By the time a patient at Robert Wood Johnson University Hospital (RWJUH) in New Jersey gets hooked up to an intravenous (IV) bag filled with antibiotics, the drug has already left its mark on the environment.
The production of IV drugs requires far more energy than producing pills, and large amounts of IV drugs get disposed of because they come in single-use packages with more medication than the patient needs. For instance, a study conducted through the United Kingdom’s National Health Service found that the IV form of the antimicrobial ciprofloxacin “has a carbon footprint 60 times higher than in tablet form.”
Reducing that impact poses a challenge for all hospitals, and several months ago RWJUH set out to reduce its use of IV antibiotics by transitioning selected patients more quickly from IV to oral versions of the drugs.
“We’re trying to reduce our hospital-generated waste,” including drugs and the many supplies used to administer them, says Catherine Chen, MD, who leads the waste audit and life cycle assessment project for the Office of Climate Action at Rutgers Health.
RWJUH selected several of its most commonly used antibiotics (including vancomycin and levofloxacin) for the pilot, and is choosing patients who can safely complete their antibiotic schedule orally, says Chen, assistant professor of medicine at Rutgers Robert Wood Johnson Medical School. The effort addresses a concern of health care facilities that are attempting to reduce their carbon footprints, because about 80% of greenhouse gas (GHG) emissions from health care come from indirect emissions — that is, those emitted along the supply chain through the production and delivery of the goods and services that care providers use. In addition, disposing of unused drugs not only wastes products that produce GHGs during manufacturing and shipping, but it creates demand for the production of more of those products.
While the entire health care sector is responsible for up to 4.6% of GHG emissions worldwide, according to a 2020 report from Northeastern University and Yale University, an Oxford University study published last year estimated that the production, distribution, and use of pharmaceuticals account for about one-quarter of GHG emissions in health care.
As part of the growing effort to reduce their role in GHG emissions, the U.S. health care industry is just beginning to look for ways to reduce drug use and waste. One challenge is that the impact of pharmaceuticals is not immediately obvious. As noted in a commentary written by Chen and pharmacists at Rutgers Ernest Mario School of Pharmacy and scheduled to be published in April in the Journal of the American Pharmacists Association: “Healthcare professionals – physicians, pharmacists, nurses, and others – may be unaware of GHG emissions and the long-term environmental effects of the medications they prescribe, dispense, and administer daily.”
Drug production adds to GHGs
The GHG impact of pharmaceuticals arises from three broad sections of the supply chain: manufacturing, packaging/shipping, and use.
My Green Lab, a nonprofit led by scientists to improve the environmental sustainability of scientific research, explains that the emissions come from energy used for, among other things: running the manufacturing facilities (everything from basic heating and cooling to lab equipment); goods and services that the manufacturers purchase to produce the drugs; the delivery of those supplies; delivering the manufactured drugs to health care providers and others; and the disposal of packaging and products by end users, including hospitals and pharmacies.
“The biggest contributor to carbon emissions from pharmaceuticals is the energy source used for production,” researchers from Cornell University and the Clinton Health Access Initiative noted in a 2023 analysis of HIV medications.
The production of drugs involves numerous steps — such as synthesizing raw materials and coating the drugs — that involve the use of machinery that consumes large amounts of energy. In addition, many of those drugs are produced in countries, such as China and India, that rely on coal as a source for their electrical production.
Pharmaceutical companies do, however, have options in how they produce their products. Under pressure from governments and environmental organizations, more of these companies across the globe are looking for ways to reduce their GHG emissions. At least 35 companies in the biotechnology and pharmaceuticals sector (accounting for most of the sector by revenue) have signed on to the Race to Zero climate change initiative, backed by the United Nations, to establish measurable reduction targets, according to a December 2023 report by My Green Lab.
Among the strategies that pharmaceutical companies are carrying out: purchasing or generating renewable energy; shipping more products by ground freight rather than air; urging suppliers to use environmentally sustainable practices in their use of energy and water; and redesigning packaging to cut down on waste.
Hospitals find limited options
Health care systems in the United States are increasingly taking action to reduce their carbon footprints by reducing energy use and product waste within their buildings, changing their food practices along the supply line, and switching to reusable gowns and gloves. When it comes to reducing the GHG impact of the drugs they use, however, hospitals face fundamental impediments — some of which are beyond their control, and some of which can be moderately circumvented. For example:
Lack of information about GHG impact: Drugs do not come with information about the environmental impacts of their creation and use. One example is metered-dose inhalers, often used to treat asthma, that use propellants to provide a specific dose of medication through a short burst. “There’s really no easy way to tell what propellant is in any of them,” Chen says. “They have kind of a hidden footprint.”
Many of the inhalers use hydrofluoroalkanes, a GHG.
“The medication itself isn’t the major contributor to GHGs,” says Jodi Sherman, MD, associate professor of anesthesiology and epidemiology at the Yale School of Medicine. “It’s the propellant used to deliver the drug.”
Little choice in what to buy: Many drugs — especially highly specialized medications to treat severe medical conditions — are supplied by one or only a few manufacturers. In some industries, large companies (such as General Motors) have pressed their suppliers to reduce their GHG emissions. But hospitals have little leverage with pharmaceutical companies because the hospitals would have difficulty finding alternative suppliers, much less suppliers confirmed to produce less GHG.
In addition, hospitals often buy their drugs through group purchasing organizations (GPOs) that represent a bundle of clients (such as multiple hospitals across a region). The GPOs use that collective bargaining power to get the lowest purchase price.
“They’re going to negotiate the best price for a drug that fits all [of their clients], and you can’t blame them,” says Janet Kozakiewicz, PharmD, retired director of Pharmacy Services at Yale New Haven Hospital in Connecticut who now consults for health care systems.
Sometimes, alternatives do emerge. Consider inhaled anesthetics, which are among the biggest contributors to GHG emissions from hospitals. The anesthesia that is inhaled by patients is released from operating rooms to the outdoors through waste gas evacuation systems.
“The vast majority of the inhaled anesthetic emissions are from the waste gases, the stuff we throw away,” Sherman explains.
Hospitals are increasingly shifting from anesthetics (the drugs used in anesthesia) that produce high GHG emissions, such as desflurane, to less environmentally damaging drugs, such as sevoflurane. (Studies have found sevoflurane to be safe and effective.)
As for inhalers, research has identified certain ones that contribute less to GHG emissions than others, but there can be limits on their usefulness depending on the patient’s condition.
How drugs are packaged: IV drugs are typically delivered in single-use packaging (bags or vials) that contain more product than what a patient needs. Sherman explains that when a patient is taken off a drug that’s being delivered from an IV bag, any remaining drug gets disposed of with the bag, for reasons of sanitation and safety. And when a nurse uses a syringe to draw a fraction of a drug from a vial for an injection, the drug that remains is usually disposed of with the vial, for the same reasons.
“The industry games the system for us to buy more than we need,” Sherman says. “We throw away more than we need.”
She believes pharmaceutical companies should create more single-use packages that are in the doses that patients are more likely to need.
And hospitals can reduce some of this waste by using syringes that are prefilled to specific doses. A pilot program in England found that emergency rooms that switched to prefilled syringes reduced waste from an average of 585 syringes worth of emergency drugs per year to just 93 syringes.
Expiration dates might be too soon: Hospitals discard or return a lot of drugs because they’ve reached their expiration dates. Making matters worse, Sherman says, is that opening the package of some drugs sets an earlier expiration date, because of concerns that the unused portion will get contaminated or degrade quickly.
It’s not clear, however, that the expiration date marks the point at which a drug is ineffective or unsafe.
“The manufacturer takes into account stability and sterility” when setting an expiration date, Kozakiewicz says. But that just means the company tested the drug to a certain date that it chose. It does not mean that it found the date when the drug actually becomes unstable.
“They’re saying that on any date after [expiration], they can’t ensure stability,” Kozakiewicz explains. “But you don’t know that it’s going to cause harm” if used.
Chen wishes medical organizations and regulators would press manufacturers to conduct more long-term studies of the viability of their medications.
Insufficient information about hospital drug waste: It’s extremely difficult for a health care system to account for all of the drugs that it disposes of or returns after partial use or expiration. (Federal law requires hospitals to track their use and disposal or return of certain controlled substances but not of other medications.)
“Hospitals don’t even know how much medicine they waste,” Kozakiewicz says. “You’re wasting small quantities 24 hours a day, seven days a week, 365 days a year. It’s in the pharmacy, the nursing station, the emergency room.”
Results are not yet public for the IV-to-oral medication pilot at RWJUH. A 2022 report in Clinical Infectious Diseases noted that “numerous studies on converting antimicrobials from intravenous to oral have shown dramatic decreases in costs without compromising efficacy or safety.”
Chen says the RWJUH pilot could lead to similar efforts with other types of drugs that are often administered by IV. “Our life cycle assessment team hopes to provide data to encourage transitions that have [positive] climate impact and patient health benefits,” she says. “If we can show that this type of thing works, we could do assessments for other medical processes.”
