Environmental impact

The healthcare industry is increasingly asked to account for the negative climate and environmental impact generated through providing medical care.

In Scotland, every 10 days a 10-tonne truck of medicines waste is transported for incineration. There are associated costs with incineration; travel costs and environment impact (see the figure below). This is in addition to the direct costs of unused medicine.

Annual cost of managing medicines waste in Scotland

There are many factors which contribute to medicines waste and a Department of Health and Social Care report in September 2021⁵⁸ showed that over prescribing is commonplace, accounting for at least 10% of all prescribed medications.

This guidance supports reducing inappropriate prescribing by recommending person-centred medicine reviews; providing guidance and support for clinicians and promoting the use of non-pharmacological alternatives where available and effective. This may involve physical and social activities, lifestyle change and regular medicine reviews for those with long-term health conditions.

The Royal Pharmaceutical Society policy, ‘Pharmacy’s role in climate action and sustainable healthcare’,⁵⁹ identifies medicines as contributing 25% of carbon emissions in the NHS. This can be reduced by:

• improving prescribing and medicines use
• tackling medicines waste
• preventing ill health and
• improving infrastructure and ways of working

The Royal College of General Practitioners⁶⁰ has identified that prescribing accounts for over 60% of general practice’s carbon footprint.

Reduction of medicines waste can be achieved by ensuring appropriate prescribing and initiation of medicines, regular person-centred medication reviews to ensure continued effectiveness and deprescribing medicines where appropriate.

Reducing waste from medicines has a double carbon and environmental benefit by:

• reducing upstream emissions, e.g. those associated with distribution, and
• downstream emissions, where fewer medicines need to be disposed of

Medicines that are disposed of in general waste, poured down the sink or flushed down the toilet, increase the risk of environmental harm. Residues from medicines which are unused, not properly disposed of, or from those that pass through the body, can be found in water, soil and sludge and in organisms at all stages of their lifecycles.⁶¹

Unused or unwanted medicines should be returned to community pharmacy for safe disposal or recycling where available.

Sustainable Markets Initiative (SMI)

The Sustainable Markets Initiative established in 2020 identify seven levers to reduce carbon emissions in care pathways,⁶²

1. Decarbonising facilities and fleets
2. Preventing disease onset
3. Diagnosing early
4. Optimising disease management
5. Improving the efficiency of interventions
6. Delivering care remotely or closer to home when appropriate – digital innovations
7. Using lower-emission treatments where available

Pharmaceuticals in the water environment

The Royal Pharmaceutical Society’s Sustainability Policies also point to the occurrence of pharmaceuticals in the water environment.⁵⁹ Every oral dose of a medicine taken is excreted unchanged or converted to a metabolite with 30-100% entering our wastewater system, which cannot effectively remove all traces. The occurrence of pharmaceuticals in the environment is of global concern and the extent of the risks and impacts on human health and biota is growing. There is already evidence that they can affect aquatic wildlife, increase microbial resistance and enter the human food chain.

The consumption of antidepressants has increased on a global scale and continues to do so. These compounds have been detected in wastewater treatment plants and surface waters, raising concerns about their potential impacts on the environment. After exposure to antidepressants, aquatic life has been found to have behavioural, physical, cardiovascular and reproductive changes.⁶³

Current research using estimated risk quotients to predict levels of toxicity to aquatic life indicates that sertraline (RQ4.88), followed by citalopram (RQ 1.55) and bupropion (RQ 1.12) pose the highest known risk from antidepressant therapy to the aquatic environment.⁶³ Research into this area is evolving but highlights the need to prescribe medicines appropriately and consider non-pharmacological interventions where they are available and effective.

There is some existing evidence around the environmental impact of antidepressants globally and the need to ensure appropriate prescribing of antidepressants where indicated, alongside non-pharmacological interventions where available and appropriate.⁶⁴ However, a comprehensive Scotland-based environmental profile of antidepressants needs to be developed for use in the Scottish context.