we need to kno w the number of doctors with access to the sample stash (for extrapolation), the amount that gets wasted, and whether or not the supplier takes it back. We think in doctors ’ offices that this is a large volume

wastestream.King County - Pharmaceutical Waste Survey 35 

# APPENDIX C

SURVEY PLAN AND CONSIDERATIONS36 King County - Pharmaceutical Waste SurveyKing County - Pharmaceutical Waste Survey 37 Area to Survey # to Survey Major source of waste expected Data needed for extrapolation Survey considerations

OutpatientClinics Ambulatory or Surgical Care Ctr
NAICS 6214--*
Offices of MDs
and ODs
NAICS 6211--
Etc Practitioners
NAICS 6213-- 10,000 in WA 1 Wt = 2.5 2

10,000/100*2.5= 250 Samples Volume of samples,
Est. closet or bin size

# physicians w/ access to each sample stash Diversity – Get large, small, groups, individuals, affiliated w/ hosp and not (difference?) Capture also podiatrist, inhalation /respiratory therapist Dialysis center ( Stan ) Need
list of centers in state and # patients served in state Diagnostic Imaging Centers
NAICS 62151- Include with clinics Contrast media # patients served / population / not sure how to extrapolate... Nursing Homes
NAICS 623110
400 in WA 1 Wt = 1 2

400/100*1= 4 Oral solids # patients served or
number of beds
Interview nurses
Measure waste
accumulated in bin over
what time? Lic’d by DSHS, include skilled nursing staff Can we get # of beds / home / county / state?

Boarding Homes, e.g., Adult Family
Homes
NAICS 6232--
500 in WA 1 Wt = 1 2

500/100*1= 5 Oral solids Bingo cards # of residents served. Interview person in charge for meds
wasted. HHW? Domestic sewage
excl? No skilled nursing staff.
Need list of homes and # beds by home in WA.
Check with DSHS website.

Pharmacies
NAICS 446110
1200 in WA 1 Wt = 1 2

1200/100*1= 12 Oral solids Bingo cards – those returned to pharmacy by others (are full cards reused and partials returned to RD?) Types of pharmacies:

- Retail - Serves nursing home - Institutional or hospital pharmacy Stan will call several pharmacies to find out if any
toss out their waste pharmaceuticals.

Hospitals
NAICS 6221--
110 in WA 1 Wt = 3 2

110/100*3= 3 Oral solids Injectables
Solutions Topicals Swedish Virginia Mason
- done - go back for photos - Pyxis info to come
Harborview/UW
- do Need # pts served in hospital, # beds, # beds
in WA state Need to extrapolate data across WA using # patients

Need to know # patients served on annual basis by hospital diagnostic imaging centers – will apply D.I.C. into to hospitals. Same re O.R . (capture under surgical center)

Reverse
Distributors
NAICS 562920 Wt = 0 Get one anyway PSI, Easy Returns Capital Returns Med-Turn (Auburn) Veterinary clinics
NAICS 541940 Wt = 0 Get one or two anyway # non-food animals served per hospital, # hospitals in WA Small & large animal – nonfood!

1 – These state-wide estimates are ta ken from Don Williams’ (WA DOH Board of Pharmacy) presentation by to the
IRAC Pharmaceuticals Workgroup, April 2001. For the purposes of this survey, we may choose to use King County

numbers.

2 – Weights were determined by Tom Georgianna, KC DNR Statistician, in meeting with Stan Jeppesen, Cheri Grasso,
Alice Chapman, Brian Westra and Debra Oliver on 10/8/2002.


### *

– NAICS Codes are provided in as much detail as possible gi ven the broad or specific range of industries within the

class.38 King County - Pharmaceutical Waste Survey 

### From Tom Georgianna: What question drives everything? What will we do with the data? Answers: Show Ecology the totals. Ho w much goes to SS, SW, RD, BioH, etc.

From Stan Jeppesen: Breakdown by drug class is impossible; has never been done. Some RCRA drugs have been designated/classified.

We will look for: Oral Solids or Tabs/Caps. This is what we see most of – aspirin, high blood pressure meds, etc. Solutions. This includes cough syrups, some antibiotics, etc. Injectables. Insulin, vaccines, flu shots, etc.

TPNs and IVPs. Nutritional fluids, include dextrose , saline, electrolytes. Expect huge volumes in home health care situations (HHW), but small volumes in hospitals and nursing homes. Expect it to be of no consequential value. Will not include in this survey.
However, we do need to do some research on these fluids.

Chemo. This is unnecessary as chemo waste is proper ly managed as hazardous waste; however it is a good place to start the survey.

For data entry, we must simplify and collect the following fields:

Tabs/Caps Nominal Wt Quantity Unit of Msrmt

Solutions of Tab/Cap Injectables Topicals

_________ _________ _________

And we need a conversion factor so all of these can equal one or two units of measurement, e.g. mg or cc

Hospitals: PO = # tabs or caps/week wasted Injectables = mg/wk wasted = Ratio

#units issued #units issued

We can find this ratio using information from Virg inia Mason & Swedish Pyxis system used to track controlled substances and apply the ratio to legend drug s, then / patients served to extrapolate statewide. We may have to use billing information from hospitals to get some handle on the amounts of legend drugs

consumed.

Nursing Home: Interview nurses for wasted injectables. Examine the waste bin for quantity of drugs over quantity of time / number of patients. # tabs, caps, cc’s of inj wasted / pati ents served or beds => extrapolation Example: 1⁄2 of one oral solid wasted per patient per week = total tabs wasted multiplied by number of patients in WA nursing homes

Waste bins: UW – Bill R. and Doug G: Can they examine t he contents of waste drug bins and determine the weights of both packaging and product in a box to project X box volume = Y drug waste?King County - Pharmaceutical Waste Survey 39 

# APPENDIX D

PROCESS FLOW DIAGRAMS BY BUSINESS TYPE40 King County - Pharmaceutical Waste SurveyKing County - Pharmaceutical Waste Survey 41 

## Doctor’s Office, Urology (Visit 17)

Dru g sam p les - Check dates

Donated to

charit y Down the

drain Ex p ired

Date O K

IV fluids with

dru g s to p atien t Empty tubing & bags Biohazardous

waste

Injectables &

multidose vials

-antibiotics

-hormones

- anesthetics Injection

used ( all ) Biohazardou

s

In

j ectable Injection

p artiall y used Biohazardou

s42 King County - Pharmaceutical Waste Survey 

## Ambulatory/Surgery Center (Visit 27)

Pills from

Pharmac y Check dates of

unused p ills Returned to

p harmac y Down drain Ex p ired

Date O K Demerol injection

from Pharmac y Injection

p artiall y used Sharps

container to Squirted into

sink drain Demerol

Empty

s y rin g e

Ampoules from

Pharmac y Ampoule

p artiall y used Biohazard

container to StericycleKing County - Pharmaceutical Waste Survey 43 

### Narcotic injection

from p harmac y Injection

p artiall y used Squirted into

linens Squirted into

sink drain Sometime

Sometime 

## Ambulatory/surgical center (Visit 28)44 King County - Pharmaceutical Waste Survey 

## Specialty outpatient (Visit 37)

Pharmacy

p urchases dru g Date ex p ired DEA-licensed

vendo rKing County - Pharmaceutical Waste Survey 45 

## Specialty outpatient (Visit 44)

Vendor provides drugs (birth control, allergy ) Date ex p ired In a box, never

dis p osed46 King County - Pharmaceutical Waste Survey 

## Doctors office (Visit 51)

Sam p le dru g s Date ex p ired Sewe r

DEA dru g s Date ex p ired Witnessed

dis p osal to

Injectables (single

dose vials ) In j ected ( all ) Empty vial & syringe to

biohazard

containerKing County - Pharmaceutical Waste Survey 47 

## Doctors office (Visit 54)

Sam p le p ills Date ex p ired Biohazardous

waste48 King County - Pharmaceutical Waste Survey 

## Podiatrist (Visit 55)

Sam p le dru g s Date ex p ired Biohazardous

wasteKing County - Pharmaceutical Waste Survey 49 

### Drug samples

from Dru g s ex p ired

Biohazardous

waste Garba g e Sometime

Sometime 

## Specialty outpatient (Visit 56)

Returned to Sometime

IV fluids with drugs to patient; injectables Vials, tubing

& debris emptied (drug to Biohazardous

waste50 King County - Pharmaceutical Waste Survey 

## Specialty outpatient (Visit 57)

Drug samples

received from

main clinic Dru g Disposed to

biohazard

container & sent

to main clinicKing County - Pharmaceutical Waste Survey 51 

# APPENDIX E

WASTE QUANTITY DATA BY BUSINESS TYPE52 King County - Pharmaceutical Waste SurveyWaste Quantity Databy Business TypeBusiness Type Waste Name Waste Name Description Generation Rate Description Quantityper YearUnitsambulatory/surgical centerInjectableanestheticswaste about 1 mg drug (activeingredient) per week for a total ofapproximately 8 patients per week,no data on total amount of wasteampoules partially used no dataSubtotalCount of wastestreams generating this quantity: 2Empty syringe no meds in syringes, generatedduring flu season2,500 per year2500 eachSubtotal each2500Count of wastestreams generating this quantity: 1injectables fentanyl, demerol, versed,morphine - controlled substances;propofol, lidocaine, marcaine42 cases over 7 days, average 205cases/month, with (a very closeestimate) 3117 mg activeingredients - calculates to 50 ccsolution per week2600 mlliquids narcotics 10 cc per year10 mlPartial injections Demerol maybe once per month12 mlinjectableanestheticsnarcotics, Propofol, Versed Average approximately 3 cc perpatient, range 2-5 cc's". 3 ml/pt x250 pt/mo x 12 mo/yr = 9000 ml/yr9000 mlLeftover narcotic 10 cc per month120 mlSubtotal ml11742Count of wastestreams generating this quantity: 5pills 10 doses per year10pillsTuesday, November 12, 2002Page 1 of 14Business Type Waste Name Waste Name Description Generation Rate Description Quantityper YearUnitsPills Unused expired pills less than 25 per year24pillsSubtotal pills34Count of wastestreams generating this quantity: 2dialysis centerBetadynedisinfectantsspray bottles used, disinfectantwiped up with rags"no waste" however, waste ragsare going into the garbageSubtotalCount of wastestreams generating this quantity: 1Injectables only heparin and IV iron maytypically become wasteestimated at much less than 15cc/day of total injectables;assumed 15 for estimate below:15 ml/day x 365 day/yr = 5475 ml/yr5475 mlSubtotal ml5475Count of wastestreams generating this quantity: 1doctors officesamples two physicians give out about 90%of samples, leaving 10% wastequantity of sample waste isunknownDEA drugs no quantity/volume data availableother, mostlyglovesmost of our wasteSubtotalCount of wastestreams generating this quantity: 3syrup one pint/month6405 mlinjectables DHE - single-dose vials no drug waste - drug all used up.Just the syringe0 mlantibiotics about once a month they have 1/2ml of waste6 mlTuesday, November 12, 2002Page 2 of 14Business Type Waste Name Waste Name Description Generation Rate Description Quantityper YearUnitsvaccine about once a mnoth they have 1/2ml of waste6 mlOral solids andunused injectablesBottles of pills are emptied into thebiohazard container located in thepharmacy. Empty pill bottles go inregular garbage. Unused injectableliquids in vials also go into thepharmacy biohazard container.One gallon container filled every 6months.7571 mlUsed injectables About once a month, an individualdose is withdrawn from a septumvial of injectable drug that is lessthan the total amount in the vial.The left-over liquid (about 1 cc) inthe vial is disposed into thebiohazard container with the usedinjection sharp. Sometimes thepharmacist adds used sharps/vialwaste from teaching patients selfinjection.One cc in one vial per month12 mlexpired samples usually liquids she really couldn't give me anumber. But she agreed that itwas probably once a month theywould have some liquids theywould flush down the toilet. I willassume the smallest number 1 mleven though this is a huge facility12 mlliquids 2 cc per year2 mlunused injections once every 2 to 3 months theyhave about 1 cc of waste injectionto put into sharps container5 mlone dose one dose, between five and tenccs every six months15 mlexpired meds once every 6 months 24 oz goesdown the drain1421 mlTuesday, November 12, 2002Page 3 of 14Business Type Waste Name Waste Name Description Generation Rate Description Quantityper YearUnitsLiquids Typical wastes are cough syrupand lidocaine.cough syrup 240 ml/yr other (e.g.,lidocaine) 100 ml/yr.340 mlvaccines about once a month they have 1/2ml of vaccine they have to waste6 mlSubtotal ml15801Count of wastestreams generating this quantity: 13expired samplesand pills2000 in last four months6000pillspills about once every 6 months wehave 6 bills we throw in thegarbage12pillsoutdated samples 20 pills every 6 months40pillspills/powder 10 doses / month120pillspills one or two doses one or two doses (pills) per month18pills5 pills per year5pillssamples and pills 25 boxes of four pills each100pillspills (samples) pills-samples 6 to 10 a year in thebiohazard8pillssamples I check the samples about every 3or 4 months. I find about 10samples that have expired. Theyhave 1 or 2 pills in each sample60pillsexpired samples about every month there are 2boxes of pills in bingo cards,around 6 pills in each bingo card144pillsoral solids neurology clinic - pills only on sitein bingo cards20 to 50 pills in bingo cards everythree months140pillsTuesday, November 12, 2002Page 4 of 14Business Type Waste Name Waste Name Description Generation Rate Description Quantityper YearUnitsexpired meds about every 6 months they have 3or 4 boxes of pills (5 pills in echbox average) that expire. Wethrow them in the garbage35pillsexpired pills one of the doctors take the expiredpills to Latvia. Also they have inthe past sent some to WorldConcern. I got her to give me arange and she agreed to "morethan a dozen in a year" I willassume that each packet contains4 pills 4 x 13 = 5252pillsexpired samples about once every 6 months theyhve 12 or less pills. They crushthe pills, soak them in water andput down the drain24pillsSubtotal pills6758Count of wastestreams generating this quantity: 14hospitalNarcotics DEA controlled substances contact to compile data from Pyxiscomputer systemlegend injectables generated at pharmacy IV room,legend drug (<1%) combined witha solution composed primarily ofpotassium, phosphorus, calcium,magnesium, insulin, normal salinecontact unable to estimateNarcotics - othermiscellaneousDEA controlled substances contact checked Pyxis system forquantity data; 1015 mgs disposedNarcotics -solution basedDEA controlled substances contact checked Pyxis system forquantity data; 15 mls disposedTuesday, November 12, 2002Page 5 of 14Business Type Waste Name Waste Name Description Generation Rate Description Quantityper YearUnitsChemo, <3% If chemo remaining in container is< 3% of the total waste, it goes tosolid waste. Site referred to this asthe bag factor.contact to compile data from Pyxiscomputer system; most chemowaste is managed this wayTPN total parenteral nutrition, patientreceives nutrients through IV, maynot designate as hazardous,contains amino acids, dextrose,enzymes, vitamins (K &C),potassium, calcium, sodium andsaline solutioncontact compiled data from Pyxiscomputer system, 28.4 liters over13 daysNarcotics -injectablesDEA controlled substances contact checked Pyxis system forquantity data; 448 mg disposedPresser, ICU IV liquids that regulate bloodpressure, commonly prescribed forpatients coming out of surgery andin the intensive care unitcontact to compile data from Pyxiscomputer system; amount isexpected to be smallOTC over-the-counter drugs expired drugs go to reversedistributor, don't generate wasteOTCsOR drugs Anesthetics, controlledsubstances, and other drugs usedin surgerycontact to compile data from ORrecordsOral solids Antibiotics and other pills or tablets initially said that 1% of the time,waste may be generated; however,contact checked Pyxis records andall oral solids were returned toreverse distributor, but no quantitydata was availableNarcotics -tabs/capsDEA controlled substances in solidtablets or caplets.contact compiled data from Pyxiscomputer system; 8765 mg activeingredient, timeframe?SubtotalCount of wastestreams generating this quantity: 12Tuesday, November 12, 2002Page 6 of 14Business Type Waste Name Waste Name Description Generation Rate Description Quantityper YearUnitsChemo Chemotherapy drugs in solution ina vial or in a bag10 gallons per week1968408 mlExpired solutions saline solutions, total parenteralnutrition, most don't containmedicine10-20 liters per day3650000 mlPresser, nurse'sstationIV liquids that regulate bloodpressure10 bags (250 cc each) per day912500 mlHydrations normal saline, dextrose-basedsolutions, not likely to designate asdangerous wastecontact obtained data from Pyxissystem, 189.3 liters over 13 days5315000 mlIV room Expired small volume parenteralliquids, septum lid vial size rangedfrom 2 ml to 100 ml, partially filledwith leftover or expired solutions,some bags60 liters per month (dumped daily)720000 mlSubtotal ml12565908Count of wastestreams generating this quantity: 5Narcotics C-II 45.28 grams over 5 months0poundsChemo, >3% If chemo remaining in container is>3% of the waste, it is collected ashazardous waste.25 pounds per 9 months (assumedthis is total waste)33poundsIf chemo remaining in container is>3% of the waste, it is collected ashazardous waste.385 pounds per 9 months(assumed this is total waste)513poundsOral drugs Most are packaged for individualdoses, most in "bingo cards" andsome in resealable bags labeledfor a particular patient, several areantiviral drugscardboard box lined with red bag,about 1/2 drum size (25 gal) isfilled every 2 weeks; estimatedweight includes packaging80poundsTuesday, November 12, 2002Page 7 of 14Business Type Waste Name Waste Name Description Generation Rate Description Quantityper YearUnitsChemo, >3% If chemo remaining in container is>3% of the waste, it is collected ashazardous waste.data compiled from Pyxiscomputer system; 995 pounds for9 months (unclear whether this istotal waste or active ingredient,assumed it was total waste).1327poundsSubtotal pounds1953Count of wastestreams generating this quantity: 5nursing/boarding hometabs & pills 125 pills/week6500pillsSubtotal pills6500Count of wastestreams generating this quantity: 1other accountingno dataSubtotalCount of wastestreams generating this quantity: 1pharmacy - retailall wastes oral solids, injectables, topicalsand oral solutions, even droppedtabsno waste, all, even dropped tabs,returnedpills, tabs, etc. no quantity information givenSubtotalCount of wastestreams generating this quantity: 2oral solids estimated at 100 mg each 25 tabs or caps / year, each tab =100 mg, 2500 mg/year300pillsSubtotal pills300Count of wastestreams generating this quantity: 1pills and tablets expired OTC and Rx products Products not returned to reversedistributor estimated to be 3pounds per month - gross weight36poundsTuesday, November 12, 2002Page 8 of 14Business Type Waste Name Waste Name Description Generation Rate Description Quantityper YearUnitspills & tabs miscellaneous dropped andunidentified pills and tabletsFrom all 54 stores, eight liters ofmisc pill are collected, each literweighing about two pounds16poundspills and tablets All expired, unused, partial and fullpharmaceuticalsEight boxes (18" square) weighingan estimated 20 pounds each arecollected from the 54 Bartellsstores240poundsSubtotal pounds292Count of wastestreams generating this quantity: 3podiatristgloves, gownsand plasticthis is the majority of our waste -no quantity information givenSubtotalCount of wastestreams generating this quantity: 1ointment/lotion most are outdated samples about one cup per month2842 mlSubtotal ml2842Count of wastestreams generating this quantity: 1expired samples there is about 1 pill per packet andwe have maybe 5 pills per year5pillspills mostly outdated samples about 20 per month240pillsSubtotal pills245Count of wastestreams generating this quantity: 2reverse distributorIV solns/oralsolns/lg vials, etc.controlled substances regulated byDEA881 pounds over a nine monthperiod (packaging removed, andincludes basic container packaging1175poundslegend drugs 27 pounds (packaging removed,and includes basic containerpackaging) over a nine-monthperiod36poundsTuesday, November 12, 2002Page 9 of 14Business Type Waste Name Waste Name Description Generation Rate Description Quantityper YearUnitstabs/caps/vial/inj/patches/otic, etc.controlled substances regulated byDEA241 pounds in nine months (afterpackaging removed, and includesbasic container packaging)321poundstabs/caps/vials/inj/patches/otics, etc.legend drugs 151 pounds (after packagingremoved, and includes basiccontainer packaging) over a ninemonth period201poundsSubtotal pounds1733Count of wastestreams generating this quantity: 4specialty outpatientsamples fromreps (pills)receptionist was unable toestimate the amountinjectable antibiotics, hormones, anethetics no meds disposed, only sharpspills samples shared by three doctors;less than 5% of samples arewastedvery small quantity <5%samples/pills Guide unable to estimate astevolume of samples and pillsgenerated by three physicians andone physician assistantClass 2 Narcotics expired no idea; person questioned said hepurchases for 80 different doctorsand clinincs, but has nothing to dowith disposalSubtotalCount of wastestreams generating this quantity: 5debris IV tubing, syringes one IV tubing/syringe/gloves, etc.per month36 eachIV tubing, syringes one IV tubing/syringe/gloves, etc.,per month36 eachTuesday, November 12, 2002Page 10 of 14Business Type Waste Name Waste Name Description Generation Rate Description Quantityper YearUnitsvaccine sharps Occasionally a vaccine mightexpire, but it's very rare. We don'tkeep anything in stock - very fewinjections. We order only theamount we need and sendexpirations to the pharmacy. Wedispense meds through AllScript.We have multidose vials ofLidocaine, but use them up andhave no waste. We also havesome Neosporin, anantiflammatory.18 eachIV debris IV meds and debris. All the medsare used up2 doses per month24 eachSubtotal each114Count of wastestreams generating this quantity: 4injectables diuretics, fluids Guide said rarely administer IVs orinjections. Estimate IV fluids at1000 cc/month; injectables at 5cc/month12060 mlliquid inhaler 50 cc ev 6 months100 mlinjectable lidocaine 2 cc lidocaine left in syringe / 10vasectomies a month240 ml5 cc ev 6 months10 ml0.5 cc 2c/wk52 mlnarcotic 1 cc ev 3 months4 mlinjectable 1 cc ev 3 months4 mlone cc / two weeks26 mlexpired IV meds one sandwich-sized Ziploc bag50 mlTuesday, November 12, 2002Page 11 of 14Business Type Waste Name Waste Name Description Generation Rate Description Quantityper YearUnitsSubtotal ml12546Count of wastestreams generating this quantity: 9pills 10 pills ev 6 months20pillsoral solids expired birth control and allergypills20 or 30 per month30pillsantibiotics 5 to 10 pills/quarter30pillsSubtotal pills80Count of wastestreams generating this quantity: 3veterinaryChemo Chemotherapy drugs for animals,not a common vet procedurebecause pet owners often can'tafford treatment.Very small quantityChemotherapy drugs for animals,not a common vet procedurebecause pet owners often can'tafford treatment.Very small quantityChemotherapy drugs for animals,not a common vet procedurebecause pet owners often can'tafford treatment.Very small quantityTablets/pills Tablets/pills none disposedChemo Chemotherapy drugs for animals,not a common vet procedurebecause pet owners often can'tafford treatment.Very small quantitySubtotalCount of wastestreams generating this quantity: 5Hg thermometers 2 thermometers per year2 eachTuesday, November 12, 2002Page 12 of 14Business Type Waste Name Waste Name Description Generation Rate Description Quantityper YearUnitsSubtotal each2Count of wastestreams generating this quantity: 1injectableanestheticsKetamine/valium 99+% andPropathal0.5 ml/day183 mlinjectable anesthetic 1.5 cc twice a week150 mlexpired injectables 100 cc year100 mlinjectableanestheticsKetamine/valium 99+% 3-5 ml/day1460 mlKetamine/valium 99+% 1 ml/day365 mlKetamine/valium 99+% 1 ml/day365 mlKetamine/valium 99+% 2 ml/day730 mlKetamine/valium 99+% 1 ml/day365 mlinjectable antibiotic 10 cc week500 mlSubtotal ml4218Count of wastestreams generating this quantity: 9Tablets/pills Tablets/pills 6 tablets or pills per year6pillsTablets/pills none disposed0pillsTablets/pills none disposed0pillsTablets/pills none disposed0pillsSubtotal pills6Count of wastestreams generating this quantity: 4Chlorhexidene Disinfectant/irrigant for wounds,absorbed with surgical scrubs orsterile gauze3 cups per year plus debris(assumed 3 cups weighed 2pounds and debris weighed 2pounds)4poundsTuesday, November 12, 2002Page 13 of 14Business Type Waste Name Waste Name Description Generation Rate Description Quantityper YearUnitsSubtotal pounds4Count of wastestreams generating this quantity: 1Tuesday, November 12, 2002Page 14 of 14King County - Pharmaceutical Waste Survey 67 

# APPENDIX F

WHERE ARE DRUG WASTES DISPOSED?68 King County - Pharmaceutical Waste SurveyWhere are Drug Wastes Disposed?Waste Goes: Waste Name and Description Generation Rate Description Quantityper YearUnitsDisposition CommentsNo dataNarcotics - tabs/caps DEA controlled substances in solidtablets or caplets.contact compiled data from Pyxiscomputer system; 8765 mg activeingredient, timeframe?Notes unclear, sanitary sewer? Solids also?legend injectables generated at pharmacy IV room,legend drug (<1%) combined witha solution composed primarily ofpotassium, phosphorus, calcium,magnesium, insulin, normal salinecontact unable to estimateNarcotics - othermiscellaneousDEA controlled substances contact checked Pyxis system forquantity data; 1015 mgs disposedNarcotics - solution based DEA controlled substances contact checked Pyxis system forquantity data; 15 mls disposedNarcotics - injectables DEA controlled substances contact checked Pyxis system forquantity data; 448 mg disposedno dataSubtotalCount of wastestreams generating this quantity: 6Down the drainTuesday, November 12, 2002Page 1 of 18Waste Goes: Waste Name and Description Generation Rate Description Quantityper YearUnitsDisposition CommentsPresser, ICU IV liquids that regulate bloodpressure, commonly prescribed forpatients coming out of surgery andin the intensive care unitcontact to compile data from Pyxiscomputer system; amount isexpected to be smallAll solutions except chemo go to the sanitary sewer. Emptieddebris goes to solid wasteDEA drugs no quantity/volume data availablewitnessed disposal to sewerInjectable anesthetics waste about 1 mg drug (activeingredient) per week for a total ofapproximately 8 patients per week,no data on total amount of wasteTPN total parenteral nutrition, patientreceives nutrients through IV, maynot designate as hazardous,contains amino acids, dextrose,enzymes, vitamins (K &C),potassium, calcium, sodium andsaline solutioncontact compiled data from Pyxiscomputer system, 28.4 liters over13 daysAll solutions except chemo go to the sanitary sewer. Emptieddebris goes to solid wasteSubtotalCount of wastestreams generating this quantity: 4injectable anesthetics Ketamine/valium 99+% 2 ml/day 730 mlGoes into the sinkinjectable anesthetics Ketamine/valium 99+% 1 ml/day 365 mlGoes into the sinkTuesday, November 12, 2002Page 2 of 18Waste Goes: Waste Name and Description Generation Rate Description Quantityper YearUnitsDisposition Commentsinjectables fentanyl, demerol, versed,morphine - controlled substances;propofol, lidocaine, marcaine42 cases over 7 days, average 205cases/month, with (a very closeestimate) 3117 mg activeingredients - calculates to 50 ccsolution per week2600 mlThese are mostly controlled substances that are "wasted" downthe drain as that is the only safe way known to us to deal withnarcoticsIV room Expired small volume parenteralliquids, septum lid vial size rangedfrom 2 ml to 100 ml, partially filledwith leftover or expired solutions,some bags60 liters per month (dumped daily) 720000 mlExpired solutions saline solutions, total parenteralnutrition, most don't containmedicine10-20 liters per day 3650000 mlinjectable anesthetics Ketamine/valium 99+% 1 ml/day 365 mlGoes into the sinkinjectable anesthetics Ketamine/valium 99+% 1 ml/day 365 mlGoes into the sinkinjectable anesthetics Ketamine/valium 99+% 3-5 ml/day 1460 mlGoes into the sinkHydrations normal saline, dextrose-basedsolutions, not likely to designate asdangerous wastecontact obtained data from Pyxissystem, 189.3 liters over 13 days5315000 mlto sanitary sewerinjectable one cc / two weeks 26 mlTuesday, November 12, 2002Page 3 of 18Waste Goes: Waste Name and Description Generation Rate Description Quantityper YearUnitsDisposition Commentsinjectable anesthetics Ketamine/valium 99+% andPropathal0.5 ml/day 183 mlGoes into the sinkInjectables only heparin and IV iron maytypically become wasteestimated at much less than 15cc/day of total injectables;assumed 15 for estimate below:15 ml/day x 365 day/yr = 5475 ml/yr5475 mlexpired meds once every 6 months 24 oz goesdown the drain1421 mlsome expired meds go overseasLeftover narcotic 10 cc per month 120 mldischarged into the linens, when linens are laundered the druggoes down the drainPartial injections Demerol maybe once per month 12 mlinto the sinkPresser, nurse's station IV liquids that regulate bloodpressure10 bags (250 cc each) per day 912500 mlAll solutions except chemo go to the sanitary sewer. Emptieddebris goes to solid wasteexpired samples usually liquids she really couldn't give me anumber. But she agreed that itwas probably once a month theywould have some liquids theywould flush down the toilet. I willassume the smallest number 1 mleven though this is a huge facility12 mlliquids narcotics 10 cc per year 10 mlnarcotics are "wasted" down the drainTuesday, November 12, 2002Page 4 of 18Waste Goes: Waste Name and Description Generation Rate Description Quantityper YearUnitsDisposition CommentsSubtotal ml10610644Count of wastestreams generating this quantity: 18pills 10 doses per year 10 pillsdissolve down the drainantibiotics 5 to 10 pills/quarter 30 pillsDestruction policy: Immediate destruction to toilet if expired atquarterly reviewsamples and pills 25 boxes of four pills each 100 pillsPills Unused expired pills less than 25 per year 24 pillsMost unused pills are sent back to the pharmacy before theexpiration date to avoid waste. If expired, pills go down thedrain.expired samples and pills 2000 in last four months 6000 pillsSamplesexpired samples about once every 6 months theyhve 12 or less pills. They crushthe pills, soak them in water andput down the drain24 pillsSubtotal pills6188Count of wastestreams generating this quantity: 6In the trashBetadyne disinfectants spray bottles used, disinfectantwiped up with rags"no waste" however, waste ragsare going into the garbageTuesday, November 12, 2002Page 5 of 18Waste Goes: Waste Name and Description Generation Rate Description Quantityper YearUnitsDisposition CommentsChemo, <3% If chemo remaining in container is< 3% of the total waste, it goes tosolid waste. Site referred to this asthe bag factor.contact to compile data from Pyxiscomputer system; most chemowaste is managed this waySubtotalCount of wastestreams generating this quantity: 2debris IV tubing, syringes one IVtubing/syringe/gloves, etc.,per month36 eachsometimes into biohazards, thoughSubtotal each36Count of wastestreams generating this quantity: 1narcotic 1 cc ev 3 months 4 mlSubtotal ml4Count of wastestreams generating this quantity: 1pills outdated samples 20 pills every 6 months 40 pillsthey crush pills before they throw in the trashpills about once every 6 months wehave 6 bills we throw in thegarbage12 pillsexpired meds about every 6 months they have 3or 4 boxes of pills (5 pills in echbox average) that expire. Wethrow them in the garbage35 pillsTablets/pills Tablets/pills 6 tablets or pills per year 6 pillsMost pills returned to distributor or manufacturer, so only a fewgo in the trash.Subtotal pills93Count of wastestreams generating this quantity: 4Tuesday, November 12, 2002Page 6 of 18Waste Goes: Waste Name and Description Generation Rate Description Quantityper YearUnitsDisposition CommentsChlorhexidene Disinfectant/irrigant for wounds,absorbed with surgical scrubs orsterile gauze3 cups per year plus debris(assumed 3 cups weighed 2pounds and debris weighed 2pounds)4 poundspills and tablets expired OTC and Rx products Products not returned to reversedistributor estimated to be 3pounds per month - gross weight36 poundsSubtotal pounds40Count of wastestreams generating this quantity: 2Into biohazard containerinjectable antibiotics, hormones, anethetics no meds disposed, only sharpssharps/biohazardsmultidose vials from which amounts are taken as needed untilused up. All med in syringe is used.Chemo Chemotherapy drugs for animals,not a common vet procedurebecause pet owners often can'tafford treatment.Very small quantityAll chemo waste disposed in "Chemo" containers and routed asbiohazardous waste for incineration.gloves, gowns and plastic this is the majority of our waste -no quantity information givensamples/pills Guide unable to estimate astevolume of samples and pillsgenerated by three physicians andone physician assistantTuesday, November 12, 2002Page 7 of 18Waste Goes: Waste Name and Description Generation Rate Description Quantityper YearUnitsDisposition CommentsChemo Chemotherapy drugs for animals,not a common vet procedurebecause pet owners often can'tafford treatment.Very small quantityAll disposed in Chemo containers and routed as biohazardouswaste for incineration.Chemo Chemotherapy drugs for animals,not a common vet procedurebecause pet owners often can'tafford treatment.Very small quantityAll disposed in Chemo containers and routed as biohazardouswaste.Chemo Chemotherapy drugs for animals,not a common vet procedurebecause pet owners often can'tafford treatment.Very small quantityAll disposed in Chemo containers and routed as biohazardouswaste.samples from reps (pills) receptionist was unable toestimate the amountpackaging and pills are disposed of together in the biohazardscontainer, which is shipped off to main clinic in Renton anddisposed of as biohazard.ampoules partially used no datagoes into biohazard container and gets collected by stericycleother, mostly gloves most of our wasteSubtotalCount of wastestreams generating this quantity: 10Empty syringe no meds in syringes, generatedduring flu season2,500 per year 2500 eachGoes to StericycleTuesday, November 12, 2002Page 8 of 18Waste Goes: Waste Name and Description Generation Rate Description Quantityper YearUnitsDisposition CommentsIV debris IV meds and debris. All the medsare used up2 doses per month 24 eachdebris waste goesinto biohazarddebris IV tubing, syringes one IVtubing/syringe/gloves, etc.per month36 eachsometimes in the trash, though.Hg thermometers 2 thermometers per year 2 eachSubtotal each2562Count of wastestreams generating this quantity: 4syrup one pint/month 6405 mlinjectable anesthetics narcotics, Propofol, Versed Average approximately 3 cc perpatient, range 2-5 cc's". 3 ml/pt x250 pt/mo x 12 mo/yr = 9000 ml/yr9000 mlcollected in sharps container and sent to Stericycleointment/lotion most are outdated samples about one cup per month 2842 mlliquids 2 cc per year 2 mlinjectables DHE - single-dose vials no drug waste - drug all used up.Just the syringe0 mljust the syringe, emptyinjectables diuretics, fluids Guide said rarely administer IVs orinjections. Estimate IV fluids at1000 cc/month; injectables at 5cc/month12060 mlTuesday, November 12, 2002Page 9 of 18Waste Goes: Waste Name and Description Generation Rate Description Quantityper YearUnitsDisposition Commentsinjectable lidocaine 2 cc lidocaine left in syringe / 10vasectomies a month240 mlsharps/biohazardsinjectable antibiotic 10 cc week 500 mlinjectable expired injectables 100 cc year 100 mlinjectable 1 cc ev 3 months 4 mlantibiotics about once a month they have 1/2ml of waste6 mlvaccine about once a mnoth they have 1/2ml of waste6 mlunused injections once every 2 to 3 months theyhave about 1 cc of waste injectionto put into sharps container5 mlOral solids and unusedinjectablesBottles of pills are emptied into thebiohazard container located in thepharmacy. Empty pill bottles go inregular garbage. Unused injectableliquids in vials also go into thepharmacy biohazard container.One gallon container filled every 6months.7571 mlGoes to Harborview Medical Center Purchasing, and ultimatelydisposed as dangerous waste.Tuesday, November 12, 2002Page 10 of 18Waste Goes: Waste Name and Description Generation Rate Description Quantityper YearUnitsDisposition CommentsUsed injectables About once a month, an individualdose is withdrawn from a septumvial of injectable drug that is lessthan the total amount in the vial.The left-over liquid (about 1 cc) inthe vial is disposed into thebiohazard container with the usedinjection sharp. Sometimes thepharmacist adds used sharps/vialwaste from teaching patients selfinjection.One cc in one vial per month 12 mlGoes to Harborview, ultimately goes to BFI biohazardous waste.injectable 0.5 cc 2c/wk 52 mlinjectable anesthetic 1.5 cc twice a week 150 mlvaccines about once a month they have 1/2ml of vaccine they have to waste6 mlSubtotal ml38961Count of wastestreams generating this quantity: 18pills (samples) pills-samples 6 to 10 a year in thebiohazard8 pillsonly takes samples of things he can use. Uses them up - rarelyexpire. Has and would dispose of them in the red bag.pills mostly outdated samples about 20 per month 240 pillspills/powder 10 doses / month 120 pillsThe biohazards go out with associated adult clinic and labbiohazardous wasteTuesday, November 12, 2002Page 11 of 18Waste Goes: Waste Name and Description Generation Rate Description Quantityper YearUnitsDisposition Commentsexpired samples about every month there are 2boxes of pills in bingo cards,around 6 pills in each bingo card144 pillspills 5 pills per year 5 pillsSubtotal pills517Count of wastestreams generating this quantity: 5Oral drugs Most are packaged for individualdoses, most in "bingo cards" andsome in resealable bags labeledfor a particular patient, several areantiviral drugscardboard box lined with red bag,about 1/2 drum size (25 gal) isfilled every 2 weeks; estimatedweight includes packaging80 poundsGoes to Richard with Biohazardous waste, marked forincineration at StericycleSubtotal pounds80Count of wastestreams generating this quantity: 1In a collection binoral solids expired birth control and allergypills20 or 30 per month 30 pillsStored in several biohazard boxes, but not disposed of yet. Wedon't know what to do with it.Subtotal pills30Count of wastestreams generating this quantity: 1Back topharmacyone dose one dose, between five and tenccs every six months15 mlback to Swedish Hospital pharmacyLiquids Typical wastes are cough syrupand lidocaine.cough syrup 240 ml/yr other (e.g.,lidocaine) 100 ml/yr.340 mlBack to PacMed Pharmacy - Beacon Hill, or back to Dept. ofHealth (vaccines). Cough syrup only goes to biohazard.Tuesday, November 12, 2002Page 12 of 18Waste Goes: Waste Name and Description Generation Rate Description Quantityper YearUnitsDisposition CommentsSubtotal ml355Count of wastestreams generating this quantity: 2Reverse distributorpills, tabs, etc. no quantity information giventhrough central officeOral solids Antibiotics and other pills or tablets initially said that 1% of the time,waste may be generated; however,contact checked Pyxis records andall oral solids were returned toreverse distributor, but no quantitydata was availableMore expired drugs at this site go to reverse distributor than atother hospitals observed.OTC over-the-counter drugs expired drugs go to reversedistributor, don't generate wasteOTCssamples two physicians give out about 90%of samples, leaving 10% wastequantity of sample waste isunknownOR drugs Anesthetics, controlledsubstances, and other drugs usedin surgerycontact to compile data from ORrecordsPS Industries picks up the wasteall wastes oral solids, injectables, topicalsand oral solutions, even droppedtabsno waste, all, even dropped tabs,returnedAll, even dropped tabs, are returnedNarcotics DEA controlled substances contact to compile data from Pyxiscomputer systemPS Industries picks up the wasteTuesday, November 12, 2002Page 13 of 18Waste Goes: Waste Name and Description Generation Rate Description Quantityper YearUnitsDisposition CommentsSubtotalCount of wastestreams generating this quantity: 7tabs & pills 125 pills/week 6500 pillsSubtotal pills6500Count of wastestreams generating this quantity: 1Narcotics C-II 45.28 grams over 5 months 0 poundspills and tablets All expired, unused, partial and fullpharmaceuticalsEight boxes (18" square) weighingan estimated 20 pounds each arecollected from the 54 Bartellsstores240 poundspills & tabs miscellaneous dropped andunidentified pills and tabletsFrom all 54 stores, eight liters ofmisc pill are collected, each literweighing about two pounds16 poundsThe pharmacy recognizes it will not receive credit for theseitems, but doesn't know how to deal with them otherwise anddoes not want to contaminate the water or soil.Subtotal pounds256Count of wastestreams generating this quantity: 3HW VendorChemo Chemotherapy drugs in solution ina vial or in a bag10 gallons per week 1968408 mlGoes to Richard with Environmental Services (not BioHazard)Subtotal ml1968408Count of wastestreams generating this quantity: 1Chemo, >3% If chemo remaining in container is>3% of the waste, it is collected ashazardous waste.data compiled from Pyxiscomputer system; 995 pounds for9 months (unclear whether this istotal waste or active ingredient,assumed it was total waste).1327 poundsTuesday, November 12, 2002Page 14 of 18Waste Goes: Waste Name and Description Generation Rate Description Quantityper YearUnitsDisposition CommentsChemo, >3% If chemo remaining in container is>3% of the waste, it is collected ashazardous waste.385 pounds per 9 months(assumed this is total waste)513 poundstabs/caps/vial/inj/patches/otic, etc.controlled substances regulated byDEA241 pounds in nine months (afterpackaging removed, and includesbasic container packaging)321 poundsChemo, >3% If chemo remaining in container is>3% of the waste, it is collected ashazardous waste.25 pounds per 9 months (assumedthis is total waste)33 poundsIV solns/oral solns/lgvials, etc.controlled substances regulated byDEA881 pounds over a nine monthperiod (packaging removed, andincludes basic container packaging1175 poundstabs/caps/vials/inj/patches/otics, etc.legend drugs 151 pounds (after packagingremoved, and includes basiccontainer packaging) over a ninemonth period201 poundsIV solns/oral solns/lgvials, etc.legend drugs 27 pounds (packaging removed,and includes basic containerpackaging) over a nine-monthperiod36 poundsSubtotal pounds3606Count of wastestreams generating this quantity: 7Other - describeTuesday, November 12, 2002Page 15 of 18Waste Goes: Waste Name and Description Generation Rate Description Quantityper YearUnitsDisposition Commentspills samples shared by three doctors;less than 5% of samples arewastedvery small quantity <5%most are donated tofree health clinics orchurchorganizations. Afew go to the sewer.Class 2 Narcotics expired no idea; person questioned said hepurchases for 80 different doctorsand clinincs, but has nothing to dowith disposalDEA-licensedvendor whoincinerateseverythingTablets/pills Tablets/pills none disposedAll returned todistributor ormanufacturer ordonated to freecare clinicsSubtotalCount of wastestreams generating this quantity: 3vaccine sharps Occasionally a vaccine mightexpire, but it's very rare. We don'tkeep anything in stock - very fewinjections. We order only theamount we need and sendexpirations to the pharmacy. Wedispense meds through AllScript.We have multidose vials ofLidocaine, but use them up andhave no waste. We also havesome Neosporin, anantiflammatory.18 eachsharps containerNote conflict: expired meds go to pharmacy, but expiredvaccines go into sharps container.Subtotal each18Count of wastestreams generating this quantity: 1injectable 5 cc ev 6 months 10 mlto MD that doesmissionary work in3rd world countriesTuesday, November 12, 2002Page 16 of 18Waste Goes: Waste Name and Description Generation Rate Description Quantityper YearUnitsDisposition Commentsliquid inhaler 50 cc ev 6 months 100 mlto MD that doesmissionary work in3rd world countriesexpired IV meds one sandwich-sized Ziploc bag 50 mlWorld ConcernSubtotal ml160Count of wastestreams generating this quantity: 3pills 10 pills ev 6 months 20 pillsto MD that doesmissionary work in3rd world countriessamples I check the samples about every 3or 4 months. I find about 10samples that have expired. Theyhave 1 or 2 pills in each sample60 pillsreturn to vendorexpired pills one of the doctors take the expiredpills to Latvia. Also they have inthe past sent some to WorldConcern. I got her to give me arange and she agreed to "morethan a dozen in a year" I willassume that each packet contains4 pills 4 x 13 = 5252 pillsother countriesTablets/pills Tablets/pills none disposed 0 pillsAll returned todistributor ormanufacturer ordonated to freecare clinicsexpired samples there is about 1 pill per packet andwe have maybe 5 pills per year5 pillsthey save andoccasionallysomeone calls whois going to a 3rdworld country andtakes themthey haven't had anyone call for a whileTuesday, November 12, 2002Page 17 of 18Waste Goes: Waste Name and Description Generation Rate Description Quantityper YearUnitsDisposition CommentsTablets/pills Tablets/pills none disposed 0 pillsAll returned todistributor ormanufacturer ordonated to freecare clinicsoral solids neurology clinic - pills only on sitein bingo cards20 to 50 pills in bingo cards everythree months140 pillsthe drug sales reptakes themdon't know what rep does with themTablets/pills Tablets/pills none disposed 0 pillsAll returned todistributor ormanufacturer ordonated to freecare clinicsoral solids estimated at 100 mg each 25 tabs or caps / year, each tab =100 mg, 2500 mg/year300 pillsundiscloseddo these go back to reverse distributor? If not, where are theydisposed?pills one or two doses one or two doses (pills) per month 18 pillsany expiredvaccines go back tothe Health Dept.Nothing goes to the red bag.Subtotal pills595Count of wastestreams generating this quantity: 10Tuesday, November 12, 2002Page 18 of 18King County - Pharmaceutical Waste Survey 89 

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