This article, in a slightly edited form, first appeared on Pain News Network on January 4, 2020.

JAMA Internal Medicine published a paper in 2016 stating that most Americans choose not to dispose of their unused pain medication because they want to keep it for potential future use. This is entirely understandable.

People have little incentive to dispose of their pain medication. It is expensive to replace drugs, and the person who owns the prescription has already paid for it. Also, a growing number of people are concerned that, should they someday need pain treatment, they will find it difficult to obtain medication. They may even be accused of being a drug seeker if they ask for it.

So people don’t necessarily have nefarious reasons for holding onto medication. However, unused pain medication has been blamed for causing much of the opioid crisis because it can be easily diverted.

Unused medication can end up on the streets or in the wrong hands — even the hands of family members or friends. In all cases, they can cause harm. Let’s look at some numbers.

Unused Pain Medication by the Numbers

In 2013, nearly 9 billion pills containing hydrocodone were produced for prescription purposes. Other opioids added to the surplus. Although this was several years ago and opioid production quotas have significantly reduced the supply of opioids, leftover pills are still a potential problem. Of those that are prescribed after surgery, more than 40% percent go unused.

Opioid drugs lose only about 1 percent of their potency per year.

This means prescription opioids have a half life of more than 50 years. These potent medications can remain viable (or toxic) for nearly a lifetime.

At any given time, an estimated 80 billion pills that still retain their potency are available for diversion and non-medical use. That is a problem.

Conflicting Information About How to Safely Give Up Medication

A public education campaign may convince some people who are reluctant to give up their extra medication that it would be better for society if they let go of drugs they no longer need. However, even if people were persuaded to dispose of their unused medication, they may not know how to do so safely.

A recent Time report suggests that even pharmacists do not know how patients should dispose of their unused pain medications. Of 900 pharmacists surveyed, only 23 percent correctly told callers how to dispose of opioids. The survey compared the pharmacists’ answers to the FDA guidelines for disposing of medicines. Pharmacists’ confusion is understandable. Various authorities have delivered different messages throughout the years about the best way to dispose of unused drugs.

Confusing Information From the FDA

The FDA recognizes that there are environmental concerns about flushing medicines down the toilet. However, the agency believes that the risks associated with accidental exposure to strong narcotic medicine outweigh any potential risks associated with disposal by flushing. The FDA included fentanyl patches on a list of medicines that should be flushed down a toilet because they could be especially harmful, and possibly fatal, if even a single dose is used by someone other than the person for whom the medicine was prescribed.

In addition, the FDA recommends flushing unused transmucosal fentanyl (ACTIQ) units. The disposal instructions are very complicated. They require both a pair of scissors and wire-cutting pliers, and are roughly as convoluted as Walter White’s method of making crystal meth in television’s “Breaking Bad.” I suspect that not everyone who is prescribed ACTIQ would be willing or able to follow all of those steps.

Evidently, the FDA believes that the risk of harm from overdose is greater than the danger the drugs present to the environment. That is why the FDA recommends flushing them down the toilet—which puts the drugs in contact with our water supply.

The Time quotes the 1017 U.S. Geological Survey (USGS) and Environmental Protection Agency (EPA) report that reveals hundreds of drugs, including prescription opioids, were found in 38 streams across the country.

Yet, in the same year, an article in an issue of Science of the Total Environment reported that buprenorphine, diazepam, fentanyl, hydromorphone, meperidine, methadone, methylphenidate, morphine, oxycodone, and tapentadol pose a negligible eco-toxicological risk.

Yet the Time article points out that the FDA seemingly contradicts its own instructions; it provides different disposal recommendations for different types of drugs. Some medication, according to the FDA, is flushable, while other types of drugs are not.

Time states, “According to the FDA, unused medications should be put (without crushing any pills or capsules) in an ‘unappealing substance such as dirt, cat litter, or used coffee grounds;’ that mixture should then be put into a sealed container like a secure plastic bag before it is thrown out. In addition, all personal information should be scratched out or otherwise destroyed.”

So What Is the Truth?

Is it harmful to flush or not? Who stands as the authority on the subject?

Whom should consumers trust?

Drug take-back programs are intended to reduce excess prescription opioid supply and destroy the pills in an ecologically safe way. However, not all take-back programs collect controlled substances. The FDA provides a list of permanent collection location and sites to help people find a take-back program that would be appropriate for the type of unused medication they have.

However, it is estimated that fewer than 2 percent of total unused drugs are returned. Also, these take-back programs are costly to implement.

The messaging around disposal of pain medication is conflicting. In a perfect world, all unused medication would be easily disposed of without causing negative consequences to the environment or the community. Also ideally, people in pain would not have to worry they might not receive a prescription for medication if they need one. Unfortunately, neither of those propositions is true.

Lynn R. Webster, MD, is a vice president of scientific affairs for PRA Health Sciences and consults with the pharmaceutical industry. He is author of the award-winning book, “The Painful Truth,” and co-producer of the documentary, “It Hurts Until You Die.” Opinions expressed here are those of the author alone and do not reflect the views or policy of PRA Health Sciences.

You can find him on Twitter: @LynnRWebsterMD.