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Disposal of inhalers scrutiny working group

DISPOSAL OPTIONS FOR USED
RESPIRATORY INHALERS WITHIN

Environmental Services Scrutiny Working Group Review.
March 2012.

FOREWORD
I was pleased to receive the referral from Council asking us to review the disposal options of inhalers. Like myself and other members of the Environmental Services Scrutiny Committee, 15% of Cwm Taf residents are being treated for respiratory illness, and over a quarter of a million people live with asthma in Wales. With such figures in mind, considering the amount of inhalers used and the subsequent disposal of inhalers, the referral allowed members of the Scrutiny Committee to raise some important questions for consideration. It was pleasing to discover during our review the recycling scheme for inhalers in all Co-operative pharmacies in Wales, in partnership with GSK and Terracycle UK, which provides recycling for all GSK inhalers across Wales. . During the scrutiny review consideration was given to RCT Council running a recycling pilot for inhalers, but the group saw this as duplication, following the current GSK recycling scheme and the group felt that Council resources could be better spent. It was evident following the review however, that awareness of the recycling scheme needed to be heightened, as many inhaler users were unaware of the recycling scheme Awareness raising was a strong theme that ran throughout the review, and again the working group were aware of the role the Council could provide in educating its residents on disposing of inhalers through the GSK scheme and also educating residents in respect of wasted medicines, a message heavily promoted by Cwm Taf Health Board and the Welsh Government. It was also highlighted within the review that general awareness surrounding wasted medicines could potential save the NHS an estimated £50million each year. I would personally like to thank all the members of the scrutiny working group for their input into the review and special thanks also goes to the Community Pharmacy Officer -Cwm Taf Local Health Board, the Waste Strategy Officer – Welsh Government, the Respiratory Nurse- Cwm Taf Health Board, the Breath Easy User group and the Development Manager, GlaxoSmithKline for giving up their time to contribute to this review. County Borough Councillor (Mrs) C Leyshon Chairman, Environmental Services Scrutiny Committee. 1 Creating Altogether Healthier Communities – Interim Annual report of the Director Public Health 2010. 2 A quarter of a million voices…and counting. Asthma in Wales today.2008. 3 Reducing medicines waste – A team approach across health and social care. Welsh Assembly Government. RECOMMENDATIONS
1 That the Local Authority assist in raising awareness and promote the recycling of inhalers through the GSK recycling scheme conducted in all Co-operative pharmacies throughout Wales. 2 That the Local Authority joins the Welsh Government and Cwm Taf Health Board with its educational campaign on raising awareness of wasted medicines and the returning of medicines including inhalers via all pharmacies for incineration / Co-op pharmacies for recycling. 3 That the Service Director, Street Care evaluate whether the plastic outer case of inhalers could be recycled through the Council recycling scheme, if the GSK recycling scheme is concluded. 4 That the group review the recommendations if / when the GSK recycling scheme is concluded and consideration be given to the Service Directors evaluation on inhaler recycling. INTRODUCTION

REFERRAL
On the 23rd February, 2011 a notice of motion was considered at Rhondda
Cynon Taf’s Council meeting that ‘this council, as waste disposal authority,
discuss the disposal option of used respiratory inhalers with the
pharmaceutical industry and manufacturers TerraCycle UK with a view to
introducing a recycling scheme throughout the County Borough.’
Following discussions, it was resolved to refer the matter of the ‘Disposal
options for used respiratory inhalers within the County Borough’ to the
Environmental Services Scrutiny Committee for investigation.
During the Environmental Services Scrutiny Committee on the 11th July, 2011,
the Committee resolved to create a working group to consider the Council
referral.
WORKING GROUP
The working group consisted of the following County Borough Councillors
from the Environmental Services Scrutiny Committee:-

TERMS OF REFERENCE
The working group at its inaugural meeting on the 23rd November, 2011
agreed the following terms of reference and scope for the scrutiny review:-
“To consider the disposal options for used respiratory inhalers within the
County Borough.”
Scope:-
To consider any guidance published on the disposal of respiratory inhalers
To consider and establish the role the Council have in disposal of inhalers
To consider and establish the role Cwm Taf Health Board have in disposal of
inhalers
To consider the role local pharmacies have in disposal of inhalers
To consider users of respiratory inhalers and how they currently dispose of
inhalers
Stakeholders:-
Proposed stakeholders - Rhondda Cynon Taf Council Service Officer(s); Cwm
Taf Health Board representative(s), Pharmacies, Environment Agency Wales;
Respiratory inhaler users; Breathe Easy Group
APPRECIATION
The Working groups thanks are conveyed to the following individuals for
attending meetings / providing information to the group on the scrutiny
review:-

Ms Emma Hinks – Community Pharmacy Officer – Cwm Taf Local Health Board Ms Liz Howlett – Respiratory Nurse Cwm Taf Health Board Mr Russell Owens – Waste Strategy Officer, Welsh Government Mr Gary Ilbrey – Commercial Development Manager GlaxoSmithkline (GSK) Mr Nigel Wheeler – Service Director, Street Care, Rhondda Cynon Taf Council Mr George Jones – Group Director, Environmental Services, Rhondda Cynon Taf Council BACKGROUND
RESPIRATORY INHALERS.
Medication for respiratory conditions is generally administered via the inhaled
route, delivering the drug directly allows a more rapid onset of action and
minimises systemic adverse effects. An inhaler will deliver a specific amount
of medication to the lungs in the form of a short burst of aerosolised medicine
that is inhaled by the patient. It is the most commonly used delivery system
for treating asthma, chronic obstructive pulmonary disease and other
respiratory diseases.
Metered dose inhalers consist of 3 major components – canister where
formula resides; metering value which allows a metered quantity of
formulation to be dispensed, mouthpiece which allows patients to operate
device.
5.4 million people are currently receiving treatment for asthma and in Wales
1 in 10 children and 1 in 12 adults in Wales suffer from asthma.
CLINICAL WASTE & DISPOSAL.
Clinical Waste is defined in the Controlled Waste Regulations 1992 as any
waste which consists wholly or partly of:-
Human or animal tissue; blood or bodily fluids, excretions, drugs or other
pharmaceutical products, swabs or dressings, syringes, needles or other
sharp instruments.
If patients treat themselves in their own home any waste produced as a result
is considered to be their own. Only where a particular risk has been identified
(based on medical diagnosis) does such waste need to be treated as
hazardous clinical waste. If the waste is non-hazardous, and as long as it is
appropriately bagged and sealed, it is acceptable for the waste to be disposed
of with household waste.
In the case of pharmaceuticals (medicines etc) the recommended means of
disposal is to return them to a pharmacist.
Approximately 35 million GSK respiratory inhalers, including 25million ventolin
packs are used in the UK each year, generating some 450 tonnes of waste,
which potentially ends up in landfill or incineration. This is equivalent to
approximately 270 black cabs. In 2008, in general, the UK generated an
estimated 334,127,092 tonnes of waste, of which 31,539,338 tonnes was
household waste.
4 Asthma UK. 2011. 5 A quarter of a million voices….& counting. Asthma in Wales today. 6 The Department of Environment, Food And Rural Affairs 7 Elite London taxis. http://www.elitelondontaxis.co.uk/faq-3html 8 European Commission - Eurostat – Waste Statistics GLAXOSMITHKLINE AND CO-OPERATIVE PAHARMACY PILOT.

GlaxoSmithkline (GSK) and the co-operative pharmacy launched the first
respiratory inhaler recycling programme in Europe, in 2011 in partnership with
Terracycle UK. From the 1st February 2011, 40 co-operative pharmacies
across south Wales and the south east of England exclusively piloted the
service to patients for an initial 6 month period. Co-operative pharmacies had
the responsibility for promoting the scheme and reminding patients to bring
their used inhalers to their branch for recycling.
Terracycle UK collected and recycled every element of the inhaler device and
all residual medicines were incinerated in line with clinical guidance.
“GSK is delighted to be working with the co-operative pharmacy and teracycle
UK on this pioneering project. Finding innovative ways of transforming how
we do our business, increasing our use of renewable materials and creating
less waste, is a priority. As a company, we are determined to do more and
set the standard for the pharmaceutical industry, stepping up our efforts to
become more sustainable”
Nick Lowen, Commercial Operation Director, GSK. “The potential for recycling these products and reducing wastage is huge. Pharmacists are ideally placed to help reduce the impact of inhalers on the environment and as an organisation committed to responsible retailing as part of our ethical strategy; we are delighted to be at the forefront of this exciting initiative, which is simple yet effective.” Fiona Caplan Dean, Clinical Services Manager, Co-Operative Pharmacy. The process – When an empty GSK inhaler is returned to the pharmacy it is placed in a specially designed recycling box as supplied by TerraCycle UK. The box will be returned to TerraCycle UK via courier at least once a month. Once the inhalers reach the TerraCycle facility in Essex, they will be processed and sorted into material type. The plastics will remain on site for processing, after which the recycled components will be sold on for use in new products. The recovered aerosol will be sent to a specialist company who use compaction and gas liquid separation in order to recycle the metal components and collect any remaining liquid or propellant gas. The gas is then used as a replacement fuel in high temperature incinerators and cement kilns and no part of the aerosol container goes to landfill. The blister strip which previously contained medically active ingredients is then treated by a specialist process in accordance with clinical guidelines.
9 GSK & the Co-operative Pharmacy launch innovative inhaler recycling project – release document 1st February 2011. STAKEHOLDERS

LOCAL AUTHORITY
RCTCBC website provides residents with details surrounding waste and
recycling collections. Details surrounding clinical waste are also provided on
the website. Residents are advised that non hazardous clinical waste,
appropriately bagged and sealed can be disposed of through the usual
household waste collection. Where the waste is categorised as hazardous
clinical waste, such waste must not be disposed of in such ways. The Local
Authority provides clinical waste collections for those items that cannot be
disposed of safely.
The plastic outer shell of respiratory inhalers could potentially be recycled
through the Councils own recycling scheme and further analysis of this needs
to be conducted by the Service Director, Street Care. However, to avoid
duplication it Is suggested that such analysis only be conducted following if
and when the GSK recycling scheme is concluded.
CWM TAF LOCAL HEALTH BOARD
During 2010 /11 one pharmacy within the Cwm Taf area conducted an audit
review on returned prescriptions. Utilising the results of this review as well as
some assumptions, the following can be assumed:-

Approximately 450 000 inhalers were dispensed within Cwm Taf, from a small study approximately 10% of waste returned to community pharmacies was Inhaler waste, this would be mainly part used or unused inhalers Approximately 100 000litres of medicines were returned to Cwm Taf pharmacies for disposal last year • based on assumption 10% of waste = inhalers, within Cwm Taf Assuming that every litre of waste contains 5 inhalers, can assume approximately 50 000 inhalers returned to community pharmacies for disposal (10%)
Cwm Taf Local Health Board along with other Health Boards across Wales
are working further to promote the campaign of reducing wasted medicines
and encouraging patients to return unwanted medicines to local pharmacies
for disposal, including the disposal of inhalers. Unwanted medicines cannot
be reused or recycled and all have to be destroyed in an incinerator.
The Community Pharmacist officer advised the Committee that Pharmacies
are obliged to accept returned medication as part of the pharmacies essential
services contract and highlighted the need to further promote the education
strategy for wasted medicines to patients, pharmacies and GP’s.
WELSH GOVERNMENT
The Welsh Government is currently producing guidance in support of The
Recycling, Preparation for Re-use and Composting Targets (Definitions)
(Wales) Order 2011 and The Recycling, Preparation for Re-use and
Composting Targets (Monitoring and Penalties) (Wales) Regulations 2011,
both Made under the Waste (Wales) Measure 2010. The flavour of the
guidance in respect of clinical waste is that inhalers should be disposed of as
advised by medical advisors. Provided that it is consistent with this advice
then these items may be disposed of in local authority 'black bag' waste.
The Waste Strategy Officer, Welsh Government advised Members of the
working group that recycling inhalers was not seen as an issue of priority for
the Welsh Government although the Welsh Government is continuing to
support the campaign for reducing waste medicines. In 2010 an Assembly
Government campaign revealed that more than 250tons of out of date,
surplus and redundant medicines were returned each year to pharmacies and
dispensing GP surgeries across Wales at an estimated cost of £50 million to
the NHS. The Assembly Government therefore developed a toolkit tailored to
the needs of the health profession, offering practical advice on how to support
patients to get the best from their medicines, and help minimise waste. The
toolkit also includes recommendations for every sector of the profession from
Health Boards to GPs, pharmacists and hospices, and guidance on the
actions each could take to help reduce waste, as well as how to measure
success.
ENVIRONMENT AGENCY
The residual medicine within inhalers, although classed as clinical waste
would be categorised as ‘non hazardous waste’ so would not need a separate
collection. The best method of disposal for partly used inhalers is return to
the pharmacist for disposal like other medicines. With regards to empty
inhalers these can be disposed of through general household waste, via black
bag waste.
The Environment Agency have advised that inhalers may also be suitable for
recycling but this would depend on the amount of medicine contamination left
within the inhaler, and a Generic Risk Assessment would need to be carried
out.
DEPARTMENT OF ENVIRONMENT, FOOD AND RURAL AFFAIRS.
DEFRA’S guidance is that if the waste is non-hazardous, and as long as it is
appropriately bagged and sealed, it is acceptable for the waste to be disposed
of with household waste.
GLAXOSMITHKLINE (GSK)
As previously advised, GlaxoSmithkline (GSK) and the co-operative pharmacy
launched the first respiratory inhaler recycling programme in Europe during
2011, in partnership with Terracycle UK. From the 1st February 2011, 40 co-
operative pharmacies across South Wales and the South East of England
exclusively piloted the service to patients for an initial 6 month period. Co-
operative pharmacies had the responsibility for promoting the scheme and
10 The Department of Environment, Food And Rural Affairs reminding patients to bring their used inhalers to their branch for recycling.
Terracycle UK collected and recycled every element of the inhaler device and
all residual medicines were incinerated in line with clinical guidance.
The Commercial Development Manager from GSK provided the working
group with the following information upon request:-

Was the Pilot Successful?
- The GSK pilot with Terracycle UK finished at
the end of July 2011, and as yet, further analysis needs to be completed to
see how successful a pilot it was. However, from the 1st August 2011 every
co-operative pharmacy in Wales will continue to offer the GSK inhaler
recycling scheme.
Why recycle? - Although the scheme is costly for GSK, they recognised the
sustainability issues associated with inhalers and the current method of
disposal through landfill. The appetite of inhaler users was also recognised
with inhaler users wanting to recycle old inhalers.
Recycling Process – Boxes are available within Co-operative pharmacies for
the collection of inhalers. Once a box is full the pharmacy will send the box to
Terracycle UK to be recycled. This is usually done on a monthly cycle, or
depending on the number of returns received at each pharmacy.
Cost – GSK are currently unable to share the exact costings of the pilot, but
the scheme does represent a significant cost when compared to the cost of
manufacture and distribution to the pharmacy initially.

Returns within Cwm Taf Area- GSK are currently unable to break down the
returns by specific area, but up to the end of November 2011 the total number
of inhalers returned from Welsh co-op branches is approximately 6000.
INHALER USERS
A questionnaire regarding the disposal of inhalers was circulated around the
Breathe Easy Group for Cwm Taf area. Members of the working group who
were also inhaler users provided comments regarding disposal of inhalers:-
How do you currently dispose of Inhalers?
The majority of users either placed their used inhalers within the household
waste for collection or took the aerosol canister out of the plastic structure,
placed the aerosol in the black bag for household collection and the plastic in
the bag for household recycling”
“Put in a plastic Bag and put in the bin”
“Canister in black bin – plastic part in recycle bin”

Were you aware that you could return inhalers to pharmacies for
disposal?
All inhaler users contacted were unaware that inhalers could be returned to
pharmacies for disposal through incineration. Inhaler users were also
unaware that the co-operative pharmacies in Wales were collecting GSK
inhalers for recycling.
“My monthly prescription comes from the Co-Op Pharmacy, why haven’t we
been told?”

In light of the information surrounding pharmacy returns, will your
method of disposal now differ?
All inhaler users questioned have advised that they will now dispose of their used inhalers via local pharmacies in particular the Co-operative pharmacies for recycling. “I will return them in the future to the pharmacy” FINDINGS
The GSK pilot of recycling inhalers with the co-operative pharmacy in Wales has been extended by GSK for the foreseeable future and will be continually monitored by the company to review it success. Within the Cwm Taf area there are 17 Co-operative pharmacies offering the recycling service to patients. Following the comments received from GSK on the recycling scheme and from the RCT’s Service Director, Street Care the working group noted the potential of the Council conducting a recycling scheme for inhalers, although the working group had concerns whether conducting a scheme would add value to the residents of the County Borough and whether other priorities for the Council should be considered first. Members of the working group felt that if the Council were to provide a recycling scheme along side that of the extend GSK scheme, then issues surrounding duplication and cost compared to the benefits received would be evidently highlighted. The returned Breathe Easy questionnaires illustrated that generally disposal of inhalers is via household waste. Users did not see disposal as an issue although the majority were unaware that inhalers could be returned to any pharmacy for disposal through incineration and were also unaware of the GSK pilot with the co-operative pharmacies, and were keen for this information to be promoted further to users. Reducing waste to landfill is the responsibility of everyone and promoting and achieving recycling targets within the County Borough is a priority for the Local Authority. Recycling is also a high priority for the Welsh Government and the challenge of reducing waste in Wales is outlined in the ‘Towards Zero Waste’ strategy document. Guidance received from the Welsh Government and confirmation from the Welsh Government Waste Strategy officer, recycling of inhalers is not currently seen as a priority and users are advised to dispose of inhalers via household waste. Throughout the review Member’s attention was predominantly drawn to the awareness raising campaign of the Welsh Government and the Local Health Board in respect of returning waste medicine to pharmacies and discussions surrounding the Local Authority helping to drive such awareness was highlighted by the group. Utilising the Councils website to promote such a message was seen as key area to assist, as well as promoting the message through other Council services such as home care, One4All centres and leisure centres to encourage awareness over ordering repeat medicines responsibly, not stock piling drugs and disposing of any stock in the correct manner. It is estimated that 50% of prescribed medicines are not taken as intended or at all by patients. The cost of this is measured not only in wasted medicines but in poorer health outcomes for patients who fail to understand how or why they should take their medicines. 11 Chief Medical Officers’ Annual Report 2009 RECOMMENDATIONS
1 That the Local Authority assist in raising awareness and promote the recycling of inhalers through the GSK recycling scheme conducted in all Co-operative pharmacies throughout Wales. 2 That the Local Authority joins the Welsh Government and Cwm Taf Health Board with its educational campaign on raising awareness of wasted medicines and the returning of medicines including inhalers via all pharmacies for incineration / Co-op pharmacies for recycling. 3 That the Service Director, Street Care evaluate whether the plastic outer case of inhalers could be recycled through the Council recycling scheme, if the GSK recycling scheme is concluded. 4 That the group review the recommendations if / when the GSK recycling scheme is concluded and consideration be given to the Service Directors evaluation on inhale recycling.

Source: http://www.rctcbc.gov.uk/en/relateddocuments/publications/legaldemocraticservices/overviewscrutiny/scrutiny%20reports/disposlaofinhalersscrutinyworkinggroup.pdf

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