3R's of Medicine

By - 1) Shubham Ghosh
2)Ankit Jaiswal
3)Mazhar Shaikh
4)Bharat Choudary
5) Abhishek Gawada
6)Nikhil Kharote
7) Amey Deshmukh
Content
How waste Arises
Meaning of 3Rs
Apllication of 3R's in medcine
1. Reuse
2. Reduse
a) Drug companies accused of polluting water in India
3. Recyle
. Types of medical waste
. Biblography
 How waste ar
ises
In fairness pharmacy has taken steps towards reducing waste, including the Waste
Reduction Scheme in Wales where any medication on a prescription identified by
pharmacist as not being required by the patient is not dispensed and the pharmacist
is able
to claim a small fee. The question of how medical waste in the community is created
is not straightforward (the waste produced by hospitals is a different and far greater
problem).
Examples of how drug waste arises in the community-
Medication no longer required but still on repeat.
Patient has a surplus but still orders medication because they think if they do not
order it each month it will be taken off repeat.
Patient not taking the medication but does not want to admit it.
Medication being stopped or altered just after being given a new supply.
A regular months supply given for an item that is taken only when
required.
28 tablets per month given when they are only taking half a tablet daily.
30 tablets given on a 28-day cycle.
 Monthly prescriptions for an item dispensed in a three-monthly container that
cannot be split.
Monthly scrips for two inhalers, each of which would last a month.
Inappropriate medication being dispensed, eg lactulose and loperamide on the
same scrip .
A pharmacist could say that they are just dispensing what the doctor
has prescribed (they get paid for the most part on what they dispense,
not for what they dont dispense).
Meaning of 3Rs
1. The 'Reduce', 'Reuse' and 'Recycle' elements ar
e referred to as the '3 R's'
2. Reducing - Try to reduce the amount of waste you produc
e, as this is the best way to help the environment! If you c
annot avoid producing the waste, try
3. Reusing - Think of ways you could reuse something, like s
hredding paper for your hamster rather than buying bedd
ing or saving glass jars for storage. If you can not reuse so
mething try
4. Recycling (and composting)-This enables the materials yo
u throw away to be used again by making them into new
products.
The 3 Rs
Application of 3R's in medicine
REUSE ( OR REDISTRUBUTION OF MEDICINES ) -
It Means the utilisation of Unused Medication .We have been
investigating the reuse of medicines in various countries and trying to
assess the different methods used and the hurdles that must be
overcome.
Case 1 - Pharmacists in the UK fall back on the argument they
are not allowed to reuse medication: this is true, and if any
pharmacist was caught reusing medication they would face
being struck off the register. The issue is two-fold: the practice
goes against the ethical framework of the professionsregulator,
and also invalidates the terms and conditions under which
medicine are supplied from wholesalers(General Pharmaceutical
Council, UK, personal communication).
Case 2 - In the USA, many states allow redistribution of prescribed and unuse
d medicines, varying from redistributing medicines from long term care and n
ursing facilities to special clinics for the uninsured, to accepting donations of
expensive drugs from patients themselves .

As in the UK, pharmacy regulators struggle with the potential for risks t
o patients, but nevertheless the National Association of Boards of Phar
macy (NABP) take a positive response to state laws that require redistri
bution of medicines (NABP, personal communication).
Many medications are relatively cheap and the effort and processes tha
t would be needed to confirm suitability for reuse would simply not be
cost effective. A mechanism for reusing expensive items (a ball-park fig
ure of 10 would be work-able) could be devised with the right blend of
training, procedures and technology, should the will be present to mak
(Continuation)
Storage :
The first issue to be tackled is storage. The issue of humidity is ea
sily resolved now that the majority of medication is now dispensed in s
ealed containers and blister packs, so anything dispensed loose woul
d not be eligible for inclusion into the scheme.

Temperature is theoretically more of an issue but heat-sensitive label

s or spots are readily available, so if storage temperature is exceeded
this can be easily identified. These are already used in medicines in c
old chains and several are approved by the WHO; other sophisticated
solutions have been developed in the food and logistics industries.
(Continuation)
Tampering :
The second issue is potential tampering. This could be resolved by p
utting the item in a clear plastic bag with a tamper-evident seal.Disp
ensaries are well used to put-ting medication in bags and sticking labe
ls on boxes, so the scheme fits in well with current work practices. The
plastic bags themselves would be recyclable and have printed on t
hem return to the pharmacy if not used in three months to prompt
returns. A pilot could be run to check safety and an SOP (standard op
erating procedure) produced to cover the pharmacist for any liability
until the schemes safety can be established. In such a pilot study we
would include recording the tem-perature of medication stored by pati
ents over a period of time in order to compare how medication
(Continuation )
is stored in the home with that in the professional sector. We believe that
home storage conditions donor differ greatly from those in pharmacies,
delivery vans, etc. Few community pharmacies are temperature
controlled, yet some medicines can spend years on shelves that we
believe can be subject to greater temperature variations than in a
home. Many pharmacies are unheated outside business hours and can
be hot in the summer, yet we do not seem to be so worried about the
risks of degradation of drugs under these circumstances. As yet we have
not been able to identify funds to support this pilot,and so we invite
readers and all those who feel strongly about this issue to help us locate
such funding to trial technologies and SOPs. If this basic groundwork and
research is not carried out, then regulators cannot be expected to change
the rules.
 (Continuation)
Conclusion:
Point scoring between health care professionals as to who is the biggest
culprit means no one seems to be getting around to looking at the problem
in terms of solving it. All health care professionals contribute to the problem
and only when they'll work together will progress remade. Most of the points
in the first part of this article are happening to greater or lesser degree
already but still need to be worked on. New ideas need to be explored if we
want to make significant improvements just changing the picture on the
annual waste awareness campaign each year is not going to work. We have
met with some resistance when suggesting our ideas,usually around the
fact that it would require changes in current legislation. Legislation is not an
irrefutable law of physics but sometimes it feels it would be easier to make
water flow uphill than changes piece of legislation.
 Reduce ( Medical Waste Reduction ) :
Regulated medical waste (RMW) is a highly regulated, ex
pensive waste stream to treat, manage and properly dispose of. RMW requi
res the development and implementation of policies and operational proce
dures to ensure compliance. With effective planning and education, a hosp
ital can reduce the volume of RMW generated, decreasing cost and enhanc
ing staff and patient safety.

Reduction of medical waste can also me done by proper

monitoring of pharmaceutical industrial waste and on Individual level
.

Lets see a Case of Pharmaceutical industrial Water pollut

ion in the City of Hyderabad
 Drug companies accused of polluti
ng water in India
Swedish scientists have found some of the highest levels of pharmaceutical pollution on the outskirts of a city
in southern India. It is alleged that factories producing drugs for western markets could be the culprits in
damaging wildlife and ecosystems in the region.
Waste flowing out of a treatment plant near Hyderabad in India pollutes the region's waters with some of the
highest levels of pharmaceuticals ever detected in the environment. In a paper being released online this
week, researchers in Sweden report how this effluent has serious adverse effects on the development of
tadpoles and zebra fish.
The findings raise concerns for the health of wildlife and ecosystems in the region, as well as underscoring
little-studied potential effects on human health."The volume of drug production in that valley is overwhelming
the system," says Stan Cox, a researcher at the Land Institute in Salina, Kansas. "Even though they have
good [environmental] laws on the books, they're being swamped by the production."
For several years, the National Geophysical Research Institute in Hyderabad and the country's Central
Pollution Control Board in Delhi have monitored heavy metal and other pollutants around the town of
Patancheru, which is home to factories producing solvents and other chemicals. But although Patancheru is
also home to numerous drug companies, the government has not monitored for drugs being released into the
environment.
High pollution levels (contin
uation)
With permission, Larsson's team sampled the waste exiting the plant; they found drugs including the
antibiotic ciprofloxacin, at concentrations of up to 31,000 micro grams per litre, and the antihistamine
cetirizine, at up to 1,400 micrograms per litre. The team estimated that the amount of ciprofloxacin entering
the river from the plant could amount to up to 45 kilograms a day the equivalent of 45,000 daily doses,
says Larsson.
The government has not monitored for drugs being released into the environment.
In new work, he and co-workers exposed tadpoles and zebrafish embryos to diluted PETL effluent,
equivalent to river water downstream of the plant. At the lowest concentration tested equivalent to 1,500
cubic meters of effluent diluted in 750,000 cubic meters of river water, or a 0.2% concentration the
tadpoles experienced 40% reduced growth compared with controls. And at concentrations of 816%, zebra
fish embryos lost color and movement within two days of fertilization, among other developmental effects.
Larsson's team has also found drugs in nearby lakes that do not receive effluent from the PETL plant
which suggests that drugs may also be entering the environment by means other than waste-treatment flow.
Past reports, including a 2004 review commissioned by the Indian Supreme Court, noted that the PETL
plant could not handle all of the waste arriving for treatment over the years. Local villagers speculated that
drivers may have dumped their waste elsewhere.
 (Continuation)
Pattancheru-Bollaram cluster is an agglomeration of different industrial areas. It is located at the North-Western
outskirts of Hyderabad.
The cluster area is known for high pollution levels throughout a long period in history already. Starting with the
first pharmaceutical production facilities in the mid 1970s, it now is one of the biggest pharmaceutical industrial
areas of India, with more than 90 manufacturers . Since 1989, waste water from these facilities is being treated
in a common effluent treatment plant (CETP) called Patancheru Effluent Tech Limited (PETL).Until the Honble
Supreme Court ordered to build a pipeline in 1998 and put the pipeline in commission in 2009, most of the
CETP pretreated effluents went straight into rivers and lakes in the Patancheru area (Larsson 2007).
Honble supreme court order:
Honble Supreme Court of India in a public interest litigation case on environment and
pollution control in Patancheru Industrial belt issued directions to lay a 18 km Pipe Line from
M/s.Pattancheru Enviro Tech Limited (PETL), CETP to K & S Main, Balanagar for carrying the
treated effluents to sewer standards.
The Patanacheru Effluent Tech Limited data states an increased reduction of organic load is being induced by
the implementation of Membrane Bio-reactor (MBR) technology. After sighting the values of COD (chemical
oxygen demand) from the months before commission of the MBR and afterwards, no significant changes are
observed. Still both, the PETL and the STP at Amberpet, which are connected via the Pipe Line, are not suited
to eliminate the variety of active pharmaceutical ingredients that are released by the pharmaceutical industry in
the Patancheru-Bollaram cluster.
A man covers his nose to keep out the stench from the
polluted Iska Vagu stream.
 Recycle

Most of the medicines in our medicine cabinet we need, but what about the yellow pills i
n a jar thats lost its label, and the eye drops we have had for a longtime. And what was that
Quivinrox B-Sulphamate for?

Old medicines lying around the home 'just in case are dangerous...

If taken when theyre out-of-date

If taken when not prescribed for you

If in reach of little prying fingers

Think before you throw

Unwanted medicines are often dumped into the toilet, tipped down the sink or put out with th
e garbage, which starts a journey that can seriously harm the environment.
Recycle Loop of Medicines
Things to recycle and not to recycle
More than 500 tonnes of medicines find their way into waterways and landfill every year.We
need to change our behaviors to solve this problem and give the environment a chance.

Dont flush medicines down the toilet.

Sewerage plants cant treat all chemicals in waste water, resulting in contamination of
waterways.

Dont pour medicines down the sink.

Household medicines contain highly soluble chemicals which when entered into water
systems can harm aquatic life.

Dont throw medicines into the garbage bin.

Household medicines disposed of this way end up in exposed landfill sites

 So why bother to recycle?

Recycling isnt simply good for the environment. A well-designed program

will also boost the performance of your health care institution from day on
e and for many years to come. Waste Management can help you develop
a comprehensive recycling program that has a positive impact on your ho
spitals bottom line.
Depending on materials markets, recycling can actually add dollars to
your bottom line.
The prospective savings associated with the estimated 50% of waste t
hat can be recycled is significant.
 Benefits of Recycling Medical Wa
ste
Recycling medical waste reduces consumption of raw material and reduces th
e volume of the waste materials that must be disposed in a landfill. Less medic
al waste in a landfill, will mean reduced emission of green house gasses, less
burning of fossil fuels as well as less carbon dioxide in the atmosphere. So, wit
h using resources that are already processed hospitals can protect the environ
ment and the already strained natural resources. In addition to the reductio
n of pollutants in the environments, hospitals can save a significant sum of mo
ney with recycling and re-using. "Health care facilities could save the industry
between $4 billion and $7 billion by adopting greener practices" (Howell, 201
1). By recycling medical waste hospitals save $5.4 billion in five years and up
to $15 billion in 10 years. Those money come from the recycling centers that tr
eat the medical waste properly and then sell it for only 40 to 60 percent of the
original price. Also, those recycling companies pay money to those hospitals w
ho provide them with medical waste that can be sterilized and re-used.
Another study showed that hospitals spend approximately $10 billion ann
ually on waste disposal in the landfill (Howell, 2011) . Landfills charge hos
pitals per pound for all the medical waste they are disposing. Therefore, b
y recycling the volume and mass of the medical waste is significantly red
uced, allowing hospitals to use saved money for better medical equipmen
t and better patient care.
Types of medical wast
e
infectious waste -infectious waste is any waste that can cause infectio
ns to humans. That is, anything contains or has been in contact with b
lood or body fluids ,as well as anatomical and pathological waste ("Ty
pical," 2013). The syringes that were washed on the shore in 1987 an
d 1988 were considered to be medical waste because they were used
in medical facilities, and most of them tested positive for the HIV virus.
This type of medical waste is considered to be one of the most danger
ous wastes. Listed below are some examples of medical waste.

Blood and/or body fluids

bandaids
surgical gloves
 saliva from dental procedure
s
urine
menstrual blood
feces
Pathological Waste-
small tissue sections and small body parts
Anatomical Waste - derived from biopsies

human tissues
human body parts
organs
 Hazardous Waste

Hazardous waste is any waste that is not infectious and cannot transmi
t any disease to humans ("Sharps and Biohazardous," n.d). However, ite
ms in this category can rapture or burn the skin. Such waste items includ
e sharps, needles, syringes, and surgical instruments. There are separat
e laws for the treatment and storage of hazardous waste.
Radioactive Waste

Radioactive waste is any waste that has been produced by radiation in c

ancer therapies, medical nuclear treatments and by medical equipment t
hat was exposed to radioactive isotopes (Hollingsworth, n.d). If any of the
infectious and hazardous waste were exposed to radiation, than they hav
e to be treated as a radioactive waste. This type of medical waste is
often not properly sorted and therefore it may not always be marked with
the appropriate radioactive sign. Laws requires that radioactive waste is
also to be stored in special containers and there are unique techniques fo
r the destruction of such a waste.
Bibliography
http://www.waterandmegacities.org/patancheru-bollaram-industrial-clu
ster/
http://earth911.com/recycling-guide/how-to-recycle-unwanted-or-expir
ed-medications/
http://onlinelibrary.wiley.com/doi/10.1002/psb.962/pdf
http://www.wm.com/enterprise/healthcare/healthcare-facility-solutions/
solid-waste-and-recycling.jsp
You cant change t
he past but you c
an change the fut
ure, always reme
Thank You