3 rd conference on sustainable pharmacy OsnabrÜck Germany 19-20 nov 2012 1/15 Stichting Huize Aarde is a private initiative founded in the Netherlands in the year 1992. This Civil Society Organization works following goals of the UN Agenda for sustainable development in the 21th Century (Agenda 21). A basic idea of this organization is that sustainability is based on how we build our knowledge and how we transfer this knowledge into techniques and services that don’t produce unwanted side effects. Therefore, the projects of Huize Aarde are characterized by interdisciplinary knowledge building, cross-sectoral coalitions, and making bridges between policy and practice, www.huizeaarde.nl .
Transcript
3rd conference on sustainable pharmacyOsnabrÜck Germany 19-20 nov 2012
1/15
Stichting Huize Aarde is a private initiative founded in the Netherlands in the year 1992. This Civil Society Organization works following goals of the UN Agenda for sustainable development in the 21th Century (Agenda 21). A basic idea of this organization is that sustainability is based on how we build our knowledge and how we transfer this knowledge into techniques and services that don’t produce unwanted side effects. Therefore, the projects of Huize Aarde are characterized by interdisciplinary knowledge building, cross-sectoral coalitions, and making bridges between policy and practice, www.huizeaarde.nl.
meduwamedicines unwanted in water
ibuprofen
paracetamol
fluoxetindiclofenacethinylestradiol
iopromid
iohexol
musk
salbutamol
triclosan
aspirin2/15
The project MEDicines Unwanted in WAter, MEDUWA, offers a methodology for a life-cycle-long or medicine-chain-wide communication and cooperation to limit water pollution by medicines and antibiotic resistance. A methodology that also could be applied for the management of other micro-pollutants.
integration of policies
water management
human health care
animal health care
3/15
Apparently, at the workplace in the health care sector “environment” is not an issue. And “health” is not an issue at the workplace in water management. However, there is no sharp line between health care and care for water quality. Sewage purification is developed to protect public health. And sewage cannot be properly purified - and thereby health cannot be well safeguarded, partly by substances released by the health care praxis. MEDUWA therefore promotes integration of health policies and environmental policies at the workplace, both in the health care sector and water sector.
4/15
new coalitions
For the development of MEDUWA, Huize Aarde teamed up with the Water Authority Regge and Dinkel in the Central east of the Netherlands, and the Dutch Institute for Responsible Medicine Use. This institute developed tight relations with the health care praxis by training physicians and pharmacists. For knowledge building around the topic a cooperation is established with several universities in the Netherlands. From the year 2003 to date about 60 students from different disciplines from four universities and two high schools did their research on this specific issue. As pollution of pharmaceuticals is a cross-border phenomenon, we also made a connexion with University Osnabrück.
no exclusion of actors
5/15
poultry/cattle breeding, agriculture & food industry (water) recreation
sport fishery &ornamental fish breeding
health care & pharmacy
water, soil & air
26000
As pharmaceuticals in the environment come from multiple sources and through multiple routes, not one link from the medicine chain should be excluded in the search of a solution. To engage all actors of the human and veterinary medicine chain, a strategy is needed for communication and cooperation. To underline the importance of a product chain-wide approach MEDUWA uses the ISO 26.000 standard for Corporate Social Responsibility.
monitoring the medicine chain in the Netherlands
0
2
4
6
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water managers drinking water prod. pharmacists hospitals cattle breeders veterinarians physicians health insurers pharm. industry
2
44
44443
4
2223333
44
problem perception in & willingness to act (situation on 1-11-2012)
problem perception willingness to act
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- Bijl G 2012, Ketenaanpak van de problematiek rondom geneesmiddelen in de verschillende watercomponenten (studentrapport), Rijksuniversiteit Groningen, Unie van Waterschappen, Stg. Huize Aarde.- Bakker M et al 2012, De rol van huisartsen bij het bestrijden van milieuvervuiling van oppervlaktewater door medicijnen (studentrapport), Inst. Verantwoord Medicijngebruik en Rijksuniversiteit Utrecht. - Vergouwen L et al 2011, Zuivering geneesmiddelen uit afvalwater, rapport Grontmij NL BV.- websites of concerning organisations on 1-1-2012 ; and network of Stcting Huize Aarde
1= no2= eventually3= yes4= urgency
1= no2= eventually3= yes4= take concrete action
At the moment only about 50% of the actors in the veterinary and human medicine chain are more or less involved in this subject. The involved actors are shown in the diagram. The water sector takes the lead. Only for them pharmaceutical contamination is a topic on the agenda. Different actors perceive the urgency of this issue in a different way. A bottleneck for problem perception is the special protected status of medicines.
concensus in the medicine chain
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“products and services should not have negative effects on the quality of the environment and, through the environment, on human health”
testing evaluation
financing
development production
health education marketing prescription
use waste management water management drinking water
To overcome this bottleneck, in the first place MEDUWA heads towards a broad agreement or consensus that products and services should not have negative effects on the quality of the environment and, through the environment, on human health.
Secondly, this consensus requires new holistic concepts that provide a common horizon, such as sustainable or green chemistry, green pharmacy and green health care. To concretize these concepts, the who, what, how and when to make the medicine chain more sustainable is being worked out for every link of the chain and is published on one of our websites.
In the third place, to achieve a green pharmacy, in the health sector and water sector fundamental changes are needed in their role in society...
Currently, the solution of this environmental issue is the exclusive responsibility of the water manager. However, this task is becoming increasingly difficult. To meet the future quality criteria for an increasing number of micro-pollutants will be difficult, costly and create new environmental side effects. For this reason, MEDUWA promotes that the role of the water quality manager shifts from problem bearer to problem sharer. In that case, the water manager delegates responsibility for water quality to the whole medicine chain.
ro l e c h a n g e h e a l t h s e c t o r
p r o b l e m m a k e r
p r o b l e m s o l v e r10/15
rolechange
And by that, the role of the other actors in the medicine chain will shift from problem maker to problem solver.A problem solver works in coordination with other actors in the product chain towards a package of complementary measures that strengthen each other. And those measures serve more than one social goal, for example health, economy and ecology, simultaneously.
An example of this role change in a product chain, is that the personal care products industry in the Netherlands (Unilever) approached the Association of Water Authorities asking which of the substances in their products cause a problem for water, willing to replace them.
regional Water authority starts pilot with regional pharmacists
irbesartan hypertension 10 ± 0 > 1* first indication in an official and independent source, www.fk.cvz.nl
Oosterhuis M et al 2011, Emissie geneesmiddelen bij de bron aanpakken, H2O(9):30-33.
Groot Twente
Another example of this role change was the collaboration of the regional association of pharmacists KNMP Groot Twente and the regional Water Authority Regge and Dinkel. To test the MEDUWA-approach, this water authority contacted the pharmacists. Together they made an inventory of the 50 most prescribed medicines in the region and measured them in untreated and treated waste water. Here you see the top 10. Not for all commonly used pharmaceuticals analytical methods were available. In treated water high concentrations were found, especially metformine and its bacterial metabolite guanylurea. At the bottom of the table two examples are given of lower emitted quantities that got equal high concentrations in treated water.Facing this unwanted side-effect of the health care practice, the pharmacists start searching for equivalent molecules for those medicines that are not well biodegradable. For example, they wonder if the less biodegradable irbesartan could be replaced by the apparently more biodegradable losartan and valsartan.But there is more to conclude: after we added the first indication for every medicine to the table, we found that pharmaceuticals entering in great quantities in the environment have avoidable illnesses as their most important indication. Therefore, prevention of illnesses is probably the most effective measure against pharmaceutical contamination.
antibiotics for bronchial infections 40% too soon & erroneously prescribing Hosptaken et al 2003
soporifics & tranquilizers 50% addiction Roorda and Derksen/IVM 2006
asthma-inhibitors for small children 50% unneccesary Zuidgeest 2008
anti-ADHD for children 64% unneccesary Pelsser et al. 2011
antibiotics for lung infections 70% too long prescriped El Moussaoui and Prins 2007
cytostatics 75% no effect Roses 2003
anti-depressives 80% unneccesary & too long prescribed Lekkerkerker 2003; Project De Doorbraak 2006
anti-alzheimer medicines 90% no effect Lekkerkerker 2003
veterinary antibiotics 90% no effect (preventive use) Kijlstra and others 2007; FIDIN 2009
overuse of medicines in the Netherlands
Another effective measure will be the reduction of overuse of medicines. In the Netherlands, where general practitioners are known to be cautious prescribers (currently 75-80% prescribe evidence based), still exists overuse of medicines. The maximum possible reductions in medicine use (represented by the blue lines in the diagram) show that there is a lot to win, not only for health and national budget but also for the environment.Reduction of overuse of medicines will be achieved by control of prescribing behavior, buying behavior and medicine use, by putting more emphasis on health promotion by physicians, by reducing drug marketing, and by encouraging volunteering to prevent medication aimed at saving elderly care costs. We think that all this kind of measures to reduce overuse of medicines should be part of green health care.
communication tool
13/15
http://www.great-er.org/pages/home.cfm
Geography-Referred Regional Exposure Assessment Tool for European Rivers
Because behavior is an essential underlaying factor of the problem, communication is of great importance. A tool that will be used in MEDUWA to support communication to public, administrations and governments is the Geography-Referred Regional Exposure Assessment Tool for European Rivers. GREAT-ER is an open source software GIS for environmental risk assessment and management of chemicals in river basins.Why GREAT-ER: in the first place, GREAT-ER is suitable for collecting and processing data from environmental monitoring and source monitoring. Source monitoring is monitoring of medicine use and emissions by several actors from the medicine chain. This GIS is also suitable for a prediction of the effect of collective measures, and it can visualize the need for action by the entire chain and therefor speed up measures.The use of GREAT-ER for this kind of participatory decision-making will be a new application.
