Up to 90% of the medicines we consume and their metabolites (the compounds that our bodies break down medicines into) are excreted in our urine or faeces and enter our wastewater systems (BioIntelligence Service 2013).  

Many pharmaceuticals are not completely removed in wastewater treatment plants, meaning they are discharged into streams and rivers.

Pharmaceuticals can affect the health of wildlife and some can cause harm (OECD 2019). 

Many drug targets are conserved across evolution and are designed to work at low concentrations, meaning that pharmaceuticals, and/or their metabolites, can have physiological effects on wildlife.

For example, oestrogenic compounds (from the contraceptive pill, HRT drugs) can alter fish reproduction (Environment Agency 2004), antidepressant drugs can alter behaviour, making fish less risk-averse and more susceptible to predation (Hellstrom 2016), and non-steroidal anti-inflammatory drugs (NSAIDs) can have a range of detrimental physiological and physical impacts, including renal failure (Swiacka 2021).

Environmental monitoring is very poor.

Out of almost 2,000 medicines registered for use in UK healthcare, only 10 compounds or their metabolites are regularly monitored for their environmental impacts through the EU Priority List (WFD Priority List).

We don’t know the environmental consequences of most of the drugs we use in healthcare.

Not all pharmaceuticals are toxic to the environment, but we only have comprehensive environmental risk data for 11% of the registered drugs (Burns 2018).  This makes it very difficult to prioritise which pharmaceuticals to target to reduce harm.

Pharmaceutical pollution levels in the environment are rising.

A recent study (Wilkinson 2022) tested more than 250 rivers around the world and detected both carbamazepine (a drug commonly used to treat epilepsy and nerve pain associated with diabetes) and metformin (a diabetes drug) in more than half of these rivers.  More than a quarter of samples had active pharmaceutical ingredients at levels considered safe for the environment.  

Globally, environmental pollution levels are already above safe planetary limits.

The planetary health boundary for novel entities (man-made compounds, including pharmaceuticals) has been exceeded to a greater extent than the climate change boundary (Persson 2022).

Pharmaceutical usage is rising as populations age and suffer from more chronic conditions.

In 2021 the UK pharmaceutical market was worth £57 billion, and this is predicted to continue to increase. The global market is also rising and was worth USD 1.5 trillion in 2022 (statistica.com).

Pharmaceutical pollution (particularly antimicrobial compounds) is driving antimicrobial resistance (UNEP 2023)

Antimicrobial resistance is considered one of the greatest rising threats to global public health; in 2019 an estimated 4.95 million deaths were associated with antimicrobial resistance (Murray 2022).

Pharmaceutical usage accounts for a large and growing proportion of healthcare resources.

Pharmaceuticals are the second biggest cost to the NHS (£17.6 billion in NHS England in 2021 and predicted to continue rising). At least 10% of prescriptions are unnecessary. An estimated 10-20% of all in-patient hospital admissions are due to adverse drug reactions (DHSC 2021).

Our culture is becoming more dependent and structured around pharmaceuticals.

Our lifestyles are becoming more sedentary, with what has been coined a “pill for every ill” culture in many high-income countries. In the UK, 15% of the population now take 5 or more drugs every day (DHSC 2021). Our infrastructure is developing to support this, with a growing number of pharmacists and pharmaceutical wholesalers (statistica.com).

Pharmaceutical usage in healthcare is not environmentally responsible.

A recent study estimated that only 27% of the UK population returns unused drugs to pharmacies for safe disposal (Watkins 2022). The environmental risks of pollution are not considered in healthcare procurement or prescribing decision-making.

Pharmaceuticals account for 25% of the NHS’s carbon footprint (NHS England 2022).

There are many efforts underway to reduce the carbon footprint of pharmaceuticals to achieve net zero targets. NHS Scotland is working to reduce pollution alongside carbon, but pollution does not feature in the sustainability policy of NHS England (NHS Scotland 2022).

The UK pharmaceutical sector is significant to the UK economy.

In 2021 the UK market was worth £57 billion, there were 690 manufacturing enterprises, 3000 wholesalers and 136,000 employees in biopharma (including service/supply chain actors) (statistica.com).

Consumers and investors are increasingly demanding more sustainable corporate strategies; with initiatives such as the Sustainable Markets Initiative supporting this for the global financial sector.

As these strategies move beyond carbon to include wider sustainability criteria, industries need guidance and support in identifying how to address their pharmaceutical pollution footprints.

In the UK there is substantial and increasing media and policymaker attention on water pollution, particularly on sewage.

Businesses are increasingly publicly scrutinised for responsible manufacturing and consumption. The UK government recognises the need to reduce “forever chemicals” such as PFAS (Poly- and perfluoroalkyl substances) in our freshwater systems (Environment Agency 2021). Around 20% of pharmaceuticals are considered to be PFAS compounds (Inoue 2021).

Looking to the future, environmental regulation and monitoring are likely to become more comprehensive and more stringent.

The EU is already moving towards stricter environmental pollutant regulation (see Politico Article 2023). This has substantial knock-on costs and consequences for the pharmaceutical, healthcare and water sectors, as they adapt long-standing processes and infrastructures to adhere to these.