Elizabeth Newman, Senior Editor

Every time I have to discard a medication, I pause.

I can never remember if we’re supposed to flush pills, pour liquid down a drain or throw medication out in the trash. Half the time, I gently shut the door to the medicine cabinet rather than deal with it. And then I wonder how we still have medications that expired in 2010.

So I’m sympathetic to long-term care facilities struggling with the disposal of hazardous waste pharmaceuticals. Since the Environmental Protection Agency published its Management Standards for Hazardous Waste Pharmaceuticals last month, some skilled nursing facilities are pondering how to reduce the amount of pharmaceuticals disposed of down the drain, effective August 21. Last month, the American Health Care Association told McKnight’s it had concerns with the short timeframe, given the “operational changes” necessary. Law firm Arnall Golden Gregory issued a 10-page brief, urging providers to up their game.

But the picture is more complicated than it seems. Let’s start with the bad news.

Skilled nursing facilities, and the SNF portions of continuing care retirement communities, are specifically called out as being included in the rule. Independent living, assisted living and their sections of CCRCs are not.

The August 21 deadline is unlikely to be extended, experts say.

Finally, there are a lot of medications that are used in nursing homes that may run afoul of hazardous waste regulations, according to Cara Simaga, Director of Regulatory Affairs at Stericycle. These include:

Cough syrups: Many have enough alcohol to be regulated as hazardous waste due to being ignitable.

Insulin: Almost all insulin contains a chemical called cresol. That’s a hazardous waste.

Multivitamins: Both solids and liquids, they usually contain enough of one more regulated metals like chromium and selenium.

Nasal sprays: Some of these contain mercury.

Aerosols: Inhalers with propellant .

But there is also good news.

While Alaska, Iowa, Kentucky, New Jersey and Pennsylvania have the rule in effect August 21, other states will have until 2021 or 2022 to adopt it, Simaga says. That’s because other states have their own version of the EPA, and will adapt the rule accordingly. Fair warning, however: Some may make it more stringent.

That means for many there’s time. Even if a lot of providers can say, “Eh, I have bigger fish to fry,” Simaga makes a solid points as to why skilled nursing should be looking at this regulation today. Specifically, knowing how much hazardous waste your facility is generating per month is data any responsible manager should know.

Studying the rule also will lead you to good news about blood thinners. When the rule was originally developed, Simaga explains, the agency had to consider drums of warfarin, also known as rat poison. Today, patients on Coumadin are often using blister packs and cards. Facilities collect the packaging and waste, growing frustrated at how they are supposed to calculate it.

“The rule is getting rid of that, which is awesome,” Simaga says. Nicotine replacement therapies also are no longer considered hazardous waste.

Trickier is issues around controlled substances. The Drug Enforcement Administration is in charge of that regulation, Simaga notes. One interesting part of the rule is that the EPA has said facilities can put hazardous controlled substances and pharmaceutical waste in a kiosk. While it has to meet DEA regulations, it may give providers a better option.

This brings the question: How much of this impacts you and your staff on a daily basis, now or in the future?

Compared to the Centers for Medicare & Medicaid Services, not much. Skilled nursing tends to deal with not only the biggest crises at hand, but understandably focuses on the possibility of fines or even decertification stemming from surveys.

Compared to that, the risk assessment of EPA knocking on your door may be small. But apart from being responsible environmental stewards, there is a belief the government may be forced to crack down in the next few years. While the focus may be on hospitals first, Simaga says she suspects there may be more “boots on the ground,” in relationship to enforcement.

Normally, the industry waits for severe punishment, or threat thereof. This time there’s a chance to get ahead of the regulation, before those boots show up at your door.

Follow Senior Editor Elizabeth Newman @TigerELN.