Medicines in the Water, Waste in the System: The Case for Green Pharmacy

Medication use affects the environment, creating pollution in numerous ways. Every actor in the chain contributes, from manufacturers to patients who consume and then eliminate medication. This fact has been known for decades, but recent events have brought the issue to the forefront.

Many people are aware of situations such as the 2004 discovery of vultures in Pakistan that died from visceral gout after consuming carcasses of animals treated with veterinary diclofenac.¹ Since then, environmentalists have identified diclofenac poisoning in European vultures.^2,3 More recently, researchers from the University of Florida harvested 93 bonefish from coastal ocean waters and found 53 pharmaceutical contaminants in their blood and tissue, most often including atenolol, venlafaxine, alfuzosin, trimethoprim, and paracetamol.⁴ Sewer forensics is an emerging science that monitors the prevalence of diseases such as COVID-19 and local populations’ illicit drug use.^5-9

Clearly, the entire pharmacy community needs to address environmental sustainability. Medications are just part of the problem. Health care, with its heavily packaged products often wrapped in plastic and designed for single use, is a major producer of garbage.^8,10 It’s time to think about sustainability, ie, health care’s ability to meet this generation’s needs without compromising future generations’ ability to meet their own.¹¹

Pharmacies need to take responsibility for their environmental impact. That means embracing the green pharmacy concept and developing insight into the harmful environmental effects of medication.¹² It has a wide scope, and all actors must engage—this is often called cradle-to-grave management.¹² Table 1¹¹ lists the areas in which pharmacies need to engage.

Advocate for medication take-back programs. Collecting unused medications is an excellent way to implement environmentally safe waste management in pharmacies. The US DEA schedules National Prescription Drug Take Back events throughout the year, and they are widely advertised (the next is April 25, 2026).¹³ Many pharmacies will provide mail-back envelopes for patients; if they don’t, patients can identify (or pharmacy staff can help them identify) sources of such envelopes using the search term mail-back envelopes for medicine in an internet search engine.

Improve waste management. Here, pharmacy managers or staff members with a passion for environmentalism might conduct an environmental assessment and monitor how the pharmacy disposes of trash generated by the dispensing process.¹⁴ Identifying areas in which the pharmacy can improve and creating reasonable, achievable goals are critical to making change. Explaining the environmental repercussions of inaction may also motivate staff to help.¹⁴ There may be no solution for some problems now, but new interventions may be available later, so periodic reassessment is important.

Use sustainable, energy-efficient packaging. Pharmacies can limit the use of plastic bags and containers and actively pursue eco-friendly procurement and distribution processes.¹⁵ The Association of Plastic Recyclers (APR) indicates that rigid plastic pharmacy stock bottles are excellent recycling candidates. APR calls these bottles “a highly marketable, quality stream of high-density polyethylene.”¹⁶

Reduce paper use. Consider this: In 2018, a single American chain pharmacy used 54,500 tons of paper (bags, patient information, labels, receipts, flyers)—an amount that would fill roughly 2500 truckloads or create a stack of 8-by-11-inch paper 130 miles high.¹⁷ Looking for ways to reduce paper use is critical.

Streamline processes to reduce waste. Procuring goods and services accounts for most of any health care system’s environmental footprint; pharmacies are heavily reliant on ordering goods.¹¹ Staff who tell suppliers that they have concerns about environmental impacts may leverage significant change. They can also look for opportunities to buy and use less, question staff about the necessity of large or unusual orders, and take steps to reduce waste.¹¹

Introduce more eco-friendly products. At the industry level, environmental activists encourage the development of greener medications.¹⁸ Pharmacy staff need to look at every product and consider its environmental impact. Consider continuous glucose monitoring devices; they run on lithium batteries, and Americans discard millions of units annually.¹⁹ Abbott has a recycling program that accepts its electronics.

Use medication responsibly. Most medicines are excreted through urine or feces and pass through wastewater treatment plants. Few municipal sewage treatment plants can remove all pharmaceutical compounds from the water.²⁰ Incorrect medication disposal or simply bathing and showering, sweating, or washing clothes after using topical medications also contributes to environmental runoff.²¹ Consulting with the Choosing Wisely series can help prescribers and patients start discussions about ways to reduce overuse and unnecessary services to improve patient outcomes.²² Table 2^15,18,23,24 summarizes ways to improve medication use.

Often, the idea of implementing changes to improve sustainability can seem overwhelming. As with many large projects, establishing goals and subgoals can help. In fact, every little bit helps.

REFERENCES

1. Shultz S, Baral HS, Charman S, et al. Diclofenac poisoning is widespread in declining vulture populations across the Indian subcontinent. Proc Biol Sci. 2004;271(suppl 6):S458-S460. doi:10.1098/rsbl.2004.0223

2. Herrero-Villar M, Delepoule E, Suárez-Regalado L, et al. First diclofenac intoxication in a wild avian scavenger in Europe. Sci Total Environ. 2021;782:146890. doi:10.1016/j.scitotenv.2021.146890

3. Moreno-Opo R, Carapeto R, Casimiro R, et al. The veterinary use of diclofenac and vulture conservation in Spain: updated evidence and socio-ecological implications. Sci Total Environ. 2021;796:148851. doi:10.1016/j.scitotenv.2021.148851

4. Castillo NA, Santos RO, James WR, et al. Widespread pharmaceutical exposure at concentrations of concern for a subtropical coastal fishery: bonefish (Albula vulpes). Mar Pollut Bull. 2024;209(pt A):117143. doi:10.1016/j.marpolbul.2024.117143

5. Harries AD, Dar Berger S, Satyanarayana S, Thekkur P, Kumar AMV. Testing wastewater to detect severe acute respiratory syndrome coronavirus 2 in communities. Trans R Soc Trop Med Hyg. 2020;114(10):782-783. doi:10.1093/trstmh/traa066

6. Santos JM, Jurban M, Kim H. Could sewage epidemiology be a strategy to assess lifestyle and wellness of a large scale population? Med Hypotheses. 2015;85(4):408-411. doi:10.1016/j.mehy.2015.06.020

7. Wang Z, Mueller JF, O'Brien JW, et al. Monitoring medication and illicit drug consumption in a prison by wastewater-based epidemiology: impact of COVID-19 restrictions. Water Res. 2023;244:120452. doi:10.1016/j.watres.2023.120452

8. Negro F, Baggio U. Wastewater analysis and drug consumption: useful assessment tool. Clin Ter. 2022;173(6):526-527. doi:10.7417/CT.2022.2476

9. Rodríguez-Jiménez L, Romero-Martín M, Spruell T, Steley Z, Gómez-Salgado J. The carbon footprint of healthcare settings: a systematic review. J Adv Nurs. 2023;79(8):2830-2844. doi:10.1111/jan.15671

10. Pharmaceutical residues in freshwater. Organisation for Economic Co-operation and Development. November 13, 2019. Accessed February 17, 2026. https://www.oecd-ilibrary.org/environment/pharmaceutical-residues-in-freshwater_c936f42d-en

11. Environmentally sustainable health systems: a strategic document. World Health Organization. Accessed February 17, 2026. https://iris.who.int/bitstream/handle/10665/340375/WHO-EURO-2017-2241-41996-57723-eng.pdf?sequence=3

12. Daughton CG, Ruhoy IS. Green pharmacy and pharmecovigilance: prescribing and the planet. Expert Rev Clin Pharmacol. 2011;4(2):211-232. doi:10.1586/ecp.11.6

13. Broman MJ, Ellis JD, Victor GA, et al. Predictors of safe prescription opioid storage and participation in drug take-back events: results from a statewide survey. J Community Health. 2021;46(5):1000-1007. doi:10.1007/s10900-021-00983-4

14. Detwiler RP. The environmental style: writing environmental assessments and impact statements. October 2005. Accessed February 19, 2026. https://www.energy.gov/nepa/articles/environmental-style-writing-environmental-assessments-and-impact-statements-doe-2005

15. Best practice paper on green and sustainable pharmacy in Europe. Pharmaceutical Group of European Union. Accessed February 19, 2026. https://www.pgeu.eu/publications/pgeu-best-practice-paper-on-green-and-sustainable-pharmacy-in-europe/

16. APR announces pharmacy stock bottle recycling resources. Recycling Today. May 26, 2017. Accessed February 19, 2026. https://www.recyclingtoday.com/news/apr-pharmacy-bottle-recycling-resources/

17. Do T, Novakowski J. Sustainable pharmacy: a regimen for the future. The DU Quark. 2020;4:2-9. https://dsc.duq.edu/cgi/viewcontent.cgi?article=1066&context=duquark

18. European Union strategic approach to pharmaceuticals in the environment. European Commission. March 11, 2019. Accessed February 19, 2026. https://eurlex.europa.eu/legal-content/EN/TXT/PDF/?uri=CELEX:52019DC0128&from=EN

19. Avari P, Cai Y, Verma V, Reddy M, Srinivasan M, Oliver N. Batteries within diabetes devices: a narrative review on recycling, environmental, and sustainability perspective. J Diabetes Sci Technol. 2026;20(2):436-442. doi:10.1177/19322968241278374

20. Rogowska J, Zimmermann A. Household pharmaceutical waste disposal as a global problem-a review. Int J Environ Res Public Health. 2022;19(23):15798. doi:10.3390/ijerph192315798

21. Daughton CG, Ruhoy IS. Environmental footprint of pharmaceuticals: the significance of factors beyond direct excretion to sewers. Environ Toxicol Chem. 2009;28(12):2495-2521. doi:10.1897/08-382.1

22. Choosing Wisely. ABIM Foundation. Accessed February 19, 2026. https://choosingwisely.org/

23. FIP statement of policy – environmentally sustainable pharmacy practice: green pharmacy. International Pharmaceutical Federation. August 28, 2016. Accessed February 19, 2026. https://www.fip.org/file/1535

24. Wedmore F, Nolan T, Watts N. Sustainable practice: what can I do? BMJ. 2023;383:2461. doi:10.1136/bmj.p2461