Every week in Des Moines, Iowa, the employees of a small nonprofit collect bins of unexpired prescription drugs tossed out by nursing homes after residents died, moved out or no longer needed them. The drugs are given to patients who couldn't otherwise afford them.
But travel 1,000 miles east to Long Island, New York, and you'll find nursing homes flushing similar leftover drugs down the toilet, alarming state environmental regulators worried they'll further contaminate the water supply.
In Baltimore, Maryland, a massive incinerator burns up tons of the drugs each year 2014 for a fee 2014 from nursing homes across the Eastern seaboard.
If you want to know why the nation's health care costs are among the highest in the world, a good place to start is with what we throw away. Across the country, nursing homes routinely toss large quantities of perfectly good prescription medication: tablets for diabetes, syringes of blood thinners, pricey pills for psychosis and seizures.
At a time when anger over soaring drug costs has perhaps never been more intense, redistributing discarded drugs seems like a no-brainer. Yet it's estimated that American taxpayers, through Medicare, spend hundreds of millions of dollars each year on drugs for nursing home patients 2014 much of which literally go down the tubes.
"It would not surprise me if as much as 20 percent of the medications we receive we end up having to destroy," said Mark Coggins, who oversees the pharmacy services for Diversicare, a chain of more than 70 nursing homes in 10 states. "It's very discouraging throwing away all those drugs when you know it can benefit somebody."
No one tracks this waste nationwide, but estimates show it's substantial. Colorado officials have said the state's 220 long-term care facilities throw away a whopping 17.5 tons of potentially reusable drugs every year, with a price tag of about $10 million. The Environmental Protection Agency estimated in 2015 that about 740 tons of drugs are wasted by nursing homes each year.
This is, of course, part of a bigger problem. The National Academy of Medicine estimated in 2012 that the United States squanders more than a quarter of what it spends on health care 2014 about $765 billion a year.
ProPublica is investigating the types of waste in health care that academics and politicians typically overlook. Our first installment examined the tens of millions worth of equipment and brand new supplies that hospitals jettison.
Today we look at the wasteful, and potentially harmful, ways nursing homes dispose of leftover meds 2014 and how some states, like Iowa, have found a solution.
On a recent Wednesday in Des Moines, Ami Bradwell, a certified pharmacy technician, popped open the lids of several 31-gallon bins full of prescription drugs. In each were hundreds of what are known as "bingo cards" filled with rows of pills in sealed bubbles.
"Metformin 2014 for diabetics," Bradwell said, holding up a card of large white pills. "It's not crazy expensive, but it's in high demand."
She held up an entire box of the anti-nausea drug Ondansetron. It goes for about $5 a pill, according to the website drugs.com. "Expensive."
Another card had three large pills stuffed in each chamber, a find Bradwell called "a 2018jackpot' card. You can't live without it because it's a seizure medication."
Bradwell works for the nonprofit SafeNetRx. Each week the group takes in dozens of bins full of such drugs, as well as boxes mailed in from across Iowa and several other states 2014 pharmaceutical trash that exists because, for convenience and cost, long-term care pharmacies often dispense nursing home patients' medications in bulk, a months2018 worth at a time.
Should a patient die, leave or stop taking the drug, what's left is typically tossed. The drugs have already been paid for, by Medicare in most cases, so there's little incentive to try to recycle them. In some states, such reuse is against the law.
Some of the cards Bradwell examined that day were missing only a few pills. One card had been thrown out even though it only lacked one of its 31 doses of oxybutynin, which reduces muscle spasms of the bladder. The remaining 30 are worth more than $13.
"There are literally millions of dollars of prescription medications thrown away every day in this country," said John Forbes, an Iowa pharmacist who dispenses SafeNetRx's recovered drugs to his low-income patients.
Although most states technically allow some leftover drugs to be recycled, Iowa is one of the few rescuing a significant percentage of the drugs from destruction. The state funds the program for about $600,000 a year, said SafeNetRx CEO Jon Rosmann, who calls it a "common sense" solution. In fiscal 2016 the program recovered and distributed drugs valued at about $3.4 million. This year it's on pace to top $5 million.
Forbes, who is also an Iowa state representative, said there are additional savings when low-income patients have access to the drugs they need. Patients who don't take their drugs "end up in the emergency room," he said, "which will wind up costing our health care system way more money."
At SafeNetRx, the drugs are sorted and organized in a 1,500-square-foot room lined with shelves stacked with bins of drugs. In the center, folding tables hold hundreds of bingo cards, sorted alphabetically by generic drug name, from the blood pressure drug acebutolol to the antipsychotic ziprasidone. None of the medications are controlled substances, though those may be included in the future.
Pharmacy officials say there may be a million dollars' worth of drugs in this small room. The 30 mg syringes of the blood thinner Enoxaparin are used by patients for weeks before and after heart surgery. They can go for $13 per dose.
One box contains scores of doses of Spiriva, inhalation capsules for chronic obstructive pulmonary disease that would sell for about $18 each. The antipsychotic Abilify runs about $46 per pill.
The biggest ticket items are the cancer drugs. They are typically donated directly from patients or their families. Those can run $8,000 or more per month.
The cancer drugs are passed on to people like Amber Judge, a patient advocate at Medical Oncology and Hematology Associates, a cancer clinic in Des Moines. Judge is accustomed to patients coming into her office in a panic. They've just learned they have cancer, only to find out they can't afford the drugs they need to battle the disease. That's when Judge opens one of the file drawers in her office, which are filled with tens of thousands of dollars' worth of the drugs recovered by SafeNetRx.
In one filing drawer she has about 30 boxes of Tasigna, which costs about $100 per pill. In another drawer she has a gallon-sized plastic bag with bottles of Stivarga, about $188 per pill.
The process is similar to patients receiving drug samples at a doctor's office. They leave her office with the drugs they need 2014 for free.
"I give them a month's supply if I have it," Judge said. "They're so thankful. They're incredulous."
In many places in the United States, however, these leftover drugs meet a very different end, one that is not only wasteful, but potentially harmful.
In recent years, scientists have detected something disturbing in the Long Island's aquifer: low levels of pharmaceuticals.
Though consumers have been warned not to flush their drugs down the toilet because sewer waste can contaminate groundwater, many still do it; more worrisome still, flushing remains a common practice at nursing homes in New York and across the country. The effects of such contamination on humans are unclear, but it has been shown to slow the metamorphosis of frogs and increase the feminization of fish.
Three years ago, New York's Department of Environmental Conservation started an annual program, funded by the state legislature, to scoop up unused medications before they were flushed. Even though the pickup service is free to facilities, only two dozen of 169 eligible Long Island nursing homes participated this February, turning over 660 pounds of drugs.
Those valuable medications didn't go into the water supply, but they didn't go to needy patients, either, though such recycling is now allowed in New York. Instead, they went to an incinerator company. Experts, including the EPA, have recommended incineration for getting rid of pharmaceuticals.
Destroying the unused drugs is always going to have environmental implications, said Carrie Meek Gallagher, region 1 director for the department. "It's always a trade-off of what's most harmful. For us, anything getting into the water is the worst solution."
The National Conference of State Legislatures said 39 states had passed laws that allowed the donation of drugs. But almost half of these states with laws lack programs to get the drugs safely from one appropriate user to another, and many of those that do have programs are focused on cancer drugs, the analysis showed.
There hasn't been a lot of public opposition to redistributing the drugs, even among drugmakers. Most concerns circle around logistics, although in Illinois trial attorneys have lobbied against a proposed program, saying it muddies liability issues.
Richard Cauchi, program director for health for the conference of state legislatures, said just passing laws doesn't guarantee success. A state agency or organization needs to oversee the program, encouraging participation and streamlining its administration so it's not a burden for pharmacies and nursing homes.
"It's a lot of work, and from a retail point of view, an expense," Cauchi said. "How do you accept these drugs? How do you confirm their safety? How do you know they meet the proper standards?"
Federal agencies are of little help, each pursuing their own, often contradictory, agendas.
The EPA discourages flushing drugs because they contaminate the water supply. But it doesn't have the authority to prohibit "sewering" the medications. Only local authorities can take that stance. It has, however, proposed reclassifying the unused drugs as hazardous waste, which would then prohibit flushing them.
The Food and Drug Administration says certain medications are so dangerous that they should be disposed of immediately, even if that means flushing them. It even provides a list of drugs recommended for flushing, mostly controlled substances like diazepam, better known as Valium, and the potent painkiller fentanyl.
The Drug Enforcement Administration wants to ensure controlled substances, like narcotic painkillers, aren't diverted to the illegal drug market. It has recommended that long-term pharmacies collect leftover drugs by placing boxes in nursing homes that must be emptied at least every three days, but that creates expense, hassle and potential liability.
Some advocates say the makers of the drugs should be responsible for disposing or recycling them. Scott Cassel, CEO of the Product Stewardship Institute, a nonprofit organization dedicated to reducing the environmental impact of consumer products, said the producers of batteries, electronics, paint and other products are required by law in some areas to pay for the safe disposal of their products. Similar laws require drug makers to pay for the destruction of leftover household drugs in two states and about a dozen counties, but no laws address nursing homes.
Coggins, who leads the pharmacy services for the Diversicare chain, said people in the nursing home industry would like to do something about the waste. But their options are dictated by laws and regulations, and there's been a lack of investment in cost-effective solutions like the one in Iowa.
About half the states where Diversicare operates allow the donation of unused drugs, but the programs required too much work sorting and inventorying the drugs without any reimbursement, he said. "It's like people have created legislation and it's a feel-good thing, but nobody's come back to see why it's not working."
Diversicare avoids flushing drugs whenever possible, Coggins said, but it still occurs sometimes. The organization has switched to a product called Rx Destroyer that chemically deactivates the medication so it can be put in the trash, he said, but even that is controversial because it goes into a landfill.
In many nursing homes, flushing is just part of the routine.
"Oh my goodness, it's so sad," said Jennifer Ramsey, a nurse who formerly worked as a house supervisor for a nursing home in South Haven, Mississippi. Once a month she and another nurse would gather all the unused blister packs of medication, she said, piles of them, probably worth tens of thousands of dollars. Then they would pop the pills one by one into the toilet.
"You would spend almost your whole eight-hour day doing it," Ramsey recalled.
Ramsey now works for the nonprofit Good Shepherd Pharmacy in Memphis. In Tennessee, the law requires nursing homes to destroy unused drugs on site. Good Shepherd's founder is pressing to change the law so the drugs can be saved and donated.
In March, state Rep. Cameron Sexton, a Republican whose wife is a pharmacist, introduced a bill that would allow unexpired medications to be donated in Tennessee. "Unfortunately, we don't have a process set up to do that so all these drugs have to be destroyed," he said.
Perhaps the most graphic way to see the waste firsthand is a visit to the Curtis Bay Medical Waste facility on the south side of Baltimore, home of the largest incinerator of its kind in the country.
Here Curtis Bay's fleet of trucks delivers load after load of unused, unexpired drugs from hundreds of nursing homes and other facilities and clinics up and down the East Coast. Drugs also come from medical waste companies like SteriCycle and Daniels Sharpsmart. In 2015, 204 tons of non-hazardous pharmaceutical waste came from the Daniels location in the Bronx, according to records filed in New York. Such waste includes not only drugs tossed by nursing homes, but also those from hospitals, doctors' offices and other facilities.
Inside Curtis Bay, the drugs are processed and destroyed in an area the size of several hockey rinks. A conveyor belt about 15 feet off the ground snakes through the facility loaded with hundreds of boxes of pharmaceutical and medical waste 2014 all leading to the two incineration chambers.
On a recent visit, the chamber was over 2,000 degrees, a heat that could be felt from 20 feet away.
From a platform above the incinerator's maw, you can watch as thousands of dollars of potentially lifesaving pills and medications tumble, box by box, into the steaming opening. Then they are shoveled into the blaze.
Experts say incineration is the least environmentally objectionable end-of-life option for unused drugs. But it's also the most expensive destruction method 2014 from 50 cents to a dollar per pound, paid for by the facilities themselves 2014 which is why many nursing homes resort to flushing.
Nursing homes save the disposal fees in Iowa, because they can donate them to SafeNetRx, where they benefit needy patients like Max Armstrong.
The 82-year-old suffers from multiple chronic conditions 2014 emphysema, congestive heart failure and more. The ailments were manageable until 2015, when he suffered blood clots in his leg and lung. Doctors put him on the generic blood thinner warfarin, but it "almost killed me," he said, so he switched to Xarelto, a newer brand name drug that costs about $700 a month.
The total tab for the Xarelto and the other 14 medications Armstrong must take each month would cost at least $1,200, according to his daughter. Armstrong, whose savings took a hit during the financial crisis, lives on $1,158 a month in Social Security.
It's "stupid" to throw away drugs that can keep so many other people healthy, Armstrong said. "There's a lot of people out there in this world who need help."
ProPublica is a Pulitzer Prize-winning investigative newsroom. Sign up for their newsletter.