Original Paper

Med Princ Pract 2006;15:352–357 Received: November 27, 2005

Accepted: February 5, 2006
DOI: 10.1159/000094268

Practice and Opinion towards Disposal of

Unused Medication in Kuwait
Eman A. Abahussain Douglas E. Ball Wandikayi C. Matowe
Department of Pharmacy Practice, Faculty of Pharmacy, Health Sciences Center, Kuwait University, Kuwait

Key Words Introduction

Medications wastage
Waste disposal
Expired
medications
Medicine supply management
Kuwait The disposal of unwanted medicines from households
is becoming an increasing problem for local and national
health and environmental authorities. Direct risks of un-
Abstract safe disposal such as inappropriate medicine sharing,
Objectives: The aim of this study was to measure the atti- childhood poisonings and diversion of medicines to il-
tude and practice of Kuwaiti patients in Kuwait with regard licit use have been recognized for some time and environ-
to safe disposal of unwanted medicines. Subjects and Meth- mental concerns are now receiving prominence. Newer
ods: Three-hundred patients or their family members wait- and more sensitive analytical techniques make it possible
ing for prescriptions at public general hospitals in Kuwait to detect organic pharmaceutical compounds in ground-
completed a questionnaire soliciting their practice with re- water and potable water even after treatment and purifi-
gard to medication use and disposal, and their opinion of the cation [1, 2]. In light of these findings, flushing medicines
best way to dispose of unwanted medicines. Results: Almost down the toilet or sink is now considered one of the least
half of the respondents (45.4%) obtained medicines on pre- desirable methods of disposal since it may lead to persis-
scription more than 3 times a year and almost all had un- tence of discarded material in water supplies [3]. Survey
wanted medicines in the home. Reasons for possessing un- reports from the USA and Canada have stated that 35%
used medication were mostly due to a change of medication and 46% of respondents reported that they disposed of
by the doctor (48.9%), or self-discontinuation (25.8%). Their unwanted medication down the drain, respectively [4, 5].
most common method of disposal was to throw unwanted Current regulations in the European Union and the USA
medicines in the trash (76.5%) or flush them down the drain require new medicines to be assessed for their environ-
(11.2%). Half (54.0%) thought that a system of taking medi- mental risk [6, 7], but existing medications are not cov-
cines to pharmacies for safe disposal would be favorable. ered by these regulations.
Conclusion: The study indicates that the need for an appro- Although international guidance for corporations and
priate method for disposal of unwanted medication exists in governments exists on the disposal of healthcare waste
Kuwait. Hence, guidelines on safe disposal of unwanted [8], little information is available to the public and what
medicines are required and an organized method of collect- is available is often inadequate and sometimes contradic-
ing unused medication needs to be introduced. tory [9]. One method that has been used to provide an
Copyright © 2006 S. Karger AG, Basel avenue for safe disposal of medication in homes is some
sort of ‘reverse distribution network’. In these systems,
members of the public are requested to return unwanted

© 2006 S. Karger AG, Basel Dr. Eman Abahussain, Department of Pharmacy Practice
1011–7571/06/0155–0352$23.50/0 Faculty of Pharmacy, Health Sciences Center, University of Kuwait
Fax +41 61 306 12 34 PO Box 24923, 13110 Safat (Kuwait)
E-Mail [email protected] Accessible online at: Tel. +965 498 6050 or 531 2300 ext. 6050, Fax +965 534 2807
www.karger.com www.karger.com/mpp E-Mail [email protected] or [email protected]
medicines to local community pharmacies, which then The questionnaires were distributed to 300 Kuwaiti patients
arrange for pharmaceutical distributors or approved visiting the outpatient (ambulatory) pharmacies for prescription
dispensing at five large public hospitals in Kuwait (Al-Adan, Al-
agents to collect and destroy them, e.g., the Return Un- Amiri, Al-Sabah, Mubarak Al-Kabeer and Ibn-Sina Hospitals).
used Medicines project in Australia (www.returnmed. The survey was conducted from April to July 2004. A pharmacist
com.au, accessed 18 October 2005). In the United King- approached the patient and/or their carer, informed them of the
dom, the value of unused medicines recovered in ‘dump’ survey and requested them to complete the questionnaire while
(Dispose of Unwanted Medicines and Pills) campaigns waiting for their medications. For illiterate patients, a structured
interview was carried out by the pharmacist based on the ques-
has been estimated at 0.5–1.8% of local primary care tionnaire. Permission to conduct the study was obtained from the
drugs budgets [10] with an annual nationwide wastage Pharmaceutical Services Administration in the Ministry of
cost of around GBP 37 million in 1996 [11]. This is likely Health. Patients were free to refuse to participate (the number
to be an underestimate given that returns to pharmacies declining to take part was not recorded). Data collection contin-
are likely to represent less than a third of all unused med- ued until 300 questionnaires had been completed. Simple propor-
tions and tally were used in analyzing the data. In cases where
icines [10]. In the United States, more than USD 1 billion respondents did not complete a question, these were treated as
worth of medicines prescribed for older patients go un- missing values and only complete answers were used for calcula-
used [12] each year and a ‘dump’ campaign in a Houston tion of the results. The number of valid responses in such cases is
suburb collected USD 26,000 worth of solid oral dosage stated in the text. The data were analyzed using the Statistical
forms over a 6-month period [13], indicating that there Package for Social Sciences (SPSS v.12, SPSS Inc.).
are significant amounts of unused medicines kept in do-
mestic environments.
One study that examined medication wastage in Saudi Results
Arabia [14] found that over 80% of homes had five or
more medicines present with an average of over 2 unused, Three hundred patients or their family members com-
expired or deteriorated products per household. It was pleted the questionnaire. The respondents’ mean (SD)
estimated that the cost of medication wastage in Saudi age was 37.9 (12.2) years and 66% were male (table 1). The
Arabian homes was USD 10 per person per household majority were married (71%), had postsecondary educa-
with an annual national medication wastage of USD 150 tion (62%) and had a monthly family income of less than
million. KWD 1,000 (about USD 3,400). Respondents had an av-
The extent of the problem of unused medication is not erage of 2.3 current medical complaints of which cardio-
known in Kuwait. Given the health, environmental and vascular disease (53.0%), diabetes mellitus (35.9%), al-
economic consequences of unused medical products, the lergy (29.6%) and gastrointestinal complaints (22.6%)
aim of this study was to measure the practice and attitude were the most common (table 2).
with regard to safe disposal of unused medicines by Ku- Almost half (45.4%) of the respondents reported that
waiti patients receiving prescribed medicines at major they obtained medicines on prescription from a health
public hospitals. center more than 3 times a year, with a similar proportion
claiming never to purchase medicines from private health
facilities without a prescription (table 3). Sixteen percent
Subjects and Methods reported getting medicines without prescription from a
An anonymous self-administered questionnaire in Arabic was
private pharmacy more than 3 times a year. The median
developed and pretested with 50 eligible patients. The instrument estimated family cost of purchasing medicines from pri-
was checked for readability, comprehension, question design and vate pharmacies was KWD 25 (about USD 85).
length. As a result of pretesting, some open-ended questions were Almost all respondents (95.7%) reported that they had
converted to close-ended responses. The questionnaire informed medicines in the home which they wished to dispose of.
respondents about the objective of the research and then elicited
sociodemographic data including what medical conditions they Solid oral dosage forms (66.2%) and syrups (51.6%) com-
were suffering from as well as their practice with regard to medi- prised the largest proportion of unwanted medicines fol-
cation use and disposal, their opinion of the best way to dispose lowed by topical ointments/creams (35.2%) and drops
of unwanted medicines and an estimate of annual medicine ex- (32.4%). Inhalers (10.5%), injections (9.1%) and syringes
penditure. All the questions were close-ended questions, some (3.8%) were not commonly cited. No validation was per-
with an option for the respondents to record their own opinion if
the choices were not suitable. It was calculated that a sample size formed to confirm these subjective self-reports. The most
of 289 was needed for a precision in proportion of 5% at a signif- common method of disposal of unwanted medicines was
icance level of 0.05. to throw them in the trash (76.5%) or flush them down

Disposal of Unused Medicines in Kuwait Med Princ Pract 2006;15:352–357 353

Table 1. Background characteristics of the respondents (n = 300) Table 2. Current medical complaints amongst respondents

Characteristic Parameter Respondents Condition Respondents, %

(n = 300)
n %
Source hospital Al-Adan 48 16.0 Cardiovascular disease 53.0
Al-Amiri 80 26.7 Diabetes mellitus 35.9
Al-Sabah 58 19.3 Allergic conditions 29.6
Ibn-Sina 64 21.3 Gastrointestinal and liver disease 22.6
Mubarak Al-Kabeer 50 16.7 Dermatological disease 19.2
Renal disease 16.0
Age, years <25 52 17.9 Asthma 16.0
26–38 107 36.9 Rheumatic disease 14.6
39–51 91 31.4 Anemia 11.1
>51 40 13.8 Other 21.2
Gender male 186 66.4
Marital status single 64 22.0
Table 3. Respondents’ frequency of obtaining medicines with and
married 206 70.8
without a medical prescription in the past year
widowed 4 1.4
divorced 17 5.8
Frequency Respondents
Schooling none 16 5.3
presecondary 42 14.1 n %
secondary 55 18.4
postsecondary 186 62.2 Medicines on never 19 6.4
prescription 1–3 times 69 23.4
Monthly income <500 67 22.6 >3 times 134 45.4
(KWD) 500–999 118 39.9 can’t recall 73 24.7
1,000–1,499 55 18.6
>1,499 56 18.9 Medicines without never 139 48.1
prescription1 1–3 times 72 24.9
Residential area capital 67 22.6 >3 times 46 15.9
(suburb) Hawalli 97 32.7 can’t recall 32 11.1
Farwaniya 35 11.8
Ahmadi 55 18.5 1
This reflects only purchases of medicines from private phar-
Jahra 18 6.1 macies since prescriptions are always required at government
Mubarak Al-Kabeer 25 8.4 health facilities.

the toilet or sink (11.2%) while some respondents (8.5%) In response to what their opinion was on the best way
said they would give them to a friend. Other methods of for unused medicines to be collected for safe disposal
disposal, e.g., returning them to a pharmacy, were cited (n = 287 valid responses), 54% thought that returning
by 11.9% of respondents. them to a local pharmacy would be appropriate, 21%
A total of 264 respondents gave reasons why they thought there should be special collection containers at
would want to dispose of medicines in the home. These local shopping cooperatives while 15% preferred that
ranged from change or discontinuation of medication by medicines be collected from homes by the municipality
the doctor (48.9%), self-discontinuation of the medicine and 3% offered other actions (7% no opinion). Respon-
(25.8%), having an excess of medication in the home dents were also asked to select ways of decreasing the
(30.3%), possessing expired medicines (10.6%) or being amount of wasted medication. Most (77%) felt the patient
prescribed and/or dispensed more medication than re- should be given the exact amount of medication required,
quired (9.8%). Seventy-four participants (28.1%) were while 40% thought that the public needed education on
motivated to return medicines because somebody else this topic. Sharing of unexpired medicines was accepted
might benefit from them while only 16.7% would return by 16%; 14% felt that a consultation with a pharmacist
them for the purpose of ‘proper disposal’. could help to decide whether to discontinue treatment. A
little over 10% of respondents felt that user fees or charg-

354 Med Princ Pract 2006;15:352–357 Abahussain/Ball/Matowe

es to obtain medicines (from government health facili- tion. This structure of the health sector and the practice
ties) would reduce wastage and 4% proposed other ac- of public pharmacies to dispense 2 months of chronic
tions. No correlation or association was found between medication at a time help explain the observation that
practice or opinion towards medication disposal and any about half of respondents obtained medicines on pre-
of the demographic descriptor variables. scription more than 3 times a year with a similar propor-
tion reporting to never obtain medication without pre-
scription. Purchasing medicines without prescription
Discussion from a private pharmacy can add to the load of unused or
unwanted medicines in the home. About 16% of respon-
This study examined the practice and opinion on un- dents said that they obtained medicines in this way, but
used medication disposal of 300 Kuwaiti patients or their this is likely to be an underestimate for the population,
family members at government hospitals in Kuwait. Ku- given that the respondents were sampled from a govern-
waiti citizens make up less than half of Kuwait’s 2.5-mil- ment health institution. Limitations of patient recall pre-
lion population, but are responsible for 60–70% of visits vented a more accurate assessment of medication-seek-
to primary and secondary health care institutions and ing behavior and health expenditures in this study, but
therefore were the focus of this study. This restriction to this should be examined further in future work.
a homogeneous Arabic-speaking population also allowed Almost all respondents claimed to have unwanted
for easier questionnaire development and data collection medicines in the home. Given that these patients seem to
since the expatriate, non-Kuwaiti population is very di- represent lower wage earners who might be more likely
verse in culture and language. Sourcing the subjects from to retain medicines for future use, the total unwanted
the major public referral hospitals in Kuwait provided a medicine burden in the patient population of Kuwait is
wide cross section of the community. However, since likely to be substantial. Three quarters of patients report-
most respondents had a monthly income less than KWD ed that they discarded unwanted medicines in the trash,
1,000, they would appear to be largely low-wage earners. with disposal down the drain, to friends (by sharing) and
A likely reason for this is that higher earners are more returning them to pharmacies each reported by around
likely to use private clinics and hospitals. The large pro- 10% of respondents. Where no organized collection sys-
portion of married respondents probably reflects that tem exists, disposal of medication in domestic garbage
single persons are more likely to be young and therefore destined for landfill is accepted as more environmentally
less likely to suffer from many of the chronic illnesses friendly than flushing them down the drains [3, 9]. The
managed at hospital ambulatory clinics. Indeed, the ma- disposal habits of these Kuwaiti patients are therefore
jority of respondents suffered from chronic illness, espe- ‘better’ than those reported for 500 United States house-
cially cardiovascular disease and diabetes mellitus, com- holds where 54% threw unwanted medication in the
mon medical conditions in Kuwait’s population. How- trash, 35% flushed them down the toilet or sink and 1%
ever, the fact that the patients were sourced from hospitals returned them to a pharmacy [4], and a Canadian tele-
may mean that they are sicker than patients who receive phone survey which found that 46% used drainage sys-
their continuation medication from local polyclinics. It tems, 31% trash and 17% returned unused medicines to
must be recognized that this study focused on Kuwaiti the pharmacy [5].
citizens. Non-Kuwaitis make up around 60% of the pop- This should however not give rise to complacency,
ulation of Kuwait and their habits in disposal of unwant- since disposal in domestic trash is still only a measure of
ed medication will also need to be investigated as part of last resort [9] given that the risks of household healthcare
a comprehensive plan to address this issue. waste disposed of by landfill have not been fully assessed
In Kuwait, Government health facilities provide free [15]. The recommended method of disposal of most phar-
health care to the population under a compulsory health maceuticals is incineration [8], which requires some ini-
insurance scheme (for noncitizens) and government sub- tial organized method of collection and sorting. In many
sidies. Private health care facilities and retail pharmacies developed countries, some form of reverse distribution
are mostly used by patients not satisfied with the nation- system or occasional ‘dump’ campaigns have been suc-
al health system or who wish to obtain medicines (or cessful in collecting substantial volumes and values of
brands of medicines) not available within the public unused or expired medicines for proper disposal [10, 11,
health system. Most medicines for chronic diseases can 13]. A similar system could be introduced in Kuwait, with
be obtained from private pharmacies without a prescrip- collection bins at local public and/or private pharmacies

Disposal of Unused Medicines in Kuwait Med Princ Pract 2006;15:352–357 355

or health facilities in which members of the public could scribing controls, e.g., formularies or clinical guidelines
place unwanted medicines. Suitable measures would and dispensing restrictions could be useful in this regard.
need to be in place to ensure the security of the returned One study in the USA found elderly patients received over
medication to prevent diversion of narcotic and psycho- 120% of the amount of medication actually needed, with
tropic drugs to illicit use [16] in keeping with interna- resultant increased health care costs [19]. It is reasonable
tional conventions [9]. Involvement of the local Kuwait to suspect that overprescription of medicines is present
Pharmaceutical Association would be essential and pub- in the public health system of Kuwait where neither pre-
lic education, e.g., through the mass media, would be cru- scribers nor patients face disincentives for prescribing or
cial for the campaign to be successful given that only 12% receiving excess medicines, respectively. In fact, at public
of the patients in this survey had returned medicines to a health facilities in Kuwait, most chronic disease patients
pharmacy in spite of half responding that this would be receive 2 months’ supply of medication per visit. Reduc-
an acceptable method. ing this to a single month’s supply could be a first step,
Other methods of collection suggested by respondents although the implications of such a change on the supply
included having special containers at local cooperative management of medicines would need to be considered.
supermarkets and arranging for special collections by the Another option is the implementation of user fees or co-
municipality. The former would need special measures to payments for medicines, which was suggested by the re-
prevent diversion of expired medicines or those of abuse spondents, although this measure is likely to be unpopu-
potential [16]. The latter would require some means of lar among Kuwaiti patients. Ideally a coordinated strat-
separating the medicines or other healthcare waste from egy to reduce overprescription of medicines together
normal household garbage, e.g., through the use of spe- with measures to dispose of unused medication would be
cial colored collection bags, and could be costly to admin- employed.
ister. One of the attractive points of reverse distribution This study adds to what is known about disposal of
through local pharmacies is that it is cost-efficient [13]. waste medicines in Kuwait. One limitation is that it only
In this survey, 9% of patients said they disposed of un- considers the opinion and reported practice of Kuwaiti pa-
used medicines by sharing them with friends and 16% tients. While they are the greatest users of the health sys-
believed sharing of unexpired medication to be accept- tem, noncitizens also contribute to healthcare waste pro-
able. It has been previously estimated that in Gulf coun- duction and may follow less safe waste disposal practices.
tries, 20–30% of household members use medicines orig- This needs to be investigated. Furthermore, the study re-
inally prescribed for other persons [14]. The lower figure lies on subjective reports by patients rather than direct ob-
in the current study may reflect that the question was servation of practice. Completing the questionnaire in a
asked in the context of medicine disposal rather than re- hospital environment in the presence of a pharmacist may
cording past medication taking habits. Sharing of medi- have led respondents to provide answers which they
cines without medical advice may be dangerous, even if thought were ‘correct’ rather than their actual perceptions
the medicine has not expired. An inappropriate medica- or practice. Validation of such data is problematic.
tion may be used and it is not possible to guarantee the This report indicates that there is a problem of unused
quality of the pharmaceutical product if it has been im- medicines in households in Kuwait. Further research into
properly stored. Unexpired, unused medication are con- the reasons for the retention of such medication, the
sidered unsuitable for drug donations according to World quantities involved and the cost to individuals and the
Health Organization guidelines [17], although the re- nation is necessary. In this regard, the practice and opin-
verse distribution system in France does involve separa- ion of non-Kuwaiti citizens are also important. Although
tion of medicines in intact containers and suitable pack- this study showed that patients appear to be generally fol-
aging for charitable use [18]. Raising the profile of phar- lowing appropriate disposal methods, there are no offi-
macists in Kuwait as health professionals who can advise cial guidelines on disposal of domestic healthcare waste
on reuse and/or appropriate disposal of medication in the in Kuwait with which to encourage them to continue in
home was identified by the respondents as one way of re- this manner. Development of these guidelines and the
ducing medication wastage in this study. introduction of a reverse distribution mechanism should
Three quarters of survey participants felt that medica- be considered to support the efforts of the public and to
tion wastage could be reduced by prescribing the exact reduce the environmental load which will result from
amount of medicine needed. This suggests that they are continuing landfill of unwanted medicines and their
receiving excessive amounts from the health system. Pre- packaging. The disposal of potentially mutagenic anti-

356 Med Princ Pract 2006;15:352–357 Abahussain/Ball/Matowe

cancer medication and biologicals also needs to be inves- disposal of unwanted medicines are required and an or-
tigated as these can lead to serious adverse outcomes if ganized method of collecting unused medication needs
discarded into household garbage. to be introduced.

Conclusion Acknowledgments

The authors would like to acknowledge the efforts of the phar-

The study indicates that the need for appropriate
macists who assisted with data collection.
methods for disposal of unwanted medication in the
home is a problem in Kuwait. Hence, guidelines on safe

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Disposal of Unused Medicines in Kuwait Med Princ Pract 2006;15:352–357 357