Pharmaceutical Product Management and Disposal

Transcription

1 CPE Information and Disclosures Pharmaceutical Product Management and Disposal Lisa Strutz, PE Army Public Health Center LTC Kevin Ridderhoff, RPh, MHA Army Pharmacy Program Lisa Strutz and LTC Kevin Ridderhoff declare no conflicts of interest, real or apparent, and no financial interests in any company, product, or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria. The views expressed in this presentation are those of the author(s) and do not necessarily reflect the official policy of the Department of Defense, Department of the Army, U.S. Army Medical Department or the U.S. The American Pharmacist Association is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. CPE Information JFPS, We Got Invited! Target Audience: Pharmacists & Technicians ACPE#: L04-P/T Activity Type: Knowledge-based Looking to build a bridge with key Pharmaceutical Points of Contact Our expertise overlaps with their areas of concern We can bring Environmental considerations into the business planning phases Form a united front when responding to upcoming regulations 5 Learning Objectives Self-Assessment Question 1 Differentiate the definitions and categories of pharmaceutical product waste. Summarize the current federal requirements to manage pharmaceutical product in a manner that is protective of human health and the environment. Identify problem situations in handling pharmaceutical product waste How are RCRA P-Listed pharmaceutical containers managed? A. Recycled B. P-listed HW C. U-listed HW D. Trash 1

2 Self-Assessment Question 2 Self-Assessment Question 3 Which are 4 characteristics of OSHA hazardous drugs? A. Carcinogenicity, Odor, Reproductive toxicity, Genotoxicity B. Carcinogenicity, Teratogenicity, Reproductive toxicity, Genotoxicity C.Ignitability, Toxicity, Reactivity, Corrosivity D.Ignitability, Toxicity, Reactivity, Flammability Which of the following lists 3 DEA waste categories? A. Trash, stocks, returnable for credit B. Pharmaceutical wastage, stocks, ultimate user collections C.Ultimate user collections, stocks, returnable for credit D. Solid waste, hazardous drugs, controlled drugs Pharmaceuticals in Drinking Water Costly Regulatory Activity Fines to public hospitals and drugstore companies NH hospital - $205K for failure to identify HW pharmaceuticals NY hospital - $353K for sewering pharmaceuticals CA CVS - $13.75M for improper disposal of waste pharmaceuticals and other HW over 7 years Fines to Department Of Veterans Affairs KS - $51K and mandated to establish a pharmaceutical waste management program at 2 hospitals in KS (cost: $500K) VT - $372K for improper handling, storage, and disposal of pharmaceutical hazardous waste Joint Commission Environment of Care Elements of Performance for EC.3.10 The organization develops and maintains a written management plan describing the processes it implements to effectively manage hazardous materials and wastes. The organization creates and maintains an inventory that identifies hazardous materials and waste used, stored, or generated using criteria consistent with applicable law and regulation The organization establishes and implements processes for selecting, handling, storing, transporting, using, and disposing of hazardous materials and waste from receipt or generation through use and/or final disposal Federal Agency #1 = Environmental Protection Agency Hazardous Waste (HW) Regulations Federal - Resource Conservation Recovery Act (RCRA) - 40 CFR State - May be more stringent than federal regulations DoD/Service Level Ex. AR 200-1, Environmental Protection and Enhancement Installation HW Management Plan Hospital HW Management Plan 2

3 Defining Hazardous Waste Categories Ignitability EPA HW Number: D001 Hazardous wastes are divided into two categories: characteristic wastes and listed wastes Characteristic wastes are regulated because they exhibit certain hazardous properties: ignitability, corrosivity, reactivity and toxicity Listed wastes appear on one of four lists of hazardous waste (F, K, P and U). Pharmaceuticals are found on two of these lists, the P and U lists which both contain commercial chemical products Liquid with flash point <140 F Aqueous solution with >24% alcohol by volume Solid that ignites easily and burns vigorously Compressed flammable gas Oxidizer Examples: Erythromycin Gel 2% Texacort Solution 1% Taxol Injection Flexible Collodion Potassium Permanganate Primatene Aerosol Hand Sanitizer Corrosivity EPA HW Number: D002 Aqueous solution with ph 2 or 12.5 Liquid that corrodes steel at a rate >0.25 inches per year Examples: Glacial acetic acid with ph less than or equal to 2 Sodium hydroxide with ph greater than or equal to 12.5 Reactivity EPA HW Number: D003 Capable of detonation or explosion Reacts violently with water Forms toxic gases Example: Lithium Batteries Toxicity EPA HW Numbers: D004-D043 (TCLP) Chemical mg/l Waste Code Some Drug Formulations Arsenic 5.0 D004 Carbasone; Glycobiarosol; Thiacetarsamide Barium 100 D005 Barium Sulfate Cadmium 1 D006 Mineral preparations Chromium 5 D007 Mineral preparations Lindane 0.4 D013 Treatment of lice, scabies Cresol 200 D024 Preservative in insulin Mercury 0.2 D009 Vaccines w/ thimerosal, eye, ear preparations Selenium 1.0 D010 Dandruff shampoo Silver 5.0 D011 Silver sulfadiazine cream Example of an Insulin SDS Section 3. Composition/information on ingredients Chemical Name CAS-No. Concentration [%] Teriparatide Mannitol Water m-cresol ,000,000 x 0.3% ( or 0.003) = 3000 ppm m-cresol (D024) = 200 ppm = HW 3

4 Vaccines, a Dual Concern Different waste concerns Live vaccines are infectious Preserved vaccines may be HW for mercury Live and Attenuated Vaccines Regulated Medical Waste (RMW) disposal IAW MEDCOM Must evaluate for thimerosal content If preserved with thimerosal Will be HW for Mercury content (>TCLP 0.2 mg/l) DLA Disposition Services (DRMO) will accept DLA Disposition Services may require facility to kill live vaccines or find a separate contractor RCRA Listed Wastes F List - Non specific sources, usually spent solvents K List - Specific sources (pink water from TNT manufacturing) P List - Discarded commercial chemical products - acutely hazardous U List - Discarded commercial chemical products - toxic P list Acutely Hazardous U Listed Pharmaceutical Wastes NAME Arsenic trioxide Epinephrine* Nicotine Nitroglycerin* Phentermine Physostigmine Physostigmine salicylate Warfarin** >0.3% EPA HAZARDOUS WASTE # P012 P042 P075 P081 P046 P204 P188 P001 Name Waste Code Name Waste Code Chloral hydrate U034 Mercury U151 Chlorambucil U035 Mitomycin C U010 Cyclophosphamide U058 Paraldehyde U182 Daunomycin U059 Phenol U188 Dichlorodifluoromethane U075 Reserpine U200 Diethylstilbestrol U089 Resorcinol U201 Hexachlorophene U132 Selenium sulfide U205 Lindane U129 Streptozotocin U206 Melphalan U150 Uracil mustard U237 Trichloromonofluromethane U121 Warfarin <0.3% U248 Chemotherapy agents are noted in italics P & U Listed Hazardous Waste Requirements P List Exclusions Unused Has not been used for its intended purpose Unprocessed has not been mixed with other chemicals/materials as part of a process Not physically connected to or used on a patient Includes items hydrated for delivery purposes Sole Active Ingredient The listed chemical in the discarded drug must be the only ingredient that performs the intended function of the formulation. Ingredients that serve ancillary functions such as mobilizing or preserving the active ingredient are not considered when determining the sole active ingredient Medicinal Nitroglycerin EPA Memorandum 16 May excluded all P & U listed wastes that are listed solely for an ignitability, corrosivity and reactivity characteristic once they no longer exhibit that characteristic Nitroglycerin (P081) is listed solely for reactivity Medicinal Nitroglycerin does not exhibit the reactivity characteristic State exception: Hawaii Epinephrine EPA Memo - 15 Oct 2007 Pure Epinephrine is a P042 listed HW Epinephrine salts are not included in the P042 listing State exception: Washington 4

5 Nicotine Items In August 2010 the EPA clarified its interpretation of manufactured articles and commercial chemical products. EPA now states that nicotine in finished forms, such as tablets, gum, lozenges, and patches are commercial chemical products with nicotine as the sole active ingredient. Unused nicotine items must be managed as P075 listed wastes when disposed. Used patches have been used for their intended purpose and can be discarded as solid waste The Problem with P-Listed Containers A container that has held a P-listed waste is not considered RCRA empty (40 CFR (b) ) unless it has been: Triple rinsed, and The rinsate is managed as hazardous waste. None of the regulatory mechanisms that allow a P-listed container to be classified at RCRA empty are feasible Residue remaining in a container or in an inner liner removed from a container that held any P-listed waste is also a P-listed waste The Problem with P-Listed Containers Pill bottles that have held pharmaceuticals such as warfarin (brand names Coumadin and Jantoven) at concentrations greater than 0.3% Blister packs and wrappers that held nicotine gum, nicotine patches and lozenges Containers such as paper/plastic dispensing cups (soufflé cups) that were used to administer an acute P-listed pharmaceutical to a patient in a MTF Federal regulations allow only one quart of an acute P-listed hazardous waste to be accumulated at a satellite site. Waste Collection or Satellite Accumulation Points/Sites At or near the point of generation and under control of the generator Limit of 55 gallons of hw or one quart acutely hw (arsenic trioxide, warfarin) > 55 gallons or one quart acutely hw must be removed within 3 days Containers marked with the words Hazardous Waste or words identifying contents Logistics: What Happens After HW Leaves the Pharmacy? 90 Day Storage Area All HWs generated on the installation are regulated under one EPA ID number The DPW/ Environmental Office manages the EPA paperwork (i.e manifest) Your waste is counted in the annual report of all waste generated on the installation What you do or don t do can affect the entire installation A waste profile is created and a disposal contract is selected The HW is transported and treated/disposed off the installation Federal Agency #2 - Occupational Safety and Health Administration (OSHA) General Duty Clause Each employer -- (1) shall furnish to each of his employees employment and a place of employment which are free from recognized hazards that are causing or are likely to cause death or serious physical harm to his employees; (2) shall comply with OSHA rules. [Like bloodborne pathogens, SDSs, spill clean-up, and chemical hygiene plans.] Each employee shall comply with OSHA rules, which are applicable to his own actions and conduct. 5

6 OSHA Hazardous Chemical vs. EPA HW OSHA Hazardous Drug Definition OSHA 29 CFR Applies when chemicals used in workplace Evaluate health hazards Health hazard = statistically significant evidence that acute or chronic health effects may occur in exposed employees. Evaluates pure chemical exposure Does not apply to waste management EPA 40 CFR 261 Applies when waste is generated Evaluate potential harm caused by release to the environment Toxicity characteristic simulates leaching over time from landfill Does not apply during use in process/workplace Drugs considered hazardous include those that exhibit one or more of the following six characteristics in humans or animals: 1. Carcinogenicity 2. Teratogenicity or other developmental toxicity 3. Reproductive toxicity 4. Organ toxicity at low doses 5. Genotoxicity 6. Structure and toxicity profiles of new drugs that mimic existing drugs determined hazardous by the above criteria. Based on 1990 American Society of Health-System Pharmacists definition Includes: chemotherapy, antiviral, hormones, some bioengineered drugs Non-EPA, OSHA Regulated Chemotherapeutic Drugs Not RCRA Hazardous Waste! Do not degrade over time found active in landfills They can be inhaled or easily absorbed through the skin Outer packaging and shipping boxes are found to be contaminated in recent studies. Includes both bulk and trace amounts: Partially used IV bags and vials Empty IV bags, tubing, and vials Absorbent pads (chucks) and gauze PPE: gloves, gowns, booties, disposable counting tray All cytotoxic pills must be counted out separately from other drugs wearing PPE Some pills (Cytoxan and Mitomycin) are uncoated OSHA Hazardous Drug Disposal Guidance Container labeled, tagged, or marked with: Product identifier; Signal word; Hazard statement; Pictogram; Precautionary statement; and, Name, address, and telephone number of the chemical manufacturer, importer, or other responsible party. Thick, leak-proof plastic bags, colored differently from other hospital trash bags, should be used for routine collection of discarded gloves, gowns and other disposable material, and labeled as Hazardous Drug-related wastes. Name Collision: EPA P and U-Listed Chemotherapy Drugs Waste Code Name Waste Code Arsenic Trioxide P012 Melphalan U150 Chlorambucil U035 Mitomycin C U010 Cyclophosphamide U058 Streptozotocin U206 (Cytoxan) Daunomycin U059 Uracil Mustard U237 Diethylstilbestrol U089 When is a Chemotherapy Vial or IV Bag Empty? If held P-listed waste (Arsenic Trioxide) it is never RCRA empty = HW Tubing from a P-listed application is HW too If held U-listed waste = empty if: all content that can be removed was removed, and no more than 3% by weight of total volume or one inch remains in container Empty containers go into chemo container The EPA has not updated the HW lists to incorporate new FDA approved drugs in several decades. 6

7 Hazardous Waste Chemo Container Management Container must be different from the non-epa regulated Chemo containers Must be labeled with the words HW or contents Waste Cytoxan Most places co-mingle all HW cytotoxics in one container Need to verify with Installation HW Manager and MTF ESEO May require an inventory Some places require separate containers for each listed waste Logistics: What Happens When it Leaves the Pharmacy? HW gets turned in through Logistics for HW pickup Goes out for HW incineration Manifested through Post HW Non-EPA, OSHA Hazardous Drug/ Chemotherapy Waste is picked up with the RMW Important to keep it identified as chemotherapy waste Must mark outer container to ensure incineration Use labels to determine whether a box goes for incineration or autoclave EPA/ OSHA Waste Management Summary Practical Application Examples EPA Hazardous Wastes Segregated from other chemo wastes EPA/DOT approved containers Satellite accumulation point Labeled per 40 CFR Turned in through Logistics MUST be treated in an EPA permitted incinerator No needles please! Non-EPA, OSHA Regulated Chemotherapy Drug Wastes Stored in yellow RMW/chemo containers Separated from other RMW to insure proper treatment Labeled as Chemotherapy Waste for incineration Picked up by Housekeeping Treated by contractor at permitted RMW incinerator You have a vial of cytoxan that has measureable amounts remaining in it but you must discard it. What type of container/management will you use? HW container You have a partially filled IV bag used to administer Rituxan. The patient had an adverse reaction and treatment was stopped. What type of container will you put the IV bag in? Chemo container You emptied a bag of Mitomycin C into a patient during treatment. Only a little residual at the bottom of the bag remains (less than 1 inch remains). What type of container will you put the IV and tubing in? Chemo container it is no longer HW Federal Agency #3 Department of Transportation (DOT) Hazardous Material Transportation No person may offer or accept a hazardous material for transportation in commerce unless properly classed, described, packaged, marked, labeled, and in condition for shipment. ORM-D material = a material such as a consumer commodity, which presents a limited hazard during transportation due to its form, quantity and packaging. (Not valid on air shipping, otherwise valid until 2020.) Anyone who offers a hazardous material for transportation certifies that the materials are properly classified, described, packaged, marked and labeled, and are in proper condition for transportation according to the applicable regulations of the DOT. (DoD 80 hour course) Hazardous Material Transportation by Government Courier Exception vs Hazardous Waste Transportation Hazardous Material (DOT) Applies to transportation between pharmacy locations in a government vehicle with government drivers, not contracted government drivers. Can be accomplished without shipping papers. Basic driver training is required. Items should be packaged so as to avoid mixing and breakage. A spill kit is needed. Hazardous Waste (EPA) Cannot transport a hazardous waste without a hazardous waste manifest as required by EPA. Makes HW drug and P- listed container disposal problematic at off installation facilities (i.e. Medical Homes) and with regard to return vendors. 7

8 Federal Agency #4 - The Federal Drug Administration (FDA) Assure the safety, efficacy and security of human and veterinary drugs, biological products, medical devices, our nation s food supply, cosmetics, and products that emit radiation. Help the public get the accurate, science-based information they need to use medicines and foods to maintain and improve their health. Disposal Recommendations: DEA Collectors Programs Household Trash via mixing with unpalatable substance Potent list of drugs to flush down the sink or toilet to help prevent danger to people and pets in the home. Includes fentanyl, morphine, and oxycodone Federal Agency #5 - The Drug Enforcement Administration (DEA) Activity Type New DEA Rule Summary Take-Back Event Mail-Back Program (US only) Collection Receptacle Law enforcement Manufacturer Distributor Return Vendor Retail Pharmacy Hospital Pharmacy The DEA Secure and Responsible Drug Disposal Act of 2010 Each physical pharmacy location requires a separate registration as a Collector. DEA Collector can participate via a third party vendor via envelopes (US only) and/or collection containers. Items deposited in an envelope or collection container cannot be inventoried at any time, but are accumulated and transported for incineration. Items can be witnessed prior to deposit into the envelope or collection container, but not physically handled. DEA Definitions Disposal = legal transfer out of registrant control Destruction = render non-retrievable Non-retrievable = change the chemical or physical characteristics such that sampling for them would be non-detect. Only applies to stockage. Sewering is prohibited. Pharmaceutical Wastage = partials remaining of dispensed medication ( ex. the little bits left in the syringe after dosing a patient on the ward) must be managed to preclude diversion not non-retrievable. DEA Drug Waste Categories for Disposal Inventory or stockage = send via a returns vendor or render non-retrievable (i.e. crumbled/broken pills) Pharmaceutical Wastage or amounts remaining in a dispensing device after it was used on a patient = local witnessed destruction via a method that reduces diversion (sewer, unpalatable trash, incineration, chemical alteration, IAW local rules) Ultimate Users Collections = register as a collector and have sealed, lined bin in pharmacy area and under observation or locked room, or participate in vendor mailback program. Never inventoried. Collectors can observe, but not handle. Mail Back Program (US only) Run by another Collector that has onsite destruction capability Requirements for envelopes nondescript water- and spill-proof; tamper-evident; tearresistant; and sealable prepaid postage labeled with Collector address marked with unique tracking number Only for patient disposal, not inventory, stockage, or wastage Recommend a local SOP Who gets an envelope? How does the envelope get to the mail box? Who manages/pays this contract and tracks expenses? 8

9 Minimum Collection Receptacle Program Requirements Register as a Collector with DEA (no cost) Collection receptacles secured to the structure to prevent removal placed in a location that allows observation by staff, not in ER or urgent care area small opening shall be locked or made otherwise inaccessible to the public when an employee is not present have a sign indicating that only schedules II V controlled substances and non-controlled substances are acceptable. The installation and removal of the inner liner shall be performed by at least two employees of the authorized collector. Minimum Collection Receptacle Program Requirements Recommend establishing a local SOP. Who is observing? Who has key access? Who is responsible for emptying the receptacle? What if overfilled? Does the vendor pick-up directly? How does the liner get to the shipper? Does local law enforcement have/need a role? Collision: Hazardous Wastes that are Controlled Substances* Must be secured to meet DEA requirements while awaiting pickup for disposal DEA forms and tracking still apply thru destruction Must be managed as a HW at a permitted HW treatment facility A few HW treatment facilities are also permitted to treat DEA controlled substances Special contract Coordinate in advance with Logistics * Only applicable to items that are not eligible for pharmaceutical returns Potential Collision: Pharmaceutical Returns Program DoD contract managed by the Defense Logistics Agency Pharma Logistics Ltd Useable drugs redistributed or returned to manufacturers (typically < 5% of returned items) Credit received if returned to manufacturers Non-returnable items destroyed for a fee Problem Some pharmaceuticals are HW when discarded Who is generator Healthcare Facility or Returns Company? Requires state regulatory interpretations Packaging/shipping and transport requirements Pharmaceutical Returns Program The Waste Management Details Returnable Items Unopened, expired items Recalled items Opened items (except cytotoxics) Non-Returnable Items Broken/unsealable containers (broken ampoules) Opened cytotoxics HW items in identified 10 states CA, CO, CT, KY, MO, NM, NY, OK, SC, WV Shipped back as consumer commodities ORM-D not DOT HM Types of Used Pharmaceutical Containers Used Drug Bottles/Vials/IV Bags Empty Measurable amounts remaining Syringes Pharmaceutical Waste Wheel 9

10 What Should You Do? Waste an Enterprise Problem Understand the need for a pharmaceutical waste program based on regulatory involvement and environmental concerns Evaluate how pharmaceutical waste is currently being handled in your HCF in comparison to federal and state regulations Cooperate with local staff for successful program implementation Army Pharmacy Strategic Plan FY15-18 Stewardship Primary: Secondary: Goal: Institute best business practices into daily operations that improve use of limited resources and staff. TSG Priority: (4) Health of the Soldier and Beneficiaries (Families & Retirees) Objectives (~ OCT 16) Measures of Effect Actions (~ OCT 15) Measures of Performance Retail point-of-service (POS) prescription % of Retail POS prescription expenditures of MTF Pharmacies establish active and passive % of catchment area prescriptions written for expenditures exceed MHS Goal total prescription MTF expenditures (Goal< 25% prescription recapture program enrolled and/or referred enrolled beneficiaries of overall expenditures spent at the retail POS) filled at MTF (> 50%) Standardize Non-Formulary Drug Request Proposal for MHS NDR approval process Process across MHS submitted to DHA Pharmacy Operations Division (Goal = Yes) MTF Pharmacies accept e-prescriptions from % of prescriptions originating from Network Network providers using enterprise-wide e- providers filled as electronic prescriptions at prescribing system MTF pharmacies (>75%) Pharmacy Supply cost optimization goals % of any additional or remaining savings Purchasing complies with brand to generic % prescriptions filled as generic when achieved from optimization programs (< 5%) conversion and generic preference guidelines generic is preferred agent (> 90% within 30 days) Compliance with PV National Contracts % compliance with PV National Contracts (> 90%) Optimize reverse distribution credit and waste Actual Return Value (ARV) to weight of management pharmaceuticals destroyed (> $100/lb.) Inventory Management System Cycle count of 80/20 products ( Goal > 95% Expansion of SIM Trial at Ft Sill Completion of comparative assessment with implemented/improved accountability accurate and inventory turns > 5-6 cycles) Tuttle Clinic pilot (Goal = Yes) Disposition (1 of 2) Reverse Distribution (RD) Pharma Logistics sole RD 1-Jan-15 Excess Pharmaceuticals Redistribute internally (MTF) Return to PV Creditable Pharmaceuticals MNFR container Expired, unused +/- distributed Measures Estimated Return Value (ERV) to weight of pharmaceuticals destroyed (>$100/lb) Management of credits Canned reports available to all sites Disposition (2 of 2) Way Ahead Drug Take Back (DTB) MTF Pharmacy DEA registration Each site separate registration DEA Disposal of Controlled Substances effective Oct 2014 (A) Collection (B) Events (C) Envelopes Measures Polling question (A) Active receptacles; filled and sealed liners; total weight of drugs (B) Participated; total weight of drugs collected; number of participants (C) Envelopes purchased; envelopes on hand; envelopes processed by contractor Drug Take Back events will continue twice annually - April 2015 event: 34% sites (13/38) participated; 381 patrons; 825 lbs - Require collaboration with IMCOM/law enforcement - Materiel cannot commingle with other pharmacy stock or waste - Only part OCONUS MTFs can utilize (no receptacles or envelopes) Collection receptacles - Installed interior of MTFs DEA-registered location - Central purchase request for 38 sites/43 receptacles and initial liner - Liners and envelopes available through pharmacy prime vendor Education - Provided at MTFs, receptacles, DTB events - Patient contacts OTSG/MEDCOM policy published 30-Sep-15 - Floor sweeps separation requirement - Hazardous waste; regulated medical waste; RD 10

11 Fort Leonard Wood Receptacles SAMMC Separated Waste Key Points EPA (environment): HW pharmaceuticals collected and disposed by permitted incineration. Exempt household waste. Require HW to be manifested to track proper disposal. OSHA (worker safety): hazardous pharmaceuticals used, stored, labeled, and disposed in a manner that protects workers. DOT (public safety): hazardous material pharmaceuticals properly packaged and tracked in transport. FDA (human health): pharmaceuticals taken to collection events, disposed as solid waste or into the wastewater. DEA (criminal): individual documented disposal of controlled substances at the registrant level and ultimate users to participate in collection events. Answer to Self-Assessment Question 1 How are RCRA P-Listed pharmaceutical containers managed? A. Recycled B. P-listed HW C. U-listed HW D. Trash Answer to Self-Assessment Question 2 Which are 4 characteristics of OSHA hazardous drugs? A. Carcinogenicity, Odor, Reproductive toxicity, Genotoxicity B. Carcinogenicity, Teratogenicity, Reproductive toxicity, Genotoxicity C.Ignitability, Toxicity, Reactivity, Corrosivity D.Ignitability, Toxicity, Reactivity, Flammability Answer to Self-Assessment Question 3 Which of the following lists 3 DEA waste categories? A. Trash, stocks, returnable for credit B. Pharmaceutical wastage, stocks, ultimate user collections C.Ultimate user collections, stocks, returnable for credit D. Solid waste, hazardous drugs, controlled drugs 11

12 References EPA Hazardous Waste WIKI aceuticals/pharmwiki.htm NIOSH Hazardous Drug List DEA Controlled Drug List FDA Flush List BuyingUsingMedicineSafely/EnsuringSafeUseofMedicine /SafeDisposalofMedicines/ucm htm#Flush_List Closing Remarks Lisa Strutz, PE Army Public Health Center LTC Kevin Ridderhoff, RPh, MHA Army Pharmacy Program