Environmental considerations along the life cycle of pharmaceuticals: Interview study on views regarding environmental challenges, concerns, strategies, and prospects within the pharmaceutical industry

Environmental impacts of medicines arise throughout their entire life cycle. The pharmaceutical industry has a key role in reducing these impacts in early production phases, but currently has limited possibilities to reduce the environmental exposure arising from drug consumption and end-of-life. The aim of this interview study was to explore the current environmental actions within the industry, as well as the views and attitudes toward the strategies to address the environmental challenges and concerns. Semi-structured interviews were conducted among representatives (n = 15) from twelve pharmaceutical companies operating in Finland in February-May 2021. The data were analyzed using qualitative content analysis. The representatives of pharmaceutical industry were overall well aware of the multifaceted environmental challenges related to the life cycle of pharmaceuticals and of their role in improving sustainability in production. Improving waste management and reducing impacts from companies' own operations were the most commonly mentioned actions already taking place within the companies (15/15). "Environmental impacts arising from drug consumption" (6/15) and "centralized drug manufacturing in countries with lax environmental regulation" (4/15) were most frequently brought up challenges difficult to resolve. "Development of environmentally more sustainable drug production in the company" was the most frequently raised key development need (5/15). To address this, establishment of tangible economic drivers, regulatory incentives, or reputational rewards were called for. "Incorporation of environmental aspects into decision-making in different situations" was suggested by 11/15 interviewees as a means to promote sustainable development, e.g. in selection of medicines by physicians and consumers. However, the attitudes towards the types of criteria and their evaluation differed between interviewees. Attitudes towards the "incorporation of environmental fate assessment into early phases of drug design and development" were mostly positive (10/11), suggesting that there is a keen interest in the industry to foster the introduction of new tools enabling the development of pharmaceuticals intrinsically less harmful for the environment.

Knowledge and attitude about drug pollution in pharmacy students: A questionnaire-based cross sectional study

INTRODUCTION

The environmental impact of drugs or pharmaceuticals is an issue of growing concern. Healthcare professionals, and pharmacists in particular, are used to managing medicines, yet aspects about drug pollution are generally neglected in schools of pharmacy worldwide. Formation in this issue is essential to tackle the problem. In this study, we aimed to find out the degree of knowledge about the problem of pharmaceuticals in the environment and the attitude about the matter of pharmacy students at the University of the Basque Country.

METHODS

We conducted a pilot study (186 students) using an online questionnaire available in two languages (Basque and Spanish). The attitude scale was validated for Spanish. To improve participation, a combination of indirect and direct recruitment was applied in the final study.

RESULTS

Four hundred eighty-seven students participated in the final study (response rate: 65.8%). The final questionnaire contained a total of 25 questions: 13 (knowledge), eight (attitude), and three (opinion). The results showed that knowledge can be considered relatively poor, whereas attitude was generally positive, and students considered drug pollution to be a relevant issue in general and in pharmacy practice.

CONCLUSIONS

We believe there is an urgent need to include aspects about pharmaceuticals in the environment in pharmacy studies worldwide.

The assessment of environmental risk related to the occurrence of pharmaceuticals in bottom sediments of the Odra River estuary (SW Baltic Sea)

The occurrence of 130 pharmaceutically active compounds (PhACs) in sediments collected from 70 sampling sites in the Odra River estuary (SW Baltic Sea) was investigated. The highest concentration levels of the compounds were found in the vicinity of effluent discharge from two main Szczecin wastewater treatment plants: "Pomorzany" and "Zdroje", and nearby the seaport and shipyard. The highest environmental risks (RQ > 1) were observed for pseudoephedrine (RQ = 14.0), clindamycin (RQ = 7.3), nalidixic acid (RQ = 3.8), carbamazepine (RQ = 1.8), fexofenadine (RQ = 1.4), propranolol (RQ = 1.1), and thiabendazole (RQ = 1.1). RQ for each compound varied depending on the sampling sites. High environmental risk was observed in 30 sampling sites for clindamycin, 22 sampling sites for pseudoephedrine, 19 sampling sites for nalidixic acid, 4 sampling sites for carbamazepine, and 3 sampling sites for fexofenadine. The medium environmental risk (0.1 < RQ < 1) was observed for 16 compounds: amisulpride, amitriptyline, amlodipine, atropine, bisoprolol, chlorpromazine, lincomycin, metoprolol, mirtazapine, moclobemide, ofloxacin, oxazepam, tiapride, tolperisone, verapamil, and xylometazoline. Due to the scarcity of toxicological data related to benthic organisms, only an approximate assessment of the environmental risk of PhACs is possible. Nevertheless, the compounds with medium and high risk should be considered as pollutants of high environmental concern whose occurrence in the environment should remain under close scrutiny.

Hazardous drugs (NIOSH's list-group 1) in healthcare settings: Also a hazard for the environment?

Healthcare workers can be exposed to dangerous drugs during their daily practice. The National Institute for Occupational Safety and Health (NIOSH) considers "hazardous drugs" as those that had shown one or more of the following characteristic in studies with animals, humans or in vitro systems: carcinogenicity, teratogenicity or other toxicity for development, reproductive toxicity, organ toxicity at low doses, or genotoxicity. In the actual list (draft list 2020), drugs classified in group 1 are those with carcinogenic effects. Moreover, the global human and veterinary cancer is expected to grow, so antineoplastic drug consumption may consequently grow, leading to an increase of anticancer pharmaceuticals in the environment. Not all drugs pertaining to group 1 can be classified as "antineoplastic" or "cytostatic". Since most of the research on environment presence and ecotoxicological effects of pharmaceuticals has been focused on this therapeutic class, other carcinogenic drugs belonging to different therapeutic groups may have been omitted in previous studies. In this study we aim to review the presence in the environment of the hazardous drugs (NIOSH group 1) and their possible environmental impact. Of the 90 drugs considered, there is evidence of presence in the environment for 19. Drugs with more studies reporting positive detections are: the antibiotic chloramphenicol (55), the alkylating agents cyclophosphamide (39) and ifosfamide (30), and the estrogen receptor modulator tamoxifen (18). Although the original purpose of the NIOSH list and related documents is to provide guidance to healthcare professionals in order to adequately protect them from the hazards posed by these drugs in healthcare settings, we believe they can be useful for environmentalists too. Absence of data regarding the potential of environmental risk of certain hazardous drugs might tell us which drugs ought to be prioritized in the future.

Experimental safety testing shows that the NSAID tolfenamic acid is not toxic to Gyps vultures in India at concentrations likely to be encountered in cattle carcasses

Population declines of Gyps vultures across the Indian subcontinent were caused by unintentional poisoning by the non-steroidal anti-inflammatory drug (NSAID) diclofenac. Subsequently, a number of other NSAIDs have been identified as toxic to vultures, while one, meloxicam, is safe at concentrations likely to be encountered by vultures in the wild. Other vulture-safe drugs need to be identified to reduce the use of those toxic to vultures. We report on safety-testing experiments on the NSAID tolfenamic acid on captive vultures of three Gyps species, all of which are susceptible to diclofenac poisoning. Firstly, we estimated the maximum level of exposure (MLE) of wild vultures and gave this dose to 40 Near Threatened Himalayan Griffons G. himalayensis by oral gavage, with 15 control birds dosed with benzyl alcohol (the carrier solution for tolfenamic acid). Two birds given tolfenamic acid died with elevated uric acid levels and severe visceral gout, while the remainder showed no adverse clinical or biochemical signs. Secondly, four G. himalayensis were fed tissues from water buffaloes which had been treated with double the recommended veterinary dose of tolfenamic acid prior to death and compared to two birds fed uncontaminated tissue; none suffered any clinical effects. Finally, two captive Critically Endangered vultures, one G. bengalensis and one G. indicus, were given the MLE dose by gavage and compared to two control birds; again, none suffered any clinical effects. The death of two G. himalayensis may have been an anomaly due to i) the high dose level used and ii) the high ambient temperatures at the time of the experiment. Tolfenamic acid is likely to be safe to Gyps vultures at concentrations encountered by wild birds and could therefore be promoted as a safe alternative to toxic NSAIDs. It is manufactured in the region, and is increasingly being used to treat livestock.

The non-steroidal anti-inflammatory drug nimesulide kills Gyps vultures at concentrations found in the muscle of treated cattle

Throughout South Asia, cattle are regularly treated with non-steroidal anti-inflammatory drugs (NSAIDs) and their carcasses are left for scavengers to consume. Residues of the NSAID diclofenac in cattle carcasses caused widespread mortality and catastrophic population declines in three species of Gyps vulture during the 1990s and 2000s. Diclofenac is now banned, but other NSAIDs are used in its place. Different lines of evidence, including safety testing in Gyps vultures, have shown that some of these other NSAIDs are toxic, or probably toxic, to vultures. The NSAID nimesulide is widely available and commonly used, and has been found in dead vultures with signs of renal failure (i.e. visceral gout) and without the presence of diclofenac and/or other vulture-toxic NSAIDs. Nimesulide is therefore probably toxic to vultures. Here, we report safety testing of nimesulide in Gyps vultures. In a controlled toxicity experiment, we gave two vultures the maximum likely exposure (MLE) of nimesulide calculated from initial pharmacokinetic and residue experiments in cattle. Two other control birds were given an oral dose of water. Both vultures dosed with nimesulide died within 30 h, after showing outward signs of toxicity and increases in biochemical indicators of renal failure. Post-mortem examinations found extensive visceral gout in both vultures. Both control vultures survived without biochemical indicators of renal failure. With this evidence, we call for an immediate and comprehensive ban of nimesulide throughout South Asia to ensure the survival of the region's Critically Endangered vultures. More generally, testing the impacts of drugs on non-target species should be the responsibility of the pharmaceutical industry, before their veterinary use is licensed.

Drug pollution & Sustainable Development Goals

The United Nations set "The 2030 Agenda for Sustainable Development," which includes the Sustainable Development Goals (SDGs), a collection of 17 global goals designed to be a "blueprint to achieve a better and more sustainable future for all". Although only mentioned in one of the seventeen goals (goal 3), we argue that drugs in general, and growing drug pollution in particular, affects the SDGs in deeper, not readily apparent ways. So far, the emerging problem of drug pollution has not been sufficiently addressed. Here, we outline and discuss how drug pollution can affect SDGs and even threaten their achievement.

A comprehensive aquatic risk assessment of the beta-blocker propranolol, based on the results of over 600 research papers

A comprehensive aquatic environmental risk assessment (ERA) of the human pharmaceutical propranolol was conducted, based on all available scientific literature. Over 200 papers provided information on environmental concentrations (77 of which provided river concentrations) and 98 dealt with potential environmental effects. The median concentration of propranolol in rivers was 7.1 ng/L (range of median values of individual studies 0.07 to 89 ng/L), and the highest individual value was 590 ng/L. Sixty-eight EC50 values for 35 species were available. The lowest EC50 value was 0.084 mg/L. A species sensitivity distribution (SSD) provided an HC50 value of 6.64 mg/L and an HC5 value of 0.22 mg/L. Thus, there was a difference of nearly 6 orders of magnitude between the median river concentration and the HC50 value, and over 4 orders of magnitude between the median river concentration and the HC5 value. Even if an assessment factor of 100 was applied to the HC5 value, to provide considerable protection to all species, the safety margin is over 100-fold. However, nearly half of all papers reporting effects of propranolol did not provide an EC50 value. Some reported that very low concentrations of propranolol caused effects. The lowest concentration reported to cause an effect - in fact, a range of biochemical and physiological effects on mussels - was 0.3 ng/L. In none of these 'low concentration' papers was a sigmoidal concentration-response relationship obtained. Although inclusion of data from these papers in the ERA cause a change in the conclusion reached, we are sceptical of the repeatability of these 'low concentration' results. We conclude that concentrations of propranolol present currently in rivers throughout the world do not constitute a risk to aquatic organisms. We discuss the need to improve the quality of ecotoxicology research so that more robust ERAs acceptable to all stakeholders can be completed.

Environmental pollution with psychiatric drugs

Among all contaminants of emerging interest, drugs are the ones that give rise to the greatest concern. Any of the multiple stages of the drug's life cycle (production, consumption and waste management) is a possible entry point to the different environmental matrices. Psychiatric drugs have received special attention because of two reasons. First, their use is increasing. Second, many of them act on phylogenetically highly conserved neuroendocrine systems, so they have the potential to affect many non-target organisms. Currently, wastewater is considered the most important source of drugs to the environment. Furthermore, the currently available wastewater treatment plants are not specifically prepared to remove drugs, so they reach practically all environmental matrices, even tap water. As drugs are designed to produce pharmacological effects at low concentrations, they are capable of producing ecotoxicological effects on microorganisms, flora and fauna, even on human health. It has also been observed that certain antidepressants and antipsychotics can bioaccumulate along the food chain. Drug pollution is a complicated and diffuse problem characterized by scientific uncertainties, a large number of stakeholders with different values and interests, and enormous complexity. Possible solutions consist on acting at source, using medicines more rationally, eco-prescribing or prescribing greener drugs, designing pharmaceuticals that are more readily biodegraded, educating both health professionals and citizens, and improving coordination and collaboration between environmental and healthcare sciences. Besides, end of pipe measures like improving or developing new purification systems (biological, physical, chemical, combination) that eliminate these residues efficiently and at a sustainable cost should be a priority. Here, we describe and discuss the main aspects of drug pollution, highlighting the specific issues of psychiatric drugs.

Antipsychotics as environmental pollutants: An underrated threat?

The heterogeneous class of what we nowadays call antipsychotics was born almost 70 years ago with the serendipitous discovery of chlorpromazine. Their utilization is constantly growing because they are used to treat a diverse group of diseases and patients across all age groups: schizophrenia, bipolar disease, depression, autism, attention deficit hyperactivity disorder, behavioural and psychological symptoms in dementia, among others. They possess a complex pharmacological profile, acting on multiple receptors: dopaminergic, serotoninergic, histaminergic, adrenergic, and cholinergic, leading scientists to call them "agents with rich pharmacology" or "dirty drugs". Serotonin, dopamine, acetylcholine, noradrenaline, histamine and their respective receptors are evolutionary ancient compounds, and as such, are found in many different living beings in the environment. Antipsychotics do not disappear once excreted by patient's urine or faeces and are transported to wastewater treatment plants. But as these plant's technology is not designed to eliminate drugs and their metabolites, a variable proportion of the administered dose ends up in the environment, where they have been found in almost every matrix: municipal wastewater, hospital sewage, rivers, lakes, sea and even drinking water. We believe that reported concentrations found in the environment might be high enough to exert significant effect to aquatic wildlife. Besides, recent studies suggest antipsychotics, among others, are very likely bioaccumulating through the web food. Crucially, psychotropics may provoke behavioural changes affecting populations' dynamics at lower concentrations. We believe that so far, antipsychotics have not received the attention they deserve with regards to drug pollution, and that their role as environmental pollutants has been underrated.

Pharmacology-informed prediction of the risk posed to fish by mixtures of non-steroidal anti-inflammatory drugs (NSAIDs) in the environment

The presence of non-steroidal anti-inflammatory drugs (NSAIDs) in the aquatic environment has raised concern that chronic exposure to these compounds may cause adverse effects in wild fish populations. This potential scenario has led some stakeholders to advocate a stricter regulation of NSAIDs, especially diclofenac. Considering their global clinical importance for the management of pain and inflammation, any regulation that may affect patient access to NSAIDs will have considerable implications for public health. The current environmental risk assessment of NSAIDs is driven by the results of a limited number of standard toxicity tests and does not take into account mechanistic and pharmacological considerations. Here we present a pharmacology-informed framework that enables the prediction of the risk posed to fish by 25 different NSAIDs and their dynamic mixtures. Using network pharmacology approaches, we demonstrated that these 25 NSAIDs display a significant mechanistic promiscuity that could enhance the risk of target-mediated mixture effects near environmentally relevant concentrations. Integrating NSAIDs pharmacokinetic and pharmacodynamic features, we provide highly specific predictions of the adverse phenotypes associated with exposure to NSAIDs, and we developed a visual multi-scale model to guide the interpretation of the toxicological relevance of any given set of NSAIDs exposure data. Our analysis demonstrated a non-negligible risk posed to fish by NSAID mixtures in situations of high drug use and low dilution of waste-water treatment plant effluents. We anticipate that this predictive framework will support the future regulatory environmental risk assessment of NSAIDs and increase the effectiveness of ecopharmacovigilance strategies. Moreover, it can facilitate the prediction of the toxicological risk posed by mixtures via the implementation of mechanistic considerations and could be readily extended to other classes of chemicals.

Lay people and experts' risk perception of pharmaceuticals in the environment in Southwestern Europe

This study aims to contribute to the risk management of pharmaceuticals in the environment, illustrating risk perceptions of lay people and experts from Southwestern Europe (Portugal, Spain, and France). The psychometric paradigm was applied to assess risk regarding four hazards: pharmaceuticals in the environment (i.e., broadly framed), pharmaceuticals in treated wastewater, pharmaceuticals in drinking water, and pharmaceuticals in crops. Two factors explained most of the variance of risk assessments: dread and unknown. The dread factor combined immediacy and severity of effects, and the old nature of hazards. Pharmaceuticals in crops and drinking water scored higher in this factor, as did experts and French respondents. The unknown factor differentiated between the assessments of lay people and experts. Lay people assessed the hazards as being more known by those who were exposed but less known by science; and exposure was perceived as more voluntary and the risk as more controllable. Even though pharmaceutical residues are present in much higher concentrations in treated wastewater, risk assessments were overall higher for drinking water and crops. Moreover, data also revealed risk management preferences: whereas lay people preferred technological and awareness-type measures, experts preferred measures to improve the disposal of pharmaceutical waste and health-type measures.

The importance of household pharmaceutical products disposal and its risk management: Example from Southwestern Europe

The presence of pharmaceuticals in the environment is an emergent unknown environmental problem, linked to increased production and consumption of pharmaceuticals and, as such, understanding risk perception is fundamental. This study focuses on exploring causes (trust and knowledge) and effects (intention and proper individual disposal of pharmaceutical leftovers) of environmental and health risk perception. Survey data was collected in Portugal, Spain, and France (sample of 509 individuals). Data illustrated that in France, where the quantity of recycled pharmaceuticals is much higher, respondents reported a higher need for knowledge, but not a higher risk perception nor self-reported behaviour. Although previous research illustrates that higher trust correlates with lower risk perception, we found a positive correlation, which highlights the need to comprehend these variables in emergent risks. Results further confirmed a hypothesized moderated mediation model to explain proper disposal behaviour. We found an indirect effect of risk perception on behaviour through intention, which was stronger for participants with higher environmental identity. Understanding the causes and effects of risk perception of pharmaceuticals in the environment thereby contributes to improve pharmaceutical waste management processes and to promote the proper disposal of pharmaceuticals.

Determination of twenty pharmaceutical contaminants in soil using ultrasound-assisted extraction with gas chromatography-mass spectrometric detection

In this paper, an analytical method for the simultaneous determination of twenty pharmaceuticals (eight non-steroidal anti-inflammatory drugs, five oestrogenic hormones, two antiepileptic drugs, two β-blockers, and three antidepressants) in soils was developed. The optimal method included ultrasound-assisted extraction, a clean-up step on a silica gel column, derivatization using N,O-bis(trimethylsilyl)trifluoroacetamide (BSTFA) and 1% trimethylchlorosilane (TMCS) in pyridine and ethyl acetate (2:1:1, v/v/v) for 30 min at 60 °C, and determination by gas chromatography-mass spectrometry working in the selected ion monitoring mode. This affords good resolution, high sensitivity and reproducibility, and freedom from interferences even from complex matrices such as soils. The method detection limits ranged from 0.3 to 1.7 ng g^-1, the intra-day precision represented as RSDs ranged from 1.1 to 10.0%, and the intra-day accuracy from 81.3 to 119.7%. The absolute recoveries of the target compounds were above 80%, except for valproic acid and diethylstilbestrol. The developed method was successfully applied in the analysis of the target compounds in soils collected in Poland. Among the 20 pharmaceuticals, 12 compounds were detected at least once in the soils. The determination of antiepileptic drugs, β-blockers, and antidepressants was also performed for the first time.

The potential effects of efavirenz on Oreochromis mossambicus after acute exposure

Antiretroviral drugs (ARVs) are hazardous therapeutic pharmaceuticals present in South African surface water. Efavirenz is an ARV commonly used in human immunodeficiency virus (HIV) treatment in South Africa. Although little is known about the toxic effects of efavirenz on fish health, threats of toxicity to the aquatic environment have been reported. Oreochromis mossambicus were exposed under controlled conditions to environmentally-relevant efavirenz concentrations (10.3ng/l) as measured in rivers that flow into the Nandoni Dam in the Vhembe District, South Africa. Acute (96h) exposures were conducted using efavirenz concentrations of 10.3ng/l and 20.6ng/l. The overall health of exposed fish was determined using a histology-based fish health assessment index. Necropsies and haematology were conducted and somatic indices calculated after which the liver, kidney, heart, gills and gonads were microscopically quantitatively assessed. Results indicated that fish exposed to 20.6ng/l efavirenz had significantly (p<0.02) higher liver indices than the control fish, indicating increased liver damage including steatosis and frank necrosis. Fish exposed to 20.6ng/l efavirenz presented with significantly (p<0.02) higher total fish indices, representative of declined overall health compared to control fish. It was concluded that the exposure of O. mossambicus to efavirenz resulted in liver damage and overall decline in fish health. These novel findings may indicate a health risk for O. mossambicus and other biota exposed to efavirenz in aquatic ecosystems. Thus, ARV's in water sources of South Africa pose a definite threat to wildlife and ultimately human health.

An integrated approach for prioritizing pharmaceuticals found in the environment for risk assessment, monitoring and advanced research

Numerous active pharmaceutical ingredients (APIs), approved prior to enactment of detailed environmental risk assessment (ERA) guidance in the EU in 2006, have been detected in surface waters as a result of advancements in analytical technologies. Without adequate knowledge of the potential hazards these APIs may pose, assessing their environmental risk is challenging. As it would be impractical to commence hazard characterization and ERA en masse, several approaches to prioritizing substances for further attention have been published. Here, through the combination of three presentations given at a recent conference, "Pharmaceuticals in the Environment, Is there a problem?" (Nîmes, France, June 2013) we review several of these approaches, identify salient components, and present available techniques and tools that could facilitate a pragmatic, scientifically sound approach to prioritizing APIs for advanced study or ERA and, where warranted, fill critical data gaps through targeted, intelligent testing. We further present a modest proposal to facilitate future prioritization efforts and advanced research studies that incorporates mammalian pharmacology data (e.g., adverse outcomes pathways and the fish plasma model) and modeled exposure data based on pharmaceutical use.

Screening level mixture risk assessment of pharmaceuticals in STP effluents

We modeled the ecotoxicological risks of the pharmaceutical mixtures emitted from STP effluents into the environment. The classic mixture toxicity concept of Concentration Addition was used to calculate the total expected risk of the analytically determined mixtures, compare the expected impact of seven effluent streams and pinpoint the most sensitive group of species. The risk quotient of a single, randomly selected pharmaceutical is often more than a factor of 1000 lower than the mixture risk, clearly indicating the need to systematically analyse the overall risk of all pharmaceuticals present. The MCR, which is the ratio between the most risky compound and the total mixture risk, varies between 1.2 and 4.2, depending on the actual scenario and species group under consideration. The mixture risk quotients, based on acute data and an assessment factor of 1000, regularly exceed 1, indicating a potential risk for the environment, depending on the dilution in the recipient stream. The top 10 mixture components explain more than 95% of the mixture risk in all cases. A mixture toxicity assessment cannot go beyond the underlying single substance data. The lack of data on the chronic toxicity of most pharmaceuticals as well as the very few data available for in vivo fish toxicity has to be regarded as a major knowledge gap in this context. On the other hand, ignoring Independent Action or even using the sum of individual risk quotients as a rough approximation of Concentration Addition does not have a major impact on the final risk estimate.