Recycling Unused Medicines to Save Money and Lives

It always troubled Deane Kirchner to throw away good medicine. When residents of the Lincoln Glen long-term facility in San Jose, Calif., where she is the director of nursing, changed dosages, had adverse reactions, or died, she did what health professionals regularly do: sent their unused medicines to be destroyed.

“Throughout my entire nursing career, it’s something I‘ve done,” said Kirchner, who has been a nurse for 21 years. “And each time I would think: ‘It’s such a waste. There are people out there who have to choose whether to buy medications or buy groceries.’”

Lots of people, in fact. In 2012, studies indicate, about one in four American adults — perhaps 50 million people — failed to fill a prescription they needed because of the cost. Among adults who were uninsured, the figure was 43 percent. (PDF, p. 28).

For older adults, who take four to five medicines on average per week, this is a crisis. Sadly, one in five seniors reports cutting back on basics like food or heat to afford prescription drugs. This is dangerous. Those with cardiovascular disease who said they took less medicine than directed due to cost were 50 percent more likely to experience angina, strokes or non-fatal heart attacks. For many others, cutting back on medicine led to faster health declines, increased hospitalizations and premature death. (PDF, pp. 7-8).

And yet, each year, hospitals, pharmacies, manufacturers and nursing homes send billions of dollars worth of medicines to be destroyed.

Lincoln Glen is no longer one of them.

Now, one day each quarter, Kirchner logs on to a web-based service created by a nonprofit organization called Sirum, which was founded by three young Stanford graduates: George Wang, Adam Kircher and Kiah Williams. “We’ve been compared to a Match.com for unused medicine,” said Williams. “Our goal is to save lives by saving unused medications. We thought we could use technology to bridge this gap between surplus and need.”

Sirum was designed to make it easy for institutions to donate medicines with the assurance that they would be safely transported and dispensed to people who needed them. Kirchner finds the process surprisingly simple. “I scan the label on each prescription that was applied by the pharmacist,” she said. “It tells me what medicine it is and I enter in the number of tablets or units.”

Donors can select the clinics or pharmacies that will receive their medications. Kirchner’s recipient is Santa Clara County’s public health pharmacy, which re-distributes medicines county-wide, based on need. “Once I get it all entered and click submit, it prints off a FedEx mailing label. I put it in the box, mark out the names for confidentiality, apply the label and set it outside my door. He picks it up the next day.”

Sirum later sends an email indicating that the recipient has verified the contents. State laws require a pharmacist or, in some cases, a physician to check donated medicine before dispensing, said Adam Kircher, one of Sirum’s co-founders.

The organization tracks the value of the medications using the National Average Drug Acquisition Cost database and follows up with the donor quarterly, reporting the value of the drugs donated and the estimated number of patients assisted.

Last week, Kirchner sent out two dozen medications — worth $825 — anti-depressants, anti-psychotics and drugs for conditions that included hypertension, chronic obstructive pulmonary disease, diabetes and asthma.

“The process took me about 45 minutes,” she said.

Not a bad use of time. “For a midsize nursing home with 50 to 75 beds, we’ll typically see $6,000 in medications donated each year, usually once per quarter,” Kircher said. “It costs us $10 in shipping to get that $1,500 donation to a clinic. If we could do this across the country, it would prevent many needless deaths and emergency room visits and the savings could be astronomical.”

Health care facilities aren’t the only sources in positions to donate unused pharmaceuticals. Drug manufacturers keep safety stocks to avoid potential shortfalls and pharmacies regularly have unclaimed prescriptions. When unused stocks reach their expiration dates, they are most often returned to manufacturers or distributors and then destroyed, usually by incineration. This happens with about 3 percent of drugs. In a country that spends $270 billion on prescriptions annually, that’s a huge waste. (PDF). 

 Some drugs that have gone through Sirum’s system are almost literally worth their weight in gold. A unit of Invega Sustenna, used to treat schizophrenia, is listed on the drug cost database at $1,250, but it can retail online for upwards of $2,000. The price for a typical fill of Procrit, used to treat anemia caused by chronic kidney failure, H.I.V. therapy or chemotherapy, is more than $1,800.

“If we’re recycling five-cent soda cans,” said Williams, “we should be recycling medicine.”

In fact, over the past 15 years, about 40 states have enacted laws authorizing the reuse, at the institutional level, of unused drugs that are not controlled substances. Still, the staffs at many institutions are unaware of the donation programs and many lack accessible systems to take advantage of them. (In most circumstances, individuals cannot donate unused medicines. The Food and Drug Administration provides guidelines for safe disposal.)

The largest state-level drug donation program is believed to be in Iowa, where it’s estimated that close to $13 million worth of medications have been reused to assist 52,000 low-income patients since 2007. “It’s growing significantly,” said Jon-Michael Rosmann, executive director of the Iowa Prescription Drug Corporation, a nonprofit organization that is a centralized repository for the program. “But there’s much more demand.” The donation program costs about $500,000 a year to run, and annually distributes four to six times that cost in donations.

California passed its first drug recycling legislation in 2005. The bill’s sponsor was Joe Simitian, then a California state senator and now a Santa Clara County supervisor. “Basically, you’ve got folks on one side of the street who have a desperate need and folks on the other side of the street who are tossing the stuff away,” he said. “Shouldn’t there be a way to connect them?”

At the time, the state’s board of pharmacy approved a pilot program allowing medicines to be donated provided they were collected and maintained under the authority of a pharmacist. In 2011, Sirum asked Simitian to see if the law could be expanded to encompass more facilities.

He sponsored legislation that allowed more facilities to donate medications and permitted recipients to be either pharmacies or clinics that operate dispensaries.

That set the stage for Sirum, which has a full-time staff of only five, to forge relationships across California with help from organizations like the California Health Care Foundation. “We’d been hearing from people that this was a big need,” said Margaret Laws of the foundation. Using technology to make an efficient transfer seemed like an obvious idea, she added. “But it’s not a no-brainer to get it done.”

Educating institutions about the new laws and getting them to change their habits are still big challenges. “Health care is very regulated field and a lot of people are rightfully concerned with following regulations,” said Williams. “They’ve been destroying medicines for 20 or 30 years. Their hair isn’t on fire with a burning need to change. Yes, there’s a cost to destroy the medicines — but it’s not their biggest cost. And there is a cost to switch — it requires a behavior change.”

Last year, Sirum started working in Oregon and Colorado. Currently the platform is used by 200 donating facilities and a dozen receiving organizations — county-owned and federally qualified health centers, and clinics that serve low-income patients. Donors pay nothing, but Sirum asks recipients with sufficient means to pay a membership fee that is roughly 25 percent of the value of the medicines they receive. To date, Sirum reports that it has facilitated donations worth $3.7 million and estimates that 35,000 patients have been assisted.

One new partner organization, Central City Concern, provides housing, health care, employment and recovery services to homeless and other low-income people in Portland, Ore. “Our patients have multiple disease states,” said Sandy Anderson, Central City Concern’s head pharmacist. “They need medications for mental health, diabetes, hypertensions, PTSD, schizophrenia. It’s a complex group.”

Each week, Anderson’s pharmacy dispenses 600 to 700 prescriptions to people who are uninsured at a cost of $1,500 to $2,000. Now some of those medicines are being donated from Oregon institutions like the Mennonite Village nursing home in Albany, the Payless Long Term Care Pharmacy in Tigard, and the Consonus Pharmacy in Milwaukie.

“I had talked with Payless,” Anderson said. “They said we have so much medicine that we throw away. But I didn’t have any way of getting it to our pharmacy.” Neither wanted to assume the legal or logistical responsibilities for transporting medicines.

Now, with Sirum managing the transfers, she envisions cutting the cost of medications for her uninsured clients in half. “Any time we can save money, we have more for our housing and community wellness programs,” she said.

Drug donations also mean less waste. In Colorado, Sirum helped the state’s Department of Health and Environment draft a drug donation bill that was signed into law last week, and helped to set up a pilot program. Colorado has some 300 nursing care facilities, each of which throws out 100 pounds of medicine per year on average, said Joe Schieffelin, who manages the department’s solid and hazardous waste program.

“About three years ago, we started outreach to long term care facilities because we learned they weren’t managing their drugs in a compliant way,” he said. Some facilities were flushing pharmaceuticals down the toilet.

Sewage treatment is not set up to handle medicines. The chemicals flow right through and end up discharged into creeks and rivers, said Schieffelin. “Even very low doses of some pharmaceuticals can cause the feminization of fish, throwing things off balance.” (PDF).

Sirum’s founders are eager to go national. They want to launch programs this year in two or three other states, possibly Ohio and Washington. “If we can find five potential donors and one recipient, we will come to your state,” said Williams

Kircher added that “the benefit we can offer is on the technology side” — making inventory management and record-keeping easier and improving the “user experience for medicine donors.”

And, of course, improving the “user experience” for recipients.

“These tiny pills and inhalers can be the difference between someone living a good life or not,” said Williams

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David Bornstein is the author of “How to Change the World,” which has been published in 20 languages, and “The Price of a Dream: The Story of the Grameen Bank,” and is co-author of “Social Entrepreneurship: What Everyone Needs to Know.” He is a co-founder of the Solutions Journalism Network, which supports rigorous reporting about responses to social problems.