Analysis of expired medications in Serbian households

To the best of our knowledge, our study analysed for the first time the contents of a pharmaceutical waste generated in households in Serbia. Although this study collected information on the percentage and types of medications that expired without investigating the underlying reasons for not using them, it provides evidence to an under-researched area.

The findings are mostly consistent with other studies in terms of the percentage of expired medications, but varied in the most common therapeutic groups. The extent of expired medications in Serbian households of 9.2% is comparable to those reported in Croatia, where expired medication comprised 10.8% of total household medication supplies (17).

More than 70% of expired medications in Serbian households were prescription-only medications. The existence and extent of expired prescription medications could be adopted as a direct measure of non-compliance and poor adherence by the patient population, as demonstrated in many studies. For example, in the United Kingdom, only one third of people surveyed did not complete a course of the prescribed medication. In addition, more than 20% of the prescribed medications in British homes were not being taken, while 14% of prescribed medications were partly used. In an Iranian and the British study, approximately 10% of patients who filled their prescriptions have never taken the prescribed medications (12). Notwithstanding the reasons for leftovers of prescription medications, these medications can definitely lead to unintentional pharmaceutical poisonings of children, facilitate abusive use, and promote emerging social problems, such as teenage “pharming”, a recreational use and abuse of prescription medications among teenagers (18).

The structure of expired medication according to the type of formulation was similar to other studies with by far the highest percentage of solid dosage forms, followed by semisolids (e.g. crème, ointments) (15). In our study, the expired medications in the households belonged mostly to 3 categories: anti-microbials for systemic use, dermatological preparations, and medications for alimentary tract and metabolism. On the contrary, both Mexican and U.S. studies reported the painkillers and cardiovascular medications as the most common expired medications, while antibiotics occupied the third place (15, 16). In our opinion, as these studies were carried out in different countries, these differences are potentially attributable to the difference in demographic characteristics, health seeking practices or different supply ways of medications in surveyed households. However, the main reason for large quantities of expired antibacterials stored in Serbian households was easy access. This study was conducted just after Serbian authorities enforced stricter law rules regarding antibiotics’ acquisition in November 2011. Until then, antibiotics were routinely available without a medical prescription in private pharmacies.

The second possible reason for the levels of storage of antibacterial medications is patients’ non-compliance with recommended treatments. The presence of expired antimicrobial agents implicates that the patients did not complete the full dispensed course, and left-over antibiotics might later be used for self-medication without proper indication, in insufficient quantities, or even when contraindicated (7, 19). In contrast to a Mexican study, where dermatological preparations comprised less than 2% of all medications expired, they ranked second in households in Novi Sad, with mostly topical antibiotics and corticosteroids.

Expired medications from alimentary tract category were also commonly encountered in Serbian households. Many of the gastrointestinal tract (GIT) medications are OTC medications (e.g. antacids, laxatives), which could partially explain the high percentage of expired GIT medications. Abushanab et al. also identified medications for alimentary tract and dermatologicals as the medications that commonly go unused and expire (19).

Surprisingly, the expired cardiovascular medications comprised a noticeably lower percentage of expired medication in households than in other studies (15, 16). This discrepancy could be partially attributed to the demographic characteristics of surveyed Serbian households (e. g. low presence of persons older than 65). In addition, Serbian National Health Insurance Fund allows for chronic disease medications, including cardiovascular medications, to be prescribed in maximum two months’ course, definitely decreasing the possibility of the medication passing the expiry date. A high percentage of medications belonging to musculoskeletal (mostly antiinflammatory and antirheumatic products) and nervous system (mostly analgesics) was also demonstrated in other studies (11, 16, 18, 22).

The attitude of around a fifth of the Serbian respondents is that medication can be used up to 6 months after the expiration date, while the majority thought that expired medications should not be used. This is in accordance with the general opinion that expiration date is the end of the useful life of the medication. However, this may not be necessarily true, since the labelled expiration date is the final day that the manufacturer guarantees the full potency and safety of a medication, while the actual shelf life of some products is, in fact, longer (15).

Despite the fact that Serbian public was generally concerned on how improper medication disposal detrimentally effects the environment, the behaviour regarding disposal of unused medications did not equate the awareness. A previous study carried out in South Backa District, Serbia, showed that environmental awareness may not necessarily affect how people dispose of their medications, because other factors, such as the availability of formalized disposal protocols, may also play an important part (7, 20). However, according to Food and Drug Administration (FDA) recommendations, where no organized collection system exists, a disposal of medications in domestic garbages destined for landfills is accepted as more environmentally friendly than flushing them down the drain. Actually, in this situation, medications may be disposed of in the household trash by removing them from their original containers, mixing them with unpalatable substances, such as kitty litter or used coffee grounds, placing the mixture in a sealed plastic container, and putting that sealed container into the household trash (21, 22).

Disposal of expired medications into the garbage, the leading method of disposal in Serbia, has also been identified as the predominant way of disposal in Kuwait, United Kingdom and Lithuania (4). Disposal of medications into the sewage system is still a common practice in New Zealand, USA and Bangladesh, and is mostly reserved for liquid dosage forms (6, 23, 24). In contrast, in Sweden, a country with a long tradition of the reverse distribution network for the collection of unused and unwanted medications, a high percentage of population returns unused medications to pharmacies (43%). Sweden is an excellent example of how the essential part of communicating a message to the public is to postulate a clearly defined mechanism for disposal and an unambiguous obligation on specified agent/agencies to take medications for disposal (25). Also, confusion over the adequate methods of medication disposal still exists in many countries, mostly because of conflicting or incomplete guidelines for disposal of unused medications (4).

Despite the fact that an in-home inventory of medications obtained by direct observation has been shown to be a more reliable measurement tool than self-report recall methods, some weaknesses of our study need to be mentioned. First of all, it may be difficult to extrapolate our study results to the other parts of our country, because Novi Sad, a wealthy university city, might not be representative of Serbia in general. Secondly, answers to the questions regarding disposal habits and attitudes are self-reported in nature, and some respondents may not have been telling the truth. Notwithstanding these limitations, the study adds information to the area of scant knowledge.

Serbia must seriously consider the issue of medication wastage. A part of this wastage can be prevented and, considering the limited health resources of the country, it is prudent to start taking action. Firstly, like in many countries, Serbian government should limit prescription medication wastage by dispensing medication according to the exact number needed for treatment, rather than by the original pack, and also by increasing compliance through educational campaigns targeting different age groups and using various communication routes. Also, in order to limit environmental effects of improper expired medication disposal, an established formalized state-run disposal system that is cost-effective and easily accessible is necessary in Serbia.