Patricia Deesy, a registered nurse, is worried about the drinking water in her home state of North Carolina.
"When I started out in nursing almost 30 years ago, policy at hospitals was to waste partial doses of narcotics in the sharps containers," Deesy said. "These containers would then be incinerated by a company that picked them up when they became full."
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Yet this incineration caused air pollution, Deesy said, so over time, hospitals shifted to "dumping the containers into landfills."
"People would actually break into the containers and steal the wasted meds and syringes and use them," said Deesy, who lives near Charlotte. As a contract nurse, she has worked "for just about every hospital within two hours of my home."
Today, the policy "in every facility that I am aware of" is to "waste" unused medicines down the sink or toilet.
"If someone is ordered morphine 1 milligram every four hours and it comes supplied in 2-milligram vials, then I have to waste 1 milligram down the sink each time," she explained. "It's ridiculous." Imagine all the nurses on all the shifts in all the hospitals across the country doing the same, she said.
"Every time I waste something, I think I'm destroying my water system," she said. "I've got kids and grandkids. I hate to see us polluting their water like that."
A 2017 study titled "Drugs down the drain: When nurses object" begins with an observation: "Many times during a typical workday, American hospital nurses routinely discard unused portions of narcotics and other controlled substances into municipal water supplies." The reason this practice is routine, the authors suggest, stems from inconsistencies in regulations and how they are interpreted by hospitals.
"There are agencies at the federal, state, and local levels that have issued conflicting rules" about pharmaceutical disposal methods for hospitals, the authors wrote.
The Environmental Protection Agency strongly discourages pouring or flushing pharmaceuticals down the drain in any setting, including at health care facilities, because they may enter and pass through water treatment systems and contaminate the water supply. As part of its rule for managing hazardous waste pharmaceuticals, the EPA has banned the "sewering" (or pouring down the drain or toilet) of hazardous waste pharmaceuticals at health care facilities.
However, this rule, which was only finalized this month, applies only to drugs considered hazardous waste, such as toxic chemotherapy drugs. Most pharmaceuticals do not fall into this category.
In contrast to the EPA's stance, the US Food and Drug Administration has advised individuals to sewer narcotics and controlled substances, including morphine and other opioids, in order to avoid harm to animals and humans, including children, who could gain access to these powerful and dangerous drugs.
"To date, scientists have found no evidence of harmful effects to human health from medicines in the environment," the FDA website says.
The FDA does not provide official guidance to hospitals. Still, the recommendation of this federal agency might carry weight with hospital administrators, who must also consider and follow the requirements of the US Drug Enforcement Administration.
Rusty Payne, a spokesman for the DEA, explained that diversion is his agency's primary concern when it comes to how hospitals handle pharmaceutical drugs.
"Many problems associated with drug abuse are the result of legitimately made controlled substances being diverted from their lawful purpose into illicit drug traffic," the DEA website says. In plain English, doctors, nurses or other hospital staff sometimes steal pharmaceuticals labeled controlled substances by the DEA -- opioids, mostly -- in order to sell them for profit or use themselves.
"We document the sales, what comes in and out, in terms of controlled substances, not all drugs, just controlled substances," Payne said. For example, the DEA demands that painkillers such as morphine and other opioids be "heavily documented in terms of how they're distributed and administered in a hospital."
For this reason, hospitals and hospital pharmacies have strict regulations that require nurses to document each use of a controlled substance, according to Payne. He's been told that "it's fairly common" for hospitals to waste liquid medicines down the sink.
"There aren't too many contaminants that would build up in drinking water," said George Cushnie, technical director for the EPA-sponsored Healthcare Resource Center, which provides pollution prevention and environmental information to health care organizations.
Because most drinking water comes from rivers or reservoirs, "you're constantly using water, and there's new water coming in, so there's really not an opportunity for it to build up."
Mike Focazio, program coordinator of the Geological Survey's Toxic Substances Hydrology Program, said his agency has not done testing of waste specifically coming out of hospitals, but it has done "wastewater studies that come out of what we call sewer sheds -- in other words, a city or a town that does include hospitals."
"We have sampled that water for many years," he said. "We have found that we can detect a variety of pharmaceutical residues at very low levels in quite a lot of different waste streams across the country."
'Complicated' mixture of drugs
Pharmaceutical water contamination is common knowledge. A 2011 Government Accountability Office report on environmental health reads, "pharmaceuticals may enter the environment and ultimately drinking water supplies in various ways, such as through the elimination of human and animal waste, disposal of unused medicines down the toilet or drain, veterinary drug usage, hospital waste disposal, and industrial discharges."
What is unknown, Focazio said, is how much of that is due to hospitals versus people in their homes discarding unused medicines or simply metabolizing medicines, which we excrete in urine and feces that flows into our toilets.
Cushnie said his "gut feeling is, most likely, households are discharging a lot more of their unused meds into the sewer system than hospitals." He believes that a larger number of people are using and disposing medications at home compared with the number of patients lying in hospital beds.
Whether pharmaceutical residues in water samples come from hospital or home use, Focazio said, the concentration levels are much higher in some places than in others.
"If you look at the concentrations that we detect -- even at those high concentrations -- and you compare it to the dose that somebody would take -- even in, again, those places with very high levels or higher than elsewhere -- you'd have to drink enormous amounts of water just to get back to that prescribed dose," Focazio said.
"But the question is: What does it mean from a health standpoint when these low levels get out into the environment?" he said. The human health effects are unknown. And it's not just one drug, say, one particular antidepressant. It's many brands and types of antidepressants plus an assortment of antihistamines and anti-inflammatories and all sorts of other pharmaceuticals mixed together.
"It gets very complicated very fast," Focazio said.
Medicine or poison?
Increasingly, environmental scientists are wondering whether the very substances that are meant to cure us -- medicines -- might also pose a threat to our health when found in drinking water. As a result, pharmaceuticals have been listed as "contaminants of emerging concern" by the EPA.
In some cases, contaminants of emerging concern have probably been discharged into the environment for a long time before new and more sensitive detection methods could identify them, notes a GAO report. Harms to aquatic life have been documented by a number of studies, yet possible negative effects for human health are inconclusive. The EPA has begun the process of revising its existing guidelines for the protection of aquatic life.
Other public health agencies, including the UN's World Health Organization, express similar concerns and findings as the EPA. "There is a substantial margin of safety between the very low concentrations of pharmaceuticals that would be consumed in drinking-water and the minimum therapeutic doses, which suggests a very low risk to human health," a recent WHO report finds.
'A whole soup of drugs'
Dr. David J.C. Constable, science director of the American Chemical Society's Green Chemistry Institute, explained the rationale behind the WHO report, though he was not involved in it or in decisions made at the EPA.
"When you take a drug, it is given at a dose which causes a desired therapeutic effect. However, it will cause some physiological response at a lower dose," Constable wrote in an email. "This difference in response vs effect gives a significant margin of safety for most drugs." This is why WHO says concentrations well below therapeutic effect are very low risk to human health, he said.
Mae Wu, a senior attorney in the health program for the Natural Resources Defense Council, an environmental advocacy group, said one of its big questions and concerns is that the EPA and other groups, when examining the safety of pharmaceuticals in drinking water, may be basing their assessment on the "therapeutic" levels approved by the FDA.
"But the reality is, once it gets into our drinking water, we are not talking about any one drug, right? We're talking about a whole soup of drugs, and for every location, it's a different mixture," she said.
Though toxicologists test chemicals in combinations, they do not test each and every unique combination of mixed drugs and other chemicals found in the sewers of individual cities in the United States.
Wu also said that most FDA-approved drugs have been tested only in adults. Young babies and children do not participate in clinical trials that test adult medications for safety and effectiveness, she said, yet babies and children "are often more vulnerable and more sensitive to these types of things."
"We definitely don't know what's happening there," she said.
Constable believes that "the question of mixtures is what has people in the EPA most concerned." The assumption is that the cocktail of chemicals in drinking water, food and air "can't be good for you," he wrote. "There is a fear of synergistic effects; that is, 1+1 > 2, or that the presence of one compound decreases the body's ability to metabolize another."
There are additional concerns that low-concentration exposures to chemicals, including pharmaceuticals, are leading to "multigenerational impacts" that we have not been able to discern, he said.
"The problem for everyone is that we just don't really have a good handle on this. No one does, and the debate is that the precautionary principle should be applied," Constable wrote in an email. That principle amounts to "if we don't know, there is no acceptable level," he said, and once that point is reached, science begins to devolve into "a discussion of policy."
Since the late '90s, when scientists learned of a variety of contaminants, including pharmaceuticals, in the nation's waterways, "there was a lot of activity by the government and the Pharma industry to systematically assess the extent of pharmaceuticals in the environment," Constable wrote. A great deal of work has been going into this "over many years," he said.
Focazio said the US Geological Survey has started looking more recently not just at what can be detected but at "what does it mean from a health standpoint."
"The human health aspect of this is a little bit out of our wheelhouse, so we are working with other public health agencies to give them the data so at least they know what the levels are," he said. The Geological Survey has begun studies on fish and aquatic biota to see how these other life forms are affected.
Awaiting more extensive research into human health effects, simple solutions at the hospital level may be available.
"There is a company that has a safe box that comes with a neutralizing solution in it that can be used for wasting narcotics, but I have yet to see anyone use it," Deesy said, adding that she's asked several hospitals "to investigate using them with no response."
Awareness among hospital staff is also key, she said, and though she tried repeatedly to raise the awareness of health care administrators through local media, she once again hit a brick wall of "no response."
"We don't need to be destroying our water," Deesy said. "We should be taking care of our water."