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SUSTAINABLE PHARMACY: FROM
PERSON TO POLICY
Katherine Gruenberg, PharmD, BCPS
UCSF School of Pharmacy
UCSF Medical Center
PGY2 Pharmacy Resident, Infectious Diseases/Education
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CLASS OBJECTIVES
1. Describe the relationship between climate change and
healthcare.
2. Based on the anticipated effects of climate change on
health, identify drugs that may be in higher demand
3. Explain how pharmaceutical companies, hospitals,
healthcare professionals, and patients contribute to
climate change
4. Discuss challenges and barriers to practicing
sustainable healthcare
5. Analyze the environmental opportunity costs in each
step of a pharmaceutical lifecycle, from drug
development to disposal
6. Apply systems thinking and multidisciplinary
perspectives to develop strategies that promote health
service sustainability
SESSION GOAL
To develop awareness of climate-related
illness and to encourage sustainable
healthcare practices, including patient
education about the impact of
pharmaceuticals on climate change
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WHY LEARN ABOUT CLIMATE CHANGE?
• Climate change is a significant threat to health
• In 2007, U.S. healthcare contributed 7% of all
CO2 emissions (39% hospitals, 14% Pharma)
• Medications impact our ecosystem
• Pharmacists have a vital role in climate-related:
• Prevention
• Education
• Policy
1. Crimmins A. USGCRP. 2016
2. Chung JW. JAMA. 2009
CLIMATE CHANGE
• “Changes in average weather conditions that persist over
multiple decades or longer”
• Temperature increase or decrease
• Changes in precipitation
• Severe weather events
• Causes:
• CO2
• CH4
• N2O
• Halocarbons (ie, CFC)
1. U.S Global Change Research Program, 2016
2. IPCC, 2013
3. EPA website. Accessed Nov 1, 2016.
“It is extremely likely that human influence
has been the dominant cause of the observed
warming since the mid-20th century.”
IPCC, Climate Change 2013: The Physical Sciences Basis.
WHY WE SHOULD CARE NOW
Haines A. The Lancet. 2014
SUSTAINABILITY IN THE WORKPLACE
A WORLD OF CONVENIENCE
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CLIMATE CHANGE  HEALTH
• Climate-sensitive vs climate-induced disease
• Exacerbation of respiratory and CV illness
• Malnutrition, heat stroke, infectious diseases,
mental illness, food & waterborne illness
• Adaptive capacity and inherent inequities
• Exposure
• Vulnerabilities
Maxwell J. Journal of Public Health Research. 2016
WHICH MEDICATION CLASSES DO
YOU THINK WILL BE IN GREATER
DEMAND DUE TO THE EFFECTS OF
CLIMATE CHANGE ON DISEASE?
U.S Global Change Research Program, 2016
HEALTH(CARE)  CLIMATE CHANGE
• Resource and energy utilization
• Resources: Single use gowns (>200/d), surgical supplies
• Energy: appliances, computers, lights
• Emissions
• Indirect: transportation of patients, employees, materials
• Direct: formaldehyde, volatile organic compounds, HW
• Waste
• Human, material, pharmaceutical
Maxwell J. Journal of Public Health Research. 2016
• US operating rooms produce ~2000 tons of waste/d
• Quantify wasted supplies from 58 UCSF NS cases
• Sponges, gauze, gloves, OR towel, sutures
• Average cost: $653 ($89-3640)
• 13% total surgical supply costs, $2.9 million per year
• Predictors: case type/category and surgeon
• Action: Price transparency, education
• Savings to date: $800,000
Zygourakis CC. J Neurosurg. 2016
PHARMACEUTICAL WASTE
MANAGEMENT
• Safe Drug Disposal Stewardship Ordinance
• Pharmaceutical companies required to facilitate drug disposal
through Stewardship Plans in San Francisco
• Volunteer Collectors: law enforcement, pharmacy, mail
• CA BoP Regulation: Prescription Drug Take-Back Programs
• Management Standards for Hazardous Waste (HW)
Pharmaceuticals Rule
• Regulates disposal of HW (ie: nicotine, warfarin)
• Bans flushing of all HW by healthcare facilities, pharmacies,
and reverse distributors
1. San Francisco, California, Environmental Code § 31*-15
2. 16 CRR § § 1776-1776.6
3. 40 CFR Parts 261, 262, 266
IDEAS FOR WASTE REDUCTION
Inventory
management
• Order/expiration tracking
Formulary
selection
• Insulin pen, fosphenytoin
Preparation
• Standardized IV Prep
Dispensing
• Labels, packaging/pill bottles, PI
WHO ARE THE HEALTHCARE
STAKEHOLDERS THAT MAY
CONTRIBUTE TO CLIMATE CHANGE?
STAKEHOLDER ANALYSIS
Pharmaceutical
Company
• Design
• Manufacturing
• Packaging/
Distribution
Hospital
• Emissions
• One-time use
supplies
• Hazardous and
non-hazardous
waste
Healthcare
Professional
• Patient
counseling
• Ensure Rx
indication and
Qty appropriate
• Packaging
• Auto-refill
Patient
• Compliance
• Disposal of
unused drug
• Excretion
PHARMACEUTICAL IMPACT ON
CLIMATE CHANGE
• Drug
Development
• Resource Use
Birth
Life
• Transportation
• Packaging
• Prescription
• Persistence
• Bioaccumulation
Afterlife
PATIENT CASE #1
RM is a 3 y/o female with no
PMH or allergies brought to
the pediatrician by her
mother for complaints of right
ear pain and fever to 100F
this morning.
She is examined and
prescribed amoxicillin
suspension 600mg PO BID x
7d for her first case of
presumed Otitis Media.
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AMOXICILLIN LIFECYCLE
R&D
Manufacturing
Rx
Dispensing
Disposal
Pharmaceutical LifeCycle
R&D
• Targeted MOA
• Degrading/Accumulation
Properties
Manufacturing
Rx
• Packaging
• Sustainable materials
• Appropriate
• Optimized
Dispensing
• Packaging
• Adherence
Disposal
•Take-back program
•Flushing
•Trash
ADDITIONAL RESOURCES:
FOR PATIENTS
• CDC: http://www.cdc.gov/climateandhealth/default.htm
• San Francisco Disposal
Sites:http://sfenvironment.org/article/safe-medicinedisposal-for-residents
• California Disposal Sites:
http://www.calrecycle.ca.gov/FacIT/Facility/Search.aspx
?FeedStockCategoryID=13#LIST
• Carbon Footprint: http://www.carbonaddict.org/about
• Meatless Monday: http://www.meatlessmonday.com/
ADDITIONAL RESOURCES:
FOR HCP
• CDC:
http://www.cdc.gov/climateandhealth/default.htm
• 2020 Healthcare climate change: https://noharmglobal.org/issues/global/2020-health-care-climatechallenge
• Pharmaceuticals in Municipal Wastewater Webinar:
https://www.epa.gov/waterresearch/pharmaceuticals-municipal-wastewaterwebinar-supplemental-materials
• Hazardous Waste Pharmaceutical Wiki:
http://hwpharms.wikispaces.com/
PATIENT CASE #2
JJ is a 50 y/o male admitted yesterday to the hospital
with his second asthma exacerbation this year. His
Symbicort dose was recently increased to 1 puff
(160/4.5) BID. He also has an albuterol HFA that he
uses PRN SOB. He is now stabilized on the medicine
floor receiving ipratropium 0.5mg/albuterol 2.5mg
(Duoneb) nebulized Q6H.
The hospital has introduced a new proposal to transition
patients with obstructive pulmonary symptoms from
nebulizers to inhalers (either albuterol HFA or
albuterol/ipratropium (COMBIVENT Respimat) within 24
hours of administration. This change is expected to save
money and enhance patient inhaler education.
WOULD YOU ADOPT THE POLICY OF
SWITCHING NON-ICU PATIENTS FROM
NEBULIZERS TO INHALERS 24 HOURS
AFTER INITIAL ADMINISTRATION?
PATIENT CASE #2 CONTINUED
Since the adoption of the automatic switch from
nebulizers to inhalers within 24 hours of first neb
administration, the cost for COMBIVENT Respimat
has increased to $251 per inhaler. The nebulized
version, Duoneb, is available for $0.08 per vial.
The new proposal is to replace COMBIVENT
Respimat with Albuterol HFA and Tiotropium inhaler
(Spiriva), costing $17.78 and $46.36, respectively.
GROUP QUESTION
1. Would your team adopt the policy of
switching all patients from COMBIVENT
Respimat to Albuterol HFA and Tiotropium
inhaler? (YES or NO)
2. If not, state your alternative proposal and
explain why.
3. Justify your answer by stating how each
stakeholder (administration, environmental,
patient, pharmacy, and respiratory therapy)
played a role in your decision