Piled on a table are plastic bags of drugs, medication worth an estimated $3,000.
The drugs come from Hospice Atlanta patients who died or had their medicine changed. Carol Reifenberger, a pharmacist, and registered nurse Suzanne Hughes record the medications.
The medical pros then do something that bothers them: They dump the pills and pour the liquids into a bucket of hot water. Morphine. Oxycontin. Percocet. Hughes uses scissors to destroy patches of the narcotic Fentanyl - worth about $70 each - and drops the strips into what has become a beige soup.
After about 45 minutes, Hughes pours the contents like dirty mop water into a toilet-like basin and flushes.
Such disposal of unused drugs occurs with numbing frequency at hospices and long-term care facilities across the country, and also in people's homes. But now, with the cost of pharmaceuticals rising, more people are paying attention to the destruction, including lawmakers.
The amount of drugs wasted annually is unknown, but it's potentially enormous. A 2001 study in the Journal of Family Practice estimated that more than $1 billion in drugs for the elderly is wasted nationally every year.
The flushing and incinerating and burying have frustrated health care administrators and workers for years. The executive director of nonprofit Hospice Atlanta, Catherine Radle, calls the drug destruction "ridiculous, when we have so many people who could benefit from medicine."
Harley Smith, administrator of 97-bed Miller Nursing Home in Colquitt, said, "Just for our little nursing home, it's thousands and thousands of dollars a month. Every nursing home has the same problem. It's an awful lot of drugs wasted."
The Environmental Protection Agency, the Food and Drug Administration and the Drug Enforcement Administration, are discussing alternatives. The EPA said it's researching and monitoring pharmaceuticals in waterways, studying the potential risks involved in the trace amounts found.
And a few states, with varying degrees of success, have created programs to recycle drugs still wrapped in single-dose packaging to protect against tampering, and properly identified with expiration dates. Some states send recovered medicines to pharmacies in clinics that treat people without health insurance.
There are many patient safety and privacy concerns related to drug recycling, including proper handling and storage. Pharmaceuticals, for example, are sensitive to cold, heat and moisture. And narcotic drugs or controlled substances are especially problematic because federal law prohibits their return or transfer.
Yet in North Carolina, which recycles non-narcotics, the executive director of a group of free clinics there gives a conservative estimate" of recycled drugs at $5 million a year.
Georgia has no such program, though
a provision in its Board of Pharmacy
regulations allows the return of certain
medications from nursing homes. The
Georgia Pharmacy Association said drugrecycling likely is done occasionally,
but
Fred Watson, president of the Georgia
Health Care Association, representing
the state's nursing homes, said he's unaware
of any recycling.
Nurses, in particular, are bothered, Watson said. "We just don't want to continue to see the waste."
The Georgia Drugs and Narcotics Agency said it doesn't recommend flushing drugs down a toilet.
"Now that drugs cost so much, [recovery of drugs] has become a big issue," said Rick Allen, deputy director of the Georgia Drugs and Narcotics Agency. "It's something that needs to be looked at.
"It's going to have to be addressed at the federal level, because most states take their lead from the federal government."
Yet an underground network exists here for recovering unused drugs among people with HIV, according to the AIDS Survival Project, a statewide advocacy group for people with HIV.
"It helps people get access to medications who cannot afford them or get government assistance for them," said Jeff Graham, senior director of advocacy for the group. Drugs cost an HIV patient an average of $12,000 per year, he said.
"People are getting drugs from other people they know and trust," said Graham, who acknowledged the transfers are illegal.
It's a sign of the desperate measures people will go to, to get prescription medications."
Meanwhile, inertia seems to prevail on setting up a legal, formal Georgia recycling program. The Georgia Pharmacy Association said it has mixed feelings about the issue.
"We understand the economic impact and that it would help people, but we're concerned about the liability and about the danger to the patient," said Buddy Harden, executive vice president of the group. "The drugs might be adulterated."
Those concerns could ease, Harden said, if the pills to be recycled came in single-dose packaging.
One member of the House Appropriations Subcommittee on Health wants the state to study recycling.
"My biggest concern is safety," said Rep. Mark Butler (R-Carrollton). But he believes that if a "safe and responsible" system was devised, some pharmaceuticals could be recovered. "These [drug] costs are skyrocketing, " he said.
A recycling proponent, David Levine, 86, of Athens, said that not only are expensive drugs being flushed, but also the chemicals entering the water system pose an environmental threat.
"It seems to be a foolish thing to do," said Levine, a member of the Georgia Council on Aging, an advocacy group for seniors.
Nationally, the National Hospice and Palliative Care Organization has talked with members of Congress interested in drug disposal.
"We see the waste," said Jon Keyserling, vice president of public policy for the group. "We want to do something about it but want to do it responsibly."
He said hospices are ordering fewer days' supply of drugs for patients, thus minimizing waste. Hospitals already limit waste by distributing a patient's drugs each day, experts say.
The image of tons of destroyed drugs inspired North Carolina's program, which allows medicines to be donated from a licensed pharmacy serving a nursing home to another licensed pharmacy housed at a free clinic.
"They're not going to a church basement - they're stored properly and dispensed in traditional packaging," said John Mills, executive director of the North Carolina Association of Free Clinics, representing 65 medical clinics and pharmacies that serve the state's uninsured.
"I don't buy the safety issue, because they're going from one licensed pharmacy to another," Mills said. "If there's any question about it, you destroy it."
Mills called the state's recycling effort of popular drugs such as Lipitor "hugely successful."
"The biggest barrier was convincing nursing homes and pharmacies that they wouldn't get in trouble," Mills said.
Ohio's program, in fact, has lagged because nursing home pharmacies haven't embraced it. William Winsley, the executive director of the Ohio Board of Pharmacy, cited, in part, pharmacies' concerns about liability, though the law has built-in protections against lawsuits.
Missouri's recycling effort, structured around retail pharmacies, has gone nowhere in its first year. Pharmacists have not volunteered to receive unused drugs because of a heavy administrative and operational burden, said Susan McCann, of the Missouri Bureau of Narcotics and Dangerous Drugs.
"I've heard it equated to someone taking a package of raw chicken back to the grocery store for someone else to buy," she said. "This is a really well-intentioned program. I'm not sure this is the way to do it."
Free drugs of any type would be welcomed at clinics serving Georgia's uninsured. Della Lago, administrator of Good Shepherd Clinic in Morrow, pointed out that when patients get a diagnosis of high blood pressure, they still need medicine to treat it.
"It can be frustrating for a free clinic if you can't provide the medication needed to complete the treatment," Lago said.
North Carolina's drug recovery program has saved Donna Jorgensen, who has diabetes, thousands of dollars. Earlier this year, Jorgensen, 50, of Winston-Salem, lost her health insurance along with her job.
Crisis Control Ministry Pharmacy, a Winston-Salem pharmacy that offers medicines recycled from nursing homes to the uninsured and underinsured, fills Jorgensen's prescriptions at no charge. Including diabetes supplies, it would cost her more than $1,000 per month if she paid retail prices.
"I'm very thankful," she said. "This is a blessing to me."