Save Dutchess County Tax Dollars-- Safely Recycle Unused Expensive Nursing Home Medications sign now

Do you think our county's Health Department should help set up a program similar to Tulsa County in Oklahoma to save tax dollars by safely recycling unused expensive medications at local nursing homes and delivering them to indigent citizens and local nonprofits like health care clinics, homeless shelters, and mental health agencies?

As the National Association of Counties News reported on December 2nd, Tulsa County has saved quite a bit of money for local taxpayers in just the first two years of their program alone:

"Since the start of the Recycled Medication Program, 6,114 prescriptions have been filled at an estimated value of $1.3 million."

Note: Tulsa County has a population of 572,000-- about twice the population of Dutchess County.

Logic dictates that Dutchess County taxpayers could save at least half a million dollars with a similar program here.

[Tulsa Oklahoma recently won an Acts of Caring Award for Health/Social Services for their Recycled Medication Program from the National Association of Counties for this (see: ).]

As cited a bit below, the fact is that Republicans elsewhere in the country have publicly gone on record for recycling unused prescription drugs; our county should delay no longer in setting a program up here modeled after the successful example of Tulsa County-- this should not be a partisan issue; all legislators should be able to get behind this and make it a reality sooner rather than later.

Help make it happen by signing on to this petition and with a short letter to pass it on.

[Note: Thanks to County Legislators Fred Knapp and Rick Keller-Coffey for agreeing to co-sponsor a resolution I drafted on this]

Joel Tyner
County Legislator
324 Browns Pond Road
Staatsburg, NY 12580
[email protected]
(845) 876-2488

p.s. Thanks to many in Pawling for already signing on to a similar petition on this-- see (originally back last August I submitted a similar resolution on this; see complete text of that resolution at petition url).

p.p.s. Must-read:

"Recycling Expensive Medication: Why Not?" by Jay M. Pomerantz, M.D.
[Medscape General Medicine 4/26/04]
[Pomerantz-- Private Practice of Psychiatry, Longmeadow, Massachusetts; Assistant Clinical Professor of Psychiatry, Harvard Medical School, Boston, Massachusetts. Email: [email protected]]

p.p.p.s. Also see:

"Our Environment: Eat, Drink and Be Wary: Chemicals Often Linger in Water After Treatment"
by Brian Buckley
[Poughkeepsie Journal 1/18/04]

Pharmaceuticals in Waterways Raise Concern Effect on Wildlife, Humans Questioned"
by Juliet Eilperin [Washington Post 6/23/05]

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[Unfortunately, judging from this article so far at least one Republican in our County Legislature has publicly gone on record against safe recycling of medications at local nursing homes-- but that's just one it's up to all of us to lobby all 25 on this.]

From "Medicine Disposal Plan Sought: Bill Would Protect Water Resources" by David Paulsen...
[Poughkeepsie Journal 3/4/07]

Flushing unused prescriptions down the toilet may be an easy way to get rid of the drugs, but it could be wreaking havoc on the environment.

The U.S. Geological Survey tested 139 streams in 30 states for organic wastewater contaminants, including pharmaceutical drugs, and found contaminants in 80 percent of the streams, according to a 2002 report.

Local governments across the country have responded by creating drug "take-back" programs, and Dutchess County could be the next to do so.

Dutchess legislators have introduced two similar resolutions calling for a county program, to be overseen by health and law enforcement officials. The Legislature's Environment Committee is scheduled to discuss the resolutions March 8...

Legislator Joel Tyner, D-Clinton, is the leading sponsor of the Democratic resolution. Like the Republican legislation, it would ask the health department and sheriff's office to consider ways of collecting unused medicines at sites around the county.

Controlling waste

The goal, Tyner said, is to prevent medications from entering drinking water systems and "ending up in the kitchen sinks of our neighbors"...

One obstacle could be Tyner's references to a program in Oklahoma that recycles collected prescriptions, something Reilly doesn't support.

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From "Counties Protect Environment by Collecting Unwanted Medication" by Dan Miller....
[National Association of Counties News 12/2/06]

Tulsa County recycles old medicine

Tulsa County, Okla. has taken a completely different approach to unneeded medications: using them.

In January 2005, Tulsa County Social Services and the Tulsa Medical Society began recycling medications from eight nursing homes around the county and delivering them to indigent citizens, local nonprofits as well as victims of Hurricane Katrina.

Since the start of the Recycled Medication Program, 6,114 prescriptions have been filled at an estimated value of $1.3 million.

This program operates by having the director of nursing at county nursing homes collect extra medications and giving them to the county for testing, repackaging and free distribution to members of the community who are not otherwise able to afford them.

The NACo Acts of Caring Award-winning program was able to fill 190 prescriptions for Family and Childrens Services, as well as provide over-the-counter medications to most indigent health care clinics, homeless shelters and mental health agencies in the county. Katrina survivors at Tulsas Camp Gruber also received free medications.

According to the University of Oklahoma, Tulsa County nursing homes destroy up to $7 million in medications annually.

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Fact: Many Republicans elsewhere in the country have publicly gone on record for recycling unused prescription drugs.

"Rep. Ron Peters Proposes Bill To Recycle Unused Prescription Drugs"

Contact: Rep. Ron Peters
Capitol: (405) 557-7359
Tulsa: (918) 746-0707

OKLAHOMA CITY (Jan. 22) -- A state lawmaker has filed a bill to recycle unused prescription drugs for the benefit of poor people in Oklahoma.

House Bill 1236 by Rep. Ron Peters would direct the state Health Department and the state Board of Pharmacy to develop a plan for distributing to "medically indigent persons" unused pharmaceuticals originally issued to residents of nursing homes and skilled nursing facilities.

Similar bills were filed last year by Rep. Larry Ferguson, R-Cleveland, and former Rep. John Bryant, R-Tulsa, and three years ago by Rep. Jim Reese, R-Nardin.

Peters said his program would be limited to individually packaged medications, which sometimes are referred to as "point of care dispensing" or "bubble packs." The program also would have to be consistent with the rules and regulations of the federal Food and Drug Administration (FDA), the Tulsa Republican said.

"If the doctor changes a patient's type of medication, or changes the dosage, or for whatever reason that medicine is not used or needed, the current procedure is for nurses to physically punch those pills out and one by one and flush them down the toilet." Peters said. "I imagine that potentially millions of dollars worth of unused prescription drugs are literally flushed down toilets in this state every year."

Records indicate prescription medications will consume $191 million of the Medicaid budget for indigent citizens in Oklahoma.

Peters said 36 states have some type of prescription recycling, and he believes this should not cause a major problem to implement.

Peters, who is a member of the House Committee on Human Services, said, "It just makes sense to try to recycle perfectly good medication instead of throwing it away."

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NACo [National Association of Counties] Congratulates the
Acts of Caring Award Winners

Health/Social Services

Tulsa County, Oklahoma Recycled Medication Program

In January 2005, after seven years of legislative activity, Tulsa County Social Services and the Tulsa Medical Society began recycling medications from eight nursing homes around the county and delivering them to indigent citizens, local non-profits and Hurricane Katrina survivors. The University of Oklahoma estimated that in Tulsa County alone, nursing homes destroy up to $7 million in medications annually. Since they are required to flush them, this is harmful to the environment as well as a waste for those who might need the medications but cannot afford them.

The process for the Recycled Medication Program begins with the Director of Nursing at county nursing homes collecting the extra medications and having one of the countys 15 retired physicians who work with the program take the medications to the county pharmacy. There, the medications are tested, repackaged and distributed free of charge to those members of the community who are not otherwise able to afford them. Also, the program was able to fill 190 prescriptions for Family and Childrens Services, as well as providing OTC medications to most indigent health care clinics, homeless shelters and mental health agencies in the county. Katrina survivors at Tulsas Camp Gruber also received free medications.

Since the programs inception, 6,114 prescriptions have been filled at an estimated value of $1.3 million.

Contact: Linda J. Johnston, Director of Social Services
Phone: 918/596-5561
Email: [email protected]

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"Coming of Age" Newsletter for Friends of Tulsa Area Agency on Aging, Serving Creek, Osage and Tulsa Counties [November/December 2004]

It has taken seven years for social service advocates to put Tulsas pilot program for drug recycling in place.

If you have unused medications packaged in blister packs (cards with clear plastic on top and aluminum foil on the bottom for protection) they will be recycled to low income
people who cannot afford their prescriptions.

According to Dr. George Prothro, the recycling program is going more smoothly in Tulsa because there is a full pharmacy which distributes drugs at cost to the poor.

At this time there are only two designated places in Oklahoma approved for recycling medications. In Northeastern Oklahoma take your unopened prescriptions to Tulsa County Pharmacy, 2401 Charles Page Boulevard, Tulsa (918) 596-5561...

By recycling, unused medications can help others in need and your environment too.

Other counties in Oklahoma will be able to form their own programs for recycling in January of 2005.


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"Old Pills Finding New Medicine Cabinets" by Stephanie Strom
[New York Times 5/18/05]

As the cost of prescription drugs climbs, more of the nation's officials and consumers are weighing how to salvage at least $1 billion worth of unused drugs that are being flushed down the toilet each year.

Though the Food and Drug Administration generally forbids the redistribution of prescription drugs once they are dispensed to consumers, states are free to set their own policies for drugs controlled by nursing homes, long-term-care centers and other pharmacies.

"They seem content to let the states be laboratories, and that works out rather well because the dollars the states are saving are in a lot of cases federal dollars," said James Cooley, chief of staff for Diane Delisi, a Texas state representative and the author of legislation to expand Texas's limited drug recovery program, which may pass within a week.

Several states, including Oklahoma, Louisiana and Ohio, have passed legislation in the last few years allowing unused drugs to be recovered from those organizations for distribution primarily to poor patients.

Nebraska even permits consumers to return unused drugs if they are in tamper-resistant packaging, like the blister package most familiar in over-the-counter medicines, skirting the F.D.A. prohibition.

Recovery has been modest, but California, Maine, Washington and other states are pondering similar programs in hopes of lowering health care costs, however marginally.

Other supporters are trying to push the idea further. An inventor in Massachusetts is seeking a patent on a system that would knit together existing technologies to address the myriad issues of drug redistribution.

"We recycle newspapers, we recycle soda cans, we recycle plastic," said Moshe Alamaro, the inventor, who is a visiting scientist at the Massachusetts Institute of Technology. "It's ludicrous not to recycle expensive drugs."

Mr. Alamaro added, "It should be criminal to throw these drugs away, and instead it's required."

The concept has more skeptics than believers. The hurdles include concerns about patient safety and privacy, the lack of an infrastructure to process and redistribute drugs, and administrative requirements.

"I don't want to sound overly negative, but there are lots of obstacles," said Susan McCann, administrator of the Missouri Bureau of Narcotics and Dangerous Drugs, which is struggling to begin the state's redistribution program.

To sidestep the questions of recycling, Representative Tim Murphy, a Republican who represents Pennsylvania in Congress, suggests that the federal government take a different tack and make it easier for doctors to prescribe small quantities of drugs initially to determine whether a patient can use them.

Monthly or longer prescriptions, now encouraged and sometimes mandated by states and insurers to hold down costs, lead to waste that could be curbed through redistribution.

The amounts discarded are unknown. Though many states require nursing homes, hospitals and consumers to follow specified procedures for drug disposal, the rules add costs and are largely ignored, state health officials and others say.

A study published in the Journal of Family Medicine in 2001 estimated that $1 billion a year in drugs prescribed to the elderly are thrown away, and Mr. Alamaro estimates that a more ambitious system for drug recycling could recapture 5 percent of the nation's prescriptions, or about $6 billion worth annually.

Existing programs are a long way from that, however. The prevailing method of dispensing prescription medicine in bottles leaves it too vulnerable to tampering and contamination for any chance of recovery.

Pharmacies, the most likely candidates for redistribution, have little incentive to take on the administrative burdens and potential liabilities.

And states have not committed to developing the databases and other systems that would be needed, much less wrestled with how to ensure adequate supplies of drugs for patients to continue a regimen.

"It doesn't matter how safe the drugs are, how many of them there are or how neat and crisp the records are, if there isn't a database to tell patients what's available and where it is," Ms. McCann said.

So far, only one clinic has expressed interest in participating in the Missouri program. Ohio has failed to get its program off the ground more than two years after it was approved by the legislature because of a lack of interest among nursing homes.

Among the handful of states pressing ahead, Louisiana is one of the most advanced, with 12 pharmacies that distribute unused prescription drugs. Expired drugs and controlled substances, those that are potentially dangerous, are not accepted. As in other states, the drugs are collected from nursing homes and assisted-living centers, which have a carefully controlled storage and distribution system and use blister packaging.

"We know those drugs are perfectly good," said William T. Winsley, executive director of the Ohio State Board of Pharmacy. "They've been under lock and key; they've been stored properly."

Nonetheless, concerns about safety and hygiene have dogged the Louisiana program, said Malcolm J. Broussard, executive director of the Louisiana Board of Pharmacy. "We run across the thought that these are secondhand drugs, and 'don't poor people deserve the same drugs as anyone else?' " he said.

Getting nursing homes to hand over unused drugs has also been a challenge.

"For years, they've been under the impression that they had to waste these medicines," Mr. Broussard said.

Louisiana's program intends to retrieve several million dollars' worth of medicines each year, Mr. Broussard said, though it is too early to gauge results.

The recovery and redistribution of unused medicines is handled by charity pharmacies that cater to the working poor, thus avoiding thorny questions of who gets reimbursed for returned medicines and how. Should a patient get back part of the co-payment, for example?

"You need to reimburse the state or insurer or individual who paid for the drug, and there's a big hassle in that paperwork," said Gay Dodson, executive director of the Texas State Board of Pharmacy.

Mr. Alamaro is convinced that many problems can be resolved with technology, greatly expanding the pool of retrievable medicines.

He and his partners want access to the shelved drugs in the medicine chests of consumers like Florence Weisfeld of New York. Mrs. Weisfeld, 80, a former social worker, ached and had flulike symptoms when she took Lipitor, the cholesterol-reducing medication. So her doctor changed her prescription.

"I had 25 Lipitor tablets left in my medicine chest, and all I could do with them was flush them down the toilet," Mrs. Weisfeld said. "Such a waste."

Recycling Mrs. Weisfeld's Lipitor would require sweeping changes in the way drugs are dispensed. Mr. Alamaro's plan contemplates replacing bottles of pills with blister packaging or something like a high-tech Pez dispenser.

Such packaging could be encoded with information about the drug and who paid for it. That data would then be used to determine the drug's integrity and reimbursement, which Mr. Alamaro envisions as a system of credits. For instance, a consumer returning a drug to a pharmacy would receive a credit toward a future co-payment.

Patients could return drugs by mail to a reprocessing center or deposit them in a secure box at a pharmacy, which would then forward them to an inspection center.

His own partners are the first to point out the challenges. "I'm optimistic about the technology; I'm not optimistic about the economics at present," said Mark G. Hodges, an environmental consultant who is working with Mr. Alamaro.

The states that are trying drug redistribution have found novel ways to overcome some of the problems. For instance, Oklahoma drafted a corps of retired doctors to ferry drugs between donors and two participating county pharmacies.

"There are always all kinds of reasons not to do things," said Paul Patton, executive director of the Tulsa County Medical Society, the doctors' group that led Oklahoma's efforts on drug recycling. "But this makes so much sense that we've been able to convince a lot of people that it's better to have this program and work to resolve the issues than to not have it at all."

Proponents of drug recovery programs say the real test will come in California, where the Senate is considering a bill to establish a drug recycling program that was first advocated by five first-year medical students at Stanford University.

"Throwing away valuable resources when there is already not enough to go around is cavalier and unfeeling, not to mention poor public policy," said Josemaria Paterno, one of the medical students.

The Stanford students estimate that a program to recover drugs from nursing homes and long-term-care facilities would save the state $50 million to $100 million a year.

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"Oklahoma Allows Limited Medication Recycling" by Cheryl A. Thompson
[American Society of Health-System Pharmacists 7/15/05]

BETHESDA, MD, 01 July 2005 Under a program that started in January and has environmental and economic appeal, 19 Oklahoma pharmacies have the state's permission to dispense prescription medications that had been dispensed earlier by other pharmacies.

The Unused Prescription Drug Program for Oklahoma's Medically Indigent allows nursing homes and assisted-living facilities to send unused medications, including those from deceased patients, to pharmacies that then dispense those drugs to Oklahomans in need. But those medications must be in the original, sealed unit dose package or be an unused injectable product.

Bryan H. Potter, executive director of the Oklahoma State Board of Pharmacy, traced the program's origin to a group of retired Tulsa physicians, a supportive state representative, a Tulsa County clinic that served residents in need of medications but not poor enough to obtain them through Medicaid, and a similar county-run clinic in Oklahoma City.

These clinics' pharmacies either sold the medications at cost to indigent patients or dispensed a limited variety of drugs without charge, he said.

"When they came up with the idea to recycle [nursing-home] drugs, we were concerned," Potter said, mainly about the efficacy of the drugs but also the costs to the pharmacies whose pharmacists approved and prepared the products for reuse.

A pilot program was undertaken for 18 months to test the idea.

Trial run. Potter said the state's Medicaid agency, which covers about 80\% of nursing-home patients in Oklahoma, ascertained the top 25 most expensive drug products used in nursing homes and the strengths of those products. That information yielded a formulary of about 80 items for the pilot program.

He said that the Oklahoma City clinic, which already had a small formulary and provided drug products at no charge to indigent patients, opted not to participate in the pilot program.

The clinic, he said, feared that it would dispense a one-month supply of an expensive drug product, such as a newer antipsychotic, and the next month be unable to give the patient more of the medication.

In Tulsa, the participating county-owned clinic in one year dispensed over $100,000 worth of medications from nursing homes to needy patients, Potter said.

Another $20,000 worth of medications from the nursing homes went to the Tulsa clinic and then on to state-operated mental health clinics, he said.

Medication errors at the mental health clinics had temporarily cost them access to two drug manufacturers' patient assistance programs, he explained, and the Tulsa County clinic transferred the unused nursing-home medications to fill the gap for a couple of months.

Relief from environmental burden. By transferring unused medications to clinics serving indigent patients, Potter said, Oklahoma nursing homes and assisted-living facilities have an alternative to flushing the drugs down the toilet or sending them for incineration.

Representative Darrell Gilbert, the Tulsa legislator who introduced the program's legislation in 2001, said concern about environmental waste, particularly chemicals in the state's water tables, was "one of the reasons we were able to get the legislation passed."

Cancer drugs and assistance-program leftovers. Gilbert said that once the pilot program ended and he had to amend the legislation, the local branch of the American Cancer Society asked him to discard the 25-drug formulary and specifically add cancer drugs.

Paula Warlick, grass-roots coordinator for the Oklahoma chapter of the American Cancer Society, said her group had viewed the medication-reuse program as something that could benefit underserved groups of cancer patients.

That viewpoint is not confined to the Oklahoma chapter. Warlick said medication-reuse legislation, while "not one of our top priorities," is something that the national cancer society promotes on a low-key level.

Also added to the medication-reuse program, primarily for the benefit of mental health clinics serving indigent patients, were unclaimed drugs from the manufacturers' patient assistance programs, Potter said.

Those clinics had been obtaining medications from patient-assistance programs, he said, but not giving the patients their entire supply at one time because of issues related to their mental condition.

Potter said many patients, for one reason or another, failed to pick up the additional supplies of their medications. "Consequently, [the mental health clinics] were ending up with quite a few drugs that were from the assistance programs," he said, "and they wanted to be able to use them on other patients."

Pharmacists' responsibility. Before transferring unused medications to a charitable or county- or state-owned clinic, the nursing home's consultant pharmacistnot the original dispensing pharmacistmust verify the drugs' suitability for the reuse program and complete the documentation.

Medications whose expiration date is less than 45 days away are not eligible, for example. Neither are controlled substances.

The consultant pharmacist or the nursing director must obliterate the names of the patient and pharmacy and the usage directions from the labeling on the medication packages.

Representative Gilbert said pharmacy organizations in the state initially opposed his legislation "until we excluded them from liability."

Wiley Williams, an Oklahoma City attorney and pharmacist who served as president of the Oklahoma Society of Health-System Pharmacists in 2001, said his group supported Gilbert's legislation from the beginning, although it affected relatively few members.

Williams said the medication-reuse program is probably more of a practical concern for community pharmacists.

Whose medications? As part of the program's rollout, Potter said, the state health department changed the form that patients or their guardians sign on admission to a nursing home.

Whereas signees previously agreed that all leftover medications would be destroyed, signees now also consent to the possible transfer of leftovers to the medication-reuse program, he said.

Limitations. Potter said that, as of June 1, no assisted-living facility had enrolled in the medication-reuse program because the residents, not the health care professionals, typically have control of the drugs.

At his insistence, he said, the program bans medications that have been out of the control of licensed health care workers.

Potter, who has headed the state board of pharmacy since 1971, said he had built enough credibility at the statehouse over the years to have his concerns heeded after Gilbert and State Senator Bernest Cain of Oklahoma City first proposed the legislation.

"I wrote about a three-page letter to the [legislation's] two authors," he said, "and pointed out the bad things . . . and they took out all those things."

"Most people understand when you start explaining 'Well, would you want to take somebody else's drugs that had been in their home and you knew nothing about them?'" he said.

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"Medication Recycling: New Patients for Old Pills" by Fred Gebhart
[Drug Topics 9/26/05]

Medication recycling is an idea whose time has not yet come. "We all recognize the absurdity of throwing away perfectly good and terribly expensive medications," said John Cronin, senior VP, California Pharmacists Association. California is one of several states debating legislation to allow the return and reuse of unused drugs. "The economic reality is that it is just not practical. There has got to be a way to do it, but nobody has figured out how to get it right yet."

It's not for lack of trying. Louisiana, Nebraska, Ohio, Oklahoma, and Texas have passed laws that allow medications to be recovered from long-term care (LTC) facilities, repackaged, and dispensed again. California, Delaware, Maine, Washington, and other states are looking at medication recycling to reduce costs.

Medication recycling can cut costs. Oklahoma saves about $120,000 annually by redispensing unused medications from nursing homes in the Tulsa area. The meds are collected, often by volunteer physicians, repackaged by volunteer pharmacists, and distributed by county-run charity pharmacies and state-operated mental health programs.

"It is unbelievable how much medication is flushed away every month," said Oklahoma Pharmacists Association executive director Phil Woodward. "That represents an untapped resource. It's really just a question of logistics." The logistics can be complex. When a group of physicians proposed the Oklahoma program, board of pharmacy executive director Bryan Potter sent legislative sponsors a three-page letter laying out the board's concerns.

Food & Drug Administration regulations generally prohibit the return and redispensing of medications, Potter said. That limits the practice to programs under state control, primarily medications dispensed to Medicaid patients.

In order to allay concerns about storage conditions and potential tampering, the Unused Prescription Drug Program for Oklahoma's Medically Indigent takes in only drugs dispensed to LTC facilities in which the facility, not the resident, maintained custody. Meds must be in the original, sealed unit-dose package or be an unused injectable product. Controlled substances cannot be recycled under Drug Enforcement Administration rules.

"Right now, medication recycling is all over the map," said Thomas Clark, director of policy and advocacy, American Society of Consultant Pharmacists. "Return, repackaging, and redistribution are quite costly. The critical question is will the payer be willing to cover those costs."

Payment is one of the issues holding up implementation of a recycling program in Texas, according to the Texas Pharmacy Association. Documentation is another stumbling block.

HIPAA, the Health Insurance Portability & Accountability Act, requires electronic transactions for LTC pharmacy operations, explained Paul Baldwin, executive director of the Long Term Care Pharmacy Alliance (LTCPA), which represents four national LTC pharmacy chains. Every pharmacy transaction must be part of the HIPAA Transactions Code Set.

"There is no code for returning an unused drug to stock for credit," Baldwin said. "Nobody is in favor of seeing medications wasted, but the regulations are clear. You can't recycle medications effectively until those codes are in place."

Where medication recycling moves from here is unclear. A LTCPA position paper notes that restocking fees and transaction codes are major barriers to return and reuse of medication.

There are also questions surrounding current practices such as stripping unused meds from heat-sealed packaging and reassembling them in new heat-sealed packages.

Joni Cover, executive VP of the Nebraska Pharmacists Association, said there are more effective ways to cut the medication spend than recycling. Nebraska allows recycling of drugs from LTC facilities as well as certain high-cost cancer drugs.

Cover said an obvious first step is to dispense in seven-day blister packs. If a patient stops using a medication, there is far less waste. Expanding the use of generics is another obvious cost-saver, she said. So is expanding the role of pharmacists in reviewing drug therapy for LTC patients.

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