Landfill disposal of unused medicines reduces surface water releases

Tracing COVID-19 drugs in the environment: Are we focusing on the right environmental compartment?

The Coronavirus Disease 2019 (COVID-19) pandemic led to over 770 million confirmed cases, straining public healthcare systems and necessitating extensive and prolonged use of synthetic chemical drugs around the globe for medical treatment and symptom relief. Concerns have arisen regarding the massive release of active pharmaceutical ingredients (APIs) and their metabolites into the environment, particularly through domestic sewage. While discussions surrounding this issue have primarily centered on their discharge into aquatic environments, particularly through treated effluent from municipal wastewater treatment plants (WWTPs), one often overlooked aspect is the terrestrial environment as a significant receptor of pharmaceutical-laden waste. This occurs through the disposal of sewage sludge, for instance, by applying biosolids to land or non-compliant disposal of sewage sludge, in addition to the routine disposal of expired and unused medications in municipal solid wastes. In this article, we surveyed sixteen approved pharmaceuticals for treating COVID-19 and bacterial co-infections, along with their primary metabolites. For this, we delved into their physiochemical properties, ecological toxicities, environmental persistence, and fate within municipal WWTPs. Emphasis was given on lipophilic substances with log Kow >3.0, which are more likely to be found in sewage sludge at significant factions (25.2%-75.0%) of their inputs in raw sewage and subsequently enter the terrestrial environment through land application of biosolids, e.g., 43% in the United States and as high as 96% in Ireland or non-compliant practices of sewage sludge disposal in developing communities, such as open dumping and land application without prior anaerobic digestion. The available evidence underscores the importance of adequately treating and disposing of sewage sludge before its final disposal or land application in an epidemic or pandemic scenario, as mismanaged sewage sludge could be a significant vector for releasing pharmaceutical compounds and their metabolites into the terrestrial environment.

Green hospital pharmacy: A sustainable approach to the medication use process in a tertiary hospital

BACKGROUND

Sustainable management of healthcare waste has a positive impact on the global environment. In order to reduce it, the sustainable practice of the pharmacotherapeutic process in all its stages is essential.

OBJECTIVE

To analyse the sustainability strategies proposed by the pharmacy service to reduce drug waste derived from the pharmacotherapeutic process.

SECONDARY OBJECTIVES

To analyse the stage of the pharmacotherapeutic process and the number and type of drugs involved.

METHODS

The study was carried out in a tertiary-level hospital. To coordinate the proposals, a referent pharmacist from every pharmacy department area was selected. Four stages of the process were evaluated (management, validation, dispensing and compounding), patients concerned were classified as outpatients or inpatients, and drugs potentially involved were analysed by the administration route: Into oral or parenteral.

RESULTS

Twenty eight ideas were proposed, which could affect more than 1200 drugs. 39.3% would affect the validation process, 17.9% the procurement management, 17.9% dispensing, and 7.1% the compounding. Implementation feasibility and acceptability of these proposals were evaluated. Those with the greatest potential were: Limiting the duration of treatments when possible, favouring the implementation of computer prescription order entry, favouring the use of the oral route over the parenteral route, and implementing computers in the preparation areas to avoid the use of paper guides.

DISCUSION

In our study, many ideas have been proposed by hospital pharmacists to improve the sustainability of the medication use process. When assessing these proposals by impact and feasibility, according to our results, shorten as much as possible the duration of treatments, computerization of the medication use process, and oral administration over intravenous should be prioritized in order to reduce environmental impact.

Green hospital pharmacy: A sustainable approach to the medication use process in a tertiary hospital

BACKGROUND

Sustainable management of healthcare waste has a positive impact on the global environment. In order to reduce it, the sustainable practice of the pharmacotherapeutic process in all its stages is essential.

OBJECTIVE

To analyze the sustainability strategies proposed by the pharmacy service to reduce drug waste derived from the pharmacotherapeutic process.

SECONDARY OBJECTIVES

to analyze the stage of the pharmacotherapeutic process and the number and type of drugs involved.

METHODS

The study was carried out in a tertiary level hospital. To coordinate the proposals, a referent pharmacist from every pharmacy department area was selected. Four stages of the process were evaluated (procurement, validation, dispensing and compounding), patients concerned were classified as outpatients or inpatients, and drugs potentially involved were analyzed by the administration route: into oral or parenteral.

RESULTS

28 ideas were proposed, which could affect more than 1200 drugs. 39.3% would affect the validation process, 17.9% the procurement management, 17.9% dispensing and 7.1% the compounding. Implementation feasibility and acceptability of these proposals were evaluated. Those with the greatest potential were: limiting the duration of treatments when possible, favoring the implementation of computer prescription order entry, favoring the use of the oral route over the parenteral route, and implementing computers in the preparation areas to avoid the use of paper guides.

DISCUSSION

In our study, many ideas have been proposed by hospital pharmacists to improve the sustainability of the medication use process. When assessing these proposals by impact and feasibility, according to our results, shorten as much as possible the duration of treatments, computerization of the medication use process and oral administration over intravenous should be prioritized in order to reduce environmental impact.

Estimating the Mass of Pharmaceuticals Harbored in Municipal Solid Waste Landfills by Analyzing Refuse Samples at Various Ages and Depths

Pharmaceuticals have been detected at high concentrations in municipal solid waste (MSW) landfill leachates, which are recognized as an underestimated source of pharmaceutical residues in the environment. However, limited efforts have been made to characterize pharmaceuticals in MSW landfill refuse, which is also of significant concern given the potential long-term environmental impact. Herein, we excavated landfill refuse from six cells with landfill ages of 7-27 years in the largest MSW landfill in Shanghai (in each cell, landfill refuse was collected from different depths of 2-8 m) and analyzed samples for the presence of 55 pharmaceuticals, including antibiotics and non-antibiotics. The results reveal the presence of 42 pharmaceuticals in landfill refuse, with median concentrations ranging from 0.30 to 116 μg/kg. Antibiotic and non-antibiotic pharmaceuticals exhibited diverse concentration trends with age, related to changes in policy intervention and consumption over time. Different concentration variations of individual pharmaceuticals were observed in refuse samples excavated at different depths and positively correlated to their sorption ability. The mass of pharmaceuticals in the investigated landfill was estimated from the obtained concentrations to be 80-220 tons with 95% probability, based on Monte Carlo analysis. To the best of our knowledge, this study provides the first estimate of pharmaceutical mass in an MSW landfill. The results will be helpful for understanding the potential long-term environmental impact of pharmaceuticals in landfills.

Sulfonamide and tetracycline in landfill leachates from seven municipal solid waste (MSW) landfills: Seasonal variation and risk assessment

Antibiotics have received increased attention as emerging contaminants due to their toxicity and potential risk. Landfills serve as one of the important reservoirs of antibiotics. The antibiotics in landfills leaching to nearby environment by leachate may threat ecosystem health. The present study aimed to evaluate the levels of tetracyclines (TCs) and sulfonamides (SAs) in seven Chinese Municipal Solid Waste (MSW) landfill leachates over two years (2017-2018). Seven target antibiotics, TC, oxytetracycline (OTC), doxycycline (DXC), sulfonamide sulfadiazine (SD), sulfamerazine (SM), sulfamethazine (SMX), and sulfamethoxazole (SMT), were detected in 56 landfill leachate samples. Among these, SMT had the highest mean concentration at 654 ng/L (n = 45), followed by OTC (219.58 ng/L, n = 47), and SD (209.98 ng/L, n = 49). The temporal trend showed that antibiotic concentrations were higher in 2017 than in 2018. Furthermore, physicochemical properties were significantly correlated with SAs (p < 0.05), whereas no significant correlation was found for TCs. Seasonal variation analysis revealed that antibiotic levels were higher in spring and winter compared to summer and fall seasons, which might be attributed to the higher waterfall levels in these seasons. Risk assessment revealed that SAs (SM, SMX, SMT) are associated with high risk, and the RQs follow the order of: SMX > SMT > SM. In contrast, TCs had insignificant risk. The findings of this two-year comprehensive monitoring project have produced positive results regarding antibiotic pollution at landfill sites, which can be applied to antibiotics management in landfill and further ensure public health.

Management of pharmaceutical micropollutants discharged in urban waters: 30 years of systematic review looking at opportunities for developing countries

Pharmaceutical micropollutants' contamination of urban waters has been studied globally for decades, but the concentration of innovations in management initiatives is still in developed economies. The gap between the locus of innovations in pharmaceuticals and the relative stagnation in less developed economies to manage waste originating in this activity seems fruitful for investigations on innovation in integrated micropollutant management strategies. These tensions allow for advances in current knowledge for environmental management and, particularly, finding solutions for the contamination by pharmaceutical micropollutants of urban water bodies in developing countries. We aim to list the main strategies for managing pharmaceutical micropollutants discussed to point out opportunities for developing countries to advance in this direction. Methodologically, we conducted a systematic literature review from 1990 to 2020, covering 3027 documents on "pharmaceutical micropollutants management." The framework formed by the macro-approach to integrated management operationalized by the dimensional micro-approaches: technical, organizational, community, and governmental allowed us to understand that (1) the management of pharmaceutical micropollutants tends to occur through a technical approach centered on the removal of aquatic matrices, green chemistry, and urine diversion; (2) management with an organizational approach has enabled removing drugs from water bodies by drug take-back program, collaborative projects, drug use reduction, and better organizational practices; (3) the community approach have helped minimize this type of pollution by reducing the consumption of medicines and the proper destination for medicines that are no longer in use. Finally, the government management approach emerges as a source of legal, economic, and informational instruments to reduce pollution by pharmaceutical micropollutants. Furthermore, these management approaches allowed us to identify 15 opportunities for possible adjustments for developing societies. These opportunities can be promising for practices and research and, in the medium term, contribute to minimizing pollution by pharmaceutical micropollutants in urban waters.

Photochemical mineralization of amoxicillin medicinal product by means of UV, hydrogen peroxide, titanium dioxide and iron

In the present study, the photochemical degradation of amoxicillin and total organic carbon (TOC) removal in pharmaceutical aqueous solutions was studied using UV irradiation, titanium dioxide, hydrogen peroxide and iron in a batch photoreactor operated for 120-150 min. The effect of the initial concentrations of the target compound, hydrogen peroxide and ferric ions and of their combination was examined. It was found that under direct UV photolysis, considerable TOC removals were obtained only when the initial concentration of amoxicillin (AM) was below 100 mg/L. For initial concentration of AM 250 mg/L, the TOC removals achieved were of no practical use (below 5%). The TOC removals achieved in the presence of TiO₂ were lower than 20% in all cases. In the presence of hydrogen peroxide in the range of 12.2-146.9 mmol/L and initial AM concentration 250 mg/L, for increasing H₂O₂ concentrations higher TOC removals were achieved up to the concentration of 73.4 mmol/L H₂O₂. The presence of even very small amounts of Fe(III) in the solution resulted in significantly increased TOC removals; 2.2 times higher than without Fe(III) after 120 min. Fe(III) presence accelerated dramatically the process during the first 60 min. The origin of Fe(III) ions was not important since practically the same results were obtained whether FeCl₃ or Fe(NO₃)₃ was used as source of ferric ions. Adjusting the initial concentrations of AM, Fe(III) and H₂O₂, TOC removals above 90% were achieved.

Disposal Practices of Unused and Leftover Medicines in the Households of Dhaka Metropolis

Background: This fact-finding study aimed to attain an overall idea and knowledge about medicine disposal practices in Dhaka Metropolitan households. Methods: This mixed study (both quantitative and qualitative) was orchestrated to inspect the household leftover medicine disposal pattern's governing status. A cross-sectional survey was conducted following a structured questionnaire and key informant interview with a household person and in-depth interviews with the top pharmaceutical and government officials. Results: Findings disclose that, for most of the key informants, the terms "drug disposal" and "drug pollution" were unknown; more precisely, 67% and 74% of key informants even did not hear these two terms. Almost all (87%) households faced undesired incidents due to the insecure storage of medicines. People disposed of excess and expired medication in regular dustbins (47%), threw out of the window (19%), flushed within commode (4%), burnt in fire (2%), and reused (4%). A good percentage of people (21%) returned unexpired drugs to the pharmacy and bought other medicines on a need basis. A total of 72% wanted a medicine take-back program, and 100% agreed on mass education on this issue. Officials of pharmaceuticals conferred mixed opinion: top-ranked pharmaceuticals will adopt leftover medicine disposal practices; middle and low-ranked pharmaceutical companies are reluctant, merely denied mentioning the less important issue. Conclusions: The absence of mass awareness and standard laws and policies may explain these existing aberrant practices.

A review of pharmaceutical occurrence and pathways in the aquatic environment in the context of a changing climate and the COVID-19 pandemic

Active pharmaceutical ingredients (APIs) are increasingly being identified as contaminants of emerging concern (CECs). They have potentially detrimental ecological and human health impacts but most are not currently subject to environmental regulation. Addressing the life cycle of these pharmaceuticals plays a significant role in identifying the potential sources and understanding the environmental impact that pharmaceuticals may have in surface waters. The stability and biological activity of these "micro-pollutants" can lead to a pseudo persistence, with ensuing unknown chronic behavioural and health-related effects. Research that investigates pharmaceuticals predominantly focuses on their occurrence and effect within surface water environments. However, this review will help to collate this information with factors that affect their environmental concentration. This review focuses on six pharmaceuticals (clarithromycin, ciprofloxacin, sulfamethoxazole, venlafaxine, gemfibrozil and diclofenac), chosen because they are heavily consumed globally, have poor removal rates in conventional activated sludge wastewater treatment plants (CAS WWTPs), and are persistent in the aquatic environment. Furthermore, these pharmaceuticals are included in numerous published prioritisation studies and/or are on the Water Framework Directive (WFD) "Watch List" or are candidates for the updated Watch List (WL). This review investigates the concentrations seen in European Union (EU) surface waters and examines factors that influence final concentrations prior to release, thus giving a holistic overview on the source of pharmaceutical surface water pollution. A period of 10 years is covered by this review, which includes research from 2009-2020 examining over 100 published studies, and highlighting that pharmaceuticals can pose a severe risk to surface water environments, with each stage of the lifecycle of the pharmaceutical determining its concentration. This review additionally highlights the necessity to improve education surrounding appropriate use, disposal and waste management of pharmaceuticals, while implementing a source directed and end of pipe approach to reduce pharmaceutical occurrence in surface waters.

Pharmacy students' knowledge and practices concerning the storing and disposal of household medication in Saudi Arabia

INTRODUCTION

Pharmacists, and thus pharmacy students, must participate in promoting awareness about proper storage and disposal of expired or unused medications. This study aimed to determine Saudi Arabian pharmacy students' knowledge and personal practices regarding storing and disposing of household medications.

METHODS

This was a descriptive, cross-sectional, questionnaire-based study of pharmacy undergraduates or postgraduates across Saudi Arabia. The online survey was distributed to a convenience sample of participants and supplemented with snowball sampling on social media.

RESULTS

Of 807 pharmacy students who viewed the questionnaire, 464 students completed it (response rate 57.5%). Common reasons for keeping medications included having left-over medication (74%) and self-discontinuation of therapy (63.5%). The majority of students (79%) stored their medication in a bedroom or kitchen. Gender-specific variables revealed a gender difference in storing and disposing of these medications. Many students reported previously discarding medicines in the garbage (89%) or giving them to someone else to use (22%). More than half of the sample (60%) had not received any information on how to store or dispose of medications.

CONCLUSIONS

The current practice and knowledge of Saudi Arabian pharmacy students regarding storage and disposal of household medications was inappropriate. Concerned authorities (e.g., Ministry of Health, Ministry of Education) should provide proper education to all students on the safe storage and disposal of medications, which may necessitate curriculum reform.

Expired Medication: Societal, Regulatory and Ethical Aspects of a Wasted Opportunity

A massive volume of expired medications amasses annually around the world because of pharmaceutical overprescription, combined with overproduction. The accumulation of pharmaceutical waste imposes ecological, economic and social/ethical burdens. Managing this presumed “waste” has developed into a global challenge due to the absence of specific regulations, unreasonable behavior of the patients, and an improper understanding of the concept of “expired medications” in general. This paper summaries, first, the recent literature reporting practices related to the disposal of unused medications. In this context, 48 papers from 34 countries with a total of 33,832 participants point towards a significant lack of public awareness regarding the appropriate disposal of such biologically potent chemicals. These findings are corroborated by a local survey on the disposal practices of unused medicines among pharmacy students at Saarland University. The regulatory aspects surrounding this topic, often based on the official guidelines for the disposal of expired medications and local waste management strategies, are then discussed in light of these findings. Finally, a closer inspection of the epistemic values of expired medications and different strategies for managing expired medications have been reviewed.

Photochemical mineralization of Ibuprofen medicinal product by means of UV, hydrogen peroxide, titanium dioxide and iron

Pharmaceutical compounds contribute to the emerging pollutants in water and in many cases, they are not efficiently mineralized by conventional treatment methods. At the same time, landfills remain the main final destination of discarded drugs. In the present study, the mineralization of the Ibuprofen medicinal commercial product (Algofren^®) in aqueous solutions using UV irradiation, hydrogen peroxide, titanium dioxide and ferric ions was examined. All experiments were conducted in a batch photoreactor operated for 120-150 min. The main target was to select the most effective operating conditions for the mineralization of the solutions treated. Single photolysis or TiO₂ photocatalysis were proved inefficient in eliminating the total organic carbon (TOC). By adjusting the initial amounts of Ibuprofen product and hydrogen peroxide, 81% TOC removal was achieved after 120 min. Adding iron in the solution led to a higher mineralization degree, especially during the first 30 min of the process. Iron was shown also to decrease the environmental footprint of the process as expressed via the electric energy per order, E_Eo.

Risks associated with the environmental release of pharmaceuticals on the U.S. Food and Drug Administration "flush list"

A select few prescription drugs can be especially harmful and, in some cases, fatal with just one dose when not used as prescribed. Therefore, the U. S. Food and Drug Administration (FDA) recommends that expired, unwanted, or otherwise unused portions of most of these drugs be disposed of quickly through a take-back program. If such an option is not readily available, FDA recommends that they be flushed down the sink or toilet. The goal of the current investigation was to evaluate the ecological and human-health risks associated with the environmental release of the 15 active pharmaceutical ingredients (APIs) currently on the FDA "flush list". The evaluation suggests that even when highly conservative assumptions are used-including that the entire API mass supplied for clinical use is flushed, all relevant sources in addition to clinical use of the API are considered, and no metabolic loss, environmental degradation, or dilution of wastewater effluents are used in estimating environmental concentrations-most of these APIs present a negligible eco-toxicological risk, both as individual compounds and as a mixture. For a few of these APIs, additional eco-toxicological data will need to be developed. Using similar conservative assumptions for human-health risks, all 15 APIs present negligible risk through ingestion of water and fish.

Disposal of Unused Drugs: Knowledge and Behavior Among People Around the World

The purpose of this systematic review was to determine the practice of medication disposal around the world and get insight into possible association between environmental awareness and people's behavior regarding this issue. A literature search (2005-2015) was performed to identify reports with quantitative data on disposal practices published in peer-reviewed literature. The most common method for disposal of unused medications in households is disposal in the garbage (Kuwait, United Kingdom, Lithuania, Qatar, Serbia, Ghana, Bangladesh, Malta and Saudi Arabia). The practice of flushing drugs into the sewage system still takes place in New Zealand, USA and Bangladesh. Only in Sweden and Germany, practice of returning drugs to pharmacy was practiced to a larger extent. The environmental impact of improper medication disposal is expected in countries with poorly functioning waste management schemes (Middle Eastern, Asian and African countries). Lack of the adequate information and clear instructions on proper manners of drug disposal was reported in many surveyed countries (USA, New Zealand, Bangladesh, Malta and Ireland). Clear and definite connection between knowledge about environmental detrimental effects of improper drug disposal and the preference towards disposal methods could not be established. Many respondents were generally concerned with issues of inadequate medicines discarding but the behavior regarding disposal of unused drugs often did not equate the awareness (Serbia, USA, Kuwait, Malta and UK). The current data emphasizes the global issue of improper medicine disposal, prevalent in environmentally-aware people.

Use of acute and chronic ecotoxicity data in environmental risk assessment of pharmaceuticals

For many older pharmaceuticals, chronic aquatic toxicity data are limited. To assess risk during development, scale-up, and manufacturing processes, acute data and physicochemical properties need to be leveraged to reduce potential long-term impacts to the environment. Aquatic toxicity data were pooled from daphnid, fish, and algae studies for 102 active pharmaceutical ingredients (APIs) to evaluate the relationship between predicted no-effect concentrations (PNECs) derived from acute and chronic tests. The relationships between acute and chronic aquatic toxicity and the n-octanol/water distribution coefficient (D(OW)) were also characterized. Statistically significant but weak correlations were observed between toxicity and log D(OW), indicating that D(OW) is not the only contributor to toxicity. Both acute and chronic PNEC values could be calculated for 60 of the 102 APIs. For most compounds, PNECs derived from acute data were lower than PNECs derived from chronic data, with the exception of steroid estrogens. Seven percent of the PNECs derived from acute data were below the European Union action limit of 0.01 μg/L and all were anti-infectives affecting algal species. Eight percent of available PNECs derived from chronic data were below the European Union action limit, and fish were the most sensitive species for all but 1 API. These analyses suggest that the use of acute data may be acceptable if chronic data are unavailable, unless specific mode of action concerns suggest otherwise.

A risk-based approach to managing active pharmaceutical ingredients in manufacturing effluent

The present study describes guidance intended to assist pharmaceutical manufacturers in assessing, mitigating, and managing the potential environmental impacts of active pharmaceutical ingredients (APIs) in wastewater from manufacturing operations, including those from external suppliers. The tools are not a substitute for compliance with local regulatory requirements but rather are intended to help manufacturers achieve the general standard of "no discharge of APIs in toxic amounts." The approaches detailed in the present study identify practices for assessing potential environmental risks from APIs in manufacturing effluent and outline measures that can be used to reduce the risk, including selective application of available treatment technologies. These measures either are commonly employed within the industry or have been implemented to a more limited extent based on local circumstances. Much of the material is based on company experience and case studies discussed at an industry workshop held on this topic.