Background
Pharmaceuticals are indispensable for human and animal health, but they are also a significant and growing source of chemical pollution. Global medicine consumption is rising, driven by ageing populations, the prevalence of chronic disease, climate change and a growing “pill for every ill” culture. More than 3,000 active pharmaceutical ingredients (APIs) are approved worldwide. They enter the environment at every stage of their life cycle: as discharges from manufacturing sites, through excretion by patients, through wash-off of topical products, through inappropriate disposal of unused medicines, and through their use in pets, livestock and aquaculture. Medicines are often over-purchased or not fully used, and overuse, inappropriate prescribing, stockpiling and poor waste management by both healthcare providers and patients are common. Over 650 APIs have now been detected in soils, surface waters, groundwaters and drinking waters in more than 100 countries. Around 16% of river locations monitored worldwide have pharmaceutical concentrations of ecological concern. The burden falls most heavily on low- and middle-income countries, where manufacturing hotspots, limited wastewater treatment and weaker controls combine. A major human health concern is the role of antimicrobial residues in selecting for antimicrobial resistance (AMR) in the environment. Some widely used APIs are also so persistent that they meet proposed criteria for classification as PFAS, or “forever chemicals”.
Historically, efforts to tackle pharmaceuticals in the environment have focused on end-of-pipe solutions such as advanced wastewater treatment. These technologies can remove a wide range of compounds, but they are costly and energy-intensive, can generate harmful by-products, and remain out of reach where basic sanitation is lacking. Meanwhile, the push for climate-resilient, sustainable health systems has so far concentrated mainly on reducing healthcare’s carbon emissions, and there is a growing need to also address its impact on water systems. Sustainable pharmacy takes a broader view. The Royal Pharmaceutical Society describes it as considering the impact of prescribing on sustainability, together with ways of reducing the carbon footprint and environmental impact of any medicine. It favours user-oriented, source-directed measures and considers interventions along the whole medicinal product chain, from drug design and authorisation through manufacturing, procurement, prescribing, dispensing, use and disposal. It also recognises that the most environmentally friendly medicine is the one that is never needed. Awareness of healthcare’s environmental impact is growing among both health professionals and the public, and putting sustainable pharmacy into practice depends on collaboration between healthcare providers, regulators and patients, and often with environmental and water sector specialists.
Solutions can be arranged as a hierarchy:
Preventing disease in the first place, through health promotion and by tackling environmental and societal risk factors such as air pollution, reduces the demand for medicines. For some patients, non-pharmacological treatments such as social prescribing and blue-green prescribing (nature-based or cultural activities) may help manage conditions like pain or poor mental health. Implementing these at scale requires adequate funding, supporting policies, clear guidelines and protocols, third-sector involvement and skilled health and social care workers.
Where medicines are needed, eco-directed sustainable prescribing can guide prescribers towards the least environmentally harmful option among therapeutically equivalent alternatives. Examples include Stockholm’s Wise List and the Swedish environmental classification system on Janusinfo, which draws on data from the European Medicines Agency and the pharmaceutical industry and is published alongside prescribing information. Antimicrobial stewardship, such as shorter antibiotic courses and less prescribing of antibiotics for common infections and of broad-spectrum antibiotics, helps limit AMR; World Antimicrobial Awareness Week brings together the healthcare, water and environment sectors to develop public messaging on reducing its spread. Medicines optimisation and precision medicine can further reduce unnecessary use and waste, and re-dispensing initiatives such as the Dutch PharmaSwap marketplace allow unused medicines to be shared between healthcare facilities rather than discarded. At the point of use, simple instructions to patients, such as wiping hands after applying creams or gels, or using urine bags, can limit the release of targeted pharmaceuticals into wastewater.
Further up the chain, safe and sustainable by design approaches aim to build environmental safety into new drugs from the outset. Green manufacturing standards, such as the AMR Industry Alliance standard for antibiotics, aim to reduce emissions from production sites.
Finally, take-back schemes, waste management and targeted or general wastewater treatment can intercept residues before they reach the environment. Disposal instructions on packaging and patient information leaflets can encourage patients to return unused or expired medicines to a pharmacy rather than flushing them or putting them in the bin, and media campaigns such as “Nature Calls” by NHS Scotland and Scottish Water raise public awareness. However, more standardised and accessible collection schemes are needed, building on those already offered by NHS and retail pharmacies.
No single intervention is sufficient on its own, and each involves trade-offs. Solutions must be designed so that they do not reduce access to essential medicines or shift burdens onto vulnerable communities. Progress is also held back by gaps in environmental data: many medicines lack comprehensive environmental risk assessments, and the data that exist are not always available, transparent, complete or robust enough to be used in clinical practice. Prescribers and healthcare decision-makers need training to interpret and act on environmental information, and the lack of an overarching policy on pharmaceutical pollution is a critical barrier to building environmental considerations into healthcare decisions. These challenges are also opportunities for more collaborative, whole-systems working across the pharmaceutical life cycle. Delivering an environmentally safe and just pharmaceutical life cycle will require strengthened regulation, better monitoring and data sharing, new funding mechanisms such as extended producer responsibility, and education of health professionals and the public. Measurable milestones for 2030, 2040 and 2050 have been proposed to track progress.
Lydia Niemi at UHI in Scotland gives an overview of upstream approaches to minimise the impacts of pharmaceuticals in the environment
Key Reading
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Helwig K, et al. (2024) Broadening the perspective on reducing pharmaceutical residues in the environment. Environ Toxicol Chem. 43(3):653–663. https://doi.org/10.1002/etc.5563
Janusinfo. Region Stockholm. Pharmaceuticals and Environment. Available: Pharmaceuticals and Environment - Janusinfo.se
Niemi, L., Anderson, C., Arakawa, N., Gibb, S., Pfleger, S. Do you think medicines can be prescribed in a more eco-directed, greener way? Public and prescriber focus groups on the impact of pharmaceuticals in Scotland’s water environment. BMJ Open 2025; 15 e088066. https://doi.org/10.1136/bmjopen-2024-088066 4.
OECD (2022) Management of pharmaceutical household waste: limiting environmental impacts of unused or expired medicine. https://doi.org/10.1787/3854026c-en
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Wilkinson JL, et al. (2022) Pharmaceutical pollution of the world's rivers. Proc Natl Acad Sci USA. 119(8):e2113947119. https://doi.org/10.1073/pnas.2113947119