In a recently issued guideline, the Central Drugs Standard Control Organisation (CDSCO), released a list of 17 medicines that must be immediately flushed down the sink or toilet if they are expired, unused, or unwanted (see Annexure D). These include fentanyl, tramadol, and diazepam which are strong (powerful) medications with potentially lethal consequences in the wrong hands.
“The list of drugs can be deadly even in a single dose when misused or accidentally ingested by children, pets, or even immunocompromised adults,” says Dr. Dheeraj Menon, a pharmacologist and professor at a Mumbai-based medical college.
“Keeping them lying around in a house is like storing a loaded weapon on the coffee table,” he asserts.
EXPIRED DIAZEPAM IS LETHAL
Of the drugs listed, diazepam, a drug that is most commonly prescribed to treat anxiety, muscle spasms, and seizures, is considered to be particularly worrying when expired or unused. A benzodiazepine, this medicine, doesn’t completely break down quickly after expiration. Diazepam has the potential to retain much of its sedative power, making it a silent hazard even several years later.
“There is a myth that expired drugs have just become ineffective. But that isn’t the case with some medications,” informs Dr. Ria Sadana, a brain surgeon based out of Bengaluru. “Diazepam, even when the drug is slightly degraded, can still slow brain activity significantly. This can lead to unconsciousness, respiratory depression, or even death if misused.”
Experts list the side effects of this anti-anxiety pill as depressed breathing and heart rate. They believe, if taken accidentally by children, pets, or anyone not accustomed to them, these drugs have the potential to lead to serious health outcomes.
“A very small dose or even a single expired tablet left tossed in a rubbish bin may be enough to cause a medical emergency,” adds Dr Sadana. “There have been multiple cases globally where toddlers ingested just one old tablet and slipped into a coma,” warns Dr. Vikas Goyal, a paediatric emergency consultant at a Delhi hospital.
It is medically proven that expired diazepam can produce calming and euphoric effects. This makes it a possible common target for recreational misuse, particularly by teenagers or those struggling with substance abuse. Expired diazepam may be unevenly degraded, increasing the chance of overdose (especially when mixed with alcohol or other sedatives).
The other issue is that diazepam can degrade into unknown or unstable compounds. These can cause unexpected side effects, or dangerously interact with other medications, particularly antidepressants or sleep aids.
Dr. Goyal believes expired benzodiazepines, if chemically altered, can have effects that we don’t fully understand.
WHY FLUSHING IS THE RIGHT CALL
Environmentalists often advise against flushing medicines, and with good reason: pharmaceuticals in water systems can damage ecosystems and contribute to antibiotic resistance. But the CDSCO makes an exception for these 17 high-risk drugs because of the immediate and direct threat they pose at home.
“For this specific list, flushing is the safest immediate option,” says Dr. Menon. “The public must be made aware that these aren’t just expired drugs — they are potential poison.”
For all other medications not on the “flush list,” the CDSCO has a separate recommendation which is a more environmentally sound approach. This comes in response to growing concern over pharmaceutical pollution in India’s rivers and soil.
In 2018, alarming levels of some drug residues were found in the Yamuna river and also in Delhi’s bore wells. Among the drugs detected were antibiotics, anti-inflammatories, and even psychiatric medications — suggesting that people are discarding old drugs in household rubbish bins or down drains, contaminating the water supply and contributing to bacteria that are antibiotic-resistant.
The CDSCO, in order to address this issue, has advocated the launch of a state-level ‘drug take-back’ programme, in partnership with local chemist associations and waste management services.
WHAT YOU SHOULD DO TODAY
If you have any expired or unused diazepam, fentanyl, tramadol, or other medications listed on the CDSCO’s flush list, do so immediately.
How to flush medicines down:
Drop the expired tablet or capsule into the toilet (do not crush it).
Flush immediately.
Wash your hands properly after doing what is necessary.
For other non-listed drugs:
Remember these are not to be flushed.
Make sure that you store these expired pills in a sealed container.
Drop them off at an approved take-back site when available.
– Ends