Volume 55, Number 2 - Summer 2009

 

Jessica Harvey-Taylor, MA

Pharmaceuticals have undoubtedly increased the effectiveness of modern medicine, but their ecological impact is less certain. An extensive body of research has recently developed around the presence of pharmaceuticals in our waterways and the effects of these drugs on aquaculture. Perhaps the most cited and influential findings were published by the United States Geological Survey in 2002. USGS sampled 139 streams in 30 states between 1999 and 2000, including three waterways in the Bay Area. They were looking for 95 specific organic waste compounds, including commonly used human and veterinary pharmaceuticals. 

Though the USGS was looking in streams where they expected to find waste compounds (i.e., this was not a random sample), the results were still impressive: at least one type of chemical was found in 80% of streams; seven chemical types were found in half the streams; and one-third of the streams contained 10 or more chemicals.[1] A few notable pharmaceutical residues of the myriad found were acetaminophen, ibuprofen, warfarin, digoxin, multiple common antibiotics, and codeine. The entrance of these and other drugs into waterways stems from flushing them down the toilet or sink; putting them into landfills where they leach into groundwater; and through unmetabolized excretion in urine and feces. 

The effect of pharmaceutical residues on aquaculture, humans, and the environment is unknown at present.[2] Theoretically, we might expect increased antibiotic resistance in bacterial species. We might also anticipate unexpected outcomes based on synergistic effects of these drugs. Regardless of evidence, perhaps intuitively many of us are simply not at peace with water of such compromised quality.

In a recent essay in the Annals of Family Medicine, Dr. Roger Rosenblatt writes, “Just as we have gone beyond the purely biological in medicine to incorporate both the psychological and the social, so can we realize that there is an ecological dimension to much of what we do.”3 We know that particular environmental hazards, such as asbestos and air particulates, can cause disease. Although we don’t yet know what trace pharmaceuticals mean for local ecosystems, including people, we do know that pharmaceuticals are a presence in our waterways. Rosenblatt urges clinicians to develop an “ecosystem health perspective” and warns, “Unless we devote attention to stabilizing and repairing the ecosystem, our professional and personal accomplishments as health professionals may be swept away.”[3]

Coastal Health Alliance (CHA), which includes three community health centers in west Marin County, was first confronted with the problem of pharmaceutical disposal after accruing substantial quantities of expired drug stock from the government’s 340B program. After several reprimands from our waste hauler about the presence of pharmaceuticals in our sharps containers, we realized we were without a clinical process for disposing of these drugs. To resolve this problem, clinic staff attended a symposium on safe medicine disposal in Rohnert Park during 2007. One of the organizers, the Teleosis Institute, eventually helped us develop a comprehensive pharmaceutical disposal process.

Teleosis is a Berkeley-based nonprofit whose mission is to promote an effective, sustainable health care system. One of their main projects is to establish pharmaceutical return programs in the Bay Area. In January 2008, CHA became a pilot site for Teleosis’s Green Pharmacy program.

The appropriate disposal of drugs in Green Pharmacy and similar programs is based on incineration. Integrated Waste Control, a private Bay Area medical waste handler, hauls the drugs to a facility in Utah, where their incineration fuels a local Air Force base via hydroelectric power.

Becoming a Green Pharmacy take-back site was as simple as incorporating an eight-gallon pharmaceutical waste bin into clinical space, putting up posters that we collected pharmaceutical waste, and coordinating with the waste hauler. During 2008, we collected more than 600 pounds of patient pharmaceutical waste. Since the Green Pharmacy program began in June 2007, Teleosis has prevented more than 6,000 pounds of patient pharmaceutical waste from entering Bay Area waterways.[4] 

In addition to collecting pharmaceutical waste from patients, CHA has also developed a system for disposing of our clinical and 340B drug waste. We now have a bin for our drugs and a separate bin for patient disposal. 

The County of Marin, through the Department of Environmental Health Services, has also sponsored pharmaceutical return programs since 2004. Participants include local Longs Drugs, Safeway, Walgreens, Marin Medical Pharmacy and Ross Valley Pharmacy. 

Clinicians have several options for reducing pharmaceutical waste. First, practice sites should have processes for the appropriate disposal of clinically generated waste. The Resource Conservation and Recovery Act, enforced by the EPA and local environmental agencies, categorizes as waste several pharmaceuticals that cannot be disposed through flushing, landfills or sharps containers. 

Appropriate disposal of these drugs is clear-cut for hospitals and other large institutions that generate a significant amount of pharmaceutical waste and can dedicate staff to the task. For smaller clinical systems, however, the situation is trickier. Staff in these settings are commonly responsible for many different categories of operations, with little time for dealing with pharmaceutical waste. Fortunately, advice for these situations is available from Robert Turner of Marin County Environmental Health at 499-7146 or rturner@co.marin.ca.us.

Other options include establishing return programs for unused patient medication, or ensuring that patients know where to return drugs for appropriate disposal. To establish your own program, Teleosis offers a Green Pharmacy Toolkit at teleosis.org/gpp-toolkit.php. For a list of sites that take unwanted pharmaceuticals, visit Environmental Health at co.marin.ca.us/depts/CD/main/comdev/ehs and click on “Medical Waste.”

Aside from these measures, clinicians can help reduce pharmaceutical waste by reconsidering their use of pharmaceuticals for patients. Many primary care conditions can be treated with non-pharmacological approaches. Just because patients come into the office does not necessarily mean they want drugs. A major key is adequate negotiation with patients about treatment protocol. For example, if patients with stage 1 hypertension do not want medication, there is no point in writing for HCTZ if they are going to fill the prescription and then not use it. This situation could be avoided by asking patients their preference for treatment: How do you want to treat your hypertension, and does this plan involve medication? One possible answer could result in an exercise and dietary plan, along with adequate documentation that the patient was not interested in medication. 

Antibiotics, which figured prominently in the USGS stream surveys, are a prime candidate for reduced usage. Not only do they interfere with microbial activity at water treatment facilities, but they may also contribute to antimicrobial resistance.[5] Furthermore, patients treated with antibiotics will harbor resistant bacteria for several months, complicating treatment of subsequent bacterial infection. Use of antibiotics in low-risk patients can be reduced by strictly following diagnostic and treatment guidelines, when they exist, and by using antibiotics only when there is sufficient evidence to support bacterial infection. 

Acute otitis media—the most common infection for which pediatric patients are given antimicrobials—is a case in point. A few simple changes in the practice of prescribing antibiotics for AOM can offer multiple benefits, including decreased risk for antibacterial resistance, fewer patients experiencing adverse reactions to antimicrobials, and decreased pharmaceutical waste. Clinical practice guidelines from the American Academy of Pediatrics and American Academy of Family Physicians outline the diagnostic criteria for AOM and suggest appropriate antimicrobial use based on the most common infectious agents.[6] The guidelines specifically include watchful waiting as appropriate management for otherwise healthy children, stating, “Placebo-controlled trials of AOM over the past 30 years have shown consistently that most children do well, without adverse sequelae, even without antibacterial therapy.”

Many people are already making small changes in their lives to promote sustainability, such as buying local and organic products, recycling, bicycling for transportation, or driving fuel-efficient cars. Clinicians can also make small changes in their practices with sustainability and ecological responsibility in mind. By appropriately disposing of clinical pharmaceutical waste, assisting patients with disposal, and reconsidering their use of pharmaceuticals, clinicians can help reduce the ecological footprint created by the medical community.

1. Kolpin DW, et al, “Pharmaceuticals, hormones, and other organic wastewater contaminants in U.S. streams, 1999-2000,” Env Sci & Tech, 36:1202-11 (2002).
   
2. Kuehn BM, “Traces of drugs found in drinking water: Health effects unknown,” JAMA, 299:2011-13 (2008).
   
3. Rosenblatt RA, “Ecological change and the future of the human species: Can physicians make a difference?” Ann Fam Med, 3:173-176 (2005).
   
4. Teleosis Institute, Year End Report 2008, teleosis.org.
   
5. Smith, CA, “The right prescription: Managing pharmaceutical waste is environmentally correct and the law,” Health Facilities Management (May 2003).
   
6. American Academy of Pediatrics and American Academy of Family Physicians, “Clinical practice guidelines: Diagnosis and management of acute otitis media,” Pediatrics, 113: 1451-65 (2004).
   

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