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Objectives:

Residues of pharmaceuticals, originating from production, distribution or consumption, reach the environment where they have negative consequences on ecosystems. Educating future physicians and pharmacists could promote more environmentally friendly decisions throughout the life-cycle of pharmaceuticals. The aim of this cross-sectional study was to describe how pharmaceuticals in the environment was integrated into Swedish universities' medicine and pharmacy educations.

Methods:

The study was conducted November-December 2022 and consisted of two parts; i) a review of program curricula for medicine and pharmacy programs in Sweden and ii) a questionnaire distributed to course managers at pharmacy programs, and to program managers at medicine programs. Multiple-choice questions were analysed with descriptive statistics. Openended questions and program curricula were assessed qualitatively with content analysis.

Results:

Pharmaceuticals in the environment was mentioned in the general learning objectives aligned with the Higher Education Ordinance, but content related to environment was only included in curricula for some courses, mainly regarding sustainable development. A total of 47/ 100 pharmacy course managers and 6/7 medicine program managers responded to the questionnaire. 19/47 pharmacy course managers and 6/6 medicine program managers indicated that their courses include aspects of pharmaceuticals in the environment. The most common areas in pharmacy courses were sustainable drug use, and sustainable drug manufacturing/development.

Conclusions:

Sweden's medicine and pharmacy programs contain some education about environmental impacts of pharmaceuticals but the curricula could be developed further. There is room for improvement in integrating environmental themes throughout the programs, potentially as an interprofessional education with a life-cycle perspective of pharmaceuticals.

Human-use medicines are introduced into surface water throughout their entire life cycle, from manufacturing and consumption to improper disposal, resulting in negative effects on aquatic flora and fauna. Sustainability approaches have addressed this issue, proposing frameworks like the One Health approach. A revised definition of the rational use of medicines has also been proposed, taking into account their environmental sustainability. Building on this updated definition, this paper presents a decision-making flowchart to integrate the assessment of the impact of human medicines on surface water, outlining existing actions and proposing new ones. These actions are categorized into those with primary clinical benefits and those focused solely on environmental concerns. They include both upstream and downstream measures, such as implementing regulations similar to those in the EU and the USA, educating future healthcare practitioners, promoting green pharmacy innovations, and establishing proper disposal practices.

Background

Two publicly available Swedish knowledge support systems, “Pharmaceuticals and Environment” on Janusinfo.se and Fass.se, provide environmental information on pharmaceuticals. Janusinfo is provided by the public healthcare system in Stockholm and Fass is provided by the pharmaceutical industry. The objectives of this study were to investigate the experiences among Swedish Drug and Therapeutics Committees (DTCs) with using the databases, retrieve development proposals for these, and investigate the DTCs’ challenges with working with pharmaceuticals in the environment.

Methods

A cross-sectional survey with 21 questions, both closed and open-ended, was distributed electronically in March 2022 to Sweden’s 21 DTCs. Descriptive statistics and inductive categorization were used for the analysis.

Results

A total of 132 respondents from 18 regions filled out the survey. The average regional response rate was 42%. The DTCs used the knowledge supports to consider environmental aspects of pharmaceuticals in their formularies and in education. Respondents were more familiar with Janusinfo compared to Fass but appreciated the availability of both. The DTCs especially valued the concrete proposals for certain active pharmaceutical ingredients on Janusinfo. Respondents requested that all medicinal products have environmental information on Fass. Challenges included lack of data, lack of transparency from the pharmaceutical industry and difficulties considering the environmental aspect of pharmaceuticals in their healthcare practice. Respondents wanted more knowledge, clear messages, and legislation to support their work to reduce the negative environmental impact of pharmaceuticals.

Conclusions

This study demonstrates that knowledge supports for environmental information on pharmaceuticals are valuable for the DTCs in Sweden, but the respondents experienced challenges in their work in this field. The study can provide insights to those in other countries interested in considering environmental aspects in their formulary decision-making.

Background: Pharmaceuticals treat and prevent diseases but can pose a risk to organisms, predominantly in aquatic environments. The use of pharmaceuticals is predicted to increase due to, among other factors, a growing and aging population and climate change. Therefore, it is important to develop mitigation strategies to prevent pharmaceutical residues from entering the environment. In Sweden, two public pharmaceutical web-based knowledge supports provide information on the environmental impact of pharmaceuticals.

Objective: To explore stakeholder perspectives, use and future opportunities related to two webbased knowledge supports publicizing environmental information on pharmaceuticals.

Methods: Stakeholders identified for their experience with the knowledge supports, pharmaceutical policy, and stakeholder collaboration were recruited using purposive and snowball sampling for semi-structured interviews. Interviews were conducted in person or via video calls. Respondents included twenty-one representatives from the pharmaceutical industry, regional and national authorities, academia, and an independent research institute. Interview transcripts were analyzed using content analysis.

Results: Respondents valued having environmental information on pharmaceuticals publicly accessible on two wellknown pharmaceutical knowledge supports. The knowledge supports have been used in Sweden and internationally. Perceived differences were recognized between the impact and perspectives of the two knowledge supports with a general preference for the Janusinfo knowledge support. The preference was especially identified regarding transparency and the use of the information in clinical practice. Barriers to impact were a lack of resources and decision-making criteria. Respondents believed that the impact and value of the knowledge supports could be improved with more authority involvement.

Conclusion: Public knowledge support providing environmental information on pharmaceuticals has been valuable across sectors, especially, among Drug and Therapeutics Committees. We believe the results from this study could be useful for other countries interested in implementing a similar system.

Pharmaceuticals can reach the environment at all stages of their lifecycle and accumulate in the ecosystem, potentially reaching toxic levels for animals and plants. In recent years, efforts have been made to map and control this hazard. Assessing country-specific environmental risks could drive regulatory actions towards eco-friendlier drug utilization and disposal practices. By starting from a list of 25 environmentally hazardous pharmaceuticals developed by Region Stockholm, we integrated eco-toxicological and 2019-2021 Italian drug utilization data to estimate the environmental impact of pharmaceuticals in Italy. We calculated the risk as the ratio between the predicted environmental concentration (PEC) and the predicted no-effect concentration (PNEC). We found a high risk for levonorgestrel, ciprofloxacin, amoxicillin, azithromycin, venlafaxine, sertraline and diclofenac and a moderate risk for ethinyloestradiol, oestradiol and clarithromycin. This analysis can be periodically performed to identify the pharmaceuticals with the highest risk for the environment and ascertain if containment measures should be implemented.