MEDICINE STORAGE TRENDS & PRACTICES: A
Azhar Hussain, Madeeha
Malik, Rabia Iram
Hamdard Institute of Pharmaceutical Sciences, Hamdard
University, Islamabad, Pakistan.
Keywords: Medicines, storage, trends, practices.
are useful for provision of better health among consumers. Safe use of
medicines is still a major issue for healthcare system in developing countries
. Medicines are stored at home during or after
their use. It is a common practice that consumers take medicines from pharmacies
for treating their various forms of illness at home . The effectiveness of
treatment is ensured only when consumers are able to use safe and effective
medicines during the whole course of treatment because the quality and efficacy
of medicines is maintained when medicines are properly stored at home .
Knowledge of consumers is important for making decisions before, during and
after using medicines along with what to do with the leftover medicines .
Lack of knowledge regarding storage of medicines at home promotes inappropriate
storage patterns of consumers [6,
7, 8]. The
inappropriate storage and use of medicines leads to the wastage of resources.
Therefore, special attention must be given to consumers as they are the
ultimate users of medicines and their beliefs and attitudes affect the way they
use their medicines at home . There is an increased trend
towards purchasing both prescription and over the counter medicines from
community pharmacies among consumers in developing countries . In order to preserve
quality of medicines, attempts are made to avoid exposure to temperature, light
and humidity to maintain appropriate storage conditions according to
regulations both at point of manufacture and distribution of medicines . Further
safe storage of medicines at point of use requires multidisciplinary approach
including provision of information to consumers, addressing their beliefs and attitudes
and controlling unnecessary storage of medicines through regulatory
restrictions on sale of medicines . The most important
is the information that can be provided in
counseling during dispensing process . The main objective of this paper is
to systematically review medicine
storage trends and practices around the globe.
data was retrieved from electronic databases Pub Med, Google Scholar and
Science direct from searched articles published from 1999 to 2016. The keywords
‘medicines storage’, ‘consumers’, ‘unused medicines’, ‘medicines wastage’ and
‘medication disposal’ were used for searching full research papers and
abstracts. The bibliographies of the retrieved references were also searched.
The features that describe the storage of medicines are the place of storage of
medicines, duration for which medicine is being stored, the type of medicine
stored and disposal of unused medicines stored at home .Therefore, 82
studies covering any of these areas were included both from developed and
developing countries. Data obtained from the studies included the study population
demographics, knowledge and patterns of respondents regarding storage of
medicines at home and potential health outcomes associated with storage of
medicines. The methodologies used and target populations in some studies is
summarized in (Table 1).
Table 1 Methodology of studies
from some developing countries
F, et al
Twelve hundred patients were randomly selected
from King Khalid University Hospital (KKUH), and King Saud University (KSU).A
paper-based questionnaire with self-enumeration was used to collect data.
Northern Ethiopia (Tigray Region)
sampling was used; 1000 households were selected using systematic random
sampling from randomly selected cultures of districts and regional states
from Tigrey.By using structured questionnaire, the trained pharmacists
collected data from adult household member (18 years) at time of data
Al-Haddad, Qasem Mahmoud Aref Abdallah
Trained data collectors distributed
questionnaire among 1446 university students who were conveniently sampled from public areas of
See, Florencio Arce, Jr, Yolanda Deliman
Talamban, Cebu City.)
A written interview questionnaire was
distributed among 101 households who were sampled by systematic random
Kheir et al
A list of
telephone numbers was generated from Qatar’s telephone directory using a
systematic sampling method. Individuals consenting to participate were
interviewed by 25–30-minute structured telephone interview carried out by two
Auta, A., et
An interview questionnaire was used to collect
data from 650 households selected by systematic random sampling,
Trained data collectors used structured
interview questionnaire, also
inspected medicines in cabinets from 465 households
A et al
A patient exit interview by using close ended
questionnaire was used to collect data from 6,675 patients or their carers on
exit from randomly selected 75 primary health care centers
E.A. and Ball.D.E,
The data was
collected by Questionnaire and face to face to face interview, inspection of
medicines from two groups of households (total sample size 214)
Place of storage of
most common places of medicine storage such as bedrooms, kitchens and bathrooms
were reported among families of Qatar, Sudan, Saudi Arabia, and New Zealand
during household surveys and inventory of home medicine cabinets [4, 5, 13]. It
was identified that consumers preferred such places because it was convenient
for them as they find it easy to place medicines at places where they can
frequently visit at any time in routine, or intend to take medicine at meal
times of their ‘personal judgments’ guided their choice of storage place .
Refrigerator was identified as the most common place of medicine storage in
household survey in Oman, Saudi Arabia and households of Jordan as consumers
wanted to protect medicines from high temperature [4, 12, 15]. A study
conducted in Nigeria reported that majority of the respondents placed medicines
at places including bags, dining table, at the top of refrigerator and glove
compartments of car . Medicine cabinets
were reported as
common storage place
among majority of the respondents
of Croatia and Northern
Arab Emirates [17,8]. Likewise, cabinets and pill containers were
the most common storage location among households of Philippine . Medicines
storage in cabinets and cupboards was also reported from studies from Saudi
Arabia and Palestine stored medicines in [4, 10]. Although, these places do not
comply with the recommended storage conditions as medicines have
chemical nature different storage conditions are required to store different
dosage forms but still [3-5,12,17,18]. Some medicines such as insulin and
liquid preparations of oral antibiotics must be stored in refrigerator for
maintaining their stability during shelf life . Similarly, suspensions must
also be stored in refrigerator . However, poor storage of liquid
formulations which were not refrigerated, rather placed at open shelves
demonstrating the patterns of inappropriate storage was reported in Sudan .
Humidity, temperature and light can affect the stability and quality of stored
medicines . Thus, medicines placed at such locations are at risk of degradation
due to exposure to high temperature in kitchen . Beside this, storing
medicines at multiple locations increases the chances of missed doses of
safety concerns are increased if medicines are placed in access of children,
even though stored in medicine cabinets . Children are curious by nature
and they express their curiosity at homes by roaming freely and exploring
everything that can capture their attention. The appearance of medicines,
particularly their colors such as pink and orange greatly attracts children
. Consequently; they make efforts to ingest medicines considering them as
candies which actually are poisons for them. This form of unintentional
poisoning is one of the major reasons for injuries among young children .
Different studies conducted Ethiopia, Qatar, Saudi Arabia, Palestine and Brazil
reported medicines stored at home in reach of children [4,17,18,21,23].A
hospital based study conducted in Pakistan on childhood
cases of unintentional poisoning concluded that majority of the children were
admitted to hospitals as a consequence of ingesting medicines that were in
their access . The risk of poisoning could be increased if medicines are
placed at height
of storage places which are less than two meters, unlocked cabinets in
bedrooms, kitchens and bathrooms and in the reach of
young children with less than five years [25-26]. Another
study conducted in Pakistan revealed that intake of medicines such as
benzodiazepines, opioids, acetaminophen, aspirin and antihistamines and lack of awareness of
parents regarding safe storage of medicines at home caused
poisoning among young children .
Duration of storage
The duration of use through which
the use of medicine offers claims of maximum efficacy and safety is limited and
is specified on labels of containers by manufacturers as expiry date .The
studies conducted in Northern Uganda and Ethopia and households of Palestine
revealed that medicines at home were not adequately labelled, were having
unclear expiry dates and without original containers [2,18,28].On the contrary,
findings from Malaysia revealed that majority of the respondents had stored
medicines in original packages, but
occasionally checked expiry dates of medicines . However, the pattern
of checking expiry date of medicines regularly was reported from consumers of
Malaysia, Saudi Arabia, and Northern Arab Emirates [4,8,30].A study was
conducted by pharmacy personnel in New Zealand with the aim to collect unused
and expired medicines from consumers and to find out the extent of storage of
expired and unused medicines at home. The presence of unused medicine was
reported to be 62% of the collected medicines . Another study from Mexico
revealed that 90% of the collected expired and unused medicines stored at home
were prescription only medicines . Similar studies from Serbia, Ireland and
United States revealed that large amounts of expired or unused medications were
stored by respondents at their homes [23,33,34]. The prevalence of expired or
leftover medicines at home was reported from other countries as well. In 2006,
a questionnaire based survey in Kuwait revealed that 97.5% respondents had
medicines stored at home which were not required . In 2007, the study from
households of Kuwait revealed that about 52% of the collected medicines were
expired, out of which major proportion was of cough syrups . Similarly,
surveys investigating medicines stored among households of Croatia, Saudi Arabia, Jordan, Northern Uganda, Iraq and
Malaysia, Palestine and Nigeria [2,27,28,10,33,37].
of medicines stored at home
The most common types of medicines
encountered during surveys (Saudi Arabia, Iraq, Croatia, Jordan and Northern
Uganda, Nigeria) were analgesics (paracetamol, aspirin and antibiotics) both in
large amounts [2,3,4,22,28,38]. The studies conducted in Iraq, Sudan and
Qatar have highlighted
that large amounts
of over the counter medicines and antibiotics were
stored among surveyed households [3,5,17]. However, the most common medicines
stored among consumers of Qatar were analgesics followed by allergy, cough and
cold medicines. It was further reported that comparatively less
availability of antibiotics is attributed towards strict legislations on sale
. In addition to analgesics and antibiotics, consumers in Malaysia and Oman
also stored herbal medicines [39,40]. The other types of medicines in different
households are shown in (Table 2).
Table 2 Storage and utilization patterns of medicines at
medicines at home
patterns of stored medicines
types of medicines
associated with storage of medicines
of4279 with average household
possessed 14.26 products ,range was 1-72 per household
kept for future use (23%)
compliance , use of drugs that have been kept beyond their expiry date
W.M., et al,2010
households in Palestine
5505 medicines ,
mean ± SD
was 13.3 ± 7.8.
expiry date (11%)
tract drug category (18.52%)
USD estimated nation wide
A et al,2009
households in Sultanate Oman
medicines per household (95% surveyed household had medicines)
medicines (24.91%), respiratory medicines (14.60%) cardiovascular system
medicines (12.05%). Antibiotics (45.83%)
channels of obtaining medicines; abundance of expired, unused or deteriorated
medicines in the households, absence of proper labeling or clear instructions
households in Sudan
medicines were 2079,
household unit was 4.4
of unfinished stored medicines(55%),
S.I., et al,2010
households inNorthern United Arab
number of drugs per household unit was 6 items
medicines kept but not used (13%) Disposed of expired (87%)
Antidiabetics (14%) Antihistaminics (44%) Antihypertensive (26%)
households in Northern Uganda
number of medicines was 6,and 68.1% had medicines 8-10
M.I. Ibrahim, and S. Palaian,2010
481 female students in USM Malaysia
Medicines were stored by 93.1%
future use (10.4% )
analgesics& antipyretics (30.2%),
ear, nose & throat drugs (10.8%),vitamins &
minerals (10.8%), GIT drugs (8.5%), anti-infections
(7.3%) and herbal medicines (3.5%).
S., et al,2012
households in the North of Jordan
Total medicines 2835
Nervous system medicines (25.2%), anti-infective agents
Respiratory system agents
Medication wastage(The total cost of unused medications
in Jordan was estimated as 6,326,000 JD)
households from Saudi Arabia and other Gulf countries
Total of 12,463 were found with
number of medicines per household 8.0 (4.3)
number of drug products unused, deteriorated, or expired was 2.2 (2.7) and
2.7 (1.9) per household
nervous system agents (16.4%)
self-medication(43.5 % )
The medicines which have passed
their expiry date are not suitable for use; it is advisable to dispose off such
medicines . The most common methods of disposal of unused medicines stored
at home among consumers of Kuwait, Qatar, Arab Emirates,Saudi Arabia, Oman
,Nigeria and Malaysia were reported as
throwing medicines down to toilet or in household waste [39,17,8,12,42,43]. These
are unsafe disposal practices because active ingredients of medicines which
were being flushed down the sink or toilet by consumers were not processed
through water treatment plants and were added as traces in water table thereby
posing risks to environmental safety [44-46]. Similarly, medicines thrown in
garbage are leached through landfills and become part of ground water .
Sudanese families disposed medicines by giving them to friends or relatives
. Unsafe disposal
of used sharps and needles of insulin directly to waste
among diabetic consumers has also been reported
[44,45]. A comparatively safe method of disposal was suggested and followed
during studies to collect unused and expired medicines. It included returning
medicines to pharmacies which could be destroyed through incineration at high temperature and is less
detrimental to environmental safety [48-49].
For this purpose, consumers of New Zealand, Mexico, Kuwait, were provided with
collection bags for collecting unused medicines and returning to pharmacies
encouraging safe disposal practices [42,41,46].
The investigation of factors that influenced disposal practices revealed that the consumers, who were aware of the detrimental effects of
disposing unused medicines on environment, were more likely to return medicines
to pharmacies as reported from Swedish surveys [50-52]. A study was conducted
to investigate the practices and perceptions of consumers towards disposal of
medicines by using questionnaire among customers visiting pharmacies of Kuwait.
It was found that some consumers returned medicines to pharmacies because they
thought it would be better to be used by someone else while others did so as
they were convinced by the appropriateness of this method . The respondents of a study from USA reported that
they considered it appropriate to flush medications down to sink or toilet;
however, the respondents who were counseled earlier on safe disposal of
medicines were of the opinion to return medicines to the pharmacies . Some consumers considered type of dosage form being
important when they were going to dispose of medicines. Therefore, an online
survey conducted in New Zealand identified that respondents preferred to
dispose of liquid formulations to water systems, while tablets and capsules
were more likely to be returned to the pharmacies . In a review
study regarding disposal of unused medications it was highlighted that lack of
legislations and guidelines regarding disposal of unused medicines is a barrier
towards safe disposal of medicines which ultimately completes the cycle of safe
use of medicines among households . The impact of legislations and
guidelines was emphasized to improve safe disposal practices of medicines
stored at home [46,8,12].
associated with unsafe storage of medicines at home
Unsafe storage can result in
poisoning, increased risk of toxicity, unsafe disposal to environment . The researchers both from developed
and developing countries conducted population based surveys to investigate the
magnitude of medicine storage among consumers and concluded that significant
amounts of medicines were stored at homes and associated risk factors were also
found [2-5,18]. A high percentage (82%) of customers attending pharmacies of
Tabriz, Iran reported the presence of medicines stored at home constituting
mainly analgesics and antibiotics indicating trend of self-medication among
consumers . Both household surveys and medicine inventory modules among
consumers of rural areas of Crete, Greece,
Brazil, Serbian, Belgium, Switzerland revealed that large amounts of medicines stored at
home were found along with indications of unsafe storage
practices such as self-medication and wastage of resources [19-25]. In a study
from Arab Emirates, respondents reported that they use medications from stock
of medicines stored at their homes . The availability of leftover medicines
at homes indicates the consumer intentions for future use without seeking
consultation that may result in reduced quality and effectiveness of therapy
. Such patterns of self medication were reported from Ethopia, Croatia, Iraq and
Northern Uganda, [2,3,18,22,43,]. The female consumers from Palestine
(school teachers), from Veitnam (mothers) and from Malaysia (university
students) stored leftover antibiotics for treating
cough and diarrhea in future [16,39,53]. In Saudi Arabia, it was found that
suspensions ,meant to be discarded, were also kept for future use . In
Pakistan, it was found that self-medication with OTC and analgesics was
associated with acquiring medicines from friends, family or using medicines
previously stored at home medicine cabinets . Given,
the storage of large amounts of analgesics and antibiotics at home, it is quite
predictable that consumers are at risks of adverse events and interactions that
are inherent with concomitant unsupervised use of medicines. For example,
chronic use of analgesics can cause renal failure . Overuse of antibiotics
results in antimicrobial resistance . Using OTC medicines such as NSAIDS and antibiotics
frequently and without consultation of physician increases risks of adverse
effects such ashemorrhagic duodenitis and emergence of antibiotic resistance
[39,55,56,57]. Unintentional exposure of such
medicines to children can be a significant risk factor of accidental poisoning
Significant relation of ethnicity
was observed among Malay students who shared medicines more frequently as
compared to other students from Chinese origin in Malaysia . A common
practice of sharing was found in children and adults with more likeliness among
girls especially for treating acne problems . Sharing of medicines poses many risks to
the health of consumers .The reason being that a consumer would give
medicine to friend or relative without dose instructions, precautions and
sharing warnings associated with its safe use [59,60,61].
Some medicines have teratogenic effects, therefore, the sharing of medicines
with pregnant women may cause serious complications for mother and fetus . The main factor that
influenced the extent of sharing
medicines was that the consumers in Kuwait considered sharing medicines from household stock as an acceptable behavior .
of resources resulting from improper storage of medicines
As medicines constitute significant
proportion of health expenditure, the unused medicines at home that are not
fully consumed are considered as wastage of resources spent on them which may
reach up to billions of dollars [28,63]. Globally, the
studies investigated the extent of wastage from unused medicines stored at home
and presented a quantified estimate of
wasted resources from unused medicines at home and its economic impact . A
study was conducted at tertiary care hospitals of Oman with the objective to
investigate value and type of medicines returned by patient. The estimated
wastage was reported as Omani Rials (OR) 20,140 which comprised largely of
anti-infective and cardiovascular medicines . Similarly the reports of
estimated wastage were found from Saudi Arabian homes as national medication
wastage of USD 150 million, from households of Egypta total cost of 49507.2 LE
(8348.5 $) was reported, from Palestine it was about 19 million USD nationwide
[64-65].Another survey in Palestine investigated wastage with antibiotics
stored at home. The estimated total cost of antibacterial agents found in the
study was $4,769, approximately $11.5 cost per household. The total wastage on
antibacterial agents was reported as$2,790 making it to approximately $6.7 per
household .Similar study was conducted among households of Jordan. It was
found that a cost of 6,326,000JD was incurred on unused medicines stored at home,
while expired medicines constituted an estimated cost of 1,267,000 JD . A
potential medication wastage of 53.8% was found among households of Iran with
medications stored at home .
Factors affecting storage of medicines at home
are some factors that affect the storage of medicines at home. These include
demographics of respondents, perceptions and beliefs, knowledge regarding
increased pattern of unsafe storage of medicines was found among elderly
consumers, consumers with low education level as in households of Iraq, Sudan, Nigeria and Northern Uganda,
higher level of education among Palestinian, Malay and Saudi Arabian
consumers [10,39,4,66.67].However ,in Arab Emirates, level of education of
consumers had no influence on storage of
medicines at home .The studies from United kingdom, Malaysia
Arabia showed that younger individuals and females were more likely to store
medicines at home [39,68-72].Mothers from Iranian households and Rural
communities of Vietnam ,having dominating role of mothers in managing health
related issues at home stored antibiotics for future use [9,16,73]. It was reported from various studies that unsafe storage of
medicines was found to be associated with noncompliance of consumers,
when consumers stop taking medicines either because of side effects or when
they feel better from illness [74-75].
Another factor reported was
overprescribing of antibiotics by physicians, change in regimen or treatment
modifications as reported by the respondents Egypt, and Kuwait [76-78],
In developing countries, there is an
increased trend among consumers towards purchasing both prescription and over
the counter medicines from community pharmacies, which is considered as
convenient and economical source for supply of medicines .The unchecked sale of medicines to the
consumers with inadequate knowledge raises the possibility of medicines to be
part of home medicine cabinets which later becomes source of treatment for
households indicating self-medication [47,79].
The availability of free of charge medicines in some countries may also cause
an increased number of stored medicines at home such as in Oman and Kuwait
safe storage of medicines is largely affected by the quality of information
provided to the consumers [15,16]. It includes both written such as labels of
medicines and verbal source of information such as counseling by physician and
pharmacists [12, 80]. It was found in Ethiopia that respondents following
inappropriate storage patterns were not having knowledge of recommended storage
conditions . The respondents from Nigeria and
India were aware of the fact that improper storage of medicines badly
affects their quality and thus makes
medicines unfit for subsequent use by consumers yet inappropriate patterns were
followed because of lack information regarding proper storage of medicines at
home [31,74]. The results of household surveys investigating storage of
medicines at home revealed patterns of improper storage of medicines among
consumers of Qatar, Iran, and Philippine, even though, physicians were reported
as major source of information regarding storage [17,26,32]. However, some
(29%)of the respondents identified pharmacists as source of information
regarding storage among families of Saudi Arabia . Lack of information
regarding safe disposal practices was reported from Kuwait Nigerian families
and Saudi Arabia [31,46,82].It was recommended that public education involving
pharmacists should provide necessary information regarding storage of medicines
at home and safe disposal practices to consumers [18,32,4,5,31,17]. In fact, it
is the responsibility of pharmacist to provide instructions on storage of
medicines to consumers . It must be ensured that consumers understand well
the instructions on label regarding medicine use . For example, pharmacist
must explain that what it means by instruction “keep at cool place”. The places
at home should be identified where conditions of cool temperature are
fulfilled. It should also be elaborated that placing medicines in windows
expose them to sunlight.
The instructions regarding safe storage can also prevent cases of poisoning
. Further, the term “keep away from
reach of children” should be explained by suggesting that keeping medicines
should be kept at height and in locked cabinets. Pharmacist should warn
consumers to place caps of bottles after use, never leave medicines
unsupervised to avoid cases of accidental poisoning. The physicians
assume that patients will receive instructions from pharmacist, while
pharmacist must not assume that customer has knowledge regarding quality use of
medicines [81-82]. In some countries the educational
campaigns were conducted and the role of pharmacists was acknowledged in
promoting safe storage of medicines at home. These educational campaigns
included displaying posters in waiting areas in hospitals having information
and instructions regarding safe disposal of medicines by returning them to
pharmacies . Student facilitated education program on the knowledge of
patrons attending community pharmacies in Scotland . Pre and post
intervention for pharmacist were found as an effective tool in promoting appropriate use of medicines and thus preventing the wastage .Moreover, drug use assessment programs and comprehensive
evaluation of national policies can reduce wastage from medicines stored at
The review concluded
that consumers store a good number of medicines inappropriately at different
places including bedroom, kitchen, on shelves and in reach of children at home.
This reflects that consumers are not well informed regarding proper storage of
medicines at home even at point of purchase. Such inappropriate practices could
also lead to irrational drug use like accidental poisoning by children,
self-medication, sharing of medicines, unsafe disposal harming environment
resulting in wastage of resources spent on medicines from manufacture to
delivery. There is strong need to provide legislative support in terms of
restriction on sale of POM medicines.
Participative role of pharmacist can help improve safe storage and use
of medicines at home and ensure effectiveness of therapy.
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