Photo by Nicholas Eveleigh
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Big Idea!
New Life for Old Pills
By Maggie Jones, September & October 2006
Moshe Alamaro has a plan to save millions in drug costs. So why could that land him in prison?
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Every year we flush at least $1 billion in prescription drugs down our toilets. We pour them into incinerators; we bury them in landfills. But Moshe Alamaro, an inventor and researcher at MIT with not-just-big-but-colossal ideas—such as building 200-foot ice mountains to fight water shortages—believes he has a solution for unused pharmaceuticals. "We recycle glass and plastic," the silver-haired Alamaro said one recent afternoon, wearing owlish glasses and sitting among the stacks at the MIT library. "Why all the apprehension about doing the same for a bottle of pills?"
It's not that simple, of course. You can't just toss your pills in a bin with your soda cans and drag them to the curb. Alamaro's plan entails nothing less than wholesale changes to how we think about packaging, distributing, and consuming prescription drugs. Pills would come in tamperproof packs and include a bar code or radio frequency ID to provide such details as dosage amounts and expiration date; a chemical agent would record the drug's exposure to heat and light (which can make many medicines less effective). The packs would be loaded in a Pez-like dispenser, ensuring that unused pills would be untouched and safe for recycling. Patients could then return their medications to processing centers via a drop box or prepaid mailer. The centers would inspect the drugs, and pills in good condition would be available for redistribution.
Initially, Alamaro expects, the program would be funded and tested through nonprofit and government groups. Once the benefits are clear, for-profit companies will latch on to the opportunity, he says. "We hear about all these people without health insurance and prescription drugs," says Alamaro, who is discussing a pilot program with faculty from Yale and MIT. "Yet billions of dollars of drugs are wasted. We all know it. My contribution is to say 'Let's do something about it.' "
As an inventor, Alamaro is attracted to seemingly intractable large-scale problems. Since joining MIT, first as a graduate student and currently as a research affiliate at the Harvard-MIT Division of Health Sciences and Technology, he has concocted innovative, sometimes eyebrow-raising plans. A few years ago he devised a reforestation proposal that entailed dropping "tree bombs"—seedlings in biodegradable canisters—from low-flying planes. In 2005 he garnered national media attention when he pitched a plan to thwart hurricanes with jet engines lined up on ocean barges. The barges, each with 10 to 20 engines, would be placed in the path of a hurricane; the the exhaust would trigger small tropical storms, thereby lowering the surface ocean temperature and depriving the hurricane of needed energy. As for that ice-mountain plan, he'd use snowmaking machines to create massive piles near drought-diminished lakes and reservoirs, thus replenishing them when the ice melts in the summer.
"Inventors are rebels," he says. "By nature we're dissatisfied with the status quo and try to make things more efficient." Which may explain why he's willing to risk jail time in his quest to recycle pills. Alamaro wants to create an online site where patients could donate drugs to those in need—like a nonprofit eBay, he says. He's already offering to let patients with unused drugs, as well as those who need drugs, contact him by e-mail. It's a noble idea. It's also a federal crime: the U.S. government prohibits drug distribution among individuals. "If I go to jail, it would be an act of civil disobedience," he says with a shrug and a small smile. "It would be for a good cause."
There's little argument that recycling drugs is a good concept, and one with potentially enormous benefits. Fewer flushed drugs means cleaner waterways. And under Alamaro's plan, consumers who recycle could get a partial reimbursement on their copay or perhaps a credit toward their next prescription. More important, consumers and the government save because drugs are used more efficiently. In California, experts believe a law passed last year allowing recycling of unused drugs from nursing homes may prevent the disposal of up to $100 million in pills each year. Alamaro predicts the savings could reach billions.
Those tantalizing savings have led a handful of states to roll out limited programs with nursing homes. North Carolina, for example, allows licensed nursing home pharmacies to distribute unused drugs to free clinics that serve impoverished residents. Only drugs in original packaging, sealed and labeled with expiration dates, are eligible, easing pharmacies' worries over liability. Volunteers sort and distribute the medications, which cuts costs for both the clinics and the pharmacies. "The way it's done here has been pretty successful," says Mike Darrow, executive director of the North Carolina Association of Free Clinics. "It's no different from using sample drugs from a doctor's office."
The results have been less encouraging in other states. Missouri allows unused meds to be donated to drug repositories for distribution to low-income patients; yet more than a year since the program was implemented, no repositories are up and running, and only two are in the works, says Susan McCann, administrator of the Missouri Bureau of Narcotics and Dangerous Drugs. One reason for resistance, she believes, is that pharmacies fear being sued over tainted medications. (Drug recycling "has been likened to sending people to the grocery store to buy someone's returned raw chicken," says McCann.) A similar problem has dogged Ohio, where only a few nursing homes have participated since the law took effect in 2004.
So wouldn't increasing the scale of recycling add to the concerns? Even Alamaro concedes it's a big leap from state programs, which deal with nursing homes, to a national one for millions of people. "Everyone agrees there shouldn't be this waste," says Jon Keyserling, vice president of the Virginia-based National Hospice and Palliative Care Organization, which has talked to Congress about salvaging unused drugs. "But the mechanics of it entail hurdle after hurdle." Alamaro's partner, environmental engineer Mark Hodges, says the biggest stumbling block isn't the technology—much of it already exists—but the pharmaceutical industry, which has no interest in a system that demands fewer drugs.
Despite the concerns, a number of states are considering bills that would implement new drug-recycling laws or expand existing ones. And the federal government recently gave all the states extra incentive to do so: a regulation that took effect in early 2006 requires nursing homes to reimburse the government for unused drugs issued to Medicaid patients. Though probably only a small number of patients will be affected (most nursing home patients are also Medicare patients and exempt from the new rule), states now have one more reason to recycle.
"We're not talking about some obscure problem," says Alamaro, who has about $200 in unused pills sitting in his bathroom—drugs he stopped taking because of their side effects. "Everyone I know over 50 has a mini-pharmacy in their medicine cabinet and a story about wasted pills." Whether his plan is the most feasible way to address this issue remains to be seen. "We all feel helpless about it," he says. "And we just can't be complacent anymore."
Maggie Jones is a contributing writer for The New York Times Magazine.
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