How “green” is your pharmacy? Does your pharmacy recycle?
How do you prevent pharmaceuticals from impacting the environment? Does pharmaceutical waste from your pharmacy enter the local water supply?What is your pharmacy’s environmental footprint?

These questions are not currently top of mind for most of us in pharmacy...

Pharmacy prides itself on managing formularies, compounding medications in a safe manner, and assuring patients get the right medications. That said, our profession typically does not provide formal education on pharmaceutical waste management or on pharmacy’s responsibility to the environment. There is often confusion as to the proper course for ensuring compliance with the many regulatory mandates for managing pharmaceutical waste, making the establishment of green initiatives seem even more daunting. The results of PP&P’s “Going Green” survey provide a baseline of pharmacy’s current initiatives and future plans for improved environmental responsibility. The need for pharmacy to assume a role as a primary steward of the environment has become apparent.

Cradle-to-Grave Approach
The concept of “cradle-to-grave” responsibility for a drug is part of the evolutionary growth of pharmaceutical care. The three major functions of pharmaceutical care involve:

•Identifying potential and actual drug-related problems

•Resolving actual drug-related problems

•Preventing potential drug-related problems  

Pharmacy’s responsibility to a patient does not end when a drug is dispensed, nor does it end when a drug and its packaging are disposed of. Our profession assumes full responsibility for devising an evidence-based drug list for our facilities and defining the safest ways to store and dispense these drugs from our pharmacies (i.e., “cradle”). However, we have assumed minimal responsibility for segregating waste into the proper waste streams and assuring that it is correctly disposed of via the landfill, incinerator, or sewer system (i.e., “grave”). Generally, we are comfortable leaving the responsibility of final waste disposal in the hands of environmental services; however, a collaborative approach is a better solution. To assure proper waste disposal — from verifying that on-site storage is safe for all hospital team members to completing manifests for regulated wastes — pharmacy should serve in an advisory role with environmental services. Pharmacists must adopt a “cradle-to-grave” approach and take responsibility for minimizing the potential environmental-health effects of pharmaceutical waste.

The 2008 Associated Press investigative report on trace pharmaceuticals in our nation’s water supplies touches upon all three of the functions of pharmaceutical care. The residual waste that has shown up in our water supply has left many unanswered questions as to the risks to the general population. Hospital pharmacies contribute to this problem and, quite possibly, contribute the most concentrated forms of pharmaceutical waste into the drinking water supply. Previously, the mantra of pharmaceutical care focused on the management of medication outcomes; however, neglecting to manage the waste associated with our practice may lead to unexpected drug-related problems on an unpredictably larger scale.

A Case in Point
Examining the types of wastes generated by hospitals gives us an understanding of just how environmentally unfriendly health care is today. As an example, consider Nebraska Methodist Hospital (NMH), a 440-licensed-bed, not-for-profit facility located in Omaha. In 2007, NMH generated approximately 125 tons of waste, which broke out as follows:

•80 tons of regular “brown” waste (landfill-bound)
•14 tons of “red and yellow” waste (biohazardous medical/hazardous to the incinerator)
•15 tons of cardboard waste
•16 tons of HIPAA document waste (shredded and sent to the landfill)

Of all the waste generated at the hospital, only the cardboard materials were recycled. The other wastes were either incinerated or sent directly to the landfill. In other words, 88% of the waste generated in 2007 was not recycled.
Over the course of 2007, NMH’s pharmacy department compounded and dispensed 2,238,337 doses, as follows:

•1,004,967 oral doses

•235,742 IV push/topicals/eye/ear/nose/inhalers

•285,548 large-volume sterile doses

•325,029 low- and medium-risk sterile doses

•486,545 controlled substances

•10,392 hazardous drugs

•2,107 sterile hazardous doses

Waste is generated from partially unused doses, discontinued doses, expired doses, and doses whose integrity is in question. Conservatively, we estimate that 10% of the doses dispensed resulted in pharmaceutical waste. The resulting waste was handled in the following ways:

•210,011 doses, processed by a reverse distributor

•28,884 transactions for controlled substances, sewered

•3,986 liters of outdated IV drugs, sewered

•Three 55-gallon drums of EPA-regulated RCRA waste

•539 vaccine doses (with thimerosol), disposed via RCRA container

Although NMH does not have a formal, hospital-wide recycling program, the department of pharmacy established its own recycling program that includes the recycling of aluminum from staff’s soda pop cans; bulk plastic pill bottles primarily made of high-density polyethylene (HDPE) recycling code #2; and paper package inserts from boxes and bottles. In 2007, the pharmacy department of NMH recycled 26 pounds of aluminum, 125 pounds of recycling code #2 plastic, and 742 pounds of paper from package inserts. In addition, the pharmacy department provides the local chapter of the Humane Society with outdated large-volume IVs for their use.

The waste estimates presented here are only part of the picture. They exclude the vials and other containers that are disposed of as normal brown waste, yet hold concentrated trace residuals. For example, at NMH, disposal of IV piggybacks and large volume IVs resulted in an estimated 612,684 containers (bags) destined for the landfill. Pharmaceutical manufacturers share pharmacy’s concern for the environment and are making strides with “greener” IV containers. More and more DEHP- (di-2-ethylhexyl phthalate) and PVC- (polyvinyl chloride) free IV containers have become available.2

Opportunities for Improvement
There are many opportunities for health care facilities to become more environmentally friendly. In addition to managing regulated waste, hospitals can also embark on the recycling of batteries, eliminating all mercury; utilizing green cleaners, converting to energy-efficient fluorescent bulbs, recycling non-HIPAA-regulated paper documents, minimizing red waste generation, recycling blue sterile wrap, and totally eliminating the sewering and landfilling of all pharmaceutical products. The objective is to become a steward for the patient and the environment, to protect employees and patients, and to comply with federal and state regulations. Understanding and identifying the waste generated in your hospital is a crucial starting point for developing your own green program.