Exploring the intravenous narcotics and controlled drugs wastage and their financial impact: A descriptive single-center study

Abstract

Objective

The objectives of this study were to explore the wastage of narcotics and controlled medications and, their financial impact in a tertiary care setting over a one-year period.

Methodology

The study period was of one year, i.e., October 2020 – September 2021. The venue of study was a tertiary care hospital. The narcotic medications included Fentanyl, Tramadol, Morphine, and Meperidine. The controlled medications included Midazolam, Phenobarbital, Diazepam, Ketamine and Lorazepam. The annual consumption and wastage of the narcotic and controlled medications were documented using data report generated by narcotics and controlled medication in-charge pharmacist through the hospital’s online system. Data was reported using average, minimum and maximum values. Quantities of wastage is expressed in terms of ampoules. Costs per ampoule were calculated and expressed in both Saudi Riyal (SAR) and United States Dollar (USD). The study was approved by an ethics committee.

Results

The annual wastage of narcotics was 3.19 % while the same for controlled medications was 21.3 %. An annual wastage of 3.81 % was reported for narcotics and controlled medications combined. The total wastage cost of narcotics and controlled medications was 15,443.1 SAR that was equivalent to USD 4085.5. Fentanyl 500mcg formulations had the highest consumption, i.e., 28,580 ampoules followed by Morphine 10 mg formulations, i.e., 27,122 ampoules. The highest ampoule wastage was observed for Morphine 10 mg formulations, i.e., 1956 ampoules. The highest % wastage was observed for Midazolam formulations, i.e., 29.3 %.

Conclusion

The overall wastage was less than 5% of the total consumption, however, midazolam was observed to have the highest wastage. Shifting to prefilled syringes supplied by pharmacies, making protocols, and safely pooling costly drugs could result in significant savings.

1. Introduction

Medication wastage leads to considerable financial losses to the healthcare system. It may affect the pharmaceutical budget, triggering total loss up to USD 5.4 billion in the USA (Law et al., 2015), and around Euros 100 million in the Netherlands annually (Bouvy et al., 2006). It costs about GBP 300 billion in the United Kingdom (Trueman et al., 2010). It was estimated that approximately 34 % of the healthcare spending in the US in 2011 could be categorized as waste (Berwick and Hackbarth, 2012, Shrank et al., 2019). A total of USD ∼ 150 million was spent on medicines that were never utilized by families in Saudi Arabia and other Gulf countries (Abou-Auda 2003). In hospital settings, the total spendings attributed to wastage can be higher owing to discontinuation of medications as reported by (Toerper et al., 2014).

Pharmaceutical waste or medicine waste is a type of healthcare waste generated during healthcare activities. It includes contaminated, expired, and unused medications. Other types include pathological waste, radioactive waste, and sharps (WHO, 1999, WHO, 2014; Gebremariam et al., 2019). Health and environmental risks are the key concerns in relation to healthcare waste. Such waste can pollute the air and contaminate drinking water thus, posing a health risk. According to the WHO, around 15 % of healthcare waste is dangerous, i.e., infectious or poisonous (WHO, 2018). Inadequate waste processing procedures, such as insufficient incineration or the disposal of untreated trash in landfills, may result in indirect health concerns(Manzoor & Sharma, 2019).

A study that was conducted at a tertiary care hospital in Riyadh, Saudi Arabia, showed that a total of 2061 intravenous drugs were left unused and returned to the pharmacy throughout the one-month trial period (AlSamanhodi et al., 2017). In a review, it was reported that an amount ranging from USD 191–282 billion could be saved by employing interventions to reduce wastage. This would mean a 25 % reduction in the total cost of waste in the US’s healthcare system (Shrank, Rogstad & Parekh, 2019). Hence, it could be said that there is an enormous potential to reduce wastage costs by employing waste reducing measures. In the current study, the total consumption and wastage of intravenous narcotic and controlled medication during one year was assessed. In addition, the wastage costs incurred on the healthcare system were also estimated in a tertiary care setting.

2. Methods

2.1. Objectives

The objectives of this study were to explore the wastage of narcotics and controlled medications and their financial impact in a tertiary care setting over a one-year period.

2.2. Study settings

The study was conducted in King Abdulaziz Hospital- National Guard Health Authority located in eastern region of Saudi Arabia. This public-sector, tertiary care hospital is equipped with more than 300 beds, and mainly responsible to serve military personnel and family members affiliated with the National Guard ministry.

2.3. Study design and duration

The study was an observational cohort study in which the annual utilization data of narcotics and controlled medications over a one year period i.e., October 2020 until September 2021 were observed and analyzed.

2.4. Inclusion and exclusion criteria

All medication wastage entries for intravenous (IV) narcotics and controlled drugs were included. Medication wastage entries for oral narcotics and controlled drugs as well as non-narcotics and non-controlled drugs were not included.

2.5. Operational definitions

2.5.1. Narcotics medications and inclusion

They are a class of drugs used to treat moderate to severe pain (National Cancer Institute, 2022). These medications are regulated by the Ministry of Health (MOH) Saudi Arabia. The injectable narcotic medications included in the study were fentanyl, tramadol, morphine, and meperidine.

2.5.2. Controlled medications and inclusion

They are drugs regulated by the government or health authorities as they contains chemicals that may cause addiction and may harm if not used appropriately (NHS England, 2022). The controlled medications included in the study were midazolam, phenobarbital, diazepam, ketamine and lorazepam.

2.5.3. Hospital reporting protocol

As per hospital protocol, only authorized consultant level physicians can enter the narcotics and/or controlled medications for admitted patients via computerized physician order entry system (CPOE) for a maximum duration of seven days. The narcotic/controlled medication order needs to be duly signed by processing pharmacist by electronic signature in CPOE system. Every ward is equipped with Automated Dispensing Cabinets (ADCs) that are computerized drug storage devices that allow narcotic/controlled medications to be stored and dispensed near point of care and can only be accessed by authorized nursing staff via fingerprint. For any prescribed IV Push/oral narcotic/controlled medication order, the assigned nurse of patient will take out medication, and needs to be documented, witnessed, double check, and duly signed by the responsible nurse in the presence of shift in charge nurse.

A wastage report should be made in case of: (a) broken full drug ampoule (b) excess drug left in ampoule after giving IV Push dose (c) remaining narcotic/controlled drug infusion and, (d) cancellation of narcotic/controlled medication order. As per hospital protocol, the nurse is responsible to dispose the excess/remaining amount of drug of IV Push ampoules/vials or intravenous piggyback (IVPB) infusion in the running tap water in presence of shift in charge nurse and should make the wastage report as soon as possible which also needed to be co-signed by shift in charge nurse. All documentation is in electronic format.

2.5.4. Medication wastage report

This a documentary evidence made at the time of reporting a wastage. It is made by the nursing department in electronic format through the hospital’s operating system.

2.5.5. Cost of medications

The cost of each medication was recorded as printed on the medication box at the end of data compilation. The standard set for cost calculations in this study was the cost of an ampoule. The costs were printed for the whole box of ampoules for every medication from which cost per ampoule for each medicine was calculated using the following formula:

$$Costofampouleofmedicine\left(x\right)=Costofboxformedication\left(x\right)÷numberofampoulesinboxformedicine(x)$$

The price on the box of medications was considered as a standard for cost calculation in this study. The cost were physically checked on the boxes. No discounts were known to researchers and were not applied in calculation of wastage costs. The cost of the ampoule of phenobarbital was not known and therefore, not included in the calculation.

The monetary value of per unit of each medication calculated through this formula was in Saudi Riyals (SAR). It was then converted to the United States Dollar (USD) using the exchange rate available online at the time of writing. In cases where the number of ampoules wasted were in decimals, the cost of a whole ampoule was considered for the said medicine. For instance, if the wastage calculated for a particular medicine was 1.3 or 1.5 ampoules, the cost of wastage of that medicine was considered for 2 ampoules. The costs reported in the results represent the monetary value in SAR and USD in 2021 and are not adjusted for inflation.

2.5.6. Data generation and analyses

The narcotics and controlled medications in-charge pharmacist had the access to electronic reports for wastage of medications. It was generated by the pharmacist from the hospital’s system. The report was generated and downloaded as Microsoft Excel spreadsheet. The data is reported using the average, minimum and maximum values. Frequency and percentages are also used to report the data where necessary.

2.5.7. Ethics approval

The study was based on the project approved by the Institutional Review Board at the King Abdullah International Medical Research Center (KAIMRC), Saudi Arabia (NRA21A/010/02). Field notes for the calculation generated during the study were securely disposed of. The raw data is available as an additional file.

4. Results

4.1. Narcotics and controlled medications wastage

During the study period around 1,947 narcotic medications wastage reports were generated. Most of the reports generated were those of Morphine PCA IVPB accounted for 658 reports (33.8 %) and total wastage amount was 18,714 mg (average = 28.4 mg). Among the controlled medications around 740 reports were generated regarding controlled medications wastage. Most of the wastage reports were generated for Midazolam infusion IVPB (n = 436, 54.03 %). The breakdown of narcotics and controlled medications wastage reports is presented in Table 1.

Table 1.

Wastage reports for several narcotic and controlled medications.

	Wastage reports (N)	%	Total wastage (mg)	Minimum (mg)	Maximum (mg)	Average (mg)
Narcotic medications (N = 1947)
Fentanyl
Fentanyl IV Push	52	2.67 %	3393 mcg	50 mcg	100 mcg	65.3 mcg
Fentanyl epidural infusion IVPB	16	0.82 %	924 mcg	23 mcg	176 mcg	57.8 mcg
Fentanyl PCA IVPB	24	1.23 %	6800 mcg	30 mcg	655 mcg	283 mcg
Fentanyl infusion IVPB (pediatric)	294	15.10 %	31,181 mcg	20 mcg	190 mcg	106 mcg
Fentanyl infusion IVPB (adult)	134	6.88 %	25,443 mcg	104 mcg	470 mcg	189.8 mcg
Tramadol
Tramadol IV Push	385	19.77 %	15750 mg	20 mg	100 mg	46.7 mg
Morphine
Morphine IV Push	107	5.50 %	622 mg	0.8 mg	9.75 mg	5.8 mg
Morphine infusion IVPB	32	1.64 %	202 mg	4 mg	9 mg	6.3 mg
Morphine PCA IVPB	658	33.80 %	18714 mg	7 mg	47.5 mg	28.4 mg
Meperidine
Meperidine IV Push	245	12.58 %	7410 mg	15 mg	95 mg	30.2 mg
Controlled medications (N = 740)
Midazolam
Midazolam IV push	189	23.42 %	1936.15 mg	4	15	10.2
Midazolam IVPB infusion	436	54.03 %	6190.5 mg	2.5	27.5	14.2
Phenobarbital
Phenobarbital IV Push	8	0.99 %	265 mg	8	52.5	33.1
Diazepam
Diazepam IV Push	20	2.48 %	134 mg	1	9.1	6.7
Ketamine
Ketamine IV Push	83	10.29 %	38894 mg	300	500	468.6
Lorazepam
Lorazepam IV Push	4	0.50 %	8 mg	0.5	3	2

IV = Intravenous, IVPB = Intravenous Piggyback, mcg = microgram, mg = milligram, ml = milliliter.

4.2. Annual wastage of ampoules for narcotics and controlled medications

Table 2 presents the extent of annual ampoules wastage for different narcotic and controlled medications. The wastage of quantity in terms of standard ampoule was highest for Morphine PCA IVPB, i.e., 1872 ampoules. For controlled medications, the wastage quantity in terms of ampoule was highest for Midazolam infusion IVPB, i.e., 413 ampoules.

Table 2.

Annual ampoules wastage for narcotic and controlled medications.

	Wastage reports (N)	Standard Concentration	Ampoule Strength (per ampoule)	Total Wastage Amount (mg OR mcg)	Total Wastage Amount (equivalent to nearest ampoule)	Wastage amount (≤50 % of ampoule)	Wastage amount (greater than50 % of ampoule)
Narcotic medication wastage (N = 1947)
Fentanyl
Fentanyl IV Push	52	100mcg /ml	100 mcg	3393 mcg	34	30	22
Fentanyl epidural infusion IVPB	16	200mcg /100 ml	100 mcg	924 mcg	92.4	11	5
Fentanyl PCA IVPB	24	500mcg /50 ml	500 mcg	6800 mcg	13.6	14	10
Fentanyl infusion IVPB*	294	200mcg /20 ml	100 mcg	31,181 mcg	312	139	155
Fentanyl infusion IVPB**	134	2000mcg /100 ml	500 mcg	25,443 mcg	50.88	84	50
Tramadol
Tramadol IV Push	385	100 mg /ml	100 mg	15750 mg	158	374	11
Morphine
Morphine IV Push	107	10 mg /ml	10 mg	622 mg	63	59	48
Morphine infusion IVPB	32	10 mg /10 ml	10 mg	202 mg	20.2	24	8
Morphine PCA IVPB	658	50 mg /50 ml	10 mg	18714 mg	1872	359	299
Meperidine
Meperidine IV Push	245	50 mg /ml	100 mg	7410 mg	75	228	17
Controlled medications (N = 740)
Midazolam
Midazolam IV Push	189	5 mg/ml	15 mg	1936.15 mg	129	24	165
Midazolam infusion IVPB	436	30 mg/12 ml	15 mg	6190.8 mg	413	330	106
Phenobarbital
Phenobarbital IV Push	8	60 mg/ml	60 mg	265 mg	5	3	5
Diazepam
Diazepam IV Push	20	10 mg/ml	10 mg	134 mg	14	8	12
Ketamine
Ketamine IV Push	83	50 mg/ml	500 mg	38894 mg	78	0	83
Lorazepam
Lorazepam IV Push	4	4 mg/ml	4 mg	8 mg	2	4	2

IV = Intravenous, IVPB = Intravenous Piggyback, mg = milligram, ml = milliliter, *= for pediatrics, **= for adults.

4.3. Annual consumption and wastage analysis of narcotic and controlled medications

Table 3 reports that total consumption of narcotics and controlled medications in standard unit of ampoule. The highest consumption per ampoule was reported for Fentanyl 500mcg formulations, i.e., 28,580 ampoules, and Morphine 10 mg formulations, i.e., 27,122 ampoules. The highest ampoule wastage was observed for all formulations of Morphine 10 mg combined, i.e., 1956 ampoules. Highest % wastage was seen for Midazolam 15 mg ampoules, i.e., 29.3 %. It had the highest wastage cost as well, i.e., SAR 4010.8. Slightly more than a fifth proportion of consumed controlled medications (21.3 %) were wasted resulting in a wastage cost of SAR 9,252.1. Overall, a total of 87,305 ampoules of narcotics and controlled medications were consumed and out of which 3,334 ampoules were wasted resulting in an annual wastage of 3.81 %. The total wastage cost of narcotics and controlled medications was 15,443.1 SAR that was equivalent to USD 4085.5. The breakdown of each narcotic and controlled medications is presented in Table 3.

Table 3.

Annual consumption & wastage proportion analysis with cost of wastage.

Drug	Ampoule Strength	Drug Amount Per Ampoule	Annual Consumption (ampoules)	Total Wastage (ampoules)	% Wastage	Price per ampoule (SAR)	Total cost of wastage (SAR)	Total cost of wastage (USD)
Narcotics medications
Fentanyl*	50 mcg/ml	500 mcg	28,580	65	0.23	6.8	442	116.93
Fentanyl*	50 mcg/ml	100 mcg	22,200	439	1.98	3.1	1360.9	360.44
Tramadol	50 mg/ml	100 mg	3200	158	4.93	6.4	1011.2	267.50
Morphine*	10 mg/ml	10 mg	27,122	1956	7.21	3	5868	1552.36
Meperidine	50 mg/ml	50 mg	3200	75	2.35	7.6	570	150.80
		Total	84,302	2693	3.19	–	9252.1	2448.03
Controlled medications
Midazolam*	5 mg/ml	15 mg	1850	542	29.3	7.4	4010.8	1061.06
Phenobarbital	60 mg/ml	60 mg	456	5	1.10	–	0	0.00
Diazepam	10 mg/ml	10 mg	58	14	24.14	4.8	67.2	17.78
Ketamine	50 mg/ml	500 mg	392	78	19.90	27	2106	557.15
Lorazepam	4 mg/ml	4 mg	247	2	0.81	3.5	7	1.85
		Total	3003	641	21.3	–	6191	1637.84
Overall Total (Narcotics medications + Controlled medications)			87,305	3334	3.81	–	15443.1	4085.48

* = formulations combined, SAR = Saudi Arabian Riyal, USD = United States Dollar.

5. Discussion

Medicines wastage has been reported as a contributing factor for deteriorating environmental and economic conditions as inadequate wastage techniques could lead to the waste contamination in water and could potentially harm humans (Alhomoud, 2020).

Current study aimed to quantify the annual consumption and wastage of narcotic and controlled medications in a hospital setting. This study, as per our knowledge, represents the first analysis for extent of utilization and wastage of narcotic and controlled medications in a tertiary care setting in Saudi Arabia. At the study venue, the traditional protocol is to discard the unused narcotic and controlled medications in a running tap water in presence second licensed healthcare professional (which is usually the shift in charge nurse), and signs of both staff are required on medication wastage report to document the narcotic and controlled medication wastage.

Because of its pharmacokinetic profile, which provides expected rapid onset and short duration of action, IV fentanyl is well suited for its role as perioperative analgesia (Rahimzadeh et al., 2014). Mankes and Silver (2013) reported that among narcotic medications, fentanyl, acetaminophen-codeine, and midazolam accounted for 87.5 % of the total bedside waste (Mankes & Silver, 2013). Our study findings also reported that the annual consumption of number of ampoules was highest for fentanyl formulations. Concentrated fentanyl vials used for compounding continuous infusion were reported to be in shortage during COVID-19 (Ammar, et al., 2021). During large surgical procedures, it is usual to provide fentanyl during anesthetic induction and early in the process, followed by an opioid with a longer duration of action, such as morphine or hydromorphone (Rosenfeld, et al., 2018).

Patient controlled analgesia (PCA) is regarded as one the most effective way to relieve post-operative pain by allowing patients to administer the needed dose of analgesics. Early discontinuation of the IV PCA morphine was reported as one the major contributor to wastage of morphine in healthcare setup (Kim et al., 2014). The current study revealed that one of the highest proportions of wastage reports of unused narcotic medication among morphine preparations was related to morphine PCA IVPB accounting for 658 reports. A study reported that after fentanyl the most common narcotic medication wasted at bedside in hospital setting was morphine accounting for wastage of 395 g per 4428 g dispensed (Mankes & Silver 2013). Meperidine hydrochloride (also known as Pethidine) is a synthetic opioid with various pharmacological actions, however, may lead to fatal reactions in patients who have received monoamine oxidase inhibitors (Latta et al., 2002). Around 245 (12.58 %) reports were generated for meperidine IV Push and total wastage amount was 7,410 mg.

Many pharmaceutical companies produce opioids, antidepressants, and stimulants for medical reasons, but they also have the potential for misuse. To prevent this, these pharmaceutical products have been designated as “controlled substances/medications” and have been regularized through the regulatory guidelines and acts (Musson et al., 2007). Many times during a typical workday, hospital nurses routinely discard unused portions of narcotics and controlled medications into municipal water supplies (King & McCue, 2017).

Midazolam was reported as one of the most common among narcotic/controlled medications with a higher wastage. It has been reported as one the four medications for which wastage can be prevented (Barbariol et al., 2021). Current study also reported midazolam as the highest contributor controlled medicine in terms of wastage reports. Among controlled medications, the wastage reports were generated for midazolam infusion IVPB (n = 436) and midazolam IV push (n = 189). The wastage amount for midazolam infusion IVPB was 6190 mg while the wastage amount for midazolam IV Push was 1936.15 mg.

Midazolam was also among the top three controlled drug that were wasted in another study (Mankes and Silver 2013). In a multicenter study in Italy, it was observed that the 15 mg/5ml formulation of Midazolam had 46 % wastage (Barbariol et al., 2021). Similarly, a study reported that most common controlled substance wasted was Midazolam and it accounted for 65 % of whole cost attributed to wastage (Weinger 2001). It has been found in our study that the total extent of wastage for midazolam was around 542 ampoules which accounts for approximately 29 % of midazolam ampoules consumption during the study period.

In many cases, it is impossible to prevent wastage of medications as most of the commonly used IV narcotics and controlled medications that are available as single-used vials/ampoules. Interventions are needed to reduce the medicine wastage. Education of the healthcare professionals (physicians and nurses) who are involved is reported as one of the most effective interventions (Alshehri et al., 2019, Barbariol et al., 2021). The total wastage cost of narcotics and controlled medications in our study was 15,443.1 SAR that is equivalent to USD 4,085.5 over the period of one year, i.e., 2021. However, a comparison cannot be made as there are no reliable figures available in literature from national or regional healthcare facilities.

There are various easy approaches to reduce drug waste. Clinicians may draw drugs in a number of syringes (i.e., “split doses”) if the substances of vial are expected to be used for more patients. It could be a cost- effective strategy (Weinger 2001). Pharmacists do have a role to play in reducing medicine wastage by employing myriad interventions. In a study, Alhomoud explored strategies employed by pharmacists to reduce wastage when medicines are leftover. These were safe collection of medications for dispose of, donating medication to other countries or patients, re-dispensing unused medicines, etc. (Alhomoud, 2020).

Although the usage of multidose vials may reduce waste, proper inventory management is essential to avoid the occurrence of half used or outdated vials. Increased use of original manufacturer or local formulations of medications with longer shelf life would be desired. Some hospital pharmacists are finally beginning to manufacture medications in syringes and administer these nowadays ensuring their sterility during this process. Increased use of original manufacturer or local formulations of medications with longer shelf life would be desired. Some hospital pharmacists are finally beginning to sterilely manufacture medications in syringes and administer these every day (Weinger 2001). Since narcotics and controlled medications have a higher possibility of abuse and addiction, that is why these are tightly regulated. Consequently, when controlled medicines are administered to a patient, any excess drug must be disposed of instantly.

This study has few limitations. It did not include the wastage costs of oral dosage forms for controlled and narcotic drugs. Besides, the pricing information for Phenobarbital ampoule was not available. In addition, the study solely focused on the monetary costs of the medications and not the costs of preparation, labor, storage, etc., associated with the medicines. Further, the drug prices recorded and the cost per ampoule reported in this study were charged at the time of data compilation, i.e., 2021, and may have inflated since then. The price has not been adjusted to current inflation of 2022. Therefore, the wastage and associated costs would be even higher had those been included. Lastly, this study was conducted in a single healthcare facility and therefore may not be representative.

6. Conclusion

Overall, the wastage was less than 5 % of the total consumption however, a reasonable amount of controlled drug wastage was recorded during the study period. Midazolam was observed to have the highest wastage. An effort should be made to establish a more efficient workflow that reduces waste while ensuring that these medications are available in an emergency situation. Shifting to prefilled syringes supplied by pharmacies, making protocols, and safely pooling costly drugs could result in significant savings.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.