Why You Should Clean Out Your Medicine Cabinet: Anna Edwards (Transcript)

Here is the full transcript of pharmacist Anna Edwards’ talk titled “Why You Should Clean Out Your Medicine Cabinet” at TEDxNHS 2024 conference.

Listen to the audio version here:

TRANSCRIPT:

The Double-Edged Sword of Medicines

Medicines, the very things you think help you, the things that ease our aches and pains, that protect us from deadly infection, that help us get our breath back when we’re struggling to breathe. Are medicines always good for us?

I’m Anna and I’ve been a pharmacist for around 20 years and the thing I love about pharmacy is it’s like a big puzzle. I look at people’s medicines and I work out if they’re okay. Are they okay for your kidneys? Are there any interactions? Are they causing side effects? I’m an extra layer of protection, often working behind the scenes to protect patients from harm.

And when a patient first comes into hospital, one of the first questions I ask them is, “Are you on any medicines at home?” Inevitably, they say yes. More often than not, I’m presented with a carrier bag full of medication, maybe two, balanced on their bedside table. But every time I see this, my heart sinks because this is a problem for patients, our health service and for the planet.

The Impact of Climate Change on Healthcare

It’s been difficult to miss the impacts of climate change these last few years, heat waves being linked to increased mortality, surgeries cancelled due to flooding, Lyme disease on the rise. That’s just here in the UK, a broad toxic smoke from wildfires and people being displaced from their homes.

Sometimes though, this seems a little distant to me, something that other people have more power than I do to change. The fossil fuel companies, big corporations transporting goods all around the world.

But even so, I try and do something. Do you have a bag of plastic bags under the sink to recycle or a reusable cup? Do you sometimes wonder how much of a difference this really makes?

What about at work? What’s the impact of healthcare and what can I do to reduce it? Well, the NHS accounts for about 4% of the UK carbon footprint. That’s enormous. It’s equivalent to the carbon emissions of a small country, somewhere like Sri Lanka.

What about medicines though? If I were to draw the NHS carbon footprint into a pie chart, medicines account for 25%, a quarter of the NHS carbon footprint just from medicines. That’s about 1% of the UK carbon footprint just from medicines.

The Waste of Unused Medicines

Now, I’ll always remember Bill. He presented me with a fishing tackle box, a three-tiered fishing tackle box, hundreds of tablets popped out into it. All those brightly coloured capsules, it looked like lots of different coloured sweets. It must have taken him hours.

But when I saw it, my heart sank because he had tablets that he wasn’t taking anymore, the communication systems weren’t talking to each other, and he was still getting them at home. He had boxes and boxes of laxatives on repeat, kept getting them month after month. You never know when you’re going to need a whole load of laxatives.

And he was quite grumpy with me because he said he tried to take them back to the pharmacy and they’d said they couldn’t be reused. He thought that was ridiculous. Seems a bit ridiculous, doesn’t it? But the fact is, medicines, even if they’re in their original packaging, can’t be reused. We don’t know if you’ve popped your busker pan in the microwave or the caps licked the top of your insulin vial. But when I saw these piles of medicines, my heart sank further because it seemed like such a waste, a waste financially for the NHS.

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The Risks of Polypharmacy

Collections of medicines like this, though, are a problem for patients and the planet. Taking lots of medicines increases the risk of side effects and can decrease compliance. One of the reasons for Bill’s admission was rhabdomyolysis, muscle breakdown, the result of a drug interaction from a couple of the medicines he was taking.

Now, as a pharmacist, I take great satisfaction in stopping medicines. If I can reduce that pile down or get two carrier bags into one, then I’ll swagger away thinking, “Excellent, that’s a job well done.” And that’s what we did with Bill. We stopped the medicines that he didn’t need. We definitely stopped the ones that were causing harm.

But Bill’s not an isolated case. His fishing tackle box, that’s unique. But not those carrier bags of medications. That’s an everyday thing. Now, the individual carbon impact of medicines is quite complicated. We bandy around the term carbon footprinting, but that’s got different layers to it.

The Benefits of Reducing Unnecessary Medications

Things like how far it’s travelled or what the manufacturing process is like. But if we think about it on an individual level, for an individual patient, if we’re able to stop one medication, that’s something less being used, less environmental impact, a step in the right direction. If we’re able to stop one of Bill’s medicines, we’ll get an immediate savings.

We also get a future savings from all those repeat dispensings. It’s like stopping lots of short car journeys. Add that up for multiple patients, that’s a win for the NHS and for the environment.

But sometimes we do need medicines. If we’re able to practice medicines optimisation and evidence-based prescribing well, that’s making sure that Bill’s on the right medicines for his condition at the right doses with a higher chance of keeping him out of hospital. And keeping people out of hospital helps the environment.

Generally, being at home has less impact on the environment than being in hospital. It’s easy to imagine all the energy required for the powering, the heating, the lighting, the machines, the intensive treatments. Just one day for one patient on just a general ward is the equivalent of taking the train from London to Paris.

Reducing Waste at Discharge

Now, when Bill was ready to go home, he agreed to open his medicines before he left the pharmacy and to only order those that he needed. Is this something that we can do though? Can we check with patients before they leave our surgeries or our wards? Do they need all those medicines? And if they don’t, can we take them back before they walk out the door? That brings me to my next patient of the day.

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We’ll call her Josephine. She has COPD. She’s breathless and scared. She needs an ambulance to take her to hospital. An ambulance that contributes to air pollution. Josephine’s put on IV antibiotics and oxygen masks, fluids and cannulas.

The Impact of Inhalers on Carbon Emissions

But Josephine’s admitted because she’s not being effectively treated with the medications that she’s been prescribed. Now, one of the key treatments for respiratory disease, so COPD or asthma, are inhalers. Inhalers are one of the biggest sources of carbon emissions in NHS prescriptions.

That pie chart that I was talking about earlier, where medicines account for 25% of the NHS carbon emissions, inhalers account for 3% of the total NHS carbon emissions. Now, this is especially true for metered-dose inhalers. You know those pushdown ones? Just one of a certain brand of salbutamol inhaler, the blue pushdown one that lots of your friends and family will have. That’s the equivalent of a travelling 175 miles in a car. That’s London to Nottingham or Bristol.

Now, when I looked at Josephine’s medication history, she had been receiving lots of short acting beta agonists. That’s those blue pushdown inhalers that I was talking about. Over the course of a year, she’d only had one dispensing of two other inhalers used to treat her condition.

Improving Inhaler Technique and Choosing Low-Carbon Options

Both of them metered-dose inhalers. When patients aren’t being effectively treated with their medicines, that can be sort of life-threatening. So, with patients like Josephine with respiratory disease, I use three C’s to review them. Are they controlled? How many of each type of inhaler are they using? Are they clinically suitable? Can they actually use those inhalers?

Because half of the patients that you see have errors with their inhaler technique. And could we use a low carbon option? Like Josephine, could we switch her to a combination inhaler? Or even better, a dry powder inhaler, one that doesn’t have greenhouse gases as propellants. I challenge you.

Why don’t you find out how to prioritise those patients that you have that aren’t controlled? Or find out what alternative inhalers you could use with your patients. If you’re a patient yourself, why don’t you check with your medical team? Find out if this might be an option for you. Take a step in the right direction.

Switching from IV to Oral Medications

Now, the consultant looking after Josephine that day, I’ll call him Dr. Jones, we had a good working relationship. Some of you clinicians might understand. When he’d jokingly approach, say to me as I approach, “What have I done now?” And we had a bit of a competition going to see if he could get through a ward round without me updating him on something.

“Don’t worry,” he says to me, “Josephine’s already had 48 hours of IV antibiotics. I’ve switched her to oral.” Now, there are a number of benefits of switching appropriate patients from IV medications to oral, but environmentally, it’s really easy to see. The lines, the cannulas, the infusion bags of an IV medication compared to a small strip of tablets.

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Patients who are on oral medications can generally go home sooner as well. The bed is freed, reducing the carbon impact of their stay. Well, Dr. Jones, he thought he had one up on me.

Following Guidelines for Antibiotic Courses

That was until I said, “Yeah, but the guidelines recommend five days for COPD. There’s seven days on the chart.” Now, again, there’s a number of infections where recent evidence has shown that shorter courses are just as effective as longer ones. Shorter course, less medicines used, less environmental impact, a step in the right direction, and one less thing for a pharmacist to nag you about.

As I was finishing up, I glanced over and I saw a leftover IV medication being dripped down the sink. Does this shock you? What do you do with your leftover medicines at home? Do you throw them down the loo? Well, Josephine, just like every single one of my friends that uses an inhaler, just chucks it in the kitchen bin. What’s the effect of all these medicines getting into our waste streams?

Proper Disposal of Medicines

They’re effectively getting into our waterways, ghosting the wildlife, even getting into the food that we eat. I flew into that treatment room and made sure it went into the right waste bin with the right coloured lid, so all medicines, liquids, tablets, capsules, eye drops, IVs, pills, ointments, all should be put into the right waste bin with the right coloured lid. If you’ve got a stash of unwanted or expired medicines at home, take them back to your pharmacy so that they’re appropriately destroyed.

This is especially important with those inhalers, those metered-dose inhalers that I keep going on about. They have a residual amount of propellant in them, a greenhouse gas which just leaches into the environment. If they go back to your pharmacy and to the right bin and are incinerated, that’s denatured. It makes a difference.

If you’re a bit baffled like I am with the NHS bin colours, then usually it’s blue for most medicines, sometimes purple. If in doubt though, ask your pharmacy team. They will point you in the right direction.

So medicines, yes, they are good for us, but they also contribute significantly to environmental pollution and release greenhouse gases that contribute to global warming. I’m not saying these things are going to solve the climate crisis, but you and I have the power to reduce healthcare’s impact.

Taking Steps in the Right Direction

There are lots of things that we can do to reduce medicine’s impact on the environment, whether it’s small with an individual patient or larger with policy or guideline development. Maybe, like Dr. Jones, you just want to quiet that pharmacist whistling in your ear, but let’s all take a step in the right direction.