Hidden harm: the impact of medications on our environment

In many ways medications are to physicians what scalpels are to surgeons They are our most obvious tool for curing disease and alleviating suffering. However the analogy works on another level too.  Scalpels can cause harm by cutting in the wrong place, be that the wrong structure in the patient or inadvertently lacerating the hand of the surgeon or her assistant. 

Medications, too, can cause harm both to the patient and to others.  Medications are in many ways poisons, or at least can be said to have the potential to be poisonous.  As a prescribing physician this is, to say the very least, disappointing.  More than this, it provides a profound challenge to how we see and perceive the treatment that we offer our patients as physicians. 

I trained at Charing Cross and Westminster Medical School in the 1990’s.  I had a great time, and I can even remember some of what I was taught.  However, I don’t remember ever being taught on the risk of multiple medications. 

Perhaps the medical community had yet to develop a good understanding of the risks that came with multiple medications, but that can no longer be held to be true.  There is now a plethora of evidence that multiple medications are associated with harm, to be balanced against the long term and sometimes small clinical benefits of taking long term medications.  In one study one in six acute hospital admissions were due to adverse drug reactions, with more than 40% of these recorded as avoidable.

Another subject that I was not taught at medical school was the impact of healthcare on the environment.  As a teenager I was very environmentally aware, having read Irvine and Panton’s “A Green Manifesto” in the late 1980’s.  However, the environmental impact of healthcare on our living planet never featured in my training.

We now know that healthcare has a huge negative impact: if it were a country it would be the fifth most polluting in the world.  In the NHS, 25% of all emissions are derived from medications.  Yet it is these same medications, the ‘physicians’ scalpel’, that are causing harm to both our patients and to the living world that we all ultimately depend on. 

Recognising the many negative impacts of multiple medications has significantly changed my clinical practice.  On ward rounds I now actively seek medications that might safely be stopped.  I ask questions about why medications are prescribed, what the indication was for starting it, and what the criteria are for stopping.  In clinic I more actively involve patients in the decision-making process around starting (or not starting) medications, and making the stopping criteria much clearer in my communications with both patient, carer and GP.  In addition, when prescribing, there is evidence that involving the patient also improves adherence.  In one study 77% of patients stated that their relationship and communication with their physician is the most important factor for them taking their medication. 

As a newly qualified doctor I used to get some satisfaction from prescribing a new medication, thinking that this was what was needed to do a good job.  I now get the same satisfaction from suspending medications that no longer serve a useful purpose, or deciding in collaboration with the patient to delay starting new medications, knowing that the patient has been at the heart of the decision making.  In this way we have reduced the chances of adverse drug reactions, improved adherence, and minimised the impact on the environment. 

Despite 29 “Conferences of the Parties” (COP) since 1995, each trying to reduce and prevent global warming, there is evidence that climate breakdown is accelerating rather than lessening.  The potential implications of this are profound. 

Either way, the climate emergency is real and is here now, with flooding, droughts, heat waves and climate refugees as stark reminders.  Mitigating further more extreme events requires deep systemic change across the whole of society.  We each have to do what we can where we can.  As in so many other pro-environmental actions, physicians can achieve the triple bottom line of “better for patient, better for the planet, and better for the healthcare system” by increasing our focus on reducing unnecessary medication prescribing.