Meds in our Water Supply – Part II – Green Strategies

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In my previous blog, I spoke about how drugs were ending up in our water supply. Although there are several causes by which this is happening, there are simple steps that we all can take to help mitigate the problem.

Responsible prescribing

There are several steps that prescribing physicians can take to reduce excess medications.

  1. Physicians should write scripts for smaller quantities, and should follow-up with patients closely to see if the specific medication prescribed is, indeed, appropriate.
  2. Physicians should follow evidence-based guidelines for prescribing meds.
  3. Physicians should minimize storing samples from pharmaceutical companies. Instead, they should insist that these companies provide coupons (even better: e-coupons) that patients could take to the pharmacies for a free sample. This would help streamline the supply of samples, and minimize the amount of “expired” samples that physicians have to throw away.
  4. Physicians should educate patients about their responsibility to use medications judiciously and to minimize the use of over-the-counter drugs.

Responsible disposal

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           There are now several methods by which patients, physicians, and other healthcare services can dispose of unused or expired medications. Remember: Most drugs should not be simply poured down the drain or flushed down the toilet! (The FDA has a list of drugs that can, or should be poured down the drain)

  1. Check with local city or county’s household trash and recycling service to see if they have a take-back program in the city.
  2. Check with local pharmacy to see if they have any local take-back programs available.
  3. If the drug label has specific instructions regarding the disposal follow that. Otherwise,
  4. Dispose of medications by a) removing them from their original packaging, b) sealing them in a container filled with an unpalatable substance such as coffee grounds or kitty litter, c) throwing them in the trash

Responsible consumption

           Ideally, reducing the amount of drugs coming into the system would reduce the amount being thrown out. If we were all to simply consume exactly what we need, there would be no excess. Of course, this is in an ideal situation, and like most things, ideal never translates into reality. However, as a consumer, we can be more judicious about our purchasing. Here are some ideas.

  1. Minimize the temptation to purchase large quantities of over-the-counter medications simply because it appears to be cheaper per unit. It may seem cheaper at first, but think of the cost of all those extra pills that weren’t consumed before they expired. Plus, having a smaller bottle is safer in case of over-ingestion.
  2. Take medications only when needed. This sounds a bit preachy, but I have seen a fair-share of patients who will over-consume medications simply thinking that more = better. Remember ALL drugs have a side-effect profile. Be smart about taking meds.

 

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Medications in Our Water Supply! Part I

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In March of 2008, the Associated Press had released information showing that 28 out of 35 US watersheds tested had detectable levels of numerous drugs. Although the detectable levels tested were in parts per billion, the astonishing finding was that there were so many different compounds. In fact, in a preceeding study conducted by the United States Geological Service in 2002, it was shown that 80% of the samples obtained from 139 streams contained numerous widely used drugs! Here are just a few of them:

17-α Ethynyl Estradiol

This is a a synthetic estrogen present in oral contraceptives and is potentially responsible for the feminization of male fish. In fact, an article in Scientific American (June, 2009) stated that “estrogen exposure reduces a fish’s ability to produce proteins that help it ward off disease and pointed to a possible link between the occurrence of intersex fish…male fish carrying immature female egg cells in their testes.”

Acetaminophen

Also known to us as Tylenol, Acetaminophen has been widely used for pain relief among other things. Surprisingly, detectable levels of this drug have been found in 24% of tested waterways.

Other Steroids and Hormones

Other steriods as well has hormones and hormone-mimicking agents such as nonylphenol were found in 16% of tested waterways. Although the effects of these hormones and hormone-mimicking agents are still largely unstudied, one has to wonder if they are also having a negative impact on the fish populations in many of our waterways.

Diltiazem

Less known to the public, diltiazem is part of a group of drugs called calcium channel blockers used for the treatment of high blood pressure, angina, and some types of heart arrhythmias. Diltiazem works as a strong vasodilator–it increases blood flow and decreases the heart rate.

Codeine

Many people have at one time or another used codeine as part of a mixed preparation with acetaminophen or in cough syrup. It is a alkaloid found in opium and is a controlled substance due to its potential for being habit-forming. Codeine has several indications for use including  cough, diarrhea, pain, and IBS. Given its wide use, it is no surprise that it has been found in numerous waterways as well.

Antibiotics and Antimicrobials

This is perhaps another one of those categories of drugs that has received widespread media coverage given the increased occurence of antibiotic resistance. A variety of antibiotics including ampicillin, tetracycline, penicillin and erythromycin have been found in testable amounts in numerous waterways. Not surprisingly, wild Geese resistant to these antibiotics have been found.

Ibuprofen

Ibuprofen is a commonly used drug for the treatment of pain. It has been found in 10% of sampled waterways.

Detectable levels? So what?

Although many can argue that there is a difference between detectable and therapeutic or toxic levels, the fact remains that our waterways are being contaminated by “foreign” agents. We would be remiss to simply push this alarming fact aside and ignore the potential for slow accumulation in aquatic life. To be so bold as to say that since there have been no described human effects, there should be nothing to fear is short-sighted and foolish. Additive effects of pollutants, and the concept of increased bioconcentration as we move up the food chain have already been seen in other toxic compounds such as mercury. For example, mercury poisoning from fish is a well-described phenomenon. In fact, famous actor Jeremy Piven (Old School and Entourage) suffered from mercury poisoning following a high-fish diet that forced him to cancel working on the Broadway revival, “Speed-the-Plow.”

Ok, so we have contaminated waters. How did it happen?

As with any problem, the important question to address is how did it start in the first place. There are three main routes by which these contaminants enter our environment.

1. Excretion

As the name implies, drugs are excreted by the body in two main forms: urine and feces. Excretion of most drugs is primarily through urination, and comprises a continual low-level addition to the environment by many people.

2. Bathing

Many drugs are applied directly to the skin. These drugs are not completely absorbed, and are simply washed off during the process of bathing. Additionally, some drugs can be excreted in sweat and are also washed off during bathing. Again, this represents a continuous low-level contribution to environmental contamination.

3. Disposal

The final method of contamination is the direct disposal of drugs via toilets and trash. Although disposal is not a continuous source of contamination, it is episodic, and can be a significant source if disposed in large volumes by many people.

Now that we understand how we contaminate our waters, we should go back to the reason why this happens in the first place: mass prescriptions and improper consumption of medications. As a rising physician, I have seen countless examples of patients receiving medications such as antibiotics or pain relievers for conditions that cannot be appropriately treated through such means. Additionally, I have noticed a sense of undue dependence on the part of patients to medications that is simply astonishing. People expect medications to heal when in fact, many times they are better off without them. I am not saying in any way that people should not have access to medications, however, I do believe that the justified use of medications should be advised.

Another reason is that many people do not finish their prescriptions, or choose to buy them in large quantities. I have been guitly of this myself. A simple trip to a nearby wholesale retailer will prove my point–Tylenol is sold in large bottles in quantities exceeding 300 pills. The same goes for a variety of different drugs.  If we are to minimize our waste, then we must be more responsible about consuming what we need and not running after the cheapest deal. Large drug companies should also be more aware of this phenomenon and certain actions should be taken to minimize the sale of wholesale drugs. 

  So what can we do to minimize the problem?

I will discuss ways to reduce our environmental impact in my next blog. Stay tuned!

Understanding Sustainable Healthcare

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Sustainability has been defined as “meeting the needs of the present without compromising the ability of future generations to meet their own needs.

Although most of us are aware of the many efforts being devoted to bring sustainable measures into daily life, little is being done across the country to bring sustainable measures into mainstream healthcare. Sadly, the current health reform talks in Washington do not directly address this issue either.

So what exactly is sustainable healthcare? In the broadest sense it is changing the current practice of medicine to incorporate ways to reduce waste, conserve resources, improve environmental performance and provide a healthier, happier workplace for patients and providers of healthcare.

The benefits of sustainable healthcare are numerous. Costs can be reduced, physical and emotional health of patients can be improved, a safer and healthier clinical environment for staff and clients can be realized, a stronger workplace culture based on the values of prevention, wellness and environmental stewardship can be nurtured, and a more livable workspace with fewer stressors can be attained.

There are numerous ways to approach sustainable healthcare from both micro- and macro- perspectives. I plan on discussing both, starting with simple, actionable items and then addressing  large-scale ideas. My goal is simple: to help inspire others to adopt greener ways to treat patients and to bring sustainable measures to our burgeoning healthcare arena.