Household medical waste disposal policy in Israel

Abstract

Background
Large amounts of expired and unused medications accumulate in households. This potentially exposes the public to hazards due to uncontrolled use of medications. Most of the expired or unused medications that accumulate in households (household medical waste) is thrown to the garbage or flushed down to the sewage, potentially contaminating waste-water, water resources and even drinking water. There is evidence that pharmaceutical active ingredients reach the environment, including food, however the risk to public health from low level exposure to pharmaceuticals in the environment is currently unknown. In Israel, there is no legislation regarding household medical waste collection and disposal. Furthermore, only less than 14 % of Israelis return unused medications to Health Maintenance Organization (HMO) pharmacies. Methods
In this study, we investigated world-wide approaches and programs for household medical waste collection and disposal. ResultsIn many countries around the world there are programs for household medical waste collection. In many countries there is legislation to address the issue of household medical waste, and this waste is collected in hospitals, clinics, law enforcement agencies and pharmacies. Furthermore, in many countries, medication producers and pharmacies pay for the collection and destruction of household medical waste, following the “polluter pays” principle. Conclusions
Several approaches and methods should be considered in Israel: (a) legislation and regulation to enable a variety of institutes to collect household medical waste (b) implementing the “polluter pays” principle and enforcing medical products manufactures to pay for the collection and destruction of household medical waste. (c) Raising awareness of patients, pharmacists, and other medical health providers regarding the health and environmental risks in accumulation of drugs and throwing them to the garbage, sink or toilet. (d) Adding specific instructions regarding disposal of the drug, in the medication label and leaflet. (e) Examining incentives for returning medications to pharmacies. (f) Examining drug collection from deceased in retirement homes and hospitals.

Full text

I N T E G R A T I V E A R T I C L E Open Access
Household medical waste disposal policy in
Israel
Zohar Barnett-Itzhaki
1,2*
, Tamar Berman
1
, Itamar Grotto
1,3
and Eyal Schwartzberg
4,3
Abstract
Background: Large amounts of expired and unused medications accumulate in households. This potentially
exposes the public to hazards due to uncontrolled use of medications. Most of the expired or unused medications
that accumulate in households (household medical waste) is thrown to the garbage or flushed down to the
sewage, potentially contaminating waste-water, water resources and even drinking water. There is evidence that
pharmaceutical active ingredients reach the environment, including food, however the risk to public health from
low level exposure to pharmaceuticals in the environment is currently unknown. In Israel, there is no legislation
regarding household medical waste collection and disposal. Furthermore, only less than 14 % of Israelis return
unused medications to Health Maintenance Organization (HMO) pharmacies.
Methods: In this study, we investigated world-wide approaches and programs for household medical waste
collection and disposal.
Results: In many countries around the world there are programs for household medical waste collection. In many
countries there is legislation to address the issue of household medical waste, and this waste is collected in
hospitals, clinics, law enforcement agencies and pharmacies. Furthermore, in many countries, medication producers
and pharmacies pay for the collection and destruction of household medical waste, following the “polluter pays”
principle.
Conclusions: Several approaches and methods should be considered in Israel: (a) legislation and regulation to enable
a variety of institutes to collect household medical waste (b) implementing the “polluter pays”principle and enforcing
medical products manufactures to pay for the collection and destruction of household medical waste. (c) Raising
awareness of patients, pharmacists, and other medical health providers regarding the health and environmental risks in
accumulation of drugs and throwing them to the garbage, sink or toilet. (d) Adding specific instructions regarding
disposal of the drug, in the medication label and leaflet. (e) Examining incentives for returning medications to
pharmacies. (f) Examining drug collection from deceased in retirement homes and hospitals.
Keywords: Pharmaceutical waste, Environment, Return Unwanted Medicines, Medication, Pollution, Polluter pays
Introduction
Significant developments in the drug industry, in addition
to the improved access of a variety of populations to
western medications have contributed to the increase in
medication consumption all over the world [1, 2]. This
trend is expected to extend in the next years, due to the
growth in the population and in the access of additional
populations to medications, in particular western
medications.
Currently, large amounts of expired and unused medi-
cations accumulate in households, both prescription and
over-the-counter (OTC) medications. Most of these
household expired or unused medications (household
medical waste) are thrown to the garbage or flushed
down the sink or the toilets. Polls conducted in 2009 in
Israel and in 2010 in Europe show that 50 % of the
European public and 84 % of the Israeli public throw
household medical waste to the garbage or flush them
down the toilet [3, 4]. In Israel, results of a survey in a
* Correspondence: zohar.barnett@moh.gov.il
1
Public Health Services, Ministry of Health, 39 Yirmiyahu St, Jerusalem, Israel
2
Mimshak, The Israel society of ecology and environmental sciences, 19
Kehilat New York St, Tel Aviv, Israel
Full list of author information is available at the end of the article
© 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Barnett-Itzhaki et al. Israel Journal of Health Policy Research (2016) 5:48
DOI 10.1186/s13584-016-0108-1

nationally representative sample (N=602) showed that
80 % of responders throw medications to the garbage; 4 %
flush them down toilets; and only 6 % return them to the
doctor or pharmacy or donate them to the needy [4].
Accumulation of medications in private homes ex-
poses the public to medical hazards: accumulation of
medications increases the chance of uncontrolled use of
the medication and subsequent poisoning.
More than 30 % of the poison cases among children in
the U.S on 2009 were caused by uncontrolled use of medi-
cations [5]. According to the Israel poison information
center at Rambam hospital, 43 % of the applications refer
to children under six years old, and about half of the
applications refer to exposure to medications [6]. Medica-
tion reserves can also be used for abuse or suicide.
Throwing household medical waste to the garbage or
to the sewage can also cause environmental hazards that
may have implications on the public health: some of the
medications consist of stable ingredients that may accu-
mulate in the environment and are barely removed in
wastewater treatment plants [7]. Therefore, residues of
medications may contaminate purified wastewater that
are used for agricultural irrigation (more than 90 % of
the wastewater in Israel is treated in treatment plants,
most of which is used for agriculture). In recent years,
researchers have found that agricultural products irri-
gated with treated wastewater contain pharmaceutical
compounds. Of note, some of the medications found in
wastewater are excreted from humans and animals and
not from thrown medications.
The pharmaceutical compounds may contaminate
water reservoirs and aquifers, and pollute drinking water,
in addition to contamination of ecological systems [8].
Data shows that pharmaceuticals are present in drinking
water sources [9].
Furthermore, throwing antibiotics to the sewage may
lead to selective pressure and contribute to development
of resistance to antibiotics among populations of bacteria
[10]. In 2012, antibiotic resistance genes were found in
bacteria taken from six rivers in China, including the Pearl
River which is considered the river with the highest pollu-
tion of antibiotics in China [11]. The rise of antibiotic re-
sistant bacteria and genes, is a major problem in today’s
medicine and may significantly increase the number of
deaths due to infectious diseases [12].
Here we investigated programs and actions for house-
hold medical waste collection and disposal around the
world, in order to suggest approaches to improve the
situation in Israel.
Methods
We searched PubMed and Google for reviews, papers,
reports and articles, published between January 2009
and May 2016 in English, related to medicines and drugs
(terms “medical”or “medication”or “pharmaceuticals”
or “drug”), and household (“term household”), and
disposal (terms “waste”or “disposal”or “disposed”). We
focused on the household medical waste policies in
Europe, Canada, USA, South and Central American rep-
resentative countries, Australia, Middle East representa-
tive countries (Lebanon, Egypt and Saudi Arabia), and
Israel. In addition, we searched for relevant information in
the following websites: World Health Organization, US
Environmental Protection Agency, US Drug Enforcement
Agency, US Food and Drug administration, Health
Canada, the Israeli Ministry of Health, and Israeli HMOs.
We also used information from additional health and en-
vironmental organization websites, and from international
pharmaceutical collection program websites.
World-wide approaches and programs for drug collection
and disposal
Europe
Policy An European Union (EU) directive from 2001
(DIRECTIVE 2001/83/EC) stated that special precautions
should be used for disposal of unused medicinal products
[13]. It was stated that the special precautions for disposal
must appear on the outer packaging of medicinal product
[13]. In 2004, two additional EU directives stated that: (a)
EU states should establish medication collection systems,
(b) information regarding the collection system in the spe-
cific state or county must appear on the outer packaging
of the medicinal product [14].
Today, most of the European countries supply detailed
information regarding the collection of unused/expired
medications. Information channels range from oral infor-
mation to the patient by the physician or the pharmacist on
the best way of disposal, brochures, comprehensive infor-
mationviawebsites,informationoncollectioncontainers
and information on the package of the pharmaceutical
product [3]. Of note, besides Malta, Slovenia and North
Rhine Westphalia state of Germany, all states and regions
classify pharmaceutical waste as special waste that should
be returned to a pharmacy [3].
Medication collection systems Different states in Europe
have different policies regarding household medical waste
collection:
Several states in Europe have legislation obliging
pharmacies to collect household medical waste:
Iceland, Estonia, Belgium, UK, Denmark, Lithuania,
Lichtenstein,Norway,France,Hungary,and
Croatia [3,15](seeTable1). In the UK, the
National Health Service (NHS) is in charge of
collection of medical waste from pharmacies that
were returned by households and residential
homes [16]. In France, collected drugs that were
Barnett-Itzhaki et al. Israel Journal of Health Policy Research (2016) 5:48 Page 2 of 8

still usable were used to be redistributed to
humanitarian associations [17].
In several states, pharmacies collect household drugs
on a voluntary base: Italy, Ireland, Albania, Austria,
Germany, Netherland, Luxemburg, Latvia, Slovenia,
Spain, Poland, Portugal, Finland, The Czech
republic, Sweden, and Switzerland [3].
However, despite the clear policies and accessible in-
formation, a poll conducted in 2010 by the European
Environmental Agency (EEA) shows that on average
50 % of the expired or unused drugs are not returned to
pharmacies, and are flushed down toilets or sinks [3]
(See also Additional file 1: Table 1).
Funding The collection, transfer and treatment of
household medical waste in Europe are funded by (a)
The governments, for example in Sweden [17, 18], or by
(b) the pharmaceutical industries, following the “polluter
pays”principle, for example: The Belgian program
“Bounsage”is funded by the pharmaceutical industry
and distributers [19], the Spanish program “SIGRF”and
also the French “Cyclamed”program, are funded by the
pharmaceutical industry [17–19].
USA
Policy There is no federal legislation regarding household
medical waste collection. The issueismostlyhandledbythe
health authorities (DEA-Drug Enforcement Administration,
FDA-Food and Drugs Administration).
The FDA published detailed instructions and recom-
mendations regarding household medical waste: the
main recommendation is transferring unused/expired
drugs to a DEA-authorized collector. In case no such
collector is available:
1. One should mix medications (without crushing
tablets or capsules) with an unpalatable
substance such as dirt, kitty litter, or used coffee
grounds, place the mixture in a container such
as a sealed plastic bag and throw it to the
garbage.
2. In case of especially harmful medication (which is
listed in the FDA), the medication should be flushed
down the sink or toilet as soon as they are no longer
Table 1 Comparison between the policies, collection and funding systems, regarding household medical waste in six selected countries
Country National drug
collection program
Legislation Collection method Funding Medical collected
(weight)/collection
rates (annual)
USA Some programs are
run by the DEA [23],
specific counties [25],
and by local
communities [42]
The law enables hospitals, clinics,
pharmacies and drug producers
to collect unused drugs [22]. In
several counties and in one state
(MA) there are legislations
regarding forcing pharmaceutical
companies to fund the collection
and destruction of household
medical waste [26–28]
Drug collection events,
secured drop boxes,
collection by law
enforcement agencies and
pharmacies [23–25,43]
Usually DEA, law
enforcement agencies
and NGOs [20]. In
specific counties, the
Pharmaceutical
companies [27]
0.01 kg/capita [44]
Canada Most of the
provinces and
territories run
such programs
(See Table 3)
Household medical waste laws in
several provinces [17,18]
Drug collection events,
secured drop boxes, and
pharmacies [17,18]
Government/
pharmaceutical industry/
pharmacies [17,18]
Varies between
provinces (on
average 0.01-0.02 kg/
capita) [18,45,46]
Hungary Recyclomed [15,47] The law obliges the pharmaceutical
industry to establish and operate a
disposal system or give this duty to
another organization [15]
Pharmacies and other selling
points, containers in specific
collection points [15]
Pharmaceutical Industry
Groups [15]
0.02 kg/capita [15]
UK No program According to the UK
environmental protection act and
additional regulations, all
Pharmacies are obliged to accept
back unwanted medicines from
patients [48].
All Pharmacies and hospitals
[16,48]. In addition, there are
several local initiatives for
collecting medical waste
from homes [49]
Local governments [15]. Not available
Australia RUM (Return
Unwanted
Medicines) [31]
Each state and territory have their
own regulation regarding medicine
disposal (embedded in the Drugs
and Poisons Acts of each individual
state)
Special containers mounted
in all pharmacies [31]
Funded by the
government until end
of June 2018; then will
be reconsidered. [31]
0.03 kg/capita [31]
Israel No program No legislation HMO pharmacies are
obliged to receive medicines
from the public.
The Israeli Ministry of
Health
13.9 % of the
population [40]
Barnett-Itzhaki et al. Israel Journal of Health Policy Research (2016) 5:48 Page 3 of 8

needed, in order to prevent poisoning due to
uncontrolled use of the medication [20].
However, in January 2016, more than 100 environmental
and health organizations, agencies, activists and state legis-
lators (Colorado State Legislator, the California Association
of Sanitation Agencies, California Product Stewardship
Council, Association of Metropolitan Water Agencies,
Central Marin Sanitation Agency, Environmental Services
of city of West Sacramento, Minnesota Pollution Control
Agency, San Francisco Department of the Environment
and others) and citizens signed on a letter calling on the
FDA to change its recommendation that certain medica-
tions be disposed by flushing, and to clarify that secure
medication take-back programs provide the best disposal
methodforleftoverhouseholdmedications[21].
Until 2010, household medical waste was collected only
by law enforcement agencies (police, Sheriff). In 2010, a rule
promoted by the DEA enabled hospitals, clinics, pharmacies
and drug manufactures to collect unused drugs and transfer
them to medical waste treatment centers [22].
Medication collection systems Today, unused drugs in
the USA can be collected in several ways: Drug collection
events held in accordance with the DEA [23], via secured
drop boxes [24], by the law enforcement agencies [25] or
by pharmacies [20] (See Table 2 for examples).
Funding The collection, transfer and treatment of
household medical waste, is usually funded by the DEA
and law enforcement agencies [20]. In some cases, add-
itional organizations fund or participate in the funding:
In 2016 in Massachusetts, “An Act relative to
substance use, treatment, education and prevention”
was passed. The law follows the “polluter pays”
principle, in which pharmaceutical companies fund
the collection, transfer and treatment of household
unused and expired drugs [26].
Nine counties in the USA passed legislation that
follows the “polluter pays”principle: seven counties
in California state (Alameda, San Francisco, Santa
Cruz, San Mateo, Santa Clara, Santa Barbara, and
Marin) and two counties in Washington state: King
county and Snohomish county [27,28].
InNew-YorkstatethepoliceandtheSheriffofficeusu-
ally fund the drug collection and transfer. In addition,
inseveralcountiesinthisstate,itisfundedbyadd-
itional organizations or county departments [24]:
oBRiDGES Madison Co. Council on Alcoholism
and Substance Abuse (Madison county)
oMonroe County Department of Environmental
Services
oTompkins County Department of Probation
oAlliance for Safe Kids and Department of
Environmental Facilities (Westchester county)
oGuthrie Environmental Health (Jefferson county)
oDepartment of Public Safety (Suffolk county)
In Manitowoc county (Wisconsin), the drug
collection programs are sponsored by a variety of
agencies related to health and the environment.
Canada
In Canada there is variation in the policies of provinces
and territories regarding the collection, transfer and
treatment of unused and expired household drugs. In
several provinces/territories, the pharmaceutical industry
sponsors these costs according to the “polluter pays”
principle [17, 18] (see Tables 1 and 3).
Selected central and south America countries
Mexico There is no legislation regarding collection and
treatment of household medical waste in Mexico [29].
However, 23 out of the 31 states in Mexico (for example,
Nuevo Leon state), run the program “SINGREM”for col-
lection and treatment of household medical waste. The
program is administered by Mexico’sNationalChamber
of the Pharmaceutical Industry (CANIFARMA) [19, 30].
Table 2 Collection and recycle of unused drugs in the USA
How are unused drugs collected? Examples
Drug collection events every several months in accordance
with the DEA. The collection is free and anonymous [23].
National drug collection event in September 2015 in different
US states [23], Drug collection events in Manitowoc county in
Wisconsin state [25], Drug collection events in Illinois [43].
Drug collection on a monthly base Pharmacies collect non-controlled prescription drugs and
OTC medications on the last Saturday of every month in
New-York state [24].
Secured drop boxes for drug collection that can be
accessed in specific days and times.
Secure drop boxes in New-York state that can be accessed in
specific days and times, several such drop boxes are available
for the public 24 h a day, seven days a week [24].
Collection by the law enforcement agencies
(Sheriff office, police)
In Manitowoc (Wisconsin) there are drug collection drop boxes
in police stations [25].
Collection of unused or expired drugs by pharmacies. Most of the states.
Barnett-Itzhaki et al. Israel Journal of Health Policy Research (2016) 5:48 Page 4 of 8

The program is sponsored by the pharmaceutical industry
(companies such as Merck, Abbott and also the Israeli
company TEVA) [30].
Brazil There is no legislation regarding collection and de-
struction of household medical waste in Brazil. However,
the program “Descarte Consciente”, administered by
Brazil Health Service, handles the collection of household
medical waste. Expired/unused medications are collected
at pharmacies and the collection is not mandatory. The
program is funded by the pharmaceutical industry [19].
Colombia Colombia’s National Association of Entrepre-
neurs (ANDI) administers the program “Punto Azul”
than began collecting medications in 2010 with funding
supplied by pharmaceutical manufacturers and im-
porters. Collection is located at pharmacies and large su-
permarkets but is not mandatory [19].
Australia
There is a national program in Australia for household
medical collection (“Return unwanted medicine”–The
“RUM”project). The program enables the public to re-
turn unwanted medications to the local pharmacies. The
program is funded by the government and several
pharmaceutical manufacturers [18, 31]. For additional
details see Table 1.
Selected Middle East Countries
Egypt Although there is no clear legislation regarding
collection of household medical waste by pharmacies,
there is evidence that pharmacies collect medical waste
[32, 33]. In addition, there are Egyptian NGOs who col-
lect unused medications and distribute them to low-
income families, a model that is planned to be spread to
other Arab countries [34].
Lebanon There is no law in Lebanon regarding collec-
tion of household medical wasted and no organized
pharmaceutical waste collection and disposal schemes in
Lebanon. A survey conducted in the Beirut area showed
that less than 5 % of the public return unwanted medica-
tions to pharmacies [35].
Saudi Arabia In Saudi Arabia governmental healthcare
facilities provide all Saudi citizens with free medication,
but the awareness of individuals regarding safe drug dis-
posal is low. Less than 5 % of the public return un-
wanted medications to the pharmacy or to their
physicians while most of the Saudi Arabian public throw
unwanted medications to the household trash, regardless
of medication type [36].
Approaches for drug collection and disposal in Israel
In Israel there is no legislation regarding the collection,
transfer and treatment of household medical waste and
of unused/unwanted medications (see also Table 1).
Table 3 Programs, legislations, policies, and funds regarding collection of unused and expired household drugs in Canada [17, 18]
Province/territory Program and year
of initiation
Voluntary of regulated
framework
Return location Funding sources
Alberta ENVIRx (1988) Voluntary Pharmacies Pharmaceutical companies,
provincial government
British Columbia BC MRP (1999) Regulated under environmental
management act
Pharmacies Pharmaceutical and consumer
health product industries
Manitoba Manitoba MRP (2011) Regulated under The Waste
Reduction and Prevention Act)
Pharmacies Pharmaceutical and consumer
health product industries
New Brunswick None Some of the pharmacies
Newfound-land
and Labrador
Household Hazardous
Waste (1998)
Voluntary Household hazardous waste
depots
Provincial and municipal
governments
Nova Scotia Medication Disposal
Program (mid 1990s)
Voluntary Pharmacies Pharmaceutical companies
Yukon/Quebec None Collection events, most of the
pharmacies
Nunavut None Pharmacies and health centers
Ontario Ontario MRP (2013) Regulated under Environmental
Protection Act
Collection events, pharmacies Pharmaceutical and consumer
health product industries,
Provincial government
Prince Edward
Island
Take it back (2004) Voluntary Pharmacies and Waste Watch
Drop-off centers
Island Waste Management
Corporation
Saskatchewan Pharmaceutical Waste
Disposal (1997)
Voluntary Pharmacies Pharmacies
Barnett-Itzhaki et al. Israel Journal of Health Policy Research (2016) 5:48 Page 5 of 8

However, the Israeli Ministry of Health is aware of the
subject and initiated several actions, such as updating
the procedures for pharmacies. In the last years there
have been several steps in this field:
In 2001 the Ministry of Health published a circular that
instructed the HMO pharmacies to receive unused
medications, by any person (not necessarily HMO
member), free of charge. This document requires the
HMOs to transfer the collected medications to
pharmaceutical waste centers [37]. Accordingly, the
HMOs have mounted secured iron drop-boxes for
medication collection [38].
In 2006, one leading private pharmacy in Israel
initiated, in coordination with the Israeli Ministry of
Health, a campaign for collecting unused
medications from the public. Those who returned
unused medications to the pharmacy, got in return a
new pack of vitamin C.
In 2003 the Israeli organization “Friends for health”(
“Haverim Le’refua”) was established in order to help
needy populations of sick and handicapped people.
One of its major projects deals with medication
recycling. The organization collects unused
medications from patients and their families, and
transfers them to sick people. This procedure was
formally added to the pharmacist ordinance, as part of
a legislative amendment of the Pharmacists Ordinance.
Additionally, the organization runs a pharmacy
(supervised by the Ministry of Health) which receives
pharmaceuticals from the pharmaceutical companies
and gives them to patients [39].
In Israel, there are poor rates of medication return to
the HMO pharmacies: In 2014–2015 the Central Bureau
of Statistics conducted a poll which interviewed over
7000 participants (over 20 years old). The poll included
also a question regarding the return rates of medica-
tions. The poll revealed that less than 14 % of the Israelis
return unused medications to pharmacies [40] (Table 4).
Discussion –How can the current situation in Israel be
improved?
In comparison to most developed countries, Israel is far
behind, regarding the collection and treatment of house-
hold medical waste. In recent years there have been
some improvements in this field, but the current situ-
ation in which more than 85 % of the public accumulate
medications and later throw them to the garbage or
flush them down the toilet or sink, endangers public
health and the environment [40]. Of note, there are no
data regarding the amounts and the types of medications
thrown to the garbage in Israel.
A mechanism for drug collection is expensive and
requires complex logistics. In addition, temporary
medication storage in inappropriate facilities may
cause a leak of toxic compounds on the one hand,
and may be accessible to drug addicts or criminals,
on the other hand. However, there is a need for a
comprehensive program for safe disposal of unused
medications in Israel.
There are several fields of action to cope with this issue
in Israel. In the short run –raising the public awareness,
and in the medium and long run –legislation and regula-
tion in addition to extending the expiry of medications in
order to reduce the amounts of thrown medications.
1. Awareness
It seems that one of the major problems in this field in
Israel is the public’s lack of awareness regarding the
health and environmental implications of medication ac-
cumulation and disposal. It is therefore important to
raise the public’s awareness to this issue. Awareness rais-
ing tools, including publishing relevant data in the
Ministry of Health website or in social networks, publi-
city projects, campaigns, and brochures, may be rela-
tively easy and fast to perform within the Ministry of
health without the need to collaborate or coordinate
with other external entities. It is important to raise physi-
cians’awareness to this issue, and emphasize the import-
ance of avoiding prescription of unnecessary medications
or excessive amounts of medications. In addition, it is im-
portant that pharmacists supply detailed information re-
garding disposal of unused/expired medications.
2. Legislation and regulation
There is no legislation and almost no regulation re-
garding the collection and the treatment of household
medical waste. There is a need for laws and regulations
for handling this issue in Israel regarding several aspects:
(a) laws that will enable collection of household medical
waste by institutes in addition to HMOs: collection by
pharmacies, collection drop boxes in the police, at
Table 4 Return rates of medications to pharmacies or HMOs in
2014 [40]
City Medication return (%)
Jerusalem 10.7
Haifa 18.6
Petach-Tikva 17.7
Ashdod 15.3
Tel-Aviv Jaffa 14.8
Rishon Letzion 12.1
Total 13.9
Barnett-Itzhaki et al. Israel Journal of Health Policy Research (2016) 5:48 Page 6 of 8

hospitals, in the mail office and even in big supermar-
kets. Additionally, enacting laws to allow organization to
hold drug collection events, similar to the DEA collec-
tion events held in the US, or collection of household
medical waste from people's homes. (b) Individuals who
pass away in retirement homes leave medications that
are usually thrown to the garbage. It is important to es-
tablish a mechanism to collect and transfer the non-
expired medications to needy populations [41] and the
expired ones to destruction. (c) It is worthy to examine
laws for incentives for returning medications to HMO
or private pharmacies, such as getting pay-back money
or other rewards. (d) Similarly to Europe, it is advisable
to promote regulations and procedures regarding special
instructions and precautions for disposal that will appear
on the outer packaging of medicinal product, in the pa-
tient information leaflet or on the medication label. (e)
Laws that will regulate the funding of programs for col-
lection and destruction of medications, preferably fol-
lowing the “polluters pays”principle, by which,
pharmaceutical companies will pay for the collection,
shipment and destruction of household medical waste.
The household medical waste problem is relevant to
several governmental ministries, especially the Ministry
of Health (protecting the public health), and Ministry of
Environmental Protection (waste collection is under the
responsibility of this ministry, and also the environmen-
tal implication of household medical waste). Cooper-
ation between these ministries is needed in order to
promote this important field.
3. Funding
It is important to examine programs to sponsor the col-
lection of household medical waste, according to the “pol-
luter pays”principle, as done in many countries around
the world. Producers, importers, distributers and pharma-
cies, in addition to the government, should take a part in
sponsoring the collection, transfer and treatment of
household medical waste. A cost/benefit analysis should
be done, considering the financial costs involved in dis-
posing drugs, and the outer costs (environmental damage,
investments in advanced purification systems etc.)
Conclusions
Less than 14 % percent of Israelis return unused pharma-
ceuticals. Unused drugs are a potential risk to public
health, both from risk of poisoning and from environmen-
tal contamination. There is a need for a comprehensive
program for safe disposal of unused medications in
Israel. This program should address additional types of
household medical waste such as household mercury
thermometers.
Additional file
Additional file 1: Table S1. Number of Pharmaceutical sold and
returned through European return programs in 2008. (DOCX 35 kb)
Abbreviations
DEA: Drug enforcement administration (USA); EEA: European environmental
agency; EU: European union; FDA: Food and drugs administration (USA);
HMO: Health maintenance organization; NHS: National health service (UK);
OTC: Over the counter; RUM: Return unwanted medicine (Australia)
Acknowledgements
We would like to acknowledge the important contribution of Dr. Keren Agay-Shay,
Dr. Shay Reicher and Dganit Eichen. We also thank Vivian Futran Fuhrman and Scott
Cassel from Product Stewardship Institute, Inc. for their assistance.
Funding
Not applicable.
Availability of data and material
Not applicable.
Authors’contributions
ZBI and TB conceived the paper. ZBI designed the manuscript, performed
the literature search and drafted the manuscript. TB added literature and
additional aspects to the manuscript. ZBI, TB and ES edited the manuscript.
The paper was reviewed by all authors. All authors read and approved the
final manuscript.
Authors’information
Dr. Zohar Barnett-Itzhaki is a scientific advisor in the Ministry of Health, alongside
with Prof. Itamar Grotto, director of the Public Health Services. Zohar is a Mimshak
fellow at the Israel society of ecology and environmental sciences.
Dr. Tamar Berman is an environmental toxicologist in the Public Health
Services, the Ministry of Health.
Dr. Eyal Schwartzberg is the Head of the Pharmaceutical Division and State's Chief
Pharmacist at the Ministry of Health. Dr. Schwartzberg is a senior lecturer in the
school of pharmacy in the Ben Gurion University of the Negev.
Prof Itamar Grotto is the director of the Public Health Services, manages the
Public Health Services Staff and the district health bureaus. Prof Grotto is a
faculty member in the public health department in Ben Gurion University of
the Negev.
Competing interest
The authors declare that they have no competing interests.
Consent for publication
Not applicable.
Ethics approval and consent to participate
Not applicable.
Author details
1
Public Health Services, Ministry of Health, 39 Yirmiyahu St, Jerusalem, Israel.
2
Mimshak, The Israel society of ecology and environmental sciences, 19
Kehilat New York St, Tel Aviv, Israel.
3
Faculty of Health Sciences, Ben-Gurion
University of the Negev, P.O.B. 653, Beer-Sheva, Israel.
4
Pharmaceutical
Division, Ministry of Health, 39 Yirmiyahu St, Jerusalem, Israel.
Received: 16 February 2016 Accepted: 29 September 2016
References
1. Naidu RP. Causality assessment: A brief insight into practices in
pharmaceutical industry. Perspect Clin Res. 2013;4(4):233–6.
2. Gu Q, Dillon CF, Burt VL. Prescription drug use continues to increase: U.S.
prescription drug data for 2007–2008. NCHS Data Brief. 2010; (42):1–8.
http://www.cdc.gov/nchs/products/databriefs/db42.htm. Accessed Oct 2016.
Barnett-Itzhaki et al. Israel Journal of Health Policy Research (2016) 5:48 Page 7 of 8

3. Vollmer G. Disposal of Pharmaceutical Waste in Households –A European
Survey. In: Kummerer K, Hemple M, editors. Green and Sustainable
Pharmacy. Freiburg: Springer-Verlag Berlin Heidelberg; 2010. p. 165–78.
4. Maccabi’s Corporate Responsibility Report 2009–2010. http://www.
maccabi4u.co.il/SIP_STORAGE/files/2/9392.pdf. Accessed 9 Mar 2016.
5. Alvin B, et al. 2009 Annual Report of the American Association of Poison
Control Centers’National Poison Data System (NPDS): 27th Annual Report.
Clin Toxicol. 2010;48(10):979–1178.
6. Israel poison information center. https://www.rambam.org.il/departments
andclinics/laboratoriesdiv/clinicalpharmacologyandtoxicology/poisonings/
Pages/Default.aspx. Accessed 14 Feb 2016.
7. Lester Y, Avisar D, Mamane H. Removal of pharmaceuticals using combination
of UV/H
2
O
2
/O
3
advanced oxidation process. Water Sci Technol. 2011;64(11):
2230–8.
8. Gilbert N. Drug-pollution law all washed up. Nature. 2012;491(7425):503–4.
9. World Health Organization. Pharmaceuticals in drinking-water. (2012). http://
apps.who.int/iris/bitstream/10665/44630/1/9789241502085_eng.pdf?ua=1.
Accessed 14 Feb 2016.
10. Schlüter A, Szczepanowski R, Pühler A, Top EM. Genomics of IncP-1
antibiotic resistance plasmids isolated from wastewater treatment plants
provides evidence for a widely accessible drug resistance gene pool. FEMS
Microbiol Rev. 2007;31(4):449–77.
11. Chen J, et al. A survey of drug resistance bla genes originating from
synthetic plasmid vectors in six Chinese rivers. Environ Sci Technol. 2012;
46(24):13448–54.
12. Cosgrove SE, Carmeli Y. The impact of antimicrobial resistance on health
and economic outcomes. Clin Infect Dis. 2003;36(11):1433–7.
13. DIRECTIVE 2001/83/EC OF THE EUROPEAN PARLIAMENT AND OF THE
COUNCIL, 2001. http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:
2001:311:0067:0128:en:PDF. Accessed 12 Feb 2016.
14. DIRECTIVE 2004/27/EC OF THE EUROPEAN PARLIAMENT AND OF THE COUNCIL,
2004. http://www.biosafety.be/PDF/2004_27.pdf. Accessed 12 Feb 2016.
15. Health care without harm Europe website. https://noharm-europe.org/sites/
default/files/documents-files/2616/Pharm%20Report_WEB.pdf. Accessed 30 Jun 16.
16. Pharmaceutical Services Negotiating Committee. http://psnc.org.uk/services-
commissioning/essential-services/disposal-of-unwanted-medicines/.
Accessed 14 Feb 2016.
17. Kingsmore L. The management of post-consumer pharmaceutical waste: a
comparison between British Columbia and Ontario programs. Winthrop
University. 2009 http://digital.library.ryerson.ca/islandora/object/
RULA%3A3020/datastream/OBJ/view. Accessed 14 Feb 2016
18. Health Canada. Pharmaceutical disposal programs for the public: A Canadian
perspective. Health Canada environmental impact initiative. 2009. http://c.
ymcdn.com/sites/www.productstewardship.us/resource/resmgr/imported/
Takeback%20(2).pdf. Accessed Oct 2016.
19. California Product Stewardship Council. International Programs for
Pharmaceuticals. http://calpsc.org/products/pharmaceuticals/international-
epr-programs-for-pharmaceuticals/. Accessed 10 March 2016.
20. U.S food and drug administration. Disposal of Unused Medicines: What You
Should Know. http://www.fda.gov/Drugs/ResourcesForYou/Consumers/
BuyingUsingMedicineSafely/EnsuringSafeUseofMedicine/
SafeDisposalofMedicines/ucm186187.htm. Accessed 14 Feb 2016.
21. California Product Stewardship Council. A call on the FDA to end its
recommendation that certain medications be disposed by flushing. http://
calpsc.org/mobius/cpsc-content/uploads/2016/01/FINAL-FDA-Sign-on-
Letter-Sent-1-22-16.pdf. Accessed 14 Feb 2016.
22. DEA’s Diversion Control Program - US Department of Justice. http://www.
dea.gov/divisions/hq/2014/hq090814.shtml. Accessed 10 Mar 2016.
23. Take Back Your Meds. http://www.takebackyourmeds.org/dea-events.
Accessed 14 Feb 2016.
24. New-York state department of environmental conservation http://www.dec.
ny.gov/chemical/63826.html. Accessed 14 Feb 2016.
25. Manitowoc county recycling center. http://www.manitowocrecycles.org/.
Accessed Oct 2016.
26. Massachusetts law: An Act relative to substance use, treatment, education
and prevention. https://malegislature.gov/Bills/189/House/H4056. Accessed
6 Jul 16.
27. California Product Stewardship Council. Pharmaceuticals. http://calpsc.org/
products/pharmaceuticals/. Accessed 14 Feb 2016.
28. Santa Cruz county safe drug and sharps disposal http://c.ymcdn.com/sites/
www.productstewardship.us/resource/resmgr/2016_Legislation_PDFs/2015_
CA_Santa_Cruz_Pharms.pdf. Accessed 6 Jul 16.
29. Gracia-Vásquez SL, et al. An analysis of unused and expired medications in
Mexican households. Int J Clin Pharm. 2015;37(1):121–6.
30. SINGREM. http://www.singrem.org.mx/laboratoriosParticipantes.html.
Accessed 14 Feb 2016.
31. Return unwanted medicine (the RUM project). http://www.returnmed.com.
au/. Accessed 14 Feb 2016.
32. El-Hamamsy M. Unused Medications: how cost and how disposal of in
Cairo, Egypt. Int J Pharm studies and res Clin. 2011;2(1):21–7.
33. Ibrahim SZ, Mamdouh HM, El-Haddad IZ. Analysis of medications returned to
community pharmacies in Alexandria, Egypt. Life Science J. 2012;9(2):746–51.
34. Ashoka website. https://www.ashoka.org/fellow/waleed-shawky. Accessed
30 Jun 2016.
35. Massoud MA, Chami G, Al-Hindi M, Alameddine I. Assessment of Household
Disposal of Pharmaceuticals in Lebanon: Management Options to Protect
WaterQuality and Public Health. Environ Manage. 2016;57(5):1125–37.
36. Al-Shareef F, et al. Investigating the disposal of expired and unused
medication in Riyadh, Saudi Arabia: a cross-sectional study. Int J Clin Pharm.
2016. doi:10.1007/s11096-016-0287-4.
37. The Ministry of Health, Israel. http://www.health.gov.il/hozer/sbn16_2011.
pdf. Accessed 14 Feb 2016.
38. Maccabi HMO. http://www.maccabi4u.co.il/8223-HE/Maccabi.aspx. Accessed
14 Feb 2016.
39. Friends for Health. http://www.haverim.org.il/. Accessed 14 Feb 2016.
40. Central Bureau of Statistics. http://www.cbs.gov.il/reader/newhodaot/
hodaa_template.html?hodaa=201519229. Accessed 14 Feb 2016.
41. Mir D. Hazardous Household Chemicals and Hazardous Waste: Policy and
Procedures Recommendations for Implementation in Israel. Samuel Neaman
institute for national policy research. 2012. http://www.neaman.org.il/Neam
an2011/userdata/SendFile.asp?DBID=1&LNGID=1&GID=2685. Accessed 14
Feb 2016.
42. Dispose my meds website. http://www.disposemymeds.org/. Accessed 30
June 2016.
43. Illinois Environmental Protection Agency. Disposal of Unwanted / Unused
Pharmaceuticals http://www.epa.illinois.gov/topics/waste-management/
waste-disposal/household-hazardous-waste/pharmaceuticals/index.
Accessed 14 Feb 2016.
44. The White House website (USA). https://www.whitehouse.gov/the-press-
office/2016/07/05/obama-administration-takes-more-actions-address-
prescription-opioid-and. Accessed 14 Jul 16.
45. Alberta Pharmacists association. http://www.rxa.ca/for-the-public/
medication-disposal.aspx. Accessed 30 Jun 16.
46. Health Product Stewardship association. http://www.healthsteward.ca/sites/
default/files/2014%20BCMRP%20Annual%20Report.pdf. Accessed 30 June 16.
47. California Product Stewardship Council. International Pharmaceutical EPR
Program Fact Sheet. http://calpsc.org/mobius/cpsc-content/uploads/2015/
05/Hungary_Fact_Sheet_2_24_2015.pdf. Accessed 14 Feb 2016.
48. UK department of health. Environment and sustainability Health Technical
Memorandum 07–01: Safe management of healthcare waste. 2013. https://
www.gov.uk/government/uploads/system/uploads/attachment_data/file/
167976/HTM_07-01_Final.pdf. Accessed 30 Jun 16.
49. Calderdale council website. http://www.calderdale.gov.uk/environment/
waste/household-collections/clinical-collections.html. Accessed 30 Jun 16.
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