Stewardship approaches to reducing pharmaceutical pollution

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This paper investigates to what extent stewardship can play a role in the prevention of pharmaceutical pollution. Pharmaceutical compounds have been identified as being of emerging concern in the environment; the focus of proposals for mitigation is gradually shifting from end-of-pipe solutions at wastewater treatment works to ways to reduce pharmaceutical inputs into the sewer system.

The pathway of pharmaceuticals in the environment can be described as a ‘medicinal product chain’ (Grinten et al., 2016) from drug design to discharge into the environment, and the stakeholder field thus includes the pharmaceutical industry (both the ‘innovators’ and the generics industry and including both design and manufacturing aspects); the licensing and regulatory authorities at international (e.g. EU) and national levels; wholesalers, suppliers and importers; healthcare organisations and hospital management; medical staff in hospitals, general practitioners, and other prescribers (e.g. dentists), as well as their professional bodies; pharmacies and their professional bodies; patient organisations and other NGOs; patients and the general public; environmental regulators; waste managers (e.g. waste collectors, landfill managers) and wastewater treatment companies; farmers and drinking water companies. The actions and decisions of these stakeholders play a crucial role in determining the extent and nature of pharmaceutical pollution and understanding the drivers behind these actions and decisions can help identify opportunities for its reduction. This paper explores, firstly, to what extent the concept of stewardship can contribute to a reduction in pharmaceutical inputs along this chain of processes.

Whilst it is clear that healthcare stakeholders plays a central role, the debate on mitigating environmental risk from pharmaceuticals has taken place mainly in the domain of the environmental sciences and not in the domain of healthcare. By contrast, the healthcare sector has taken ownership of the debate on reducing antimicrobial inputs into the environment and, consequently, AMR literature review yields in-depth analyses on how to achieve optimisation (e.g. Davey et al., 2013; Dixon and Duncan, 2014) – and often reduction – of antimicrobial use. In this context, the concept of stewardship has been used extensively. Calls for stewardship to prevent pharmaceutical residues entering the environment (Daughton, 2003) do not appear to be heeded significantly amongst prescribers. The second aim of this paper is therefore to identify where positive experiences from the AMR context can be transferred to pharmaceuticals more generally by considering the strategic direction of stewardship. Stewardship can be defined as ‘careful management’ towards a particular (set of) outcome(s). However, this set of outcomes, or the direction and priorities of stewardship, are not necessarily the same for all stakeholders: financial stewardship, health outcomes and environmental stewardship are weighed differently by different actors, and priorities in stewardship can be aligned or conflicting. Where they are aligned, we may find ‘low hanging fruit’: areas where changes can be made that are beneficial or at least non-controversial both internally to each stakeholder and externally to all stakeholders. Where they are conflicting, decision making on a higher level may need to consider whether it is appropriate to instigate change.

In prescribing, it has been identified that over a third of antimicrobial prescribing is inappropriate and that stewardship can achieve cost savings, optimise patient outcomes (e.g. by reducing Healthcare Acquired Infections or HAI), as well as minimise the spread of antimicrobial resistance (Dellit et al., 2007). Although usually not identified as a benefit in the AMR literature, environmental risk is also likely to be reduced by implementation of such a stewardship approach, as some of the highest ranking pharmaceuticals in terms of aquatic environmental risk are antibiotics (Helwig et al., 2016): financial, health and environmental drivers are aligned.

In community antimicrobial prescribing, relevant factors have been identified as the physician’s perception of patient expectations, concerns about liability or blame, and the extent to which drug provision is controlled by doctors, pharmaceutical marketing, and financial considerations, whilst education of both patients and physicians have been shown to be an effective intervention towards reduced prescribing. In hospital prescribing, both persuasive and restrictive interventions have shown potential to reduce antimicrobial prescribing, whilst organisational culture has also been shown to be an important factor. These issues are not unique to antimicrobials and addressing them has the potential to reduce pharmaceutical inputs more generally, provided that stewardship towards healthcare and environmental outcomes is aligned and financial outcomes are not adversely affected. Finally, stewardship amongst the general public towards alternatives to medication and more discerning use of over-the-counter products could lead to cost savings for the patient, reduced toxicities as well as reduced environmental risk.

Daughton, C.G. (2003) ‘Cradle-to-Cradle Stewardship of Drugs for Minimizing Their Environmental Disposition While Promoting Human Health’, Environmental Health Perspectives, 111(5), pp. 757–774.
Davey, P. et al. (2013) ‘Interventions to improve antibiotic prescribing practices for hospital inpatients.’, Cochrane Database of Systematic Reviews, (4), p. CD003543.
Dellit, T.H. et al. (2007) ‘Results of survey on implementation of Infectious Diseases Society of America and Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship.’, Infection control and hospital epidemiology¿: the official journal of the Society of Hospital Epidemiologists of America, 44(1), pp. 159–177.
Dixon, J. and Duncan, C.J.. (2014) ‘Importance of antimicrobial stewardship to the English National Health Service’, Infection and Drug Resistance, 2014(7), pp. 145–152.
Grinten, E. Van Der et al. (2016) Towards balancing the benefits of pharmaceutical care and minimizing its environmental harm: Identification of potential levers in the medicinal product chain. Bilthoven.
Helwig, K. et al. (2016) ‘Ranking Prescribed Pharmaceuticals in Terms of Environmental Risk: Inclusion of Hospital Data and the Importance of Regular Review’, Environmental Toxicology and Chemistry, 35(4), pp. 1043–1050.

Original languageEnglish
Publication statusUnpublished - Oct 2016


  • pharmaceutical industry
  • pollution
  • antimicrobial prescribing
  • stewardship


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