Changing Cultural Practices Around Prescription Drugs

Holding a national prescription drug take-back day has some immediate benefit in terms of protecting the environment and reducing prescription drug abuse and accidental poisonings at the far margins. But if we are still doing these sorts of “events” a decade from now, it will be a policy failure.

A sheriff in an Arkansas town of about 25,000 people told me that at one poorly advertised 5 hour take back event his deputies held in a parking lot next to Wal-Mart, they collected 50,000 pills. That’s amazing for a town that size, but consider a bigger number: There will be about 150 million prescriptions written for a single pain killer (hydrocodone) this year. Single day events, however impressive, will not stem this tide.

What is needed instead is a change in cultural practice such as what has happened with recycling. In the late 1970s and early 1980s, recycling was something that happened rarely, and was billed as an event, e.g., A dozen non-profits will be recycling your old newspapers and glass at the shopping mall this Saturday, come on down! At one such event, a friend of mine who worked at the same non-profit as I did told me as I separated brown and clear glass that when he lived in Germany there were no recycling days. There were big bins for different types of glass and people just put their glass in. He assumed they would mix everything up and climbed up on a bin to see. He was shocked to observe that the glass was nearly perfectly sorted.

We need something like this mentality to take hold in our culture around prescription drugs, just as it has for recycling glass and newspaper. We don’t have “recycling day” any more, we just do it because it’s what you do. Those recycling days were in that sense a success, because they raised the visibility of recycling and helped make it a standing cultural practice (as did other things, like a deposit on bottles).

For the same cultural practice to take hold with prescriptions, getting rid of unused medication needs to be behaviorally easy and cognitively meaningless (i.e., we just do it because it’s what we do). One possible method is to give out pre-paid return mailers with every prescription and also have them available in libraries, community centers, post offices, hospital waiting areas and the like. Another is to work with private industry such that whenever you go to a drug store, you can toss your old meds into a bin next to cash register. Until we get such a system in place pragmatically and in our cultural habits, we have little chance of making a major impact on the epidemic of prescription drug addiction and overdose that is sweeping the country.

Author: Keith Humphreys

Keith Humphreys is the Esther Ting Memorial Professor of Psychiatry at Stanford University and an Honorary Professor of Psychiatry at Kings College London. His research, teaching and writing have focused on addictive disorders, self-help organizations (e.g., breast cancer support groups, Alcoholics Anonymous), evaluation research methods, and public policy related to health care, mental illness, veterans, drugs, crime and correctional systems. Professor Humphreys' over 300 scholarly articles, monographs and books have been cited over thirteen thousand times by scientific colleagues. He is a regular contributor to Washington Post and has also written for the New York Times, Wall Street Journal, Washington Monthly, San Francisco Chronicle, The Guardian (UK), The Telegraph (UK), Times Higher Education (UK), Crossbow (UK) and other media outlets.

17 thoughts on “Changing Cultural Practices Around Prescription Drugs”

  1. I can certainly agree with this: As a former cancer patient, I've got a tackle box full of fairly expensive prescription drugs I didn't finish, anti-nausea drugs, pain killers, you name it. It seems a crying shame they can't be recycled for the benefit of patients who lack good insurance coverage. Of course, the consequence of getting two pills mixed up could be rather horrific… Seems to me there's no good reason every single tablet shouldn't have a barcode printed on it, or even a tiny RFID chip identifying it, so that sorting could be automatically 100 reliable. The latter could have come real advantages in pediatric poisoning cases, too.

    But just some provision for getting rid of them without their ending up leaching into the water table would be welcome. Think I'll take that tackle box to my oncologist next visit, thanks for the reminder.

  2. An epidemic of prescription drug addiction and overdose is sweeping the country? Numbers, please.

    All I see is an attempt to gin up yet another epidemic of unwarranted anti-drug hysteria.

  3. "All I see is an attempt to gin up yet another epidemic of unwarranted anti-drug hysteria."

    Wow eb, that's quite charge to make. Among the people who would say you are underestimating the severity of the problem are the people who run the pharmaceutical industry (They often differ from government official in how to handle the problem, but none of them or their lobbyists deny that the problem exists).

    Good place to start for information is the Centers for Disease Control, here is one key report

    Drug overdoses will probably this year be the leading cause of accidental death in the U.S. They had passed up everything but auto fatalities a few years back, and they were number one in about a dozen states in 2006 (Death data comes in very slowly, so 2007 is just being analyzed now).

    There have also been excellent articles in Journal of American Medical Association from CDC researchers, check particularly for the one on mortality in West Virginia.

    Any of the national or state surveys of drug use will also show the sharp rise in dependence on prescribed pain killers.

  4. Keith, thanks. I've only had a chance to skim the PDF from your link and it's not very fact-laden. So I'll resort to generalities for now as well – for one, I'm already more a skeptic than a fan of the War on (Some) Drugs, due to all of the obvious reasons. For another, I'm part of a large cohort who've recently hit the age associated with pain medication, and am rather keenly aware of the trepidation suffered by physicians who dare prescribe these things. I'd rather not see it get worse.

    Now, of course we should attempt to minimize accidental prescription (and OTC, and recreational) drug overdoses, which obviously occur. So you might convince me that this particular campaign is sensible. It's just that I place a higher priority on achieving saner drug laws, and these public anti-drugs campaigns – even the more-or-less sensible ones – tend to counter that goal.

  5. I don't know if there's an epidemic, but it's pretty problematic to have lots of unused pills sitting in people's medicine cabinets and there have been show to be problems with medications tossed into sewers and landfills leaching into surface water.

    As for reuse, the pills themselves are already identifiable by pharmacists (I don't really think we need to have people swallowing RFID tags with their medicine), but reusing expired medicine may not be a great idea.

  6. "So you might convince me that this particular campaign is sensible".

    If almost 20,000 deaths a year does not convince you, there is nothing I could say that could convince you of anything, so I will not try.

  7. Keith, I was puzzling over your response but on re-read, perhaps I didn't make clear enough that "this particular campaign" to which I was referring was specifically "national prescription drug take-back day", not the general notion of encouraging responsible disposal of unused drugs. Sorry if I touched a nerve.

    The specific campaign at issue, however, was coordinated by the DEA, an agency whose judgement I can only utilize as an inverse indicator.

  8. I like Brett´s idea of RFID tags to allow automated sorting – by expiry date as well as active ingredient. FuzzyFace´s objection to swallowing RFID tags does not apply if you tag the bubble strips instead. The industry might well want to do this for manufacturing quality control.

    One reason why people waste drugs is the cognitive difficulty of complying with complicated dosage régimes – and anything more that ¨take one a day at bedtime¨ counts as complicated for some. You can buy pill dispensers with compartments, but patients or carers have to fill and label them. Idea: pharmacies or physicians should print out a dosage calendar with every prescription that has a precise treatment régime, with day-by-day check boxes (eg morning, noon, afternoon, night). This would be easy to set up as a controlled public health experiment. You can make it a little bit coercive by asking patients to bring in the calendar when they ask for a renewal; not sure if this would be a good idea or not.

  9. I should point out that there is, in fact, no problem with swallowing RFID chips: They developed ones that would pass harmlessly through your digestive tract years ago. And the obvious advantage of putting them in the pills, not the bubble strip, is so that, when your two year old gets into your pill stash, and you rush him to the hospital, one quick pass with a scanner will tell them exactly what he's swallowed, and what got flushed down the toilet.

    The reason I have extra pills, by the way, is not that taking the chemo medicine as prescribed was too complicated. It's because much of it was prescribed on a "Take as needed" basis. Though clearer directions, (Like, "Take your anti-nausea medications and antacid at least an hour BEFORE the prednisone!") would have been appreciated.

  10. Another thing that will need to change for drug recycling to become second-nature (oh, and you could almost certainly do perfectly good separations of all the active ingredients from a slurry) is a change in the culture of scarcity, especially with respect to pain medications. When every regular doctor you see is still "take a couple of tylenol for that doubling-over pain" and prescription drug plans are penny-pinching and far between, those post-op percs and vicodin will be hoarded like gold. (And traded among friends or family who don't all have equal access to medical care.)

    (And of course it's not just pain meds — other expensive or rare drugs may be traded among communities of patients with certain specific disorders. And once again, even the best recycling program will have trouble making headway against a culture of scarcity.)

  11. The CDC document is a bit vague, but it seems to be saying that it's not so much an "accidental prescription drug overdose" problem as an "overdose on prescription narcotic painkillers" problem. Is exhorting people to turn in their leftover prescription drugs going to help someone who finds a doctor willing to keep on writing him oxycontin scrips to feed his addiction?

  12. Jake

    About one in eight 12th graders reports using prescription pharmaceuticals non-medically, and a major source appears to be the family medicine cabinet. I assume most of the those young people are not addicts, they are experimenting, maybe for example mixing pills and alcohol — but you can overdose of course without being an addict.

    Realtors now tell home sellers in many areas to clean out the medical cabinet before showing a house because people pose as house buyers and then clean out the pain pills.

    These are problems worth addressing, but you are dead right that they do nothing to solve the doctor's side of the problem (docs are currently writing more prescriptions for pain killers each year than there are people in the U.S., they are the most widely prescribed drugs in history). That is a separate, very tough policy problem because we simultaneously have docs way overprescribing and thereby killing people and patients in pain who can't get their medication, for example people in rural nursing homes with no on-site doc.

  13. If you mailed back prescriptions people would have to take it to the post office or a secure drop box–otherwise addicts would break into their mailboxes.

  14. Well, for the time being, these drug take back days can make a difference.

    Prescription drug abuse is a problem in our country. The 2007 National Study of Drug Use and Health found that 70% of people who abuse prescription pain relievers indicated they got them from friends or relatives, and the National Institute of Drug Abuse (NIDA) reports that upwards of 9 million people use prescription medication for non-medical uses.

    The American Medicine Chest Challenge is a community based public health initiative, with law enforcement partnership, designed to raise awareness about the dangers of prescription drug abuse and provide a nationwide day of disposal – at a collection site or in the home – of unused, unwanted, and expired medicine that will be held on November 13, 2010 in communities across the country.

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