To prevent accidental poisoning, misuse, and environmental harm, the Central Drugs Standard Control Organisation (CDSCO), India's drug regulatory body, has issued a list of 17 medicines that are considered so dangerous that they should be flushed down the sink or toilet if they are unused or expired. This guidance is part of a larger effort to promote the safe disposal of unused and expired drugs and to combat antimicrobial resistance (AMR) and other public health risks.
The CDSCO's guidance document, circulated in May 2025 to all state and Union Territory drug controllers, outlines various methods for disposing of expired or unused medications, including encapsulation, inertisation, and incineration. It also details existing policies, stakeholder procedures, and processes for collecting, storing, and transporting drugs before disposal.
The decision to recommend flushing certain medications is an exception to the general advice against this practice. The CDSCO emphasizes that flushing is a last resort when a drug take-back program is unavailable. The primary concern is that these 17 medicines, which include strong painkillers, sedatives, and stimulants, can be fatal if ingested, even in small doses, by children, pets, or unauthorized individuals.
The 17 medicines that CDSCO recommends flushing are: * Fentanyl * Fentanyl Citrate * Morphine Sulfate * Buprenorphine * Buprenorphine Hydrochloride * Methylphenidate * Meperidine Hydrochloride * Diazepam * Hydromorphone Hydrochloride * Methadone Hydrochloride * Hydrocodone Bitartrate * Tapentadol * Oxymorphone Hydrochloride * Oxycodone * Oxycodone Hydrochloride * Sodium Oxybate * Tramadol
Most of these drugs are narcotics, synthetic opioids used for pain management, or anxiety medications. Many have a high potential for abuse and misuse in non-medical situations. These drugs are regulated under the NDPS Act and the Drugs and Cosmetics Act, and their improper disposal could lead to accidental overdose or misuse.
The CDSCO is also promoting the establishment of "Drug Take-Back" programs at pharmacies and healthcare centers in collaboration with chemist associations. These collection points will ensure that expired drugs are handed over to licensed biomedical waste handlers for proper disposal. The guidance also outlines clear responsibilities for retailers, manufacturers, and hospitals. Retailers are required to return expired drugs within 30 days and maintain disposal records. Manufacturers must remove expired drugs from the supply chain within six months. Hospitals must follow strict disposal rules for radioactive, cytotoxic, and controlled substances.
Unscientific disposal of unused or expired drugs is a major cause of environmental pollution and the spread of antimicrobial resistance. Used antibiotics that are carelessly discarded can seep into the soil and water, eventually affecting human health. The CDSCO's guidelines aim to address these concerns by promoting responsible disposal practices and encouraging the development of drug take-back programs.
The guidelines suggest that drugs should be returned through the supply chain, from retailer to supplier to manufacturer, for disposal. Retailers should return expired stock to the supplier or manufacturer, and wholesalers, distributors, and stockists should accept expired or unused drugs from those to whom they have supplied them. Manufacturers are responsible for accepting all expired or unused drugs from retailers and wholesalers.
Kerala already has an operational drug take-back initiative, the New Programme on Removal of Unused Drugs (nPROUD), launched in December 2024 by the state drug control department. This program serves as a model for other states to follow.
