What literature is available on how pharmacy can play a role in reducing health care’s climate footprint?

Introduction
The 2011 United Nations Framework Convention on Climate Change (UNFCC) defines climate change as an alteration of the atmosphere leading to persistent, long-term change in climate beyond the natural, expected variability and is specifically attributed to direct or indirect human activity.1, These alterations include increasing carbon dioxide (CO2) levels, rising temperatures, extreme weather events, and rising sea levels which, among other negative impacts, lead to many adverse consequences on human health.2 According to a 2019 Healthcare Without Harm (HWH) report, the health impacts of climate change include respiratory conditions (allergies, asthma), cardiovascular disease, infectious diseases (malaria, dengue, West Nile virus, etc), malnutrition, gastrointestinal (GI) disease, mental illness, heat-related illness and death, and severe weather-related injuries and death.2 According to one estimate, more than 4 million deaths attributed to increasing global temperatures are projected to occur annually by the year 2100.3

The health care sector is a unique one, as its responsibility lies not only in caring for patients subject to the negative health effects of climate change but also plays an important role in preventing these adverse effects. Approximately 10% of the total greenhouse gas emissions (GHG) generated in the US are from the health care sector.4 These emissions are generated from health care facilities and the health care supply chain, which encompasses all processes from production to disposal of goods and services. Energy use is the largest source of GHG emissions; others include pharmaceuticals, agriculture, chemicals, and waste treatment. The 2019 HWH report estimates that almost 1% of the GHG emissions from healthcare comes from use of metered-dose inhalers (MDIs) and use of anesthetic gases.2 The purpose of this FAQ is to summarize literature and recommendations on the environmental impact of practices related to use of oral paracetamol, cancer drugs, MDIs, and anesthetic gases.

Literature summary
Paracetamol
A life-cycle assessment (LCA) is a standardized method to determine the GHG emissions that result from a product or process. For pharmaceuticals, some of the factors used for this calculation include drug weight, drug and packaging production, drug distribution, drug administration, and disposal method. The LCA of 1 gram of oral and intravenous (IV) paracetamol was compared in an analysis by Davies et al.5 The total GHG emissions (in carbon dioxide equivalents [CO2e]- the amount of CO2 with an equivalent global warming impact of another GHG) were 38 grams CO2e for an oral tablet, 310 grams CO2e for an IV dose from a plastic vial, and 628 grams CO2e for an IV dose from a glass bottle. Using this data, a prospective, observational study conducted at a single-center in Singapore evaluated the reduction in carbon emissions of a protocol switch from IV to oral paracetamol (1 gram tablet administered with 100 mL water 30 to 60 minutes preoperatively for elective surgery).6 The study compared drug quantity used, associated carbon emissions, and cost pre- and post- protocol implementation. With the intervention, the median number of patients receiving IV paracetamol annually reduced from 30.4% to 16.7% leading to a reduction of 3000 bottles of IV paracetamol. A reduction from 194.3 to 100 kg CO2e per 1000 cases of carbon emissions was calculated. Paracetamol cost was reduced by 76%. No adverse patient outcomes were reported as a result of the intervention. The authors concluded that use of oral paracetamol in place of the IV formulation provides environmental and financial benefits without compromising patient care.

Cancer drugs
The Redispensing Oral Anticancer Drugs (ROAD) study was a prospective trial that evaluated the total waste reduction and cost savings of an oral anticancer drug re-dispensing program compared with standard disposal practices in the outpatient pharmacies of 4 Dutch hospitals.7 Only patients receiving oral anticancer medications with storage requirements at room temperature were included. Over a 1-year period, 1071 patients with cancer received their oral drugs in sealed packaging with a time-temperature indicator. If the product remained unused and sealed, the patient could return them to the pharmacy for reuse. Four criteria were required to allow for re-dispensing: the package was unopened, the outer packaging was undamaged, the shelf-life was ≥ 6 months, and the time-temperature indicator confirmed appropriate drug storage. A total of 335 unused packages were returned of which 228 packages were re-dispensed. This translated to a 68% reduction in waste compared to standard disposal. The mean net annual cost savings ranged from \$680 to \$1592 per patient. No adverse patient outcomes were reported with those who received re-dispensed drugs. An analysis comparing the environmental impact of 3 re-dispensing protocols (with progressively laxed requirements) demonstrated that a protocol that used temperature indicators for only those drugs with a maximum storage temperature of 25°C (rather than all drugs) that accepted products with a shelf-life of ≥ 2 months (rather than 6 months) and accepted undamaged packaging (rather than sealed and undamaged) was beneficial in terms of reduced carbon emissions and waste.8

A retrospective analysis using the Veterans Health Administration database compared the GHG emissions associated with pembrolizumab standard dosing administered every 3 weeks compared to extended interval dosing of every 6 weeks using either a weight-based dose of 4 mg/kg or a flat dose of 400 mg.9 Pembrolizumab was selected as the agent to evaluate due to its extensive use for a variety of oncologic indications and evidence suggesting that alternate dosing strategies are as effective as standard dosing. GHG emissions associated with a single administration of pembrolizumab was calculated from 3 sources: drug production; patient transportation to and from infusions; and medical waste generated during compounding and infusion processes. Of the dosing scenarios, the 4 mg/kg every 6-week pembrolizumab regimen demonstrated the largest reduction of 200 tons of CO2 in annual GHG emissions. Additionally, this dosing regimen would lead to an annual cost savings of approximately \$106 million over a period of 29 months. Accounting for several confounding factors in their analysis, the authors concluded that use of an effective alternative dosing of cancer drugs can lead to significant environmental and cost benefits.

Multi-dose inhalers
Pressurized metered dose inhalers use hydrofluorocarbon propellants to deliver medications to the lungs.10-12 Propellants in MDIs are a significant contributor to overall healthcare-related GHG emissions.2,10-12 In contrast to MDIs, dry powder inhalers do not use propellants for drug delivery and have less GHG emissions and a calculated carbon footprint that is 10 times lower than MDIs.10,11 Prescribers are encouraged to consider use of DPIs or soft mist inhalers over MDIs when appropriate based on guidelines and shared decision-making with their patients.12 Additionally, certain MDIs may have lower GHG emissions based on the type and volume of its propellant as reported.11

Other aspects of respiratory care such as proper diagnosis, controlling disease based on established guidelines, and education on proper inhaler technique and disposal not only reduces the overall environmental impact of inhaler use but also improves patients’ respiratory health directly (with accurate diagnosis, disease control, and proper technique) and indirectly (less air pollution and climate change).12 Improper diagnosis and lack of disease control leads to overprescribing and unnecessary use of inhalers, which contributes to unnecessary GHG emissions. Improper inhaler technique leads to poor patient health, increased prescribing, and use of multiple inhalers. When an inhaler is deemed empty of medication, the propellant is still present and approximately 30% of GHG emission from MDIs occurs after disposal due to propellant leakage. A significant reduction in MDI-related GHG emissions can occur when there is a mechanism in place for proper disposal and handling of empty inhalers.

Consideration of the environmental impact when choosing from available treatment options is now part of recommendations and position statements by British Columbia, the Canadian and British Thoracic Societies, and the National Institute for Health and Care Excellence (NICE).13-16

A study by Caron et al evaluated the pattern of MDI use over a 6-month period at a single hospital in Ottawa. Data was derived from 100 patients with either respiratory tract infections or chronic obstructive pulmonary disease (COPD).17 During a median length of stay of 7 days, a median number of one MDI was dispensed. Of 200 actuations dispensed per patient, only 8% were used. Of 315 MDIs dispensed, 97 were not used at all. The authors concluded that 90% of available MDI doses are unused. This study highlights the extent of waste that can be avoided which, in turn, can reduce environmental harm.

A descriptive study using 2020 Dutch national prescription data analyzed the environmental and financial impact of replacing pressurized MDIs with non-propellant inhalers.18 In 2020, approximately 182 million daily doses of pressurized MDIs were dispensed. Upon analysis, the authors calculated that a switch of 70% of these doses to non-propellant inhalers would reduce annual GHG emissions by 63 million kg of CO2e equivalents and lead to a cost savings of approximately 49 million EUR.

Anesthetic gases
Nitrous oxide is the primary culprit of depletion of the ozone layer and its global warming potential is almost 300 times that of CO2.19,20 Researchers have also identified desflurane’s global warming potential to be similar to that of nitrous oxide. The World Federation of Societies of Anesthesiologists released a global consensus statement on environmentally-sustainable anesthesia in 2022.21 A portion of the statement related to anesthesia medications provides a hierarchy of use of inhalational agents with first preference given to the agent with the lowest global warming potential: halothane or sevoflurane followed by isoflurane. Pre-determined, designated use of desflurane and nitrous oxide is recommended for specific cases. Although consensus (75% of committee members) was not reached, 68% of committee members agreed that for environmental reasons, regional anesthesia is preferred over total intravenous anesthesia, which is preferred over inhalational anesthesia.

Role for pharmacy
With the urgent need to address the climate crisis from all angles and the recognition of the healthcare sector’s role in contributing to climate change, leaders in the field from across the world have taken on the task of addressing the issue. In 2021, the International Pharmaceutical Federation signed the Healthy Climate Prescription, which urged for governments and all nations to commit to reducing climate change and specifically, for high income countries to make larger GHG reductions.22,23 In the same year, the International Association for Health Professions Education (AMEE) released a consensus statement for an educational framework on sustainable healthcare.24 In line with this specific call to action, the UN recognizes the role pharmacists can play in sustainable development while ensuring healthy lives for all.

Healthcare without Harm is a global collaboration of healthcare leaders committed to reducing the climate impact by the healthcare sector.2 Specifically, its Pharmacists for Greener Healthcare – Europe network is a forum available for pharmacists to share practices to specifically address pharmaceutical pollution and antimicrobial resistance.

In addition to those summarized above, studies evaluating the environmental impact of specific practices related to medication use and publications on the LCA of pharmaceuticals are on the rise.25-32 These studies describe general actions that pharmacists and other healthcare professionals can take without compromising patient care – such as limiting duration of treatment, choosing once daily over multiple dosing regimens, utilizing oral over parenteral formulations, evaluating for duplicative therapy and polypharmacy, evaluating for nonadherence, and ensuring proper waste disposal. Additionally, several authors have published research on the incorporation of environmental impact and sustainability into pharmacy school curriculums.32-36

With the support of ongoing research and a shared commitment to reducing healthcare’s carbon footprint, pharmacists can be advocates for change within their practice and teaching settings as well as in their recommendations for patient care to improve both patient and planetary health.

References

  1. United Nations Framework Convention on Climate Change. Fact sheet: climate change science – the status of climate change science today. Feb 2011. https://www.uncclearn.org/wp-content/uploads/library/unfccc01.pdf. Accessed December 2, 2024.
  2. Health Care Without Harm. Health care’s climate footprint. September 2019. https://global.noharm.org/sites/default/files/documents-files/5961/HealthCaresClimateFootprint_092319.pdf. Accessed December 2, 2024.
  3. Bressler RD. The mortality cost of carbon. Nat Commun. 2021;12(1): 4467. doi: 10.1038/s41467-021-24487-w.
  4. Lancet Countdown: Romanello M, Napoli CD, Green C, et al. The 2023 report of the Lancet Countdown on health and climate change: the imperative for a health-centred response in a world facing irreversible harms. Lancet. 2023; 402: 2346–2394.
  5. Davies JF, McAlister S, Eckelman MJ, et al; TRA2SH, GASP and WAAREN collaborators. Environmental and financial impacts of perioperative paracetamol use: a multicentre international life-cycle assessment. Br J Anaesth. 2024;133(6):1439-1448. doi: 10.1016/j.bja.2023.11.053.
  6. Yeo JA, Tan MBH, Ong ET, Wong A, Koh XH, Gobindram A. Reducing costs and carbon footprint for preoperative oral paracetamol: implementation of a standardised pathway. Br J Anaesth. 2024;133(6):1410-1412. doi: 10.1016/j.bja.2024.06.033.
  7. Smale EM, van den Bemt BJF, Heerdink ER, Desar IME, Egberts TCG, Bekker CL; ROAD Study Group. Cost savings and waste reduction through redispensing unused oral anticancer drugs: The ROAD Study. JAMA Oncol. 2024;10(1):87-94. doi: 10.1001/jamaoncol.2023.4865.
  8. Smale EM, Ottenbros AB, van den Bemt BJF, et al. Environmental outcomes of reducing medication waste by redispensing unused oral anticancer drugs. JAMA Netw Open. 2024;7(10):e2438677. doi: 10.1001/jamanetworkopen.2024.38677.
  9. Bryant AK, Lewy JR, Bressler RD, et al. Projected environmental and public health benefits of extended-interval dosing: an analysis of pembrolizumab use in a US national health system. Lancet Oncol. 2024; 25(6):802-810. doi: 10.1016/S1470-2045(24)00200-6.
  10. Panigone S, Sandri F, Ferri R, Volpato A, Nudo E, Nicolini G. Environmental impact of inhalers for respiratory diseases: decreasing the carbon footprint while preserving patient-tailored treatment. BMJ Open Respir Res. 2020;7(1):e000571. doi: 10.1136/bmjresp-2020-000571.
  11. Woodcock A, Beeh KM, Sagara H, et al. The environmental impact of inhaled therapy: making informed treatment choices. Eur Respir J. 2022;60(1):2102106. doi: 10.1183/13993003.02106-202.
  12. Green S, Stoynova V, Culley C, et al. Climate-conscious inhaler prescribing for family physicians. Can Fam Physician. 2024;70(6):381-387. doi: 10.46747/cfp.7006381.
  13. Gupta S, Couillard S, Digby G, Tse SM, Green S, Aceron R, et al. . Canadian Thoracic Society position statement on climate change and choice of inhalers for patients with respiratory disease. Can J Respir Crit Care Sleep Med 2023;7(5):232-9
  14. BTS position statement. Air quality and lung health 2022. London, UK: British Thoracic Society; 2022. https://www.brit-thoracic.org.uk/about-us/our-strategic-priorities/environment-and-lung-health. Accessed
  15. BC Guidelines and Protocols Advisory Committee. Asthma diagnosis, education and management. Victoria, BC: British Columbia Ministry of Health; 2023. https://www2.gov.bc.ca/assets/gov/health/practitioner-pro/bc-guidelines/asthma_final.pdf. Accessed
  16. Asthma inhalers and climate change. London, UK: National Institute for Health and Care Excellence; 2022. https://www.nice.org.uk/guidance/ng80/resources/asthma-inhalers-and-climate-change-patient-decision-aid-pdf-6727144573. Accessed
  17. Caron C, Sajwani S, Bateman K, et al. Environmentally sustainable opportunities for health systems: metered-dose inhaler prescribing, dispensing, usage, and waste at The Ottawa Hospital. Lancet Planet Health. 2024;8 Suppl 1:S5. doi: 10.1016/S2542-5196(24)00070-6.
  18. Ten Have P, van Hal P, Wichers I, et al. Turning green: the impact of changing to more eco-friendly respiratory healthcare – a carbon and cost analysis of Dutch prescription data. BMJ Open. 2022;12(6):e055546. doi: 10.1136/bmjopen-2021-055546.
  19. McGain F, Muret J, Lawson C, Sherman JD. Environmental sustainability in anaesthesia and critical care. Br J Anaesth. 2020;125(5):680-692. doi: 10.1016/j.bja.2020.06.055. Epub 2020 Aug 12.
  20. Muret J, Fernandes TD, Gerlach H, et al. Environmental impacts of nitrous oxide: no laughing matter! Comment on Br J Anaesth 2019; 122: 587-604. Br J Anaesth. 2019;123(4):e481-e482. doi: 10.1016/j.bja.2019.06.013.
  21. White SM, Shelton CL, Gelb AW, et al; representing the World Federation of Societies of Anaesthesiologists Global Working Group on Environmental Sustainability in Anaesthesia. Principles of environmentally-sustainable anaesthesia: a global consensus statement from the World Federation of Societies of Anaesthesiologists. Anaesthesia. 2022;77(2):201-212. doi: 10.1111/anae.15598.
  22. Pfleger S. The climate, nature, and pollution crises-how more sustainable medicines use can make a difference. Int J Pharm Pract. 2024;32(3):191-193. doi: 10.1093/ijpp/riae017.
  23. Healthy Climate Prescription. Healthy climate prescription letter. 2021. https://healthyclimateletter.net/ Accessed December 3, 2024.
  24. Shaw E, Walpole S, McLean M, et al. AMEE Consensus Statement: Planetary health and education for sustainable healthcare. Med Teach. 2021;43(3):272-286. doi: 10.1080/0142159X.2020.1860207.
  25. Roy C, Fox K, Tangedal K. Development of an Environmental Audit Tool for Hospital Pharmacy. Can J Hosp Pharm. 2024 Nov 13;77(4):e3591. doi: 10.4212/cjhp.3591.
  26. Pitard M, Rouvière N, Leguelinel-Blache G, Chasseigne V. Contribution of hospital pharmacists to sustainable healthcare: a systematic review. Eur J Hosp Pharm. 2024 May 22:ejhpharm-2024-004098. doi: 10.1136/ejhpharm-2024-004098.
  27. Chen C, Jeong MSM, Aboujaoude E, Bridgeman MB. Challenges to decarbonizing medication prescribing and use practices: A call to action. J Am Pharm Assoc (2003). 2024;64(2):364-369. doi: 10.1016/j.japh.2023.12.004.
  28. Sánchez VLC, Bueno EV, Morales MA, et al. Green hospital pharmacy: A sustainable approach to the medication use process in a tertiary hospital. Farm Hosp. 2023 Sep-Oct;47(5):196-200. doi: 10.1016/j.farma.2023.05.008.
  29. Duggan C, Guiu-Segura JM. How pharmacy can transform and contribute to the global agenda on sustainable development. Farm Hosp. 2022;46(6):317-318.
  30. Adeyeye E, New BJM, Chen F, Kulkarni S, Fisk M, Coleman JJ. Sustainable medicines use in clinical practice: A clinical pharmacological view on eco-pharmaco-stewardship. Br J Clin Pharmacol. 2022;88(7):3023-3029. doi: 10.1111/bcp.15140.
  31. Cussans A, Harvey G, Kemple T, Lyons T, Tomson M, Wilson A. Environmental impact ratings that could drive positive environmental changes in the manufacture and use of pharmaceuticals. BJGP Open. 2022;6(1):BJGPO.2021.0214. doi: 10.3399/BJGPO.2021.0214
  32. Roy C. The pharmacist’s role in climate change: A call to action. Can Pharm J (Ott). 2021 Feb 10;154(2):74-75. doi: 10.1177/1715163521990408
  33. Chen EYH, Forrester C, McEvoy AM, Singleton J. Pharmacy students’ perceptions on environmental sustainability in pharmacy education and practice. Explor Res Clin Soc Pharm. 2023 Nov 10;12:100366. doi: 10.1016/j.rcsop.2023.100366
  34. Mathers A, Fan S, Austin Z. Climate change at a crossroads: Embedding environmental sustainability into the core of pharmacy education. Can Pharm J (Ott). 2023;156(2):55-59. doi: 10.1177/17151635231152882
  35. Lapatto-Reiniluoto O, Siven M, Backman JT, Törrönen A. Medicines, environment and clinical pharmacology. Basic Clin Pharmacol Toxicol. 2022;131(2):149-152. doi: 10.1111/bcpt.13757
  36. Gruenberg K, Apollonio D, MacDougall C, Brock T. Sustainable Pharmacy: Piloting a Session on Pharmaceuticals, Climate Change, and Sustainability within a U.S. Pharmacy Curriculum. Innov Pharm. 2017;8(4):3. doi: 10.24926/iip.v8i4.929.

Prepared by:
Rita Soni, PharmD
Clinical Assistant Professor, Drug Information Specialist
University of Illinois at Chicago College of Pharmacy

December 2024

The information presented is current as November 25, 2024. This information is intended as an educational piece and should not be used as the sole source for clinical decision-making.