PowerPoint Presentation

Pharmaceutical Waste Effects on Water Systems and a Healthcare Action Plan

http://www.medicaldump.com/2011/09/internal-medicine-powerpoint-template.html

Pharmaceutical waste effects on water sources and a healthcare action plan by Katelyn Duncan. 1

(Karnish et al., 2010)

Working as healthcare professional I am sure that you are aware of the term pharmaceutical waste but many healthcare workers are uninformed of what problems pharmaceutical wastes induce upon our environment, particularly our water systems. The short video clip you will be watching in a moment is the eighth in a twelve-part Pedal and Paddle Pollution Video Tour chronicling watershed and runoff issues on the Lower Chippewa River here in Eau Claire, Wisconsin. This video segment will explain a quick overview of pharmaceuticals and analyze some of the potential effects of pharmaceutical wastes in our water systems. [After video] The video clip that you just viewed gave a brief introduction to pharmaceutical wastes and its effects on water sources. Now we will look at this issue more in depth and later talk about what you can do as healthcare workers to help diminish this issue.1

What are pharmaceutical wastes?

http://www.sdcounty.ca.gov/deh/hazmat/hmd_pharmwaste.html/http://www.paradiserecycles.com/aph.pir.231.html/http://www.promo-wholesale.com/syringes.html/

Pharmaceutical wastes include, but are not limited to, unused medications, either prescribed or over-the-counter, discarded drugs, which can be classified as digested remnants, or flushed or thrown away medications, and medical containers or devices that may contain drug residues, such as syringes, medical tubing or medicinal containers. Medications and medical devices are used by patients in healthcare every day. Because of the large need for administering medications in hospital or clinical settings, many healthcare professionals handle great amounts of medications and in return are exposed to a great deal of pharmaceutical wastes. 1

Pharmaceutical wastes are released into water environments through...

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What many healthcare workers, like yourself, fail to realize is that they can help determine whether pharmaceutical wastes are disposed of properly or if they reappear in our water systems. Pharmaceutical waste are released into water environments through drainage out of sewer systems after flushing or draining pharmaceuticals, throwing pharmaceuticals in the trash which are linked to landfills where pharmaceuticals seep into the ground and into water sources, or lastly through human or animal excretion after the ingestion of processed pharmaceuticals in their systems. 1

Sowhy are pharmaceutical wastes a concern to water environments and what does research have to say about it

?

You may be wondering why pharmaceutical wastes are a concern to water environments and what research has to say about it? Over the past ten years researchers have done a variety of studies focusing on the issue of pharmaceutical wastes, indicating that pharmaceutical wastes are becoming more prominent in aqueous environments and that they pose observable risks for aquatic organisms such as fish and potentially humans as well.1

The Concern: Concentrations

The issue of pharmaceutical wastes begins as a result of inappropriately disposed of pharmaceuticals. Pharmaceutical waste can be categorized as inappropriately disposed of when you flush, trash, or burn inorganic pharmaceutical material. When you inappropriately dispose of pharmaceutical wastes you subject harmful chemicals into our water sources. Even though our city makes use of a waste water treatment plant to help keep our water systems clean, as seen in the video clip, not all pharmaceutical contaminants are caught before entering the water system. 1

Veach & Bernot, Fig.1 Water sample sites for watersheds in Indiana

In a controlled study by Veach and Bernot in 2011 researchers tested water for pharmaceutical chemical residues in an upstream, urban site, Killbuck Creek and a downstream agricultural site, Buck Creek as seen on the map above. 1

COMPOUNDCHEMICAL STRUCTUREPRIMARY USEFREQUENCEY (%)RANGES (ng/L)SulfamethoxazoleHuman antibiotic841.2-16AcetaminophenAnalgesic/ fever reducer841.6-460IbuprofenNSAI/pain reliever681.8-42CarbamazepineAnticonvulsant281.1-2.7TrimethoprimHuman Antibiotic283-58TriclosanAntiseptic/ disinfectant 129.1-22

Veach & Bernot, Table 2. Pharmaceutical frequency of detection (%) and concentration range for all analytes detected in Buck (N=13) and Killbuck Creek (N=12) combined. Analytes not detected: lincomycin,sulfathiazole, tylosin.

The study identified numerous pharmaceuticals in each of the creeks. The chart here shows just a portion of the pharmaceuticals that researchers found in each of the creeks both. You may recognize these compounds as pharmaceuticals you see on a daily basis. Also when comparing the two sites researchers found that the Killbuck Creek, the urban site, had a significantly higher pH level than the agricultural site, yielding a P value of less the 0.05. 1

Koplin et al., Fig. 3, Frequency of Detection in Urban Streams

Also, in a study by Koplin et al. in 2004 , water samples were taken from 23 locations located upstream and downstream of ten Iowa cities, both urban and rural. Water sampling was administered at high, normal, and low stream flow conditions. The slide above shows some common pharmaceutical substances found in low stream flows of urban areas which yielded significant frequencies of detection, all with P values under 0.05. Again urban areas are significantly correlated with higher pharmaceutical concentrations in their water. 1

http://toxipedia.org/display/toxipedia/Environmental+Protection+Agencyhttp://water.epa.gov/scitech/wastetech/guide/upload/unuseddraft.pdf

Researchers have shed light on the fact that numerous pharmaceuticals do occur in our water sources, but government-funded agencies such as the EPA (Environmental Protection Agency) have not specified acceptable frequency levels for pharmaceuticals and their abundance in water sources, despite the fact that they do have guidelines for pharmaceutical disposal which can be found online at the website found on the screen above.

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The Issue: Deformities

Concentrations of pharmaceutical waste in our water systems leads to an even greater problem; the dangers it places on life. Research indicates that pharmaceutical wastes in water are causing deformations in aquatic life, such as fish.1

frontier.cincinnati.com/mmh/cin/htmlThats not what I wanted to eat!

http://www.shopping.com/Walgreens-Walgreens-Ibuprofen-200-Tablets-USP-Tablets-87lb-Walgreens/info?sb=1http://www.allegromedical.com/cold-flu-season-c5030/naproxen-sodium-caplets-p192194.html

In research experiment by Lahti et al. in 2011 researchers studied the intake levels of waterborne pharmaceutical residues in rainbow trout. Rainbow trout were collected from several U.S. rivers and individually exposed to a series of pharmaceutical compounds then evaluated. When examining pharmaceutical concentrations in the trout researchers found substantial concentrations of pharmaceutical compounds including medications such as Ibuprofen and Naproxen.

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Sanchez et al., Fig 4., Analysis of sex-ratio gudgeon populations from three investigated sites. * depicts a statistically significant difference as compared to the site A.

In another research experiment, Sanchez et al.s study from 2011, studied concentrations of pharmaceutical chemical products in fish endocrine systems and fish tissues. Fish were collected from a series of three sites, where site A was conducted upstream from the industrial effluent, site B was downstream form the industrial effluent, and site C was downstream from site B. Of the three sites, site A measured 41% male fish, 53% female fish and 5-8% intersex fish. Compared to site A, site B had a significant 63% increase of intersex fish within the testing location in the stream. Also, site C collected 38% male fish, 4% female fish and 58% intersex fish. The results are significant having a P value of less than 0.05, correlating increased levels of intersex fish downstream from industrial effluents with inappropriately disposed of pharmaceutical waste compounds in the water.

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Sanchez et al., Fig.3, Histological analysis of gudgeon (Gobio gobio) gonads after hematoxylin-cosin-saffron staining.

The above figures are taken from data within Sanchez et al.s study showing stained tissue slide analyses for the gonads of gudgeon fish that were examined and researched for effects of pharmaceutical wastes. (Slide A is a gonad of a female gudgeon from site A located downstream from an urban Waste Water Treatment Plant. Slide B shows a gonad of a male gudgeon from site A. Slide C shows an intersex gonad with primary oocytes observed in fish from site B located downstream from and urban wastewater treatment plant and pharmaceutical factory discharge and slide D shows an intersex gonad with primary and secondary oocytes observed in fish from site B.)1

The Issue: Unknown Health Risks

If deformations and problems are happening to fish in our aquatic environments as seen in Sanchezs study, can you imagine what effects pharmaceutical waste in our lakes, rivers, and streams may be having on us as humans that we are currently unaware of or the effects that pharmaceutical waste could potentially cause in the near future? Despite the fact that there is no research at the time being linking pharmaceutical wastes to health complications in humans, as caregivers and caregiving administration we should help protect the sanctity of human life in any way possible. Fortunately there are ways that you as healthcare professionals can help reduce the amount of pharmaceutical waste in our water system. By eliminating pharmaceutical waste out of our water supply you can help clean our water systems, protect fish, and reduce risks on human health. If you arent convinced that reducing pharmaceutical waste in water is a good idea, ponder the idea of swimming in pharmaceutically infested waters the next time you over prescribe without reason, or forget to comply to proper disposal methods.1

Photo taken by Katelyn Duncan, Genoa WITAKE ACTION: keep our water systems clean and safe

You as healthcare staff have a very powerful impact on pharmaceutical outcomes, therefore I feel it highly appropriate and necessary for you to take a stand for our water systems and implement a pharmaceutical action plan within your facility. 1

Action Plan; reducing pharmaceutical wastes in aquatic systems

My proposed action plan consists of the participation from three healthcare segments within your facility; physicians, nurses, and health administration. With the use of multiple strategies, implemented by yourself and other of your fellow coworkers, it is proven that efforts will be significantly more effective. The idea of multiple strategies is verified in Titz and Dlls study of 2009 where optimal strategies for disposing of pharmaceutical waste products were evaluated. 1

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Whether you are a healthcare administrator, physician, or nurse you can work hand-in-hand with each other towards the same goal; decreasing the occurrence of pharmaceuticals in the water cycle. The best part of this action plan is that it complies with government laws, is extremely feasible, and makes pharmaceutical disposal programs more organized in your hospital or clinic while at the same time promoting a cleaner and safer water system here in Eau Claire.1

FIRST DEFENSE; HEALTH ADMINISTRATION1. Manage disposal programs

2. Advocate to patients3. Encourage other staff

http://www.srph.tamhsc.edu/health-policy-mgmt/master-of-health-administration/index.html1

The pharmaceutical action plan is initiated through health administrators. Therefore health administrators are called the first defense. Health administers can take action by managing disposal programs in their facilities, advocating proper disposal practices for patients, and encouraging physicians and nurses to continue to implement there strategies. An easy way to remember this is M, A, EMAE.1

Health AdministrationMANAGING DISPOSAL PROGRAMS:- Recognize, Implement, or Tweak- Stay up to DateADVOCATE TO PATIENTS:- Take-back Programs- Proper Disposal Techniques- Answer question and concernsENCOURAGE OTHER STAFF:-Make Guidelines/Regulations Available- Oral or Visual Reminders

M stands for managing disposal programs and includes recognizing your facilities current pharmaceutical disposal programs and regulations, implementing new programs if preexisting programs are not working, and/or tweaking disposal programs to be more environmentally friendly. Also managing disposal programs constitutes administration to update themselves on new laws or regulations pertaining to pharmaceutical wastes implemented by the government or large research studies. You can do this by checking the EPA website online, or contacting a local government official for more information. The letter A stands for advocate to patients. For many patients entering your facility, they have never heard about the negative of pharmaceutical wastes occurring in water environments, so they may not be aware of the importance of disposing of pharmaceutical wastes properly. But, they too can help diminish negative pharmaceutical effects. Some ways you can advocate to your patients is through posting signs recognizing local pharmaceutical take-back programs or describing proper disposal techniques as well as answering common questions and concerns about pharmaceutical wastes. Lastly E stands for encourage other staff. Primarily referring to physicians and nurses that are also participating in the action plan, some ways you can encourage staff is through making disposal program guidelines and regulations readily available in a folder or binder for them to access. Also, you can administer, oral or visual reminders, so they are continuously reminded of the guidelines. Signs saying things as simple as, Remember to Dispose of Wastes Properly, can be very helpful for nurses who may be rushed throughout the day. All together each of these objective strategies will decrease the inappropriate disposal of pharmaceuticals and eliminate the risks for it occurring in our water systems and furthermore in fish as well as possibly effecting our bodies.1

SECOND DEFENSE; PHYSICIANS1. Prescribe drug-free therapies2. Avoid over-prescription3. Avoid prescribing pharmaceuticals with unsound environmental behavior

http://www.parmahospital.org/PhysicianDirectory/Note: Information in this chart was produced by Titz & Dll, 2008, p.676)2

The second defense are physicians. Although many of you physicians may not realize how you can make a large impact on pharmaceutical waste in our water, you really can. My action plan suggest that physicians prescribe drug-free therapies, avoid over-prescription, and avoid prescription of pharmaceuticals with unsound environmental environmental behaviors.1

PhysiciansPRESCRIBE DRUG-FREE THERAPIES-

AVOID OVER PRESCRIBINGAVOID PRESCRIBING PHARMACEUTICALS WITH UNSOUND ENVIRONMENTAL BEHAVIOR

An acronym physician is PAA. (PAA) P stands for prescribe drug-free therapies. Although you will not be able to do this with every patient, by turning to a more natural but just as effective therapy you can reduce the occurrence of harmful pharmaceuticals being circulated and henceforth less in the water cycle. The first A stands for, avoid over-prescribing. Many times patients have more than enough pills prescribed which leaves them with a bottle of medication that they dont know what to do with. By avoiding over prescribing you can help prevent the excessive amounts of pills in patients medicine cabinets which could be potentially inappropriately thrown into the trash or flushed down the toilet endangering our water soruces. The last A stands for, avoid prescribing pharmaceuticals with unsound environmental behavior. As physicians you should familiarize yourself with the effects of the pharmaceuticals you are prescribing, both un patients and in the environment. If you know that a certain researched pharmaceutical has caused deformities in fish populations it would be a good alternative to turn to a different pharmaceutical. 1

THIRD DEFENSE; NURSES1. Remind patients of safe disposal methods2. Dispose of pharmaceutical wastes appropriately3. Advocate for more research

http://blog.timesunion.com/healthylife/category/nurse-appreciation-week/3

The third defense are nurses. Nurses can help meet the action plans objective through reminding patients of safe disposal methods, disposing of pharmaceutical wastes safely and appropriately, and advocating for more research. An easy way to remember these steps is to remember RDA.1

NursesREMIND PATIENTS OF SAFE DISPOSAL METHODS:- Tell Patients Orally- Give Patients Educational MaterialADVOCATE FOR MORE RESEARCH:- Contact the FDA, EPA, or Government Officials

DISPOSE OF PHARMACEUTICAL WASTES APPROPRIATELY:- Check Proper Disposal Methods for Medications- Ask yourself, How Do I Dispose of this Correctly?

R stands for remind patients of safe disposal methods. An appropriate time to remind patients to practice safe disposal methods of their medications may be when you are administering their medications because then bringing up the topic will seem more relevant to them. Also, if your facility has educational material for proper disposal of pharmaceutical wastes, such as a brochure or pamphlet, you can give them to patients for them to use in their homes. The next letter to remember is A, advocate for more research. You can do this by contacting the FDA (Food and Drug Administration, the EPA (Environmental Protection Agency), or local government officials. Last is D which stands for dispose of pharmaceutical wastes appropriately. This step is especially important because nurses are the ones that interact most directly with pharmaceutical wastes and are the determining factor of how they will be disposed of. Pharmaceuticals must be disposed of in a safe and appropriate manner, in compliance to your facilities guidelines. The healthcare facility where you work should have a detailed list of pharmaceuticals and proper disposal methods for you to refer to. However, if you are unsure of how to dispose of a substance you can ask your healthcare administrator or DON for more information. Fortunately, most prescription bottles now contain labels describing the proper disposal method for their contents. You may notice that some labels indicate for the substance to be thrown into the trash or flushed down the toilet.

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Is this pharmaceutical really okay to flush?

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To flush or not to flush?...This is a question you may ask yourself when evaluating how to dispose of a pharmaceutical.1

NursesREMIND PATIENTS OF SAFE DISPOSAL METHODS:- Tell Patients Orally- Give Patients Educational MaterialADVOCATE FOR MORE RESEARCH:- Contact the FDA, EPA, or Government Officials

DISPOSE OF PHARMACEUTICAL WASTES APPROPRIATELY:- Check Proper Disposal Methods for Medications- Ask yourself, How Do I Dispose of this Correctly?

Although it is usually not environmentally-safe to flush pharmaceutical waste especially with radioactive or hazardous materials, the FDA (Food and Drug Administration) has announced that some particular pharmaceuticals are okay to be disposed in this way. The FDA rationalizes flushing or trashing for pharmaceuticals with a chemical structure that is mostly organic and will not pose a threat to our environment or aquatic systems. The key objective to remember when encountering pharmaceutical wastes is to ask yourself, How do I dispose of this Correctly? By asking this question you can ensure that you put pharmaceutical wastes in their appropriate settings, and not into our water sources! 1

pbase.com, picture animation by Ernest ShawYou Can Make a Difference!

Through carrying out this action plan with the participation of each of you working together I believe that you can help make a difference; keeping our water systems clean, our fish happy, and our neighbors safe from pharmaceutical wastes! You can make a difference!Thank you for your time and I hope you choose to implement the action plan learned today for your healthcare facility.1

References

Food and Drug Administration. Food and Drug Administration. (2011). How to dispose of unused medications. Retrieved from website: http://www.fda.gov/downloads/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/UnderstandingOver-the-CounterMedicines/ucm107163.pdf

Karnish, Lisa and Julie Murphy. (2010). Pharmaceuticals [Video file]. Retrieved from http://www.uwec.edu/Watershed/tour/pharmaceuticals.htm

Kolpin,D. , Skopec,M. , Meyer,M. , Furlong,E. , & Zaugg,S. (2004). Urban contribution of pharmaceuticals and other organic wastewater contaminants to streams during differing flow conditions. Science of the Total Environment, 328(1-3), 119-130.

Lahti, M., Brozinski, J.-M., Jylh, A., Kronberg, L. and Oikari, A. (2011), Uptake from water, biotransformation, and biliary excretion of pharmaceuticals by rainbow trout. Environmental Toxicology and Chemistry, 30: 1403-1411. Doi: 10.1002/etc.501

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Sanchez, W., Sremski, W., Piccini, B., Palluel, O., Maillot-Marechal, E., etal. (2011). Adverse effects in wild fish living downstream from pharmaceutical manufacture dischages. Environment International, 37(8), 1342-1348.

Titz, Alexandra, & Dll, Petra. (2009). Actor modeling and its contribution to the development of integrative strategies for management of pharmaceuticals in drinking water. Elsevier.

Veach, V.M., & Bernot, M. J. (2011). Temporal variation of pharmaceuticals in an urban and agriculturally influenced stream. Science of the Total Environment, 4553-4563. Retreived from www.elsevier.com/locate/scitotenv

Therapeutic Reserach Center. (2007). Proper disposal of expired or unwanted drugs. Pharmacists Letter; Prescribers Letter, 23(230401), 1-9. Retrieved from http://www.benzos.une.edu/documents/pharmacistslettervol23.pdf