What Is Your Pharmaceutical Footprint?

I have been a pharmacist for more than 30 years, and in that time, we have made great strides in recycling outdated and unusable medication.

Most medications expire and are unusable when they lose about 5% of their labeled potency and carry expiration dates determined by the manufacturer. For much of my career, we discarded, flushed, or poured down the drain those medications that were past the labeled expiration date but still probably 95% active. Results of studies have shown that some of this discarded active medication makes its way through the landfill and waste water treatment systems and into our drinking water. On the way, it can affect fish and aquatic life, and the ramifications of that are of concern though not fully understood. The effects of low-level antibiotics, hormones, and nonsteroidal anti-inflammatory agents in the water supply are being studied.

As a result, extensive efforts have been made to reduce this pollution waste and collect unused medication from consumers in community take-back programs and through reverse distributors and pharmaceutical waste collection in hospitals and retail pharmacies.

We are doing a better job of collecting and destroying unused and expired medication that previously went to landfills and in the sewer systems. But what about other sources of medication leakage into the environment? Believe it or not, much of the medications we consume are largely eliminated from our bodies intact. Yes, in our tears, sweat, urine, and feces, as much as 90% or more active drug or metabolites sometimes remain after the medication has completed its pharmaceutical duty in your body and then is lost to the environment. Studies have shown that this waste and the waste from personal-care products are some of the largest contributors in the waste stream, with perhaps as little as 50% removed by waste water plants.^1,2 These low levels of medications then find their way to our water supplies.³

My favorite example of a shocking part of the problem is the bone-building drug alendronate. Its most common form is a once-a-week pill (Fosamax, Binosto). This drug is exceedingly difficult for the body to absorb. To enhance its poor absorption, the manufacturer recommends that it is taken on an empty stomach first thing in the morning, sitting up for 30 minutes, with a full glass of water and no food. Well, if you do all of that correctly, less than 1%⁴ of the dose is bioavailable, and that is all you need for the medication to do its job. But, what about the other 99%? That likely ends up in the sewer system and much of that eventually goes into rivers or streams. For how long and exactly how much we don’t really know, but Environmental Protection Agency data collection on medication effluent is ongoing.

However, it is not all just about the amount absorbed. Medication in the bloodstream completes its pharmaceutical duty and then is usually metabolized to a form that the kidneys can eliminate or sometimes it is excreted back into the bowel. This can result in active drug, or active or inactive metabolites being eliminated. In a perfect world, the ideal medication would be 100% absorbed, effective, and metabolized to inactive metabolites or readily broken-down metabolites and eliminated from the body. Maybe someday.

For now, the question we must ask is, what is your personal pharmaceutical footprint? We are all familiar with, what is your carbon footprint, and how much to you personally contribute to the global warming with the CO2 gas your auto produces, etc.? In my practice, I frequently see patients who take 12 or more prescriptions. Are they really all necessary? As a pharmacist, I ask that question every day, and I usually always get the same response: “Yes, I need these medications my doctors have prescribed, and I have been on them for a long time.” But sometimes, I do identify therapeutic duplications, medications that haven’t been used in a long time and others that can be eliminated or combined into a single pill. Similarly, what about those personal care products we use every day? What is their final destination, how much goes into the environment, and what is the impact?

Maybe it is time for all of us to consider changing, reducing, or eliminating some of those medications and personal care products. Maybe there is a different medication that can be used that has a smaller pharmaceutical footprint. Perhaps a better diet, more exercise, or a lifestyle change would eliminate the need for some of those medications in the first place. Before you accuse me of “shaming” poor patients, consider the following things we can all do to reduce this hazard to the environment and other people:

• Take medications exactly as directed, with or without food (the most common), with a glass of water, on an empty stomach, etc. These directions are important and maximize the efficiency and amount of medication absorbed.
• Take the lowest effective dose. This includes creams and ointments. Work with your doctor.
• Apply creams and ointments just after bathing. This maximizes the time that the active ingredient is on the skin and minimizes the amount lost when bathing.
• Because losses in absorption of an oral pill are often significant, ask your doctor for an alternative dosage form. For example, a nasal spray, eye or ear drops, inhalant, or topical gel may deliver medication more directly to the target site.
• Discard used (topical patches) and outdated medications at a “take-back” program rather than flushing them down the toilet or discarding them the trash.
• Review medications with your doctor or pharmacist. Are there medications that can be eliminated, combined into a new agent, or that are no longer needed?
• Ask your doctor or pharmacist about the pharmaceutical footprint of prescribed medications. Is there a better option in the therapeutic category required?

So, what is in store for the future? The good news is that pharmaceutical manufacturers are working on nanotechnology, which is making the drug particles smaller and easier to absorb. This increases the efficiency and percent absorbed. The FDA is also looking at the issue and considering the environmental impact of medication “lost” to the environment in the drug approval process.

References

Bienkowski B. Only half of drugs removed by sewage treatment. Scientific American. scientificamerican.com/article/only-half-of-drugs-removed-by-sewage-treatment/2013. Published November 22, 2013. Accessed October 17, 2017.Daughton CG. Pharmaceuticals and personal care products in the environment: overarching issues and overview. Environmental Toxicology and Chemistry. 2009;28 (12):2495—2521.

Environmental Protection Agency. Concentrations of prioritized pharmaceuticals in effluents from 50 large treatment plants in the US and implications for risk estimation. epa.gov/water-research/concentrations-prioritized-pharmaceuticals-effluents-50-large-wastewater-treatment. Accessed Sept 19, 2017.

Fosamax [prescribing information]. Whitehouse Station, NJ: Merck & Co., Inc; 2012. merck.com/product/usa/pi_circulars/f/fosamax/fosamax_pi.pdf. Accessed October 17, 2017.