By Timothy Do & John Novakowski
Pharmacy is moving towards a more sustainable future, but balancing the needs of patients, legal requirements, economic considerations, and medication safety and efficacy poses a difficult task. To address many of these needs, policy changes at state and federal levels will need to be implemented, but these can take years; efforts such as patient education, drug takebacks, electronic communication and documentation, and increasing awareness and advocacy can be done now by pharmacists in a point-of-care setting to improve awareness and address these difficulties by adjusting the community first.
Patient education is one of the primary jobs that pharmacists perform. Emphasis on medication compliance is a point that is not only beneficial to the patient’s medication therapy outcome, but can also be beneficial to pharmacy sustainability. Drugs and metabolites excreted by patients into sewage accounts for most of the pharmaceutical pollution in water (Lubick). Optimizing patient medication therapy ideally means avoiding polypharmacy; therefore, by educating patients on correct medication use, pharmacists can help to prevent unneeded medication use, waste, and eventual elimination into bodies of water. In addition, good compliance decreases waste and maximizes patient benefit by decreasing treatment failure and resultant downstream interventions.
Educating patients about proper drug disposal for expired or unusable medicines is another opportunity that pharmacists have at the point-of-care to improve patient awareness for and participation in sustainable environmental practices. In reality, it may be difficult for pharmacists to make a mention of disposal practices at every visit in a community setting, but adding information about proper drug disposal to patient product information documents may be a viable method. Currently, patients need to look up where to dispose of their medication (for example on the FDA website) or ask a pharmacist. These extra steps might be enough to impede someone from taking the actions necessary to properly dispose of their medication. Having the information directly handed or electronically delivered to them would ease the burden of having to track down their medication on a website just to learn how to get rid of it.
Medications released into the environment have a variety of documented effects. For example hormonal drugs used in people, such as 17-beta-estradiol, may have negative effects on the hormone systems of wildlife, such as those in fish, while antibacterials, such as Triclosan, may disrupt the natural microbiota in the soil (Boxall). The United States Environmental Protection Agency (EPA) advises that patients utilize drug take-back programs such as those sponsored by the DEA to segregate medications from regular waste (United States Environmental Protection Agency). For patients who do not have access to a drug take-back site, the FDA and EPA provide guidance on proper disposal of medications on their websites. That said, such information may not be readily available on patient information documents given at pharmacies. Including either disposal instructions specific to the medication dispensed or instructions to find such resources on patient information documents may be a step towards decreasing the amount of medication entering the environment. At the time of this writing, National Prescription Drug Take-Back Day is coming up on April 27th (Drug Enforcement Administration). This is a perfect example of something in which pharmacists can play an active role. A simple sign or mention of this take-back day could provide an opportunity for patients to safely dispose of unused or unneeded medication. Having a list of places where there are drug take-back services would also be another way that pharmacists could raise awareness for this issue and provide an easy solution to medication disposal. While improper drug disposal is not the primary reason for drugs found as environmental contaminants, it will provide some marginal benefits that can help sustainability efforts and community safety in the long run (Lubick).
Pharmacies have increasingly embraced paperless routes such as e-prescriptions and digital receipts. Taking this a step further to other documentation and patient prescription information could greatly reduce the amount of paper used in pharmacies and improve sustainability of pharmacy practice. Pharmacies are required to keep documents such as immunization records stored for many years, depending on what type of information they contain. Changing these documents to a paperless format could save thousands of tons of paper each year. For example, CVS alone used 54,500 tons of paper in 2018, some of which could likely be replaced with paperless alternatives (CVS). In addition, patient prescription information is typically given with every prescription. Once a patient has completed using the medication for an acute condition, the patient may see little use with these documents, and they will ultimately be thrown away. For patients getting refills, these documents may merely serve as additional copies and may, again, be thrown away. Even if some is recycled, replacing the paper patient information on more than 3.7 billion prescriptions (as of 2015; the number is likely much higher now) would greatly decrease the impact of pharmacies on paper usage (Centers for Disease Control and Prevention). Though this is not something that pharmacists can directly control at the moment, pharmacists can provide feedback to their higher-ups and promote sustainable paperless practices.
In addition to paper waste, pharmacies utilize large volumes of plastic containers to both store and dispense medications. Efforts to recycle medication stock bottles can further improve waste reduction. Stock bottles are a candidate for recycling services as reflected in a statement by the Association of Plastic Recyclers (APR). APR claims pharmacy stock bottles have been identified as “a highly marketable, quality stream of high-density polyethylene (HDPE)” (Recycling Today). The organization APR itself has considered establishing a Pharmacy Stock Bottle Recycling program similar to its Recycling Grocery Rigid Plastics program (Recycling Today). In addition, attempting to use the smallest dispensing bottle possible for each prescription and packaging prescriptions as efficiently as possible can cut down on this waste. Both recycling and waste reduction are important to making pharmacy practice more sustainable.
That said, that are a few barriers towards implementing sustainable practices. Some patients prefer hard copies or do not have access to an email account to receive digital information. Reusing medication bottles can raise concerns regarding safety, especially if medications previously contained were potent or toxic (for example, bottles of warfarin, a blood thinner, cannot be reused and require separate disposal due to its potential toxicity). Certain medications are of a very high cost. Both shelf stability and demand may not warrant purchasing such medications in bulk amounts. These issues can be handled by identifying patients and medications that may be exempt from overarching sustainable practices, and individual patients can opt out of electronic documentation. Certain medication bottles may also be exempt from recycling with the usual stock. When purchasing medications in certain container sizes, a pharmacist may exercise judgement as to whether it would be more efficient to purchase a bulk or small size container. The benefits of sustainable practice can be balanced with benefits of existing practice.
Though difficult, sustainability in pharmacy is most certainly attainable. Small steps taken by pharmacists today can turn into larger steps in the future as pharmacists lobby and advocate for better practices. Taking action at the point-of-care setting now can raise awareness to pharmacy’s sustainability issues. Educating patients about proper disposal methods for certain medications can improve environmental consciousness to the issues associated with medication waste and improper disposal. Applying practices like recycling and digital documentation could greatly reduce the bulk of physical waste generated as a result of pharmacy operations. Pharmacists are the most accessible healthcare workers available, and they are among the most trusted professions; this unique position gives pharmacists the ability to truly impact the sustainability of the field when they perform their role as medication dispensers, experts, and counselors.
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Cite this article:
Do, T; Novakowski, J. (2019). Sustainable Pharmacy: A Regimen for the Future. D.U. Quark, Contest Submissions.