Inappropriate prescribing in older people: not only a patient safety issue but an avoidable source of environmental harm

This is the authors' abstract. We don't add key points for this paper.

Humans are consuming more pharmaceuticals than ever. Medicines are estimated to account for 25% of NHS carbon emissions. Tackle inappropriate polypharmacy: good for the patient & the environment. Humans are consuming more pharmaceuticals than ever before [1] as a result of ageing populations, and technological innovation transforming the treatment of ageing-related and chronic diseases [2]. Moreover, climate-related environmental changes are associated with a rise in the incidence of certain chronic diseases [3], which ultimately will lead to further medicines use. Healthcare is a key contributor to the climate crisis emitting 4.4% of global net emissions [4]. Medicines are estimated to account for 25% of NHS carbon emissions in the UK [5] so any increase in their use may worsen atmospheric warming [6]. Medicines also adversely affect the water and soil compartments of the environment through effluent from wastewater treatment plants, application of contaminated sludge to crops or inappropriate disposal via domestic waste to landfill. The Global Monitoring of Pharmaceuticals project studied 258 rivers across 104 countries and showed the presence of pharmaceuticals in the environment at concentrations of concern to human and/or environmental health in over 25% of the rivers sampled [7]. The United Nations states that one in six people in the world will be over the age of 65 by 2050 [8]. Multimorbidity and the associated use of multiple medicines are common in the older population. Combined with this demographic transition, if prescription patterns are maintained, global medicine use will increase. Polypharmacy has often been defined as the use of five or more prescribed medicines [9]. It is now suggested that it is the concurrent use of two or more medicines and that the emphasis should be on whether the prescribing is evidence based and appropriate [10, 11]. It is estimated that around one-third prescriptions for older people living at home are potentially inappropriate added to which around half of all medicines for chronic conditions are not taken as intended [12]. This coupled with the fact that medication- related harm is a serious problem, causing severe or life-threatening outcomes in over a quarter of all preventable harm cases [13] and that such inappropriate use is impacting our environment strengthens the case for appropriate polypharmacy to keep both our patients and our planet safe. Efforts to limit the harm caused by inappropriate prescriptions led to the development of explicit criteria for clinically important prescribing problems to reduce older people’s exposure to inappropriate medicines, such as the AGS Beers and the STOPP/START criteria [14, 15]. Recently the iSIMPATHY European project has proposed a 7-step process to appropriate polypharmacy based on patient centred medication appropriateness index [16]. The findings from the project demonstrated that implementing the 7-step medication review to appropriate polypharmacy resulted in 82% of interventions being clinically significant, with 4% potentially preventing major organ failure or adverse drug reactions of similar clinical importance. There were 9800 potentially avoided admissions. Overall, patients reported better understanding of their medicines, improved adherence and experienced less harm [16]. Medicine reviews, apart from achieving the best outcomes for patients’ health and wellbeing, are also cost-effective in terms of reduced medication costs, health and social care utilisation costs. The more sustainable use of medicines is gaining attention among health care professionals. In Scotland, doctors and pharmacists issued a joint statement on reducing the environmental impact of medicines calling on national guidance developers to include information about the environmental impact of medicines [17]. There remain many data gaps with regard to carbon footprints, life cycle assessments and the impact of water and soil based pharmaceuticals. However, the National Institute for Health and Care Excellence estimated that implementing its medicine optimisation guideline [18] to prevent avoidable medicine-related hospital admissions could reduce greenhouse gas emissions by 202 tonnes, save 0.3 million m3 of fresh water and prevent the creation of 24 tonnes of waste in hospitals per 100 000 population [18]. Tackling inappropriate polypharmacy in older people not only improves the quality of their life, but will also help mitigating environmental effects of medicines with the added consequence that harm to human health will be reduced and will help achieving the goal set in the Third Global Patient Safety Challenge, Medication Without Harm [19]. Considering the environmental harm caused by pharmaceuticals (including their carbon footprint) is just another reason to use them rationally. We believe that including environmental aspects as explicit criteria for appropriate prescribing in older people could help clinicians to make better decisions, which will benefit both patients and the environment. None. None.