A watershed moment
Five N.Y. facilities agree to stop dumping drug waste
Now that the public is becoming aware and alarmed that much of the nation’s tap water is laced with trace amounts of pharmaceuticals, hospitals and other healthcare facilities may be increasingly finding themselves answering for it.
Last week, New York Attorney General Andrew Cuomo announced his office reached settlement agreements with two critical-access hospitals and three nursing homes alleged to have been dumping unused pharmaceuticals down drains and toilets and causing the chemicals to flow into the reservoirs and lakes that make up the watershed providing water to 9 million residents of New York City and surrounding counties.
“It’s not a new issue for healthcare professions,” said Cynthia Reilly, director of the practice development division of the American Society of Health-System Pharmacists. The association first crafted guidelines for proper disposal in the 1970s, which is when Congress passed a law to police a wide array of industrial waste, the Resource Conservation and Recovery Act.
“What’s new is some of the public scrutiny of it,” Reilly said. “It’s not just pharmacies that are involved in this—it’s also nursing, environmental services and, most importantly, the institution’s C-suite needs to understand that this is a significant issue and resources are needed to help manage it.”
The drugs in our water don’t all come from healthcare facilities, a fact consistently noted by scientists who have studied the matter and the U.S. Environmental Protection Agency. Much of the stuff is excreted by the people who take pharmaceuticals. Other sources include runoff from farmland, where livestock is treated with antibiotics and other drugs, and pharmaceutical manufacturers.
The EPA in 2006 embarked upon an effort to better understand the role of hospitals and nursing homes. A comprehensive survey was planned and then scrapped after the agency determined its preliminary data collection and communication with the industry was enough to begin developing best practices for the industry.
Advances in analytical methods have allowed researchers to detect lower concentrations of chemicals in water, according to the EPA’s September 2009 interim report, and the U.S. Geological Survey detected pharmaceutical compounds in 80% of 139 streams tested in 1999 and 2000.
Cuomo’s office is in the midst of what it describes as a broad and ongoing investigation into the disposal practices of healthcare facilities within New York City’s watershed. According to the five settlements announced last week, Cuomo’s office sent letters in January 2009 requesting information from 15 hospitals, nursing homes and assisted-living facilities.
The two hospitals that settled were 16-bed O’Connor Hospital in Delhi, N.Y., and 15-bed Margaretville (N.Y.) Hospital. Neither returned calls requesting interviews. In both cases, according to the settlements, manage- ment responded that they did not deposit any pharmaceuticals in drains and toilets, but those assertions were contradicted by interviews with patient-care staff.
Common medical products that are considered hazardous waste include nitroglycerin, nicotine and the anticoagulant warfarin. Other drugs identified by Cuomo’s office as potentially damaging to the area’s aquatic life were estrogens, Prozac, Tamoxifen and beta blockers.
The agreements with Cuomo include a few thousand dollars in fines and fees but principally call for the facilities to cease disposing of any pharmaceutical products in sinks and toilets and transport all products deemed hazardous to qualified waste incinerators.
The EPA observed in a 2008 document that “for many years, a common practice at many healthcare facilities has been to dispose of unused pharmaceuticals by flushing them down the toilet or pouring them down the drain.”
Managing unused pharmaceuticals is extremely complicated, according to professionals who strive to do it right. The recovery conservation law in the EPA’s domain was written largely for industrial plants and doesn’t translate easily to healthcare, said Janet Brown, director of facility engagement for Practice Greenhealth, a membership organization for healthcare organizations working to be good environmental citizens.
Compliance requires cross-checking a formulary that typically includes more than 1,000 medications against federal lists of chemicals and characteristics. “We try to help hospitals identify ways to make less pharmaceutical waste in the first place,” Brown said. “Instead of just paying those bills to haul hazardous waste, let’s look at what you’re generating.”
Compliance is further complicated by the variety of federal and state agencies, laws and regulations that have a hand in waste disposal, said William Churchill, executive director of pharmacy services at 776-bed Brigham and Women’s Hospital in Boston. Churchill, who has done educational presentations on the topic, said consultants can help do the work of classifying the proper waste stream for each product used by a hospital. He echoed Reilly’s observation, though, that crafting and carrying out an approach must involve leaders from several hospital departments and a willingness at the top to incur additional cost.
Just in the past few years, Churchill said, he has noticed significantly more attention paid to the issue by regulators and the media. Colleagues have shared tales of EPA investigators showing up unannounced. “I had never really heard of it six years ago,” he said. “I think there’s a combination of things that are bubbling to the surface.”
The Croton River is part of the New York City watershed allegedly contaminated with pharmaceuticals flushed by hospitals and nursing homes.