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If health care were a country, it would be the fifth largest emitter of greenhouse gases worldwide.
According to the International Pharmaceutical Federation, pharmacists are responsible for minimizing the effect their practice has on the environment through changes in “prescribing, dispensing, pharmaceutical care and disposal of unused medicines, as well as waste discharge into the environment.”1
That’s no small order to fill. Sustainable development takes time, resources, and consensus that the environment is worth all this work.
The global health care climate footprint is equivalent to 4.4% of global net emissions, with the United States holding the highest contributions.2 The scope of the health sector’s contributions to climate change is so vast that researchers haven’t completed the whole picture yet; the potential environmental impacts of medicine life cycles are not yet known.1
There’s a lot we do know, though. Studies from 123,761 incidents around the world have found active pharmaceutical ingredients (APIs) in waste-water treatment, drinking water, and even in mineral water.1 This eco-toxicity can have adverse effects on many living organisms, including hormonal imbalance.1 As the global landscape thickens and resources are strained, now is the time to figure out what it means to be sustainable in the pharmacy.
Dorie Apollonio, PhD, professor in the University of California, San Francisco (UCSF) School of Pharmacy, whose focus is on the translation of research into policy, has served as a member of the UCSF’s Chancellor’s Advisory Committee on Sustainability (CACS) since its inception in 2008. She outlined the most effective ways for pharmacists to start making sustainability a priority in their practice in an email to Drug Topics®.
“The three R’s – reduce, reuse, recycle – are still a great approach to developing a more sustainable pharmacy,” she said. “Most pharmacies are equipped with e-prescribing, which can help reduce the amount of paper use from faxed prescriptions. Pharmacies can also incorporate recycling of non-HIPAA documents as well as recycling of medication stock bottles. Before recycling medication bottles, pharmacies should check with their local recycling services to make sure they are accepted.”
“Patients interested in recycling medication bottles should also refer to their local recycling regulations. Several pharmacies now offer medication take back services, where patients can safely dispose of unused/unneeded medications. Most pharmacies avoid reusing medication vials due to sanitary concerns; however, some individuals are working on creating re-usable medication vials for the public.”
While some recommendations offer small-scale efforts, others address the institutional nature of sustainability within the health care system.
“Some pharmacies may also consider procuring generic drugs from companies that uphold sustainable principles to incentivize pharmaceutical companies to continue these efforts,” Apollonio said.
Katherine Gruenberg, PharmD, assistant professor in the UCSF School of Pharmacy and a pharmacist specializing in infectious diseases, explained the 2 major ways to consider the environmental footprint of pharmaceutical companies, in an email to Drug Topics®: “(1) The energy and waste they expend, and (2) the types of pharmaceutical compounds they create.”
“To address the first consideration, some pharmaceutical companies are increasing energy efficiency and recycling efforts,” Gruenberg wrote. “The second topic is an emerging area of interest in the pharmaceutical drug discovery process.”
According to Gruenberg, prior to approval in the United States, medications must undergo an environmental risk assessment via the FDA.
“Some compounds may present a greater direct risk to aquatic, terrestrial or atmospheric environments on the basis of their chemical properties. By developing compounds that degrade more readily, their environmental impact can sometimes be mitigated. Indirect environmental effects can also be reduced through use of less toxic reagents and development of more efficient processes that require fewer synthetic steps.”
Vivian Ip, MB, ChB, one of the founders of Green Anesthesia Special Interest Group (GASIG), explained some of the environmental problems surrounding anesthetic medications in particular.
“We're trying to raise awareness for both anesthesiologists and pharmacists about the potential pollution and try to reduce and refine how we practice because instead of drawing up 2 propofol syringes just in case you don't have enough, there are alternatives, like drawing up 1 and then maybe have another ampule just in case, but not opened,” Ip said. “Just things like that. And also, the use of local anesthetics as well really helped us. Firstly you're reducing the amount of narcotics around and hence narcotics wastage, and also to actually avoid using sevoflurane and propofol for example, which pollutes the air. The surgeries can be done under just pure local anesthetic, so then you you're not even using any propofol or wasting any propofol or not narcotics in that sense.”
GASIG intends to stand up to the colossal lack of attention sustainable development receives by the health care world. Making physicians aware of the significance of the contributions to greenhouse gas emissions by anesthesia practice and by the larger health care industry, as well as the alternative practices, is one of the group’s main goals. According to Timur J.P. Ozelsel, MD, DESA, University of Alberta in Edmonton and one of GASIG’s founders, if it were an individual country, health care in and of itself would be the fifth largest emitter of greenhouse gases worldwide.2
GASIG’s passion for sustainability has led the group to numerous successes and has been additionally fortuitous in disseminating the word about going green in anesthesia.
“A lot of places are going to get rid of desflurane in the future, which was our first goal to accomplish,” GASIG Founder Rakesh Sondekoppam, MD, University of Alberta, Canada said. “And I think lots of places are going that route. Second thing, the whole reason why we started the GASIG is to promote regional anesthesia as the green choice. And I think that's very supportive to the whole initiative. I think it's gaining traction.”
Ozelsel pointed out that environmental degradation resulting from the health care industry cannot be understated.
“We are a huge part of the problem in terms of bringing sickness to the planet and ultimately to the people and basically all organisms that live on it, which is really contradictory to what we all set out to do, right? It is our mandate to help anybody who we can help; not only limit that to people, but to all living organisms, and to the planet as a whole. And we are falling direly short of that goal right now,” Ozelsel said.
The CACS has also successfully instituted sustainability efforts at the University of California San Francisco campus.
“The CACS has made a major effort to reduce waste, and UCSF now diverts 78% of its waste to recycling and compost (an increase from 44% in 2008),” Apollonio explained. “This has involved efforts across all campus divisions to reduce single-use items, including the hospital pharmacies. The UCSF Parnassus campus also has a Walgreens store on site, which has a safe medication disposal bin.”
Some regions of the United States have been particularly proactive in supporting sustainable pharmacy growth at the legislative level.
“At the state and local level there is increasing advocacy for safe medication disposal programs, often described as “take-back programs.” Historically, drug take-back events were rare (once a year) and voluntary. The City and County of San Francisco enacted a Safe Drug Disposal Ordinance in 2015,” Apollonio said. “More recently, multiple states have passed legislation requiring drug companies to organize and fund these programs (with varying degrees of implementation), and in 2020, New Jersey passed legislation requiring pharmacists to provide safe medication disposal methods at no cost to consumers.”
According to Apollonio, while these programs are primarily focused on reducing opioid abuse and overdoses, safe medication disposal also reduces the likelihood that drugs will enter the environment. For example, prescription drugs containing estrogen that enter the watershed have caused cancers and other disorders in fish.
“On the federal level, the US [Environmental Protection Agency] has focused on management of pharmaceutical hazardous waste, with guidances issued in 2008 and 2019,” Apollonio said. “The 2019 rule bans sewering, but also allowed health care facilities to accumulate larger quantities of hazardous waste on site without following associated regulations and redefined nicotine containing products (eg patches) as ‘non-hazardous,’ increasing the risk that these products will enter the environment.”
Taking on sustainability can be overwhelming, and sometimes it can feel that one person “going green” won’t change anything. GASIG’s experts said finding like-minded people to take it on together makes a big difference.
“You seem like you’re taking 1 step forward while somebody else is trying to pull you 2 steps back,” Ozelsel said. “It’s something that requires a lot of passion, enthusiasm, and we’re very happy that we’re finding people that have like-minded interests…and that we are gathering people to speak with a louder voice cumulatively.”
1. Zuzana K, Besancon L. Green pharmacy practice: Taking responsibility for the environmental impact of medicines. International Pharmaceutical Federation; 2015. Accessed April 2, 2020. https://www.fip.org/www/streamfile.php?filename=fip/publications/2015-12-Green-Pharmacy-Practice.pdf.
2. Health care’s climate footprint. Health Care Without Harm; September 23, 2019. Accessed April 2, 2020. https://noharm-global.org/sites/default/files/documents-files/5961/HealthCaresClimateFootprint_092319.pdf.