Disposal Practices of Unused Medication Among Pharmacists in Libya

Background and objective. Globally, disposing of unused medicines has become a source of concern, as pharmaceutical waste enters the ecosystem, posing a threat to human health and the environment. This study aimed to assess the disposal practice of unused medication among pharmacists in Libya. This study also seeks to determine if pharmacists plan to have their pharmacies serve as assembly points for potential take-back initiatives. Methods. A random sample of 150 pharmacists from various government and private pharmacies in Tripoli participated in a self-administered questionnaire about their disposal practices, and knowledge on pharmacies serving as collection points for ideal disposal of unused medicines. Descriptive statistics were used to interpret the data. Results. A total of 128 pharmacists completed the survey. The majority of respondents said that throwing discarded drugs in the trash bin was their preferred method of disposal (53.1%), followed by discarding via burn and drug wholesalers (17.2%, 14.8%, respectively). Only 2.1% of the respondents disposed unused medicines according to the WHO guidelines of drug disposal. Moreover, about 65.6% had poor knowledge about Take-Back program. Conclusion. Failure to follow the WHO guidelines for drug disposal raises the risk of contamination of our environment and the likelihood of humans and animals ingesting harmful pharmaceutical wastes.


INTRODUCTION
Unused medicines (UMs) are pharmaceutical products that are expired, damaged, or contaminated products and are no longer needed [1]. Inappropriate disposal of UMs causes a variety of health and environmental hazards, including poisoning, air pollution, and contamination of water and food sources. Several drugs have been found in trace quantities in ground water, surface bodies of water, and drinking water, posing a significant threat [2]. Through drinking polluted water, people may be exposed to or absorb traces or contaminants of pharmaceuticals from the atmosphere [3].
understand that disposing of unused or expired drugs through these illegal channels puts the environment and the people who live there in danger [5].
Unwanted drugs may be produced in households or through healthcare practices, and there are a variety of factors that contribute to their occurrence. They may be the product of patient noncompliance, manufacturer advertising activities, physician prescribing practices, or dispenser practices. Furthermore, a general increase in individual awareness of health-seeking behavior has resulted in an increase in medication consumption [6]. Previous study investigated and compared the relationship between the disposal of unused medications and environmental awareness in various countries around the world, and found that there were no set policies or guidelines for the disposal of discarded drugs [7]. Unused drugs were also found to be often dumped by being flushed down the toilet or discharged into waterways, posing serious environmental concerns [7].
Because of their proximity and accessibility to health seekers in our communities, good medicine disposal practice is an essential aspect of public health preventive services provided by community pharmacists. Community pharmacies are better equipped than anyone else to collect, sort, and dispose of expired medications in a timely and equitable manner. Since they have been educated in the act of proper drug disposal, they are intended to serve as collection points for expired drugs in the communities where they are based [8]. However, Libya has no policy or take-back program that accept UMs from the public, nor does it have any clear guidelines for obtaining and disposing of returned drugs from the public. This study assesses community pharmacies' disposal practices of expired and unused medicine and their adherence to the WHO standard guideline on the disposal of expired drugs. To the best of our knowledge, no study has been conducted in Libya to address this issue, and public awareness about medication disposal is poor.

METHODS
This was study-involving pharmacists in Tripoli, Libya, which carried out from December 2020 to March 2021. The Research Committee, Faculty of Medical Technology, University of Tripoli, Libya, reviewed and ethically approved this survey-based study (Approval Number. MedTech_ANA2102). Participants were stated that there would be no risks in this research, and that all information collected would be kept private and anonymous. Only the researchers would have access to the information. An informed consent form, explaining the research methodology, attached to each questionnaire was read and signed by the pharmacist, who participated in the survey. Only licensed pharmacists who had certified pharmacy license were included in this study. Other categorize of pharmacy dispensers were excluded.
A structured, self-administered questionnaire was created to assess pharmacist awareness of drug disposal and its effect on health and the environment. A total of 128 pharmacists were participated from the visited pharmacies. The questionnaire was pre-validated with 5 pharmacists using an English version to see if it was clear and how long it took to complete. However, since some pharmacists had trouble interpreting the questions, the questionnaire was also available in Arabic. To prevent repetition, the questionnaire's order was rearranged and certain questions were omitted.
The five pharmacists who participated in the pre-test were excluded from the survey due to significant changes made in the final version of the questionnaire.
The survey was divided into three sections: Section 1 is about demographics. Section 2: Community pharmacies' disposal of various dosage forms and controlled drugs. Section 2: Implementation of a take-back program (FDA Program) (YES or NO). During a visit to the pharmacy's chief pharmacist, the researcher created a sample frame, and a randomized sample was chosen using computerized random tables. The questionnaires and consent forms were then distributed to the respondents. The data were analyzed using descriptive statistics and the chisquare test in SPSS version 22.

RESULTS
About 92 (71.9%) of the 128 pharmacists who responded to the survey questionnaire were from community pharmacies, whereas 36 (28.1%) were from polyclinic pharmacies. The sample consisted of a higher proportion of females (81.2%) than males, and a higher proportion of Libyans (90.6%) than non-Libyans, with ages ranging from 19 to 44 years (median =29 years). The majority of participants (34.4%) had length of experience between 2 to 4 years, and approximately 28.1% of them had less than 1 year of experience (Table 1).  Table 2 depicts the various disposal practices of different visited pharmacies in Tripoli. Their various routes of disposal were through a rubbish bin, burn, drug wholesaler, landfill, and sink. In general, the majority (53.1%) of the participants discarded unused medicines through rubbish bin, followed by discarding via burn and drug wholesalers (17.2%, 14.8%, respectively). Few respondents (14.8%) throw their waste through the sink and others (6.3%) discarded by landfill. There was actually no consistency in the respondents' disposal patterns. In Table 3, the majority of participants (69.8%) did not follow the WHO guidelines for disposing of unused drugs. Only 2.1% of the respondents followed the guidelines completely. Meanwhile, some (28.1%) of respondents only partially followed the guidelines. The partial compliance means that those who responded had two methods of disposal, one through WHO and the other through other means.  Table 4 shows the knowledge of pharmacists on take back program. About 65.6% had poor knowledge about the Take Back program. Approximately 62.5% of respondents agreed that there is no educational barrier in applying the take back program. However, about 31.3% of pharmacists believed that the is a cost barrier in implementing the take back program, and the majority 59.4% did not believe that the take back program was time barrier.

DISCUSSION
Currently, drug disposal and waste management are of concern, as it has been exposed that improper disposal can contaminate the nearby areas and pose a threat to air, water, the food chain, and even agricultural products [7]. The role of a pharmacist has evolved from compounding and dispensing drugs to providing care to patients. As a result, there is a pressing need to improve pharmacist awareness of drug usage and disposal. The proper collection and recycling of expired and unused drugs by well-designed systems have consequences for community safety and environmental protection. In some countries, drug take-back programs are well established, with pharmacies and pharmacists playing important roles as collection points and advocates for proper drug disposal [9]. A drug take-back program is desperately needed in Libya, and adequate data from studies on the practice and knowledge of drug disposal among healthcare professionals and the general public are required to support such programs. The FDA and WHO published guidelines for proper drug disposal, and this study assessed pharmacists' understanding of these guidelines [10,11].
In the current findings, pharmacists disposed UMs mostly in trash followed by burning and disposal by drug wholesalers. These practices are similar to the practices followed by the public in Iraqi and Kuwait [12,13]. The disposal pattern of various dosage forms revealed inconsistency in disposal practices across the various drug dosage forms. This was in agreement with earlier report on awareness, attitude, and practice toward medication disposal among healthcare professionals in Ghana found that participants were very confused about how to properly dispose drugs [14].
The presence of nationwide rules for UMs disposal has a significant impact on how people discard them [15]. As a result, in the absence of instructions on how to handle returned drugs from the public, most pharmacists in the current study dispose medication in the dustbin. In general, throwing UMs in the trash or sink are not the best option [16]. Hence, a policy from the Ministry of Health is urgently needed to enable pharmacists to accept returned UMs from the public and to instruct pharmacists on how to properly dispose them in Libya. In addition, only a few pharmacists followed WHO criteria when disposing of UMs. This low level of compliance necessitates further investigation.
Similarly, in developed countries, pharmacists' contributions to UMs discarding seem to be inadequate [17]. In a survey conducted in Iraq, more than two-thirds of participants (65.9%) decided to return UMs to the source, compared to just 14.5% in the current study [12]. According to a Nigerian survey, 18(23.4%) of people followed the drug disposal guidelines completely, 17(22.1%) partially, and 42.0 (54.5%) did not [18].
The current findings, along with previous literature, strongly encourage the implementation of drug take-back system. However, before an efficient and effective drug take-back program can be implemented in Libya, several barriers must be overcome, including a lack of information on the amounts and types of UMs returned by the patients. The general public, healthcare providers, and government leaders all need to be more informed of the scope of the issues. To introduce an effective drug take-back program, collaboration from different industries, such as law enforcement agencies, will be needed.

CONCLUSION
This study identified low compliance of pharmacists to WHO standard in the disposal of unused medicines. To enhance the positive attitudes of pharmacists toward the environment and their readiness to be the collection point for UMs collection, guidelines and plans to manage the collection of returning UMs from pharmacies, as well as their discarding and destruction in an ecologically friendly way, must be developed. There is a need for improvement in the discarding and management of expired and unused pharmaceuticals in Libya.

Limitation of the study.
This study conducted only in Tripoli city, so we cannot generalize these results to all Libyan pharmacists List of abbreviations. UMs; Unused Medicines, WHO; World Health Organization, FDA; Food and Drug Administration.

Declaration
Ethics approval and consent to participate. The Research Committee on Faculty of Medical Technology, University of Tripoli, Libya, reviewed and ethically approved this study. An informed consent form, explaining the research methodology, attached to each questionnaire was read and signed by the pharmacist, who participated in the survey.
Consent for publication. I approve the publication of this manuscript.
Availability of data and material. All data available upon request.
Competing interests. There is no competing of interest regarding this study Funding. Nil