Environmental stewardship and medication management

Tackling a global crisis such as climate change as a frontline pharmacist may seem like an unexpected ask. I will share a personal story: during the COVID-19 pandemic, when I was invited to participate in a quality improvement project at my practice site on the use of inhalation devices as it related to climate change, my first reaction was, “Huh?” and my second reaction was, “am I not already busy enough?!” When I reflected on my core role as a pharmacist, I typically described it as ensuring medications are necessary, effective and safe for the patients under my care. I struggled to see the connection between my day-to-day clinical decisions as a pharmacist and climate change, felt resentful that having to think about the planet may add to my already lengthy list of clinical roles and responsibilities, and felt skeptical that any “greener” pharmacotherapeutic decisions I made would be impactful enough to stem the tide of the climate crisis. Any time I get asked to do something new that I am unfamiliar with, I try to learn more. To my surprise, the health-care sector is a leading source of greenhouse gas emissions and is, in fact, 13% more polluting than the automotive industry.1 Medications account for approximately 25% of greenhouse gas emissions from the healthcare sector.2 Pharmacists may indeed have a role to play when it comes to environmental stewardship and medication management, and these two interests may be more interconnected than I previously assumed. This article highlights how climate change is already affecting pharmacists’ practice, and reviews four core areas where pharmacists may be able to help mitigate the impact of climate change on health outcomes: sustainable prescribing, sustainable dispensing, sustainable medication disposal, and greener pharmacy practice infrastructure and care-delivery at the practice level. Climate change—Already a threat to the health of Canadians In February 2022, Health Canada released a 768-page report titled, Health of Canadians in a Changing Climate: Advancing our Knowledge for Action.3 Health Canada describes this as the “first comprehensive study of current and projected risks from climate change to the health of Canadians since 2008….It addresses the evolving knowledge needs of government decision-makers, civil society organizations, and individual Canadians by providing evidence-based and, where possible, quantitative information to help people understand how Canada’s climate is changing, and the effects on health and health systems, including implications for those most at risk in society.”3 Key messages noted in this report are: Climate change is already negatively impacting the health of Canadians. Health risks will increase as global warming continues, and the greater the warming, the greater the threats to health. Some Canadians are affected more severely by climate change, as exposure and sensitivity to hazards and the ability to take protective measures varies across and within populations and communities. The effects of climate change on health systems in Canada—for example, damage to health facilities and disruptions to health services and operations—are already evident and will increase in the absence of strong adaptation measures. Efforts to prepare for climate change are known to reduce risks and protect health. We must take action now. The health impacts of climate change on First Nations, Inuit and Métis peoples are far-reaching, with disproportionate impacts on their communities, including food/water security and safety, air quality, infrastructure, personal safety, mental health and wellness, livelihoods, culture and identity. To successfully protect all Canadians from the health impacts of climate change, decision-makers must pursue adaptation actions that are inclusive and equitable and consider the needs of racialized, marginalized and low-income populations. Increased efforts to reduce greenhouse gas emissions are required to help protect the health of Canadians. Reducing greenhouse gas emissions can provide very large and immediate health benefits to Canadians.3 The report highlights some examples of where pharmacy practice is already being impacted by climate change.3 It cites examples of where extreme weather and climate hazards have led to supply chain disruptions for medications and other health-related supplies. It mentions that having pharmacists work to full scope, including the ability to prescribe, particularly during environmental emergencies, adds value to the care of patients. The report also discusses illnesses related to climate change that pharmacists may be involved in managing (e.g., heat-related illnesses, infectious diseases including tick-borne diseases such as Lyme disease, and exacerbations of chronic health conditions).3 The report points out that in Ontario, the hottest days between 1986 and 2013 showed a 6% increase in hospitalizations for cardiovascular disease compared to optimal temperatures. During this period, about 1.2% of overall hospitalizations for cardiovascular disease could be attributed to heat; the majority of these admissions were related to moderate rather than extreme heat. The report also shares that Ontario data suggest that each 5°C increase in temperature during the summer from 1996 to 2010 was associated with a 2.5% increase in deaths, especially those related to cardiovascular disease.3 As pharmacists, we know that medication may increase an individual’s risk of extreme heat impacts by accelerating dehydration and body heat production.2,3 Certain medications affecting the central nervous system (e.g., anticonvulsants, antidepressants, anticholinergics, psychotropic drugs), as well as others may increase the risk of hyperthermia, while some medications (e.g., thiazide diuretics) may increase vulnerability to phototoxicity and skin cancer risk.4,5 What can pharmacists do about climate change? Given the clear and present danger of climate change on the health of Canadians, what roles will emerge for pharmacists to help tackle these problems? What guidance and supports will frontline pharmacists receive from their employers, professional advocacy bodies and regulatory organizations to help in the fight against climate change? What will pharmacy trainees be learning about these issues in their curriculum? These are big questions, with no simple answers. I would, however, propose four areas to consider to advance environmental stewardship efforts by pharmacists. My recommendations are drawn from work being done by the Royal Pharmaceutical Society in the United Kingdom and have also been described in the Canadian context.2,6 Sustainable prescribing Sustainable dispensing Sustainable medication disposal Greener pharmacy practice infrastructure and care-delivery at the practice level. Sustainable prescribing I define sustainable prescribing as participating in the prescribing process with an environmental stewardship lens. Practically, this involves two main components: 1. Prescribe medications only when they are necessary.2,6,7 Manufacturing and distribution of medications is associated with greenhouse gas emissions. If there is only one thing you take away from this article, it is this—perhaps the most important way to reduce the impact of pharmaceuticals on climate change is to prescribe medications only if they are necessary, and to deprescribe medications that are no longer indicated. Overprescribing is a complex topic, but we can all agree that pharmacists are well-positioned to address unnecessary medication use. 2. Select medications that have a lower impact on climate change, if feasible.2,6,8 Most of us have no idea what the carbon footprint is for atorvastatin as it makes its journey from being produced at a foreign facility to the patient’s hands for ingestion. As a pharmacist assessing that patient’s dyslipidemia, the carbon footprint of the various therapeutic options has never been on my radar. There is, however, emerging research looking at tools to support environmentally informed prescribing. The JanusInfo database (https://janusinfo.se/) was set up in 2009 in Sweden to allow physicians to check whether medications are “green” before prescribing them, as part of Stockholm’s effort to reduce levels of environmentally hazardous medications in water.9,10 This “pharmaceuticals and environment” database rates pharmaceutical substances in terms of their toxicity, persistence and bioaccumulation potential based on data provided by pharmaceutical manufacturers. While it is not practical to check this database each time a medication is prescribed, pharmacists in community- and hospital-based practices may focus their environmentally informed prescribing efforts on two therapeutic areas: • Use dry-powder inhalers (DPIs) or soft-mist inhalers in place of metered-dose inhalers (MDIs) when clinically appropriate.2,6,8,11 MDIs are pressurized devices that rely on liquefied-gas propellants to atomize medication for inhalation delivery. In the past, MDIs used chlorofluorocarbons (CFCs) as a primary gas propellant. CFCs, however, were banned under the 1987 Montreal Protocol as they possess significant ozone-depleting properties. Soon after, pharmaceutical companies began manufacturing MDIs that use more ozone-friendly hydrofluorocarbons (HFCs). Although HFCs do not deplete the ozone layer, they do have a high global warming potential (GWP). The UK National Institute for Health and Care Excellence (NICE) reports that MDIs containing 100 doses have a carbon footprint equivalent to a 180-mile (290 km) car journey. It is also thought that most of the propellant emissions from HFA inhalers occur at the user level, typically related to poor synchronization between patient actuation and inhalation. Pharmacists can visit the University of Toronto’s Sustainable Health Systems Community of Practice Sustainable Inhaler Initiative to learn more about this, and access some practical point-of-care tools that they may wish to implement in practice.11 • Promote less carbon-intensive inhaled anesthetics, such as sevoflurane in place of desflurane, as clinically appropriate, and reduce the unnecessary use of nitrous oxide.8 The anesthetic gases most noteworthy for greenhouse gas emissions are desflurane (2,540 times more detrimental than carbon dioxide) and nitrous oxide (less damaging than desflurane, but used in high volumes throughout health care). Sevoflurane is an alternate anesthetic gas that produces seven times less greenhouse gas emissions than desflurane. Pharmacists who work with teams that use these anesthetics in procedures may be able to facilitate a shift in anesthetic use. Sustainable dispensing As we reflect on how medications are dispensed, we should re-think aspects of this process that may be more environmentally conscious: 1. Re-evaluate use of plastic prescription vials.12-14 Plastic prescription vials are a staple found in most pharmacies. We tend to use a new vial anytime we fill a new prescription. I attempted (unsuccessfully) to find data on what patients do with these vials once they consume the medication (assuming they finish the medication!). Perhaps some patients reuse them or return them to the pharmacy. Perhaps they are put in the home recycling bin or the empty vials are tossed into a regular garbage can. To what extent do these staples of our dispensing process end up in a landfill? Similarly, what do patients do with packaging of medication compliance packs once they have used them? How practical would it be to have alternatives to these plastic packages? I read about two sisters who opened a pharmacy in Nova Scotia with an environmentally friendly mandate.13,14 The Teasdale Apothecary gives their patients a choice to use plastic vials from an environmentally friendly Canadian supplier (Ecolo-Vials), or opt-in to a reusable glass vial program. Ecolo-Vials are an example of a plastic vial alternative that uses 30% less plastic with a lower carbon footprint.14 I mused whether this program would be scalable. I also recently became aware of another option called “The Phill Box,” which is marketed as a fully recyclable and compostable alternative to plastic prescription vials.15 Canadian pharmacy practice is dominated by a handful of corporate oligopolies. Are these major pharmacy chains actively looking at greener strategies in the dispensing process? We have seen shifts over the years in the availability of plastic bags in retail spaces, with a federal mandate banning single-use plastic bags. Will pharmacists be instructed to ban the use of plastic prescription vials one day? It is important to proactively discuss the issue of sustainable dispensing within our profession and with key stakeholders, before we are told what to do by decision-makers outside our profession. In the interim, I would urge pharmacists to educate patients on the need to return medication packaging, including prescription vials, to the pharmacy for safe disposal. I encourage pharmacists to advocate for the use of eco-friendly vials or sustainable alternatives as it may become necessary in the future to phase out or minimize use of plastic prescription vials. 2. Manage supply chain disruptions. Pharmacists are all too familiar with challenges in the drug supply chain. We have seen stockpiling and hoarding of medications during the COVID-19 pandemic, as well as drug shortages.16 This is something we will continue to face with the climate crisis.3 Some supply chain disruptions have been associated with extreme weather events (e.g., forest fires, hurricanes, floods), associated with climate change. Pharmacies should have an emergency plan that is enacted during disasters to help ensure patients have access to essential medications. This underscores the need for pharmacists being empowered to their full scope of practice to support patient access to appropriate therapeutics, and steward medications effectively. Sustainable medication disposal Proper disposal of unwanted medications protects our communities by preventing misuse and accidental ingestion, and safeguards our environment from contaminated landfills and waterways.2,17,18 Pharmacists should be familiar with their provincial medication return program policies and processes to dispose of pharmaceutically-generated waste, or contact their regulatory colleges for additional guidance. Pharmacy teams need to educate the public about medication disposal programs so that they are used to their full potential. It is also important to recognize gaps within these programs. For example, as mentioned previously, pharmacists can preferentially recommend DPIs or soft-mist inhalers over MDIs, to minimize the effect on greenhouse gas emissions. However, we also have a responsibility to ensure that these DPIs and soft-mist inhalers are disposed of appropriately. These inhalation devices are comprised of a number of components and it may not always be a simple process to recycle them. Are current medication disposal systems adequate for this? Or should pharmaceutical manufacturers offer more support to facilitate this process via corporate “take-back” recycling programs? How do we incentivize appropriate recycling or medication disposal so that various stakeholders buy into this? And how do we make this accessible to the end-user (i.e., patients)? These are questions that need to be examined. Greener pharmacy practice infrastructure and care-delivery at the practice level When thinking about how we usually deliver care to patients at pharmacies, it may be useful to consider whether we have invested in digital infrastructure that will allow for more sustainable models of care provision.6 The COVID-19 pandemic led to a shift towards more virtual provision of care. Virtual care may reduce the environmental impact of travel, while still providing clinically appropriate care. Pharmacy teams may wish to capitalize on ways to maximize and optimize electronic platforms to enable patients to access care wherever they may be. Likewise, pharmacy teams may wish to consider work-from-home options for pharmacists in a meaningful way. Electronic transfer of prescriptions directly from prescribers to pharmacies may also be helpful to reduce use of paper, while respecting the patient’s autonomy and preferences around prescription self-management.6 Summary In recent years, health care seems to be in a constant state of crisis. It may be challenging for frontline practitioners to tackle additional demands without supplemental resources. It is unquestionable, however, that the health of our planet is deeply woven into the health of Canadians. As there is increasing urgency to address the climate change crisis, pharmacists across all sectors need to seriously contemplate how our professional responsibilities may align with an environmentally conscious mandate.19 Pharmacists are encouraged to discuss sustainable prescribing, dispensing and medication disposal, and a greener approach to pharmacy practice within their teams, with patients and prescribers, and with their professional organizations. They can also implement some of the environmental stewardship ideas suggested in this article. The time to act is now. Suzanne Singh (suzanne.singh@sinaihealth.ca) is a pharmacist at the Mount Sinai Academic Family Health Team and an Adjunct Lecturer at the Department of Family and Community Medicine at the University of Toronto. She is an advocate for enhancing the role of the pharmacist within integrated and innovative primary care practice models. References Patel A, Ratti R. Canadian Healthcare Network. Healing the people, harming the planet?(accessed July 31, 2022). Culley C, Stoynova V. How pharmacists can tackle climate change. (accessed July 31, 2022). Berry P, Schnitter R (eds). Health of Canadians in a changing climate: advancing our knowledge for action. February 2022; Ottawa, ON: Government of Canada. (accessed July 31, 2022). Drucker AM, Hollestein L, Na Y, et al. Association between antihypertensive medications and risk of skin cancer in people older than 65 years: a population-based study. CMAJ 2021;193(15):E508-E516. (accessed October 18, 2022). Hypertension Canada. Statement on thiazide diuretics and skin cancer. April 19, 2021. (accessed October 18, 2022). Royal Pharmaceutical Society. Creating a national movement on sustainable prescribing. https://www.rpharms.com/scotland/sustainable-prescribing (accessed July 31, 2022). Department of Health and Social Care. Good for you, good for us, good for everybody: a plan to reduce overprescribing to make patient care better and safer, support the NHS, and reduce carbon emissions. September 22, 2021. (accessed July 31, 2022). Roy C. The pharmacist’s role in climate change: a call to action. Can Pharm J 2021;154(2):74-5. Davidson I, Fleming L, Redshaw C, et al. Time to act: pharmacists must be prepared for environmental changes. Pharm J 2014. (accessed July 31, 2022). JanusInfo Region Stockholm: Pharmaceuticals and environment. (accessed July 31, 2022). Centre for Sustainable Health Systems. About the CoP sustainable inhaler initiative. (accessed July 31, 2022). Bartle B. Plastic pill vials. Can Pharm J 2019;153(1):10. Ray C. Antigonish pharmacy tackles waste with reusable glass vials. CBC News. January 24, 2022. (accessed July 31, 2022). Teasdale Apothecary, Antigonish, Nova Scotia. (accessed October 7, 2022). Anon. A green alternative to standard pill bottles. Fully-recyclable paper pill boxes feature safety locking steps. Canadian Healthcare Network November 1, 2022. (accessed November 2, 2022). Elbeddini A, Hooda N, Yang L. Role of Canadian pharmacists in managing drug shortage concerns amid the COVID-19 pandemic. Can Pharm J 2020;153(4):198-203. Ontario College of Pharmacists. Proper disposal of post-consumer medication returns. Pharmacy Connection. June 3, 2022. (accessed July 31, 2022). Afanasjeva J, Gruenberg K. Pharmacists as environmental stewards: strategies for minimizing and managing drug waste. Sustainable Chemistry and Pharmacy 2019;13:100164. Gahbauer A, Gruenberg K, Forrester C, et al. Climate care is health care: a call for collaborative pharmacy action. J Am Coll Clin Pharmacy 2021;4:631-8.

Environmental stewardship and medication management

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