 Presented are the major insights, perspectives, and findings (over 40 in total) that have been gained from the body of work performed over the last 10 years at EPA's Office of Research and Development laboratory (Las Vegas, NV) on the topic of pharmaceuticals and environmental stewardship; this broad topic includes the more specific issue of disposal of consumer drug waste. This body of work included seven peer-reviewed journal articles and five book chapters, as well as creation and examination of a comprehensive bibliographic database containing over 1,400 documents relevant to the many facets of the overall topic. This document is the first to attempt a synthesis of the published literature surrounding the major issues involved with the sustainable use of consumer pharmaceuticals - a topic characterized by deceptive complexity. The single aspect of the topic that has received the most attention over the years is consumer drug disposal - largely because it was perceived as a problem that could be easily and quickly remedied. Though drug disposal in itself might seem very amenable to simple solutions, it is often fraught with numerous obstacles. Attempts to develop solutions without a holistic, systems-level objective in mind can also lead to unanticipated consequences, many of which can be adverse for human health and safety as well as for the environment.A narrow focus on drug disposal will divert attention from achieving a sustainable solution for minimizing the entry of drug active ingredients to the environment. After all, solutions for drug disposal are merely a form of end-of-pipe solution for dealing with pharmaceutical waste. A truly sustainable system for the use of medications will require a concerted effort toward designing approaches for reducing or minimizing the generation of drug waste to begin with - namely, pollution prevention and source control. A cursory examination of the attached report will quickly reveal the complexity of the topic - one with myriad interconnections and feedback loops. Changes to one aspect can have unforeseen, adverse consequences for another. Changes to dispensing or prescribing, for example, can worsen patient non-compliance (and therefore increase the incidence of leftover drugs), therapeutic outcomes, and cost - all in unforeseen ways. Countless factors contribute to the accumulation of leftover drugs, which later require disposal. Options for disposal have yet to prove satisfactory with respect to environmental impact, cost, or diversion (and poisonings). Moreover, even if an efficient and effective system could be implemented for drug disposal, leftover drugs can continue to represent a source of unintended exposure for humans and wildlife alike. The extent to which drugs become waste (thereby creating the potential for the eventual entry of their active ingredients to the environment) is intertwined with both the effectiveness and efficiency of the practice and administration of health care. Effective solutions will require a concerted transdisciplinary, holistic approach - one involving a wide spectrum of professions that have never before had reason to communicate or collaborate - from prescribers and dispensers to insurers and scientists. A nationwide solution will require collaborations across agencies, including the EPA, FDA, DOJ (DEA), and possibly others, such as USPS and DOT. Some causes and their potential solutions might seem counter-intuitive. Current approaches for protecting the environment from drug residues are sometimes at odds with protecting human health and safety, as well as with improving the effectiveness of healthcare. A sustainable solution will instead need to treat the environment and the patient as an integral whole. The ultimate objective will be redesigning parts of the healthcare system to minimize the accumulation of leftover medications, thereby reducing or eliminating the need to dispose of waste. Of key importance, however, is an understanding that many of the actions that could be taken to minimize accumulation of leftover drugs will also reduce drug usage. And reduced usage is the most effective means for minimizing the more important sources of active ingredients in the environment - namely excretion and bathing - two sources previously assumed to not be controllable. The underlying framework for a holistic approach to sustainable pharmaceutical use has been formulated in the author’s prior work and involves the concepts of the Green Pharmacy and pharmEcovigilance. Click here to read the document (Note: This link is not yet active; will be released in early week of October)
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