Medication recycling: New patients for old pills

Medication recycling is an idea whose time has not yet come. "We all recognize the absurdity of throwing away perfectly good and terribly expensive medications," said John Cronin, senior VP, California Pharmacists Association. California is one of several states debating legislation to allow the return and reuse of unused drugs. "The economic reality is that it is just not practical. There has got to be a way to do it, but nobody has figured out how to get it right yet."

It's not for lack of trying. Louisiana, Nebraska, Ohio, Oklahoma, and Texas have passed laws that allow medications to be recovered from long-term care (LTC) facilities, repackaged, and dispensed again. California, Delaware, Maine, Washington, and other states are looking at medication recycling to reduce costs.

Medication recycling can cut costs. Oklahoma saves about $120,000 annually by redispensing unused medications from nursing homes in the Tulsa area. The meds are collected, often by volunteer physicians, repackaged by volunteer pharmacists, and distributed by county-run charity pharmacies and state-operated mental health programs.

Food & Drug Administration regulations generally prohibit the return and redispensing of medications, Potter said. That limits the practice to programs under state control, primarily medications dispensed to Medicaid patients.

In order to allay concerns about storage conditions and potential tampering, the Unused Prescription Drug Program for Oklahoma's Medically Indigent takes in only drugs dispensed to LTC facilities in which the facility, not the resident, maintained custody. Meds must be in the original, sealed unit-dose package or be an unused injectable product. Controlled substances cannot be recycled under Drug Enforcement Administration rules.

"Right now, medication recycling is all over the map," said Thomas Clark, director of policy and advocacy, American Society of Consultant Pharmacists. "Return, repackaging, and redistribution are quite costly. The critical question is will the payer be willing to cover those costs."

Payment is one of the issues holding up implementation of a recycling program in Texas, according to the Texas Pharmacy Association. Documentation is another stumbling block.

HIPAA, the Health Insurance Portability & Accountability Act, requires electronic transactions for LTC pharmacy operations, explained Paul Baldwin, executive director of the Long Term Care Pharmacy Alliance (LTCPA), which represents four national LTC pharmacy chains. Every pharmacy transaction must be part of the HIPAA Transactions Code Set.

"There is no code for returning an unused drug to stock for credit," Baldwin said. "Nobody is in favor of seeing medications wasted, but the regulations are clear. You can't recycle medications effectively until those codes are in place."

Where medication recycling moves from here is unclear. A LTCPA position paper notes that restocking fees and transaction codes are major barriers to return and reuse of medication.

There are also questions surrounding current practices such as stripping unused meds from heat-sealed packaging and reassembling them in new heat-sealed packages.

Joni Cover, executive VP of the Nebraska Pharmacists Association, said there are more effective ways to cut the medication spend than recycling. Nebraska allows recycling of drugs from LTC facilities as well as certain high-cost cancer drugs.

Cover said an obvious first step is to dispense in seven-day blister packs. If a patient stops using a medication, there is far less waste. Expanding the use of generics is another obvious cost-saver, she said. So is expanding the role of pharmacists in reviewing drug therapy for LTC patients.