Environmental Burden of Pharmaceutical Pollution A Guide for Health Care Professionals Dr' Joel Krei

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Environmental Burden of Pharmaceutical
PollutionA Guide for Health Care
ProfessionalsDr. Joel Kreisberg, DC, MA
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The Problem

• Drug consumption is increasing. From 1993-2003,
  the number of prescriptions rose 701
• Drug expenditures have increased, but data shows
  that, from 1994-2000, 75 of this increase in
  price was caused by increasing consumption3
• The increase in drug use coincides with an
  increase in the amount of medications that enter
  into and contaminate the environment
• U.S. EPA Office of Research and Developments
  Strategy Plan 2000 has named pharmaceuticals and
  personal care products (PPCPs) as one of the top
  five emerging contaminants affecting human and
  ecological health4

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Emerging contaminants

• Synthetic or naturally occurring chemicals or
  microorganisms
• Not commonly monitored in the environment
• Potential to enter the environment and cause
  known or suspected adverse ecological and/or
  human health effects
• May be new chemicals OR
• Release may have occurred for a long time, but
  only recently recognized as a potential problem
  OR
• New use of existing chemicals

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Examples of emerging contaminants

• Pesticides
• Flame retardants
• Pharmaceuticals
• Personal care products
• Antibacterial compounds
• Surfactants
• Plasticizers

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Emerging Evidence

• 2002 report from the U.S. Geological Survey5
  concludes that U.S. waterways contain
• 17alpha Ethynyl Estradiol
• Synthetic estrogen present in 16 of rivers in
  USGS study
• Median concentration 73 ng/l
• Effects at as low as 1 ng/l
• Vitellogenin production (feminization) in male
  fish
• Acetaminophen (24)
• Steroids and hormones (16)
• Diltiazem (13)
• Codeine (11)
• Antibiotics and antimicrobials (10)
• Ibuprofen (10)

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Impacts of pharmaceuticals

• Wild Geese resistant to ampicillin,
  tetracycline, penicillin, and erythromycin6
• concentrations of clofibric acid in the North Sea
  (Northern Europe) to be up to 7.8 ng/L 7
• Diclofenac has been proven to be toxic to
  vultures, decimating populations in the Indian
  subcontinent due to its ubiquitous use in
  cattle.8

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More Evidence

• Prozac and Luvox induced spawning in bivalves at
  significantly low concentrations.19
• Fluoxetine enhances the release of
  ovary-stimulating hormones in crayfish.10
• SSRIs elicit aggressive behavior in lobsters,
  causing subordinates to engage in fighting
  against the dominant member, and reducing the
  propensity to retreat.11
• Concentrations of six sunscreen agents have been
  found in fish on par with DDT and PCBs.12

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Pathways to Nature

• Directly into the sewage system
• Excreted medicine
• Unmetabolized parent compounds
• Partially metabolized compounds
• Altered compounds
• Unused or unwanted medicines
• Manufacturing metabolites
• Aquatic environment
• Landfill leachate

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How Can Pharmaceutical Waste Enter The
Environment?

• 95 of antibiotics are excreted unaltered into
  the environment13
• 54 of people throw medicines into the trash14
• 35 of people flush medicines down the toilet14
• Wastewater treatment do not treat medicinal
  compounds

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Characteristics of Pharmaceutical Waste

• Persistence
• Drugs are considered pseudo-persistent due to
  continuous presence in the environment
• Significant concentrations of barbiturate drugs
  in a tributary near a landfill, even though
  barbiturates had been replaced 30 years ago14
• Bioaccumluation
• Increase in the concentration of a chemical in a
  biological organism over time, compared to the
  chemical's concentration in the environment.
• Ecotoxicity
• A lethal concentration of chemical 96 hours after
  exposure.15

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Health of Ecology v Ecology of Health

• How the environment effects us!
• Research found that a mixture of 13 common
  medications found in drinking water inhibits cell
  growth and causes negative changes in human
  embryonic cells16
• More research is needed!

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Potential Toxicological Significance

• Potential additive effects from multiple agents
  sharing common mechanisms of action (MOA).
  Individual concentrations combine to exceed an
  effects level.
• Possible interactive effects, especially
  synergism, where combined action exceeds the sum
  of individual effects.
• Hormesis- Effects below purported NOELs.
  Paradoxical U-shaped does response curves.

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Potential Toxicological Significance as a Result
of

• Dynamic Dose-Response. Toxicant-induced Loss of
  Tolerance (TILT) initial exposure sensitizes,
  and subsequent exposure levels below those
  previously tolerated trigger symptoms
• Comparatively little research performed at
  extremely low concentrations.
• Non-target species receptor repertoires not well
  characterized.

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Christian Daughton PhD

• Biological Systems and Stressors
• Complex system- 4Ts
• Toxicant
• Totality
• Tolerance
• Trajectory
• Beyond single toxicant/ single organism
  toxicology

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Pharmaceutical Waste and Medical Practices

• Medications are discontinued by physicians 27 of
  the time because they are no longer needed or
  suitable for the patient.
• In 2007, the elderly population will waste more
  than 1 billion dollars of drugs
• Reducing a prescription to a 28 day supply could
  reduce the need for discarding by as much as 30.

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Cradle to Cradle Medicine

• In theory, waste occurs when the prescription
  isnt effective
• If we get to the point where we have no leftover
  drugs, will that lead to improved therapeutic
  outcomes?
• Learning about what is unused will improve the
  quality of medical care

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What Physicians Can Do

• Do not prescribe more medications than can be
  used
• Prescribe starter packs and refill packs
• Review and regularly reassess the patients total
  consumption of medication
• Consider environmental impact when prescribing
  medications
• Learn more about which drugs have large
  environmental impacts
• Educate consumers about the importance of proper
  disposal of pharmaceutical waste

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Green Pharmacy Program

• A proactive, voluntary holistic stewardship
  program
• Cradle-to-Cradle Product Stewardship
• All sectors involved with the production,
  distribution, prescribing, marketing, and
  consuming of medicines should be involved with
  proper disposal.

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Green Pharmacy

• Manufacturing Sector
• Green Chemistry
• Reduce ecological footprint
• Reduce packaging
• Health Care System
• Hospitals
• Primary Care
• Hospice
• Pharmacies

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Green Pharmacy

• Government and Law Enforcement
• Waste Management Agencies
• NGO- Environmental Organizations
• Consumers
• Who pays
• Pharmaceutical Industry
• Waste management industry
• Advanced Recycling Fee
• Medical Professionals

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What everyone can do!

• Dispose of unused or unwanted medications at
• take-back sites
• Do NOT dispose of any medication down the toilet
  or
• in the trash
• Purchase drugs in small amounts, limiting expired
• medications
• Ask for medications with low environmental impact
• Encourage your health provider to take back
  unused and
• expired drugs
• Commit to health and wellness strategies to
  reduce your
• reliance on medications
• Donate to Teleosis Green Pharmacy Pollution
  Prevention Campaign

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References

• 1 Henry J. Kaiser Family Foundation
• 2 Chapman A., Oliver D. Pharmaceutical Waste
  Survey. http//govlink.org/hazwaste/publications/
  pharmaceuticalwastesurvey.pdf Accessed March 15,
  2007.
• 3 Berndt, E., "Pharmaceuticals in U.S. Health
  Care Determinants of Quantity and Price,"
  Journal of Economic Perspectives, Vol. 16, 4,
  Fall 2002, pp. 45-66.
• 4 Daughton C, Ternes T. Pharmaceuticals and
  personal care product in the environment agents
  of subtle change? Environmental Health
  Perspectives. 1999107(Suppl 6) 907-943.
• 5 Kolpin, Dana et al. Pharmaceuticals, hormones
  and other organic wastewater contaminants in US
  streams, 1999-2000 a national reconnaissance.
  Environmental Science and Technology. 2002 26
  1202-1211. Available at http//pubs.acs.org/journa
  ls/esthag/36/i06/pdf/es011055j.pdf Accessed June
  5, 2006

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References

• 6 Ash RJ, Mauch B, Moulder W, Morgan M.
  Antibiotic-resistant bacteria in U.S. rivers.
  Abstract no Q-383. In Abstracts of the 99th
  General Meeting of the American Society for
  Microbiology (May 30-June 3)610. Chicago, IL.
• 7 Buser H-R, Müller MD, Theobald N. Occurrence of
  the pharmaceutical drug clofibric acid and the
  herbicide mecoprop in various Swiss lakes and in
  the North Sea. Environmental Science and
  Technology. 199832188-192.
• 8. Kreisberg, J. Ecological healing and the web
  of life. Explore The Journal of Science and
  Healing. 2005 1(2)133-135.
• 9. Fong PP. Zebra mussel spawning is induced in
  low concentrations of putative serotonin reuptake
  inhibitors. The Biological Bulletin.
  1998194143-149.

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References

• 11 Huber R, Smith K, Delago A, Isaksson K,
  Kravitz EA. Serotonin and aggressive motivation
  in
• 10 . Kulkarni GK, Nagabhushanam R, Amaldoss G,
  Jaiswal RG, Fingerman M. In vivo stimulation of
  ovarian development in the red swamp crayfish
  Procambarus clarkia (Girard) by
  5-hydroxytryptamine. Invertebrate Reproduction
  and Development. 199221(3)231-240.
• crustaceans altering the decision to retreat.
  Proceedings of the National Academy of Science
  1997 945939-5942.
• 12 Nagtegaal M, Ternes TA, Baumann W, Nagel R.
  Nachweis von UV-Filtersubstanzen in Wasser und
  Fischen aus dem Meerfelder Maar in der Eifel.
  Detection of UV-sunscreen agents in water and
  fish of the Meerfelder maar the Eifel Germany.
  UWSF-Z für Umweltchem Ökotox. 19979(2)79-86.
• 13 Boehringer S. Whats the Best Way to Dispose
  of Medications? Pharmacists/Prescribers letter
  (2004).

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References

• 14 Choi, C.O. Pollution in Solution,
  Drug-Resistance DNA as the Latest Freshwater
  Threat. Scientific American. Jan 2007 22-23.
• 15 Wennmalm A, Gunnarson B.(2005) Public Health
  Care of Water Pollution with Pharmaceuticals
  Environmental Classification and Analysis of
  Pharmaceutical Residues in Sewage Water. Drug
  Information Journal
• 16 Pomati F, Castiglioni S, Zuccato E, Fanelli R,
  Vigetti D, Rosseti C, Calamari D. Effects of a
  complex mixture of therapeutic drugs at
  environmental levels on human embryonic cells.
  Environmental Science Technology. 2006
  40(7)2442-2447.
• 17. Donn, J, Mendoza, M Pritchard, J. AP Probe
  Finds Drugs in Drinking Water, 2008
• http//ap.google.com/article/ALeqM5hGsoyElv4ZL879L
  W6z2aZS0Pix7AD8VA14500 (accessed March 25,2008)