As the cost of prescription drugs climbs, more of the nation's officials and consumers are weighing how to salvage at least $1 billion worth of unused drugs that are being flushed down the toilet each year.
Though the Food and Drug Administration generally forbids the redistribution of prescription drugs once they are dispensed to consumers, states are free to set their own policies for drugs controlled by nursing homes, long-term-care centers and other pharmacies.
"They seem content to let the states be laboratories, and that works out rather well because the dollars the states are saving are in a lot of cases federal dollars," said James Cooley, chief of staff for Diane Delisi, a Texas state representative and the author of legislation to expand Texas's limited drug recovery program, which may pass within a week.
Several states, including Oklahoma, Louisiana and Ohio, have passed legislation in the last few years allowing unused drugs to be recovered from those organizations for distribution primarily to poor patients.
Nebraska even permits consumers to return unused drugs if they are in tamper-resistant packaging, like the blister package most familiar in over-the-counter medicines, skirting the F.D.A. prohibition.
Recovery has been modest, but California, Maine, Washington and other states are pondering similar programs in hopes of lowering health care costs, however marginally.
Other supporters are trying to push the idea further. An inventor in Massachusetts is seeking a patent on a system that would knit together existing technologies to address the myriad issues of drug redistribution.
"We recycle newspapers, we recycle soda cans, we recycle plastic," said Moshe Alamaro, the inventor, who is a visiting scientist at the Massachusetts Institute of Technology. "It's ludicrous not to recycle expensive drugs."
Mr. Alamaro added, "It should be criminal to throw these drugs away, and instead it's required."
The concept has more skeptics than believers. The hurdles include concerns about patient safety and privacy, the lack of an infrastructure to process and redistribute drugs, and administrative requirements.
"I don't want to sound overly negative, but there are lots of obstacles," said Susan McCann, administrator of the Missouri Bureau of Narcotics and Dangerous Drugs, which is struggling to begin the state's redistribution program.
To sidestep the questions of recycling, Representative Tim Murphy, a Republican who represents Pennsylvania in Congress, suggests that the federal government take a different tack and make it easier for doctors to prescribe small quantities of drugs initially to determine whether a patient can use them.
Monthly or longer prescriptions, now encouraged and sometimes mandated by states and insurers to hold down costs, lead to waste that could be curbed through redistribution.
The amounts discarded are unknown. Though many states require nursing homes, hospitals and consumers to follow specified procedures for drug disposal, the rules add costs and are largely ignored, state health officials and others say.
A study published in the Journal of Family Medicine in 2001 estimated that $1 billion a year in drugs prescribed to the elderly are thrown away, and Mr. Alamaro estimates that a more ambitious system for drug recycling could recapture 5 percent of the nation's prescriptions, or about $6 billion worth annually.
Existing programs are a long way from that, however. The prevailing method of dispensing prescription medicine in bottles leaves it too vulnerable to tampering and contamination for any chance of recovery.
Pharmacies, the most likely candidates for redistribution, have little incentive to take on the administrative burdens and potential liabilities.
And states have not committed to developing the databases and other systems that would be needed, much less wrestled with how to ensure adequate supplies of drugs for patients to continue a regimen.
"It doesn't matter how safe the drugs are, how many of them there are or how neat and crisp the records are, if there isn't a database to tell patients what's available and where it is," Ms. McCann said.
So far, only one clinic has expressed interest in participating in the Missouri program. Ohio has failed to get its program off the ground more than two years after it was approved by the legislature because of a lack of interest among nursing homes.
Among the handful of states pressing ahead, Louisiana is one of the most advanced, with 12 pharmacies that distribute unused prescription drugs. Expired drugs and controlled substances, those that are potentially dangerous, are not accepted. As in other states, the drugs are collected from nursing homes and assisted-living centers, which have a carefully controlled storage and distribution system and use blister packaging.
"We know those drugs are perfectly good," said William T. Winsley, executive director of the Ohio State Board of Pharmacy. "They've been under lock and key; they've been stored properly."
Nonetheless, concerns about safety and hygiene have dogged the Louisiana program, said Malcolm J. Broussard, executive director of the Louisiana Board of Pharmacy. "We run across the thought that these are secondhand drugs, and 'don't poor people deserve the same drugs as anyone else?' " he said.
Getting nursing homes to hand over unused drugs has also been a challenge.
"For years, they've been under the impression that they had to waste these medicines," Mr. Broussard said.
Louisiana's program intends to retrieve several million dollars' worth of medicines each year, Mr. Broussard said, though it is too early to gauge results.
The recovery and redistribution of unused medicines is handled by charity pharmacies that cater to the working poor, thus avoiding thorny questions of who gets reimbursed for returned medicines and how. Should a patient get back part of the co-payment, for example?
"You need to reimburse the state or insurer or individual who paid for the drug, and there's a big hassle in that paperwork," said Gay Dodson, executive director of the Texas State Board of Pharmacy.
Mr. Alamaro is convinced that many problems can be resolved with technology, greatly expanding the pool of retrievable medicines.
He and his partners want access to the shelved drugs in the medicine chests of consumers like Florence Weisfeld of New York. Mrs. Weisfeld, 80, a former social worker, ached and had flulike symptoms when she took Lipitor, the cholesterol-reducing medication. So her doctor changed her prescription.
"I had 25 Lipitor tablets left in my medicine chest, and all I could do with them was flush them down the toilet," Mrs. Weisfeld said. "Such a waste."
Recycling Mrs. Weisfeld's Lipitor would require sweeping changes in the way drugs are dispensed. Mr. Alamaro's plan contemplates replacing bottles of pills with blister packaging or something like a high-tech Pez dispenser.
Such packaging could be encoded with information about the drug and who paid for it. That data would then be used to determine the drug's integrity and reimbursement, which Mr. Alamaro envisions as a system of credits. For instance, a consumer returning a drug to a pharmacy would receive a credit toward a future co-payment.
Patients could return drugs by mail to a reprocessing center or deposit them in a secure box at a pharmacy, which would then forward them to an inspection center.
His own partners are the first to point out the challenges. "I'm optimistic about the technology; I'm not optimistic about the economics at present," said Mark G. Hodges, an environmental consultant who is working with Mr. Alamaro.
The states that are trying drug redistribution have found novel ways to overcome some of the problems. For instance, Oklahoma drafted a corps of retired doctors to ferry drugs between donors and two participating county pharmacies.
"There are always all kinds of reasons not to do things," said Paul Patton, executive director of the Tulsa County Medical Society, the doctors' group that led Oklahoma's efforts on drug recycling. "But this makes so much sense that we've been able to convince a lot of people that it's better to have this program and work to resolve the issues than to not have it at all."
Proponents of drug recovery programs say the real test will come in California, where the Senate is considering a bill to establish a drug recycling program that was first advocated by five first-year medical students at Stanford University.
"Throwing away valuable resources when there is already not enough to go around is cavalier and unfeeling, not to mention poor public policy," said Josemaria Paterno, one of the medical students.
The Stanford students estimate that a program to recover drugs from nursing homes and long-term-care facilities would save the state $50 million to $100 million a year.