Best Waste Practice takes a safer route for health care systems
The findings showed that PPCPs contaminated virtually every surface water body tested around the world and were leaching from other areas such as landfill sites.
When the U.S. Geological Survey first reported the presence of chemicals from pharmaceutical and personal care products (PPCPs) in the country’s drinking and surface water, a flurry of studies and stories followed, attempting to understand the issue and better manage the problem. The findings that followed that seminal study showed that PPCPs contaminated virtually every surface water body tested around the world and were leaching from other areas such as landfill sites.
Addressing the problem of PPCP waste has brought more questions. Does incineration— generally agreed to be the best method of disposal for health care facilities—cause even more environmental problems? Are PPCP products more or less benign than their parent compounds after breakdown? From almost every angle, addressing PPCPs with waste management is a losing proposition. Best Waste Practice® (BWP) is a strategy that examines eliminating waste at the front door rather than trying to figure out how to best manage it at the back door.
Sources of PPCP contamination include excretion by humans and animals, especially animals in confined animal feeding operations or industrialized farming, and disposal by pharmaceutical manufacturers, health care facilities, and households. Pharmaceutical manufacturers are an especially significant source of contamination, as shown by studies conducted downstream from their locations which indicate concentrations of drug contaminants 10,000 times higher than those in the surface waters upstream.
The effects of contamination reach much further than human health. Numerous studies, including one in the journal Nature, indicate that wildlife living in PPCP-contaminated waters suffer behavioral, neurotoxic, and reproductive effects. The discoveries have led regulatory agencies such as the U.S. Food and Drug Administration and the European Medicines Agency to reevaluate protocols for ecotoxicity in new drug development. (Ecotoxicity data exist for less than one percent of drugs in use today.)
Wastewater treatment plants—originally designed to treat domestic sewage with simple methods such as sand filtration, settling tanks, bacterial-based digesters, and aeration— don’t adequately treat industrial chemicals. Research is ongoing regarding more advanced treatment options, such as carbon filtration, ozonation, and increased retention time, with some positive indications. But successful treatment varies according to the chemical structure of the waste and the concentration of other waste in the water. Installation of these technologies is also very expensive, costing millions of dollars for each plant.
PPCPs in the environment have prompted health care facilities to better manage pharmaceutical waste and other types of hazardous waste by collecting and sending them to incinerators. While incineration is generally agreed to be the best method of disposal, it is not without impact on environmental and public health, including pollution of air with acid gases, carbon monoxide, greenhouse gases, heavy metals, and particulate matter. And incineration costs money.
Waste management has a variety of problems associated with it. There are the tangible costs—compliance, containers, storage, disposal, licenses, and permits; then there are the intangible costs—liability, occupational health and safety, and public relations. In a larger sense, the pollution associated with waste management is contrary to health care’s mission to protect and support public health. There is a better way.
BWP is a strategy that first looks at eliminating waste before problems occur. BWP uses the "4 R’s ": reduce, reuse, repair, and recycle. In the BWP strategy, treatment and disposal are the least preferred activities.
Source reduction and appropriate policies are a positive first step. This step can be accomplished several ways: utilizing reusable items, such as washable linens and china, and reducing the toxicity of products, such as stocking regular soap instead of antibacterial soap. Inventory management that employs actual utilization data to determine appropriate stock levels is a good source reduction policy, especially for more costly waste such as expired pharmaceuticals and lab reagents.
How recycling fits into the picture requires thought. Recycling, which differs from source reduction, involves the transformation of a waste, such as a used cardboard box, into another product, perhaps another cardboard box. However, even this type of straightforward recycling requires additional resources, such as paper fiber, water, and energy; generating additional waste. Another concern is that some types of waste that are recycled, such as pill bottles, are not recycled into the same items but are "down-cycled " into less critical uses, such as detergent bottles, which then may release pharmaceutical residues when the plastic is washed.
BWP holds many opportunities for pharmacies and pharmacists. Pilot studies conducted by the Minnesota Technical Assistance Program demonstrated success by using improved inventory management, by minimizing use of reverse distribution, by rotating stock, by eliminating pharmaceutical samples, and by implementing automated dispensing systems in long-term care facilities. It is estimated that the hospitals, the clinic, and the long-term care facility that participated saved $120,000, $6,000, and $18,000, respectively, and reduced more than 500 pounds of pharmaceutical waste. (Study summaries are available at www.mntap.umn.edu.)
The Centers for Medicare & Medicaid Services recently changed rules regarding prorated copays for patients trying new prescriptions with trial doses. The change is predicted to save more than $2.8 billion in the first five years and reduce more than 1.5 billion pounds of waste. One provision is that pharmacists can suggest trial doses to physicians. And because pharmacists are really the experts in pharmaceuticals, they can suggest less toxic but equally efficacious pharmaceuticals using the Environmentally Classified Pharmaceuticals 2012 rating system. For example, the antacid omeprazole is predicted to be less persistent in the environment than ranitidine.
The last steps in a BWP program include the following:
- Treatment of the waste to minimize the hazards associated with it (for example, autoclaving infectious waste).
- Incineration of pharmaceutical and hazardous wastes.
- Final disposition in a monitored landfill.
Using all these steps is critical to a good waste management program. However, focusing on source reduction provides the most economic, environmental, and health benefits.
Catherine Zimmer, MS, BSMT, Industry Leader, Environment & Regulatory, PSC Healthcare Services
Pharmacies can help reduce PPCP contamination by practicing environmentally preferable purchasing (EPP) through selecting items with less environmental impact in both their manufacture and their disposal. Denying waste at the "front door" can be a part of procurement processes and quality improvement projects. EPP also can be included as part of the process of requests for proposals.
Pharmacies can ask vendors how their products reduce both waste and toxicity and whether their products can be reused, reprocessed, or remanufactured. This could result in eliminating the use of redundant or unnecessary products, reducing packaging and product waste, and using equipment made with components that can be changed instead of being disposed of.
Daughton, C., "Cradle to Cradle Stewardship of Drugs Minimizing Environmental Disposition While Promoting Human Health, " Environmental Health Perspectives 111, no. 5 (2003):775–785. Available at www.epa.gov/nerlesd1/chemistry/ppcp/images/green2.pdf.
Daughton, C.G., Drugs and the Environment: Stewardship & Sustainability. National Exposure Research Laboratory, Environmental Sciences Division, U.S. Environmental Protection Agency, Las Vegas, Nevada. Report NERL-LV-ESD 10/081, EPA/600/R-10/106, September 12, 2010. Available at http://www.epa.gov/nerlesd1/bios/daughton/APM200-2010.pdf.
Practice Greenhealth, "Ten-Step Blueprint for Managing Pharmaceutical Waste. " Available at www.practicegreenhealth.org/sites/default/files/upload-files/pharmwasteblueprint.pdf.
U.S.Geological Survey, Emerging Contaminants web page: http://toxics.usgs.gov/regional/emc/index.html.