Medication Waste Attributed to Syringe Dead Space, Abandoned Initial Fills

Although significant emphasis is placed on medication adherence, another issue garnering interest is medication waste.

Although significant emphasis is placed on medication adherence, another issue garnering interest is medication waste.

Medication waste drives cost inefficiencies in our health care system. The accumulation of unused medications may occur as a result of patient nonadherence, expiration dates that occur too soon to enable the use of a given initial quantity, over-purchase by the patient, and overprescribing, among other factors.1 However, 2 overlooked types of inefficiencies resulting in waste and avoidable costs are syringe dead space and abandoned initial prescription fills.2,3

Syringe Dead Space

Recent study results attributed injectable medication waste to syringe dead space, or the volume of fluid left in a syringe after the plunger has been pushed down completely. The study compared high dead-space syringes (HDSS), which have a detachable needle, with low dead-space syringes (LDSS), which have permanently attached or integrated needles or a conical plunger to reduce dead space in the needle hub.2

The researchers found HDSS contribute to greater excess cost of injectable medication waste than LDSS. They determined the median cost of waste from self-injectable drugs delivered through HDSS was $5.43 per single dose and $1637.91 annually. In comparison, the median cost of waste from medication administered through LDSS was $0.54 per single dose and $124.52 annually.2

Therefore, replacing HDSS with LDSS is one way to avoid preventable medication waste.

Abandoned Initial Fills

Abandoned initial fills have also contributed to medication waste concerns. Common factors behind abandoned first fills are patients who can’t tolerate medication side effects, unaffordable cost, perceived lack of benefit, and failure to meet patient expectations.

Recently, researchers examined the categories, quantities, and prescribers of unused initial prescriptions and found that “the top 3…categories of unused first-fill prescriptions returned were analgesics (34%), of which 84% were opioids; antibacterial agents (13%); and cardiovascular agents (8%).”3 Moreover, of the “categories with the highest average percent returned compared with the original quantity prescribed were metabolic bone disease agents (100%), hormonal agents (91%), and central nervous system agents (91%).”3

Abandoned initial fills impose wasteful expenditures on patients and third-party payers and raise concerns about diversion, unintended poisoning, and environmental protection. In light of these issues, government agencies and insurance companies are using innovative methods to help increase adherence to first-time prescriptions. Notably, partial fills have been proposed that aim to optimize drug selection for individual patients and reduce medication waste.

Since 2013, the Centers for Medicare and Medicaid Services (CMS) has required prescribers in long-term care facilities to write prescription cycles of 14 days or less for Medicare Part D beneficiaries.4 CMS also encourages patients to obtain a “trial size” of first-fill prescriptions for medications for chronic conditions, along with prorated cost sharing based on the daily cost of the drug.4 This 2-week initial fill would help decrease environmental waste, discourage drug diversion, give patients time to determine whether they can tolerate a medication, and produce cost savings for Part D sponsors. CMS expects these efforts to produce savings of more than $1.8 billion by 2018, assuming a rate of 32% discontinued initial fills.5,6

Our health system should continue to implement and enforce innovative measures to prevent medication accumulation and its associated negative consequences. Continuing to address syringe waste and abandoned initial fills could be one strategy to address this national concern.


1. Ruhoy IS, Daughton CG. Beyond the medicine cabinet: an analysis of where and why medications accumulate. Environ Int. 2008;34(8):1157-1169.

2. Oramasionwu CU, Cole AL, Dixon MS, Blalock SJ, Zarkin GA, et al. Estimated cost of injectable medication waste attributable to syringe dead space. JAMA Intern Med. 2016;176(7):1025-1027.

3. Burns KA, Madras JM, Ray ME, O'Neil DP, Bruinsma AL, et al. Unused first-fill prescriptions: cause for concern? Am J Pharm Benefits. 2013;5(4):e103-e110.

4. Twachtman G. CMS takes a second shot at mandating “trial size” prescriptions for part D; estimates savings at $2.5 billion by 2018. The Pink Sheet. 2011;73(42):17.

5. CMS. Advance notice of methodological changes for calendar year (CY) 2011 for Medicare Advantage (MA) capitation rates, Part C and Part D payment policies and 2011 call letter. Published February 19, 2010. Accessed July 2, 2016.

6. CMS. Medicare program: changes to the Medicare Advantage and the Medicare prescription drug benefit programs for contract year 2013 and other changes: final rule with comment period. Fed Regist. 2012;77(71):22072-22175.