Sustainable medicines development and use: Our collective responsibility for action to mitigate the natural world crisis

The recent IPCC's (Intergovernmental Panel on Climate Change) report published on the 6th August 2021 and widely reported in the global media is an alarming and distressing read.1 Human impact from the industrial revolution onwards has warmed the planet at an unprecedented rate not seen in the preceding two millennia. Human activities have led to weather and climate extremes in every region across the globe. All possible future emissions scenarios suggest that the magnitude and effects of climate change due to past, present and future greenhouse gases (GHG) emissions will only worsen. Drastic action now and continued action must be taken to mitigate global warming. There are no other options. The Paris Agreement, a legal binding treaty negotiated by 196 parties at the Paris COP21 meeting in 2015 and ratified in November 2016 set the goal to limit global warming to well below 2, preferably 1.5°C.2 To do this, countries must achieve climate neutrality or net zero GHG by 2050, balancing anthropogenic source emissions and removal by GHG sinks (natural sources of GHG removal by oceans and plants). Peaks of GHG must happen as soon as possible; the time bomb is ticking. Worryingly, GHG atmospheric concentrations continue to rise despite some indication that the growth in emissions may be slowing down. GHG emissions have grown at 1.3% per year since 2010, 1.1% since 2019. However, accounting for land use change (LUC) emissions (e.g., conversion of forest to agriculture land), global GHG have actually increased 1.4% since 2010, with a rapid increase of 2.6% in 2019 due to a large increase in forest fires.3 It is undoubtedly essential that we have ambitious targets to cut GHG. The United Kingdom has set in law the target to slash emissions by 78% (relative to 1990) by 2035.4 However, the UK Climate Change Committee recently reported that progress on policies is slow, with only 20% of the emissions cuts needed by 2035 having policies “on track.”5 Actions do speak louder than words and urgent action is needed now. So, what does this have to do with clinical pharmacology? This is an obvious question to ask, and the answer is that it has everything to do with our discipline and community. Too often in our daily work lives, we fail to recognise the interconnectedness of the environmental crisis, our dependence on the natural world and our shared humanity. We might think pharmacology or healthcare are not the sectors causing the problem when it comes to emissions. The big producers are not us, but transportation, energy providers, waste and agriculture. However, the urgency of the natural world crisis, and the impact of climate change, biodiversity loss, and pollution of our local environment upon public health, means we cannot depreciate our responsibility. Many of us work either directly in delivering healthcare or are aligned to health sciences through academic research, teaching or as members of the pharmaceutical industry. As such, we have insight on the effects of climate change and pollution on health and comprehend that health inequity both between and within countries means that the most vulnerable are at highest risk of harm from climate change and environmental destruction. Ella Adoo-Kissi-Debrah, a 9-year old girl from Lewisham, London, UK, suffered a fatal asthma attack in 2013, and air pollution from the busy road near where she lived was a main contributory factor in her death.6 Over the last 20 years, there has been a 54% increase in heat related deaths in older people.7 Hunger and food insecurity worldwide, exacerbated by the climate crisis and COVID-19, mean that today in 2021, over 155 million people worldwide live with hunger.8 The potential threat to public health and ecosystems of environmental pollution caused by drugs and their metabolites is also very concerning. Antimicrobial resistance, with evidence in environmental samples of extended spectrum beta lactamase and carbapenemase-producing pathogens due to pharmaceutical pollution, presents a major challenge for the pharmaceutical industry and environmental regulatory agencies.9-11 Medicines and regulation of medicines manufacture have a key role in addressing these critical public health issues, as well as sustaining and improving health more generally. We, the global clinical pharmacology community, need to collaborate and act to ensure the development, manufacture, distribution and use of medicines are sustainable in their carbon footprint, do not result in environmental harm, and support equity of access to treatment. How do we do this? There are no easy answers and currently there is a paucity of research on this topic. It requires recognition and understanding of the problems, which may be specific to different medicines, different healthcare settings, and different regions and countries. We need lived experience collaboration to develop policy, innovative technologies and practical solutions. Parts of the pharmaceutical sector should be commended in their ambitious policies and timeframes for net zero emissions, and many pharmaceutical companies have invested heavily in research and development to innovate solutions.12 However, the global industry and market of pharmaceutical supplies is colossal and far-reaching, and much work needs to be done to ensure a partnered, shared worldwide goal of net zero and mitigation of medicines' environmental impact from development and use. Medicines prescribing, medicines optimisation and personalised approach to medicine use, stewardship of medicines, management of adherence and medicines waste, and medical and patient education are specific roles in healthcare systems that clinical pharmacologists and pharmacists often directly lead on or are actively involved in. As a discipline that traverses organ-based specialties, primary and secondary healthcare, and has a strong interface with industry and research, we are a pivotal group to explicitly set out goals for sustainable therapeutics and make them happen. From 31 October to 12 November 2021, the United Kingdom will host the next UN Framework Convention on Climate Change Conference of the Parties (COP26) meeting in Glasgow. Given this momentous chance of worldwide policy action, an editorial written by global health science editors is published simultaneously today in 200 publications including the British Journal of Clinical Pharmacology (BJCP). It is a call to world leaders for emergency action to limit global temperatures, restore nature and protect health for a fairer world. To coincide with this call for action, the British Pharmacological Society (BPS) has published the Society's statement on Sustainable Pharmacology. The Society has also launched a Sustainable Medicines network on its Communities site. The Network aims to bring together anyone interested in getting involved in this work. It is aiming for a global membership to share experiences, ideas, and actions, so please do submit a request to join if you would like to be involved. In addition to the BPS's work, the BJCP is also launching a new themed series, ‘sustainable medicines development and use’. The series is officially launched this autumn with this lead-in editorial and contributions to the series will coincide with COP26 and continue beyond. The series aims to build understanding and collaboration as a community and facilitate progress. A call for papers is now live on the BJCP website with more specific details on how to contribute. The BJCP wants to be the voice of research, evidence, commentary and experience related to sustainable medicines. We have already commissioned papers covering aspects of challenges and solutions in how medicines are developed and manufactured sustainably, insights and solutions to antimicrobial resistance relating to drug pollution, ‘ecopharmacostewardship’ of medicines, green inhalers, sustainable clinical trials and education. Sustainable medicines is a subject which has not yet had the spotlight, even though medicines contribute to 25% of the United Kingdom's National Health Service (NHS) emissions, with inhalers and anaesthetic gases accounting for 5% emissions at the point of use.13 Overall, sustainable medicines development and use must be taken seriously as an issue and will need funding, research, collaboration and education to ensure interventions of stewardship and sustainability are evidenced based for patient benefit, have a lower carbon footprint than current standards of care, and that the applicability and accessibility to different populations and healthcare systems are considered. For example, whether an intervention of de-prescribing (which in theory is a good idea) has environmental (let alone clinical and economic) benefits is uncertain unless robust research to answer these questions is undertaken. Where different formulations or mode of delivery of a medicine exist, and one involves less plastic, is this preferentially chosen by formulary groups or considered by healthcare professionals in prescribing? And what are patients' opinions or preferences relating to such issues? Are decisions regarding the environmental impact (as far as can be judged with available evidence) of a medicine routinely considered by clinical guidelines and medicines and therapeutics committees? Are short or long durations of repeat prescriptions more sustainable? How can clinical research and trials related to medicines be sustainable and maximise knowledge?14 Medicines waste management is another area of sustainable therapeutics that is poorly described and would benefit from sharing of experience, knowledge, and expertise with joined up policies to make positive changes to reduce waste. Personalised medicines and medicines optimisation are evolving ‘culture-shift’ areas of clinical practice that will intuitively payback with patient benefits, and in time result in cost savings. We similarly make the case for the sustainability of therapeutics to be a valid component of progressive change in healthcare systems. There is an urgency to get up to speed quickly on how best to do this and a multi-faceted collaborative approach is the way forward. Very recently (18 August 2021), researchers showed that the Montreal Protocol is actively helping to mitigate climate change by avoiding even greater loss of carbon sinks. Without it, they estimate we would now be dealing with a further additional global warming by 0.50°–1.0°.15 The Montreal Protocol is an excellent example of what can be done. We, as the clinical pharmacology community, can and must make sustainable medicines development and use a global reality.

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