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. 2024 Sep 9;17(1):2395535. doi: 10.1080/20523211.2024.2395535

Unused medicine take-back programmes: a systematic review

Leong Seng Wang a,b, Zoriah Aziz c,d,CONTACT, Ee Syuen Wang e, Zamri Chik a
PMCID: PMC11385643  PMID: 39257836

ABSTRACT

Background:

Improper disposal of unused medicine can impact the environment causing significant healthcare and financial burdens. While the medicine take-back programme is an effective management strategy, its effectiveness differs across countries. This study aimed to systematically review the take-back programmes in various countries and to identify areas needing improvement for programme enhancement.

Methods:

We conducted searches in Medline, EMBASE, CINAHL, Web of Science, Scopus, and Google Scholar, from database inception to June 2023.

Results:

The review included 27 studies spanning 15 countries’ medicine take-back programmes. While some programmes, mostly observed in the USA, were conducted at the local level with non-health-associated facilities, others were done at the national level within healthcare facilities. The cost of collected medicines ranged from US$7,416 to US$1,118,020, primarily involving medicines related to the nervous system, cardiovascular system, alimentary tract, and metabolism. Legislations pertaining to these programmes were available in the USA, most European countries, and Mexico, but unavailable in Spain, Austria, Australia, and New Zealand. However, despite this, the government or the industry in these countries managed the programmes.

Conclusion:

Well-structured take-back programmes featuring easily accessible collection points, regular collection schedules, clear programme ownership, with legislation defining financial responsibilities, showed positive outcomes.

KEYWORDS: Unused medicines, disposal, take-back programme, cost, legislation

Background

Unused medicine has been defined as pharmaceuticals that are no longer in use by the intended patients because these medicines have expired, contaminated, or are no longer required (Makki et al., 2019). As the usage of pharmaceuticals continues to increase, the issue of improper disposal of unused medicines to the environment has garnered a growing concern worldwide (Kristina & Wulandari, 2020; Makki et al., 2019; Paut Kusturica et al., 2017). Indeed, medicines and their metabolites have been detected in the aquatic environment since the 1970s (Bound & Voulvoulis, 2005; Gray-Winnett et al., 2010; Szymańska et al., 2019).

From the perspective of the healthcare system, the financial and healthcare burdens of unused medicines and their disposal are substantial (Daughton, 2003; Dilip et al., 2020; Mackridge & Marriott, 2007). These burdens are direct costs spent on medicine, costs for disposal, and costs for overcoming environmental and health issues related to unused medicines. The therapeutic classes of unused medicines reported in medicine take-back programmes were mostly medicines for the respiratory tract, gastrointestinal, and cardiovascular systems (Rahmadani & Kristina, 2021). As for the cost of unused medicines, an Austrian study has extrapolated that an amount of US$44.42 million of pharmaceuticals was wasted in Vienna, Austria (Vogler & de Rooij, 2018). Meanwhile, the estimated cost of waste medicines in Italy was US$211.42 million per year (Romanelli & Lucente, 2022).

It has been recognised that the collection of unused medicines from household consumers through take-back programmes is one of the most effective approaches to managing their disposal (Kümmerer, 2009; Mitkidis et al., 2022; Paut Kusturica et al., 2017). Unused medicine take-back programmes provide consumers with facilities for safe and convenient ways to dispose of their unused medicines (Kristina & Wulandari, 2020; Yanovitzky, 2016). These programmes can prevent behaviours that lead to environmental contamination and the potential abuse of unneeded pharmaceuticals by encouraging the correct disposal of medications (Kristina & Wulandari, 2020). Many countries have implemented official medicine take-back programmes, including the United States of America (USA), European countries, Australia, New Zealand, and countries in Asia such as Malaysia and Brunei (Ariffin & Zakili, 2019; Nurolaini et al., 2016; OECD, 2022). However, because of differences in healthcare systems, laws regulating pharmaceuticals, funding processes, and possible local challenges, these programmes vary in their characteristics, operations, and implementations (OECD, 2022).

Certain take-back programmes are initiated and funded by governments such as those in Australia, Switzerland, Mexico, Malaysia, and Brunei. Others operate on a voluntary self-support basis by individual community pharmacies and wholesalers or receive support from the pharmaceutical industry under the Extended Producer Responsibility (EPR) legislation (Amaral & Fop, 2013; OECD, 2022). In the USA, initiatives like the National Prescription Drug Take-Back Day (Fleming et al., 2016) and the Secure and Responsible Drug Disposal Act (2014) have facilitated the establishment of more collection centres (DEA, 2014; Ma et al., 2014; Perry et al., 2014). Australia has implemented the National Return Unused Medicine (NatRUM) programme, which was developed and funded by the government (Kirkpatrick et al., 2013; Wheeler et al., 2016). Additionally, several European countries have introduced national-level unused medicine take-back programs (OECD, 2022). Notable examples of EPR waste disposal organisations include Bonusage of Belgium, Valormed of Portugal, and Recyclomed of Hungary (Amaral & Fop, 2013; OECD, 2022). Previous systematic reviews based on studies of consumers’ perspectives, reported that the success of the medicines take-back programme has been hindered by a low rate of return (Kristina & Wulandari, 2020; Paut Kusturica et al., 2017). Factors contributing to the low rate of returning unused medicines include a lack of awareness among the public about the existence and benefits of the take-back programme, issues related to drop-off locations and operational availability, and concerns about the privacy and security of personal information when returning medications (Bettington et al., 2018; Watkins et al., 2022). Additionally, negative attitudes, lack of knowledge, and ingrained habits of disposing of unused medicines through conventional means have been identified to hinder participation in take-back programmes (Foon et al., 2020).

We aimed to systematically review the characteristics of the reported take-back programmes including their implementation, methods of collection, participants’ demography, types, quantity, and cost of unused medicines collected. Evaluating the legislation and policies governing medicine take-back programs helps in determining if there are gaps or areas for improvement. This can lead to recommendations for refining existing policies or implementing new ones for better outcomes.

Methods

Identification of study

We searched six electronic databases from their inception to June 2023, to identify studies eligible for inclusion in the review. The databases were Medline, Embase, CINAHL, Scopus, Web of Science, and Google Scholar. We supplemented the search by going through bibliographies of retrieved articles and previous reviews. The conduct and reporting of this systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) (Page et al., 2021).

Search strategy

The search terminologies used were adopted from earlier systematic reviews by West et al. (2014) and Paut Kusturica et al. (2017). Search terms used were: (‘unwanted medicine*’ OR ‘unwanted medication*’ OR ‘unwanted pharm*’ OR ‘unwanted drug*’ OR ‘unused medicine*’ OR ‘unused medication*’ OR ‘unused pharm*’ OR ‘unused drug*’ OR ‘expired medicine*’ OR ‘expired medication*’ OR ‘expired pharm*’ OR ‘expired drug*’ OR ‘medicine* wast*’ OR ‘medication* wast*’ OR ‘pharm* wast*’ OR ‘drug* wast*’ OR ‘unnecessary medicine*’ OR ‘unnecessary medication*’ OR ‘unnecessary pharm*’ OR ‘unnecessary drug*’ OR ‘extra medicine*’ OR ‘extra medication*’ OR ‘extra pharm*’ OR ‘extra drug*’ OR ‘surplus medicine*’ OR ‘surplus medication*’ OR ‘surplus pharm*’ OR ‘surplus drug*’ OR ‘untouched medicine*’ OR ‘untouched medication*’ OR ‘untouched pharm*’ OR ‘untouched drug*’ OR ‘remaining medicine*’ OR ‘remaining medication*’ OR ‘remaining pharm*’ OR ‘remaining drug*’ OR ‘returned medicine*’ OR ‘returned medication*’ OR ‘returned pharm*’ OR ‘returned drug*’ OR ‘medicine* take-back’ OR ‘medication* take-back’ OR ‘pharm* take-back’ OR ‘drug* take-back’) AND (patient* OR consumer* OR household* OR home* OR residential*) NOT (review OR ‘systematic review’ OR ‘scoping review’ OR ‘narrative review’ OR ‘letter to editor*’ OR ‘letter to the editor*’ OR editorial).

Selection criteria

We included only studies involving unused medicines take-back programme that met the following criteria (a) cross-sectional studies; (b) studies that presented their research methods, (c) studies that described study population and outcome measures of interest including unused medicine take-back programme’s implementation effectiveness, medication collection process and collected medicines’ total cost, class and quantity, and (d) studies published in English or other languages when the translation was available, and (e) studies that researched aspects of medication take-back from the perspectives of the healthcare system.

We excluded studies that were primarily concerned with (a) studies describing medical wastage such as medical devices and clinical tissue waste, (b) studies focusing solely on the potential environmental impact of unused medication, (c) studies focusing solely on medication storage and disposal, (d) studies involving non-consumer or household settings, such as hospital or manufacturing plant settings, (e) studies that only examined environmental samples containing active medicinal ingredients, (f) review articles, letters, and comments, abstracts, and conference proceedings.

Selection process

Two reviewers (LSW and ESW) independently removed the duplicates, screened the titles and abstracts of all the studies identified in the search. The studies that fulfilled the inclusion criteria were obtained in full text. The two reviewers then independently examined the full text to determine their eligibility for inclusion in the review. Any disagreement was discussed and resolved by discussion between the two reviewers or by consulting the third reviewer (ZA).

Data extraction

Two reviewers independently extracted data from the selected articles using standardised data extraction forms. Data extracted included key study characteristics such as author(s), publication year, country, aim of study, study design, facilities of collection, name of the event, demography of participants, study period, unused medicine take-back programme (implementation), medication collection process, and collected medicines’ total cost, class and quantity (Supplemental Material Appendices 1 and 2).

If the information for legislation or guidelines was not available or clearly reported in the studies, we obtained the information from two international organisations’ reports, namely, the Pharmaceutical Group of European Union (PGEU, n.d.), and the Organisation for Economic Co-operation and Development (OECD, 2022), a review on drug disposal state statues in the United States (Barenie et al., 2022), the United States Secure and Responsible Drug Disposal Act of 2010 and Drug Enforcement Administration (DEA’s) rules, 2014 (DEA, 2014).

Quality assessment

The Appraisal tool for Cross-Sectional Studies (AXIS) was used to appraise the study design, reporting quality, and the risk of bias in the included cross-sectional studies (Downes et al., 2016). The checklist contains 20 questions (with yes, no, and don't know as answers). Two reviewers (LSW and ESW) independently appraised the quality of each included study. Any differences in the opinion were resolved by discussion between the two reviewers or by consulting the third reviewer (ZA). The response for each question was aggregated and converted to a percentage to summarise the quality of each section (Downes et al., 2016).

Results

Identification and selection of studies

Our search of the six databases and the hand search of additional records resulted in 5,067 records. The number of records identified and selected is shown in Figure 1. After removing 3,088 duplicates, we screened through the remaining 1,979 records. We excluded 1,946 records based on title and abstract. Full-text articles were retrieved for 33 studies, and sixwere excluded because two did not provide a clear collection process, two did not report on the quantity of unused medicine, one was a non-consumer study and one was a non-English publication. Finally, 27 articles were included for analysis.

Figure 1.

Figure 1.

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Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Flow diagram to show the selection of papers for inclusion in the review.

Characteristics of the studies

Study aims, design, collection facility, and demography of participants

We have included 27 included studies involving 15 countries (Supplemental Material Appendix 1). One study (Amaral & Fop, 2013) involved six European countries. Out of these studies, 12 were from the United States of America (USA), European countries (n = 7), Australia (n = 4), New Zealand (n = 2), Egypt (n = 1), and Mexico (n = 1). All the studies aimed to report the implementation and outcomes of the specific medicine take-back programmes. Most of the studies were cross-sectional with one (Shealy et al., 2019) retrospective audit study. In 17 studies, the take-back facilities were in pharmacies and other healthcare facilities, while ten studies involved non-healthcare facilities.

Only nine studies provided the demographic characteristics of the consumers who return medicines to the programmes (Bekker et al., 2018; Brushin, 2005; Coma et al., 2008; Garey et al., 2004; Law et al., 2015; Moustarah et al., 2020; Perry et al., 2014; Stoddard et al., 2017; Yang et al., 2015). Participants in six of the studies consisted of more females (55.0%−61.0%), and most of the participants (60%–79%) were of the middle-aged group (>50 years old) with two studies involving participants who had secondary or higher education. Only two studies reported the income of the participants (Supplemental Material Appendix 1).

Implementation of medicine take-back programmes, collection methods

The medicine take-back programme in the USA for the included studies was implemented either at the state level, by individual organisations or in collaboration with various governmental agencies and non-governmental organisations (Supplemental Material Appendix 2). Three studies implemented the take-back programmes as part of the Drug Enforcement Agency’s National Medication Take Back Day (Jaramillo-Stametz et al., 2018; Shealy et al., 2019; Stewart et al., 2015). However, the other nine take-back programmes were specially organised local events that were held periodically. The location of these collection centres was mostly in local community areas, including retail, or universities, rather than pharmacies or other healthcare facilities. As the take-back locations were not at a healthcare facility, the take-back process in these locations required the supervision of the relevant authorities for regulatory compliance (Fleming et al., 2016; Ma et al., 2014; Moustarah et al., 2020; Perry et al., 2014; Yang et al., 2015). Only two studies involved take-back at pharmacies (Garey et al., 2004; Law et al., 2015).

Meanwhile, the programme from European countries was mostly developed and implemented at the national level, and medicines were collected continuously at pharmacies or healthcare facilities (Amaral & Fop, 2013; Coma et al., 2008; Mackridge & Marriott, 2007; Romanelli & Lucente, 2022). In the United Kingdom (UK), the medicine take-back programmes were conducted by the government, through the Disposal of Old Pharmaceuticals (DOOP) service and the National Health Service (Amaral & Fop, 2013; Mackridge & Marriott, 2007). Three European countries (Belgium, Hungary, and Spain) reported that the medicines take-back programmes were organised at the national level and sponsored by Extended Producer Responsibility (EPR) schemes. The collections were through community pharmacies (Amaral & Fop, 2013). In Lithuania, community pharmacies were obligated by legislation to collect unused medicines but the responsibility of the government agencies was not clearly defined (Amaral & Fop, 2013). However, in the Netherlands, Malta and Austria, three studies reported a local-level implementation of the programme by volunteering pharmacies (Bekker et al., 2018; Vella & West, 2019; Vogler & de Rooij, 2018).

In Australia, the continuous take-back programme named the National Return Unused Medicine (NatRUM) was developed and funded by the government (Kirkpatrick et al., 2013; Wheeler et al., 2016). Unused medicines were also continuously collected by hospitals through their outreached pharmacy (Guirguis, 2010). Both studies from New Zealand (Hanning et al., 2022; James et al., 2009) reported local-level, continuous implementation of medicine take-back programmes by volunteering community pharmacies. The organisation responsible for disposing of these medicines was Interwaste New Zealand.

One Mexican study reported the national-level implementation of a continuous take-back programme by the government (Gracia-Vásquez et al., 2015). The collection of unused medicines was at the pharmacies and healthcare facilities. Meanwhile, the Egyptian study (El-Hamamsy et al., 2011) involving 20 community pharmacies reported the medicine take-back programme. However, it was unclear from the study whether it was a formal or continuous programme.

Quantity of returned medicines

For the quantity of medicines collected, a variety of units, including dose, package or container, item or unit, and weight, were reported (Supplemental Material Appendix 2). Six studies reported more than one type of measurement unit (Bekker et al., 2018; Garey et al., 2004; Guirguis, 2010; Mackridge & Marriott, 2007; Perry et al., 2014; Vogler & de Rooij, 2018).

Most of the articles reported the quantity of medicines collected as items or units (n = 13). The highest number of items or units reported was from an Australian study with 24,400 medicine items collected from the NatRUM programme (Kirkpatrick et al., 2013). A European study involving six countries reported the highest weight of unused medicines collected with a total of 2,206.5 tonnes that ranged between 31 and 854 tonnes collected in the countries (Guirguis, 2010). Out of the six studies that reported dose units, one of the USA studies reported the highest quantity of 69.6 million units of dose collected from 1,395 events (Fleming et al., 2016) while an Italian study reported the highest package of medicines (n = 3219) from four pharmacies in eight months (Romanelli & Lucente, 2022) (Supplemental Material Appendix 2). The reported quantities were not directly comparable because of the variation of the measurement units, number of collection events, period of study, and study methods.

Cost and economic value of returned medicines

Six studies reported the cost of medicines collected ranged from US$ 7,416 to US$ 1,118,020. The highest value of collected unused medicines was from a USA study (Perry et al., 2014), through a biannual, seven-day medicines take-back event held in a local community over three years. This programme was publicised and developed through a collaboration between a university and, the Alcohol, Drug Addiction, and Mental Health Services (ADAMHS) Board of Hancock County, local law enforcement officials, and environmental organisations.

The study that reported the lowest value of unused medicines collected was from Austria (Vogler & de Rooij, 2018). This programme was conducted through the community pharmacy and municipal dedicated disposal centres and transported to the Vienna Municipal Waste Department for disposal. However, this study only reported the medicine values based on four samples and not the entire unused medicines received by the Vienna Municipal Waste Department. The value of the collected unused medicines was estimated to be US$44.42 million. The other four studies reported some substantial economic value of unused medicines based on continuous collection programmes through pharmacies, clinics, and a hospital (Bekker et al., 2018; Garey et al., 2004; Guirguis, 2010; Mackridge & Marriott, 2007).

Types of returned medicines

Seventeen of the studies classified the collected medicines by class of therapy (Supplemental Material Appendix 2). We compiled the class of medicines using Anatomical Therapeutic Chemical (ATC) medicine classes (Figure 2). Out of the 14 ATCs, 17 studies involved medicines from the nervous system, cardiovascular system, alimentary tract, and metabolism. The other classes of medicines involved were anti-infective for systemic use, respiratory system, dermatological, and musculoskeletal system.

Figure 2.

Figure 2.

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Frequency of the medicine class reported (n = 17).

Legislation of medicines take-back programme

The legislation and guidelines for the 15 countries of the included studies are shown in Supplemental Material Appendix 3. As the legislation was not reported in most of the studies clearly, we obtained information from other sources, including reports of international organisations, namely, the Pharmaceutical Group of European Union, and the Organisation for Economic Co-operation and Development (OECD, 2022; PGEU, n.d.).

In the USA, the Drug Enforcement Administration (DEA) authorises pharmacies and other organisations to collect unwanted prescription medications under the terms of the Secure and Responsible Drug Disposal Act (2010). The DEA published the Final Rule in 2014, outlining the procedures for implementing the federal drug disposal statute (DEA, 2014). These included the authorised collectors and their collection centres, as well as the methods of collection, which included mail-back programs and take-back events. Following the federal law on drug disposal, several states in the USA passed state legislation on the disposal of medicines. By the year 2022, 63% of the 50 states in the USA have passed these kinds of state laws (Barenie et al., 2022). These state laws, however, vary from one state to the other. Most states specified the types of medicines accepted (97%), collection sites (59%), and who may dispose of them (50%) (Barenie et al., 2022). A third of the states allowed mail-back options and provided funding; a small number of states specified which healthcare facilities or individuals may collect unused medicines (12%); only three states required pharmacy participation (Barenie et al., 2022). Moreover, 25 states have state-level local EPR regulations that require manufacturers to pay for the regional take-back initiatives (OECD, 2022).

In the European Union, Directive 2004/27/EC (Article 127), obligated the Member States to implement appropriate medicine collection systems (Amaral & Fop, 2013). The national legislations in Belgium, Hungary, Italy, and Portugal provided for mandatory Extended Producer Responsibility (EPR) for the collection and disposal of unused medicines, implemented by the pharmaceutical industries (Amaral & Fop, 2013; OECD, 2022; PGEU, n.d.; Romanelli & Lucente, 2022). In the Netherlands, the legislation obligated the municipalities the responsibility to collect and dispose of unused medicines, while the pharmacies provided additional voluntary collection sites. In Austria, there is no national legislation on the collection of unused medicines, but pharmacies and the local governments have voluntarily collaborated to do so (Amaral & Fop, 2013; OECD, 2022). In Lithuania, the national legislation has mandated pharmacies to collect unused medicines while the government is obligated to finance the disposal of these medicines, but the role of various institutions was unclear (Amaral & Fop, 2013). Meanwhile, in the UK, pharmacies are obligated to collect unused medicines and return them to the National Health Service under the National Health Service (Pharmaceutical and Local Pharmaceutical Services) Regulation 2013 (Amaral & Fop, 2013).

For Australia and New Zealand, there is no specific national legislation governing unused medicine disposal (OECD, 2022). In 1999, the Department of Health and Aging of Australia initiated and funded the National Return and Disposal of Unwanted Medicines (NatRUM) and pharmacies nationwide have voluntarily participated in this programme as medicine take-back facilities (Kirkpatrick et al., 2013; NatRUM, 2020). On the other hand, the community pharmacies of New Zealand voluntarily collaborated with some district health boards to implement the take-back programmes (James et al., 2009). In Mexico, under the General Law for Handling and Processing of Waste (2006), the unused medicine take-back scheme was set up as an EPR scheme in 25 states and managed by Singrem (Gracia-Vásquez et al., 2015). Egypt has not reported any national legislation or medicine take-back programme (El-Hamamsy et al., 2011).

Assessment of study quality

Figure 3 shows the quality of the studies based on the assessment using the Appraisal tool for Cross-Sectional Studies (AXIS checklist). Out of the 20 quality items assessed, 10 parameters were fulfilled by all studies. These parameters were clear research aims, appropriate design, clearly defined target population, appropriate sample frame, and risk factor, sufficiently described methods and basic data, the results were internally consistent and presented consistent with the methods, and the discussion justified by the results. Three-quarters of the studies reported no financial conflict of interest. More than three-quarters of the studies discussed their study limitation. One-third of the studies used appropriate sampling methods and received ethical approval. Almost a quarter of the studies determined the statistical significance, and only ten percent of the studies piloted their instruments.

Figure 3.

Figure 3.

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Quality assessment of studies using the Appraisal tool for Cross-Sectional Studies (AXIS) (n = 27).

Discussion

Medicine take-back programmes have been recognised as a means to provide a safe and responsible way of disposing of unused medicine to reduce the leakage of active pharmaceutical ingredients into the environment (OECD, 2022). This review summarises the characteristics of the reported take-back programmes practice in terms of their implementation and legislation, methods of collection and funding, cost, and types of unused medicines collected. We found the implementation and legislation of the medicine take-back programmes and outcomes vary among countries. This variation makes a direct comparison of the various programmes impossible. For example, a variety of measurement units was reported to quantify the medicines collected. Nevertheless, we found that factors such as the availability of relevant legislation, sustainable financial support, frequency and length of operation, and collection locations, influence the outcomes of these programmes.

The economic value of unused medicines collected can be a good indicator of the success of the medicine take-back programme. However, a direct comparison of the success of the programmes with the economic values is not possible. This is because of the variation in the features of the programmes such as frequency, duration of collection, the year the study was reported, and cost of medicines in the respective countries (Bekker et al., 2018; Garey et al., 2004; Guirguis, 2010; Mackridge & Marriott, 2007; Perry et al., 2014; Vogler & de Rooij, 2018).

Our findings also show that several programmes were conducted as per the recommendation of both Amaral and Fop (2013) and OECD (2022). These are with respect to the consistency of the collection frequencies (either bi-annually or all year round), collection centres are easily accessible and conveniently located (healthcare facilities or community locations). Also in line with the recommendation is that the take-back centres (not located in a supervised healthcare facility), are to be supervised by the relevant authority to avoid the tempering of the medicines that lead to potential abuse.

We identified the extent of the legislation structure and the funders of the take-back programmes that vary among countries because of their healthcare structures and local challenges (OECD, 2022). Countries with specific national or state legislation and with clearly defined financial responsibility are more effective and sustainable. They typically collected sizable amounts of unused medicines as observed in several European nations, several states in the USA, and Mexico. These programmes were driven and funded by either the governments or the pharmaceutical industry as an EPR scheme mandated by the legislation. In countries where the legislation does not clearly define the role and financial responsibility, such as in Lithuania, the implementation effectiveness of the programmes can be undermined (Amaral & Fop, 2013).

On the other hand, programmes like NatRUM of Australia, as well as the pharmacy-local government collaborated take-back initiatives in New Zealand and Austria have also shown success in collecting substantial amounts of unused medicines. Even though there is no specific legislation for unused medicines in these three countries, the programmes are sustainable and effective as they have clear elements of government or industry involvement and funding. These findings about support and sustainable financing by either the government or the pharmaceutical industries are in line with one of the recommendations of the Organisation for Economic Cooperation and Development (OECD), that sustainable sources of funding can ensure the long-term operation of the programmes and both EPR schemes or government-financed unused medicine take-back programmes could be effective (OECD, 2022).

The findings of this study hold important practical implications for various stakeholders involved in medication disposal and pharmaceutical waste management, including policymakers, healthcare providers, and other stakeholders. These implications can guide potential strategies for enhancing current practices and addressing gaps identified in implementation. For policymakers, the findings offer valuable insights into the effectiveness of the existing programme. By understanding the methods of collection, types, quantity, and cost of unused medicines collected, policymakers can make informed decisions regarding the allocation of resources and the development of policies that promote sustainable and efficient disposal practices. They may consider initiatives such as increasing funding for take-back programmes, implementing stricter regulations on pharmaceutical waste disposal, or promoting public awareness campaigns to encourage proper medication disposal. Healthcare providers can benefit from the study's findings by gaining a better understanding of the challenges and opportunities in medication disposal. They can use this knowledge to educate patients about the importance of returning unused medications and to facilitate convenient and accessible collection methods within healthcare facilities. Healthcare providers may also collaborate with policymakers and community organisations to improve the coordination and effectiveness of the take-back programme, ensuring that patients have reliable options for disposing of their medications.

Other stakeholders, such as environmental organisations, waste management companies, and pharmaceutical manufacturers, can also use the study's findings to enhance their contributions to medication disposal and waste management efforts. For example, waste management companies may explore innovative technologies for safely disposing of pharmaceutical waste.

Several strategies can enhance take-back programs and address implementation gaps. First, increasing public awareness through campaigns can promote proper medication disposal practices and boost participation in take-back programmes. Second, expanding the network of collection sites and introducing convenient collection methods in pharmacies and healthcare facilities can improve accessibility and encourage more people to participate. Third, collaboration among pharmacies, healthcare providers, and community organisations can simplify the collection process and ensure the safe disposal of medications. Last, regular evaluations and assessments of the take-back programme are essential to identify areas for improvement and measure their impact on medication disposal rates. Overall, these findings offer actionable insights that guide stakeholders in developing effective strategies for medication disposal and waste management, contributing significantly to improved public health and environmental sustainability.

Strengths and limitations

One of this review's strengths is the inclusion of a good number of quality studies (N = 27) from 15 countries having similar objectives. The number of countries and aspects of focus of unused medicine take-back programmes have given important insights across the practice in various regions. We also adhered to the best practices for conducting and reporting a systematic review (PRISMA guideline) (Supplemental Material Appendix 4) and assessed the study quality using the AXIS checklist. This systematic review has several limitations. First, the variation of collection and quantification methods used by the included studies have made a direct comparison of the cost of unused medicine collected a challenging task. Second, we acknowledge that the review was not preregistered. However, we ensured that two reviewers independently screened, extracted data, and assessed the risk of bias to reduce bias and errors (Waffenschmidt et al., 2019). Third, the durations of the take-back programmes are short and thus we are unable to determine their sustainability. Furthermore, the financial support and sustainability of these programmes were not clearly reported. Fourth, we did not formally assess publication bias but used AXIS checklist to identify potential bias. Last, we only included studies that were either published in English or had English translations. We applied the language restrictions because of financial constraints. However, the restriction was applied at the stage of selecting studies instead of at the stage of article search. Restricting systematic reviews to English-language publications at the stage of study selection appears to have little impact on the conclusions of systematic reviews (Dobrescu et al., 2021).

Conclusion

Unused medicine take-back programmes vary among countries because of the different healthcare systems, laws regulating pharmaceuticals, and regulations about take-back programmes. Well-structured programmes with convenient collection locations, consistent collection frequencies, and ownership of the programme are the important factors ensuring the success of unused medicine take-back programmes. Overall, the review provides a holistic view of medicine take-back programmes, informing stakeholders, policymakers, and the public about their impact, and areas needing improvement. Specific legislations and guidelines that drive the take-back initiatives by defining the functional and financial responsibilities of parties are essential for sustainable medicine take-back programmes.

Supplementary Material

Supplemental Material Appendix 1
JPPP_A_2395535_SM5353.docx (44.3KB, docx)
Supplemental Material Appendix 2
JPPP_A_2395535_SM5350.docx (64.6KB, docx)
Supplemental Material Appendix 3
JPPP_A_2395535_SM5349.docx (40.5KB, docx)
Supplemental Material Appendix 4
JPPP_A_2395535_SM5307.docx (42.9KB, docx)

Disclosure statement

No potential conflict of interest was reported by the author(s).

Ethics approval and consent to participate

Ethical approval was not required because the data of this study were retrieved and synthesised from already published studies.

Availability of data and materials

The analysis results generated in the study are presented in this published article and its Supplemental Material. The additional data that support the findings of this study are available from the corresponding author, upon reasonable request.

Author contributions

LSW and ZA conceived and designed the review. LSW and ESW searched, independently performed the screening and selection of studies, data extraction, and quality assessment. Any disagreement was discussed and resolved by discussing it amongst the two reviewers and consulting ZA. LSW analysed, interpreted the data, and drafted the manuscript. ZA reviewed the analysis, reviewed and edited the draft manuscript. LSW, ZA, ESW, and ZC contributed to the study, reviewed and approved the final version of the manuscript.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplemental Material Appendix 1
JPPP_A_2395535_SM5353.docx (44.3KB, docx)
Supplemental Material Appendix 2
JPPP_A_2395535_SM5350.docx (64.6KB, docx)
Supplemental Material Appendix 3
JPPP_A_2395535_SM5349.docx (40.5KB, docx)
Supplemental Material Appendix 4
JPPP_A_2395535_SM5307.docx (42.9KB, docx)

Data Availability Statement

The analysis results generated in the study are presented in this published article and its Supplemental Material. The additional data that support the findings of this study are available from the corresponding author, upon reasonable request.

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