How general practice can support safe asthma inhaler disposal

Dr Vasumathy Sivarajasingam and Marina Tai explain the environmental impact of failing to dispose of inhalers appropriately and highlight results of a study in their practice which aims to help change patient behaviour and cut waste and C02 emissions.

(Picture: Andrea Colarieti/EyeEm/Getty Images)
(Picture: Andrea Colarieti/EyeEm/Getty Images)

The climate emergency is one of the biggest public health threats that we have ever faced. Since the COVID-19 pandemic began, we have moved one year closer to the 2030 deadline to halve, and the 2050 deadline to reach, net-zero carbon emissions.

The NHS is a huge contributor to the UK’s carbon emissions, accountable for around 4-5% of England’s carbon footprint1 - equivalent to all the planes taking off from Heathrow in an average year. It aims to become the world’s first carbon-neutral national health system by 2040.

According to the BMA’s sustainable and environmentally-friendly general practice report, 65-90% of the carbon footprint in general practice is associated with pharmaceutical prescribing.2 Inhalers play a big role in this.

Inhaler use

There are a variety of different drug and inhaler combinations available to manage respiratory conditions and over 75m inhalers are prescribed in the UK each year.3

Each inhaler device has unique design characteristics (pMDI, DPIs, nebulizers), increasing the likelihood of finding the appropriate option for each individual patient - particularly in children, the elderly, and those with conditions that may impact on handgrip and manual dexterity.

As treatment efficacy is linked to adherence, addressing patient preferences is essential.4 Tailored device selection enhances patient satisfaction while offering the requisite level of disease control, optimising adherence and improved quality of life.4

Metered dose inhalers (MDIs) contain propellants which are greenhouse gases that are thousands of times more powerful than carbon dioxide. MDIs alone contribute to nearly 4% of the entire NHS carbon footprint and about 25% of the general practice prescribing carbon footprint.5

Disposal of inhalers

There is a significant environmental impact of inhaler use, both from the carbon footprint of propellants and plastic waste from discarded inhalers.3 Many inhalers ending up in landfill take centuries to biodegrade and micro plastics are known to enter the food chain.3

Inhalers also need to be safely disposed of to prevent propellant gases escaping into the atmosphere.6 A study by a major pharmaceutical company showed that 29% of inhalers disposed had leftover medication in them. If these inhalers go into a landfill, the medication can leak out and contaminate  local water supplies.7

Pharmacies can safely dispose of inhalers and patients should be encouraged to return used inhalers to them. The plastic and aluminium parts will be recycled, and the harmful greenhouse gases thermally degraded into less damaging products. If all used inhalers in the UK were returned for safe disposal, this could save 512,330 tonnes of CO2 annually – the same as a VW Golf car being driven around the world 88,606 times!8

What can we do in primary care?

Evidence suggests patients usually receive instructions on how to use and store medications but rarely get proper information on the safe and appropriate ways to dispose such medications, unless they asked healthcare providers.9

Most of the patients are educated by the clinicians on correct technique of using MDIs but disposal methods are seldom discussed.10 Schemes to recycle inhalers do exist, but they are not routinely advertised to patients.3 There is also lack of disposal directions in patient information leaflet.11

Our practice conducted this study to explore the knowledge and practices of patients towards safe disposal of inhalers.

Our study

The study was conducted on patients contacting clinicians at the surgery over a two-week period. Patients engaging with the practice (whether face to face, by telephone or by email) were asked about their use of inhalers (including name, device, medical condition and duration of usage), inhaler disposal practice, current knowledge of recycling of inhalers and, if they were aware of recycling, where they had obtained this information.

During these interactions we educated patients of the importance of appropriate recycling of inhalers. As we do not have a local recycling scheme in our area, we advised patients to return their expired, unwanted or used inhalers back to their local pharmacy for safe disposal. We also asked the patients, given the information about recycling whether it will now impact on their future practice.

The results

Data was collected from 70 patients. The inhalers were used to control asthma, COPD and fibrosis - and the age range of patients was 3-93 years. This involved 43% males (n=30) and 57% females (n=40). 91% of the patients have been using their inhalers for more than six months, the majority from childhood.

Of these patients, only one patient (who was a pharmacist) recycled their inhalers correctly by taking it back to the local pharmacy. 86% (60/70) were not aware that inhalers could be recycled and put their inhalers in the domestic bin.

13% patients (9/70) put their inhalers in the domestic recycling bin, so had attempted recycling but were not aware that these inhalers would still end up in landfill. 100% said they would return their unused, expired or empty inhalers to their pharmacy in the future.

All patients felt the information about safe disposal of inhalers was not shared by clinicians during consultations or pharmacists during dispensing. A few patients welcomed the idea of having a ‘recycle bin’ for the inhalers in the the practice which could be collected by the pharmacy.

Conclusions

Our pilot study demonstrated that there is a lack of knowledge and understanding on how to dispose of the inhalers amongst our patient population. Engagement and empowerment of patients regarding the safe disposal of inhalers should be a priority.

Safe disposal instructions should be provided by all healthcare providers in routine patient education. Inhaler recycling should be discussed routinely, ideally as part of inhaler technique checks, to increase knowledge around recycling facilities as patients are keen to recycle inhalers where possible.

Displaying information in waiting rooms and posting on Twitter and the surgery website would further highlight this. Patients should be encouraged to return their inhalers to a pharmacy for safe disposal. 

Pharmaceutical companies should encourage recycling on the packaging and every pharmacy should support inhaler recycling.

We hope to continue the pilot study to gather further data and educate our wider patient population. In addition, we plan to produce an information sheet explaining the implications of inappropriate disposal of inhalers and share with patients who use inhalers at every consultation.

  • Dr Vasumathy Sivarajasingam is a GP and Marina Tai is a practice nurse and asthma lead in west London

References

  1. NHS England. Greener NHS campaign to tackle climate ‘health emergency’. 25 January 2020.
  2. BMA. Sustainable and environmentally friendly general practice report. 8 September 2020.
  3. De Vos, R et al. Inhaler recycling prevalence in a secondary care clinic in England. Eur Resp J 2020; 56: Suppl. 64, 1886.
  4. Usmani OS. Choosing the right inhaler for your asthma or COPD patient. Ther Clin Risk Manag 2019; 15: 461-72. 
  5. Greener Practice. Asthma care and inhalers
  6. Greener Practice. Inhaler recyclying
  7. MedPro Disposal What do I do with old inhalers? 19 October 2016.
  8. Recycle Now. What to do with inhalers.
  9. Alazmi, A et al. Patients' Knowledge and Attitude toward the Disposal of Medications. J Pharmaceutics. 2017 https://doi.org/10.1155/2017/8516741
  10. Beena Thomas et al. Are we handling used metered dose inhaler canisters safely? – A call for action. IP Indian Journal of Immunology and Respiratory Medicine. 2019; 4(1): 24-6
  11. Oxley, J. Asthmatic inhalers: Reduce, reuse and recycle. BJGP Life. 5 October 2020.

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