Environmental Pain Approach (EPA): Sustainability in Chronic Pain Practice

Around the globe, the health care sector contributes an average of 5% of carbon emissions and nearly 10% of greenhouse gas (GHG) emissions [1]. Clinical sites and pharmaceutical production are the most significant sources of health care–related carbon emissions, 15–25% of which are produced by ambulatory physician services, such as pain clinics [1]. Despite this, there is minimal regulation of the health care sector’s environmental impact and contribution to climate change. We urge institutional leadership to improve visibility of efforts to reduce carbon footprint, which has been shown to increase commitment to environmental activism in workplace behavior [2]. Pain physicians should implement sustainability practices by using a systematic “Triple R: Reduce, Replace, Rethink” approach to greening our specialty (Figure 1). Although patient safety is paramount, we can achieve reduction of our carbon footprint while still providing exceptional care for vulnerable patients with pain. Considerations for greening an interventional pain practice via the “Triple R: Reduce, Replace, Rethink” model. MRI= magnetic resonance imaging; PPE= personal protective equipment; Tx= therapy; US= ultrasound. Reducing energy consumption is the most critical step in reducing our impact. As with any industry, using motion-sensor LED lights and electronics with sleep mode or deactivation timers set for non-working hours will reduce electricity. Energy-efficient buildings with solar panels, robust insulation, and triple-pane windows should be considered for clinical spaces. As such modifications are simpler to implement with new construction, they should be prioritized during facility renovations and selection of pain medicine offices and procedure suites. Beyond these building amenities, pain proceduralists should limit use of machinery and carefully consider the equipment selection process. The amount of electricity required varies by device type and age, as well as by overall patterns of use. Older ultrasound models can use up to 3 kW per day, quickly overshadowing the electricity use of an energy-efficient fluoroscopy device. However, newer ultrasound machines expend 760 kW hours per year, substantially less than most fluoroscopic devices. It might be prudent, both fiscally and environmentally, to replace equipment earlier than the typical obsolescence timeline. Reduction of waste is also paramount. Disposable devices and excessive sterile draping have become common as medicine becomes increasingly liability averse. This adds significantly to physical waste and GHG emissions, though the impact on infection rates is often only theoretical. In Australia, for example, proceduralists don sterile gowns for single-injection spinal anesthesia. Even in patients with an infected prosthesis, the risk of central nervous system infection after neuraxial anesthesia is 0.6% or less, which belies the logic that full gowning would further reduce risk in a non-infected patient [3]. Although local and national policies should be observed, these guidelines require collaboration with infection control experts for revision based on current evidence. For non-disposable waste, such as patient gowns and procedure table linens, reprocessing at outside facilities can lead to insidious GHG emissions. Reusable items do limit physical waste on site, but be aware that selection of close-proximity laundering facilities and environmentally safe detergents is also necessary to reduce transport emissions, as well as water consumption and contamination. Pharmaceutical waste leads to GHG emissions and environmental contamination without any human benefit. Systematic medication waste occurs when a large-volume vial is procured for an intervention requiring a small quantity of injectate, such as the practice of using only 1–2 mL of a 15-mL vial of contrast medium. The excess 13–14 mL of medication not only is wasteful in the context of drug shortages but, even if disposed of properly, will lead to energy consumption and toxic fumes when incinerated. If disposed of improperly, pharmaceuticals pose an even greater threat as water or land contaminants. Sourcing medication ampules with the amount typically adequate for the specific procedure is preferred, but division of oversized drug vials into smaller aliquots in pharmacy clean rooms is a viable alternative. In cases in which reduction is not feasible, consider making prudent replacements toward a more carbon-neutral practice. If imaging is required, consider replacing magnetic resonance imaging (MRI) with a simple radiograph, as MRI energy consumption is 111,000 kW hours per year, which is 11 times that of x-ray. Most guidelines also recommend against routine spine MRI, as the images procured often do not alter treatment plans. Of note, unnecessary medical imaging studies cost an estimated $30 billion per year in the United States and Canada and result in an equally significant carbon footprint [4]. Sound and music have long been known to suppress pain, likely through corticothalamic circuits [5], and music is therefore an obvious choice to replace sedation for minimally painful procedures. For regional anesthesia procedures, music has been used for anxiolysis, with similar efficacy to intravenous benzodiazepines [6]. Oxygen therapy substantially increases emissions secondary to the energy required to liquify the gas for medical use. Omitting sedation is the most direct approach to minimize oxygen use, but judicious titration to low flows is also beneficial. Replacing disposable equipment, such as surgical marking pens, ice packs, and radiofrequency ablation cables, with reusable options reduces physical waste, resource utilization, and energy used to create, package, and transport products. Despite a lack of evidence supporting disposable equipment, hospitals have largely eschewed reusable options because of liability concerns and the complexity of developing in-house reprocessing infrastructure. Hand hygiene is widely known to reduce surgical site infection more than frequent changing of disposable surgical masks or head and shoe covers. Reusing single-use devices in general anesthetics also caused no adverse outcomes and markedly improved life-cycle calculations [7], suggesting an opportunity for reduced carbon footprint if pain practices follow this model. Prions can survive sterile reprocessing but have an exceptionally low incidence, with only a few cases worldwide attributed to contaminated neurosurgical instruments and none to pain interventions. Given the urgency of action to prevent carbon dioxide emissions, changes in practice that generate more waste should be guided by evidence rather than by industry marketing. Moreover, reduced reliance on single-use items would ameliorate supply chain delays. In many countries, disposable draping is uncommon, and sterile drapes are laundered and re-sterilized to minimize plastic waste. Likewise, there is an absence of literature reporting further infection reduction with bulky ultrasound sleeves compared with simple covers. Single-use chemical-based cold packs are commonplace and replacing them with a reusable option would be a simple and fiscally responsible swap for facilities equipped with a freezer. Lastly, the pandemic has demonstrated that reusable high-quality face masks can be cheaper than disposable masks and certainly have a lower carbon footprint. If patient outcomes are similar, high-toxicity pharmaceutical agents should be replaced with alternatives that pose a lower risk of bioaccumulation. Traces of opioids are present in marine ecosystems, which is unsurprising given that manufacturers encourage disposal of opioid transdermal patches in the sewage system, despite their high scores for persistence. Prescribers can exchange buprenorphine patches for sublingual or tablet formularies and fentanyl patches for long-acting oral opioids. If patches are necessary, clinicians should counsel patients on safe disposal in tamper-proof bins or at dedicated medication return sites to minimize environmental contamination. Opioids and other medications can be replaced with nonpharmaceutical modalities, such as physical therapy, cognitive behavioral therapy, Tai Chi, chiropractic adjustments, and home exercise programs. If a therapy reduces medication use, a common metric by which we measure the success of an intervention, it eliminates the environmental impact of the production and distribution of analgesics. Rethinking embedded practices will require large-scale shifts in mindset. Currently, only 50% of publicly traded U.S. health care companies track their carbon footprints, and only 10% display carbon neutrality statements [8]. Pain physicians can impact industry by preferentially selecting products developed in an environmentally sustainable manner. Health care sites should work with city officials to increase public transportation routes that access central health care system sites. The hospital system, in turn, can improve shuttle services from the central site to satellites. These measures would not only reduce transport-related carbon emissions but also eliminate the need for a chaperone driver to accompany patients. Furthermore, hospital administrators could encourage carpooling by offering discounts if employees purchase a joint parking pass. Rethinking established aspects of our health care system can also be transformative. For example, replacing single-use with reusable sharps containers in the United Kingdom reduced GHG emissions by 61% [9]. Large-scale reform of in-person health care conferences to a virtual or even asynchronous format would also result in a decrease in emissions of two orders of magnitude. Virtual conferences permit similar content distribution and opportunities for networking while reducing transportation emissions, which are responsible for more than 90% of the carbon footprint, and obviating temperature regulation of sprawling conference centers [10]. In conclusion, as a community of chronic pain interventionalists, it is our duty to first do no harm to our environment, which we can achieve through the strategies outlined in this commentary (Figure 2). Clinical leadership must promptly implement all measures great and small to avert further irrevocable damage to our shared environment. The curricula for interventional pain fellowships should also incorporate sustainability education to focus our future leaders on reducing carbon footprint. Every physician is obligated to remain apprised of data-driven practice recommendations to reduce our environmental impact without compromising patient care. We urge all pain clinicians to direct their full attention to greening our clinical practices. Acronym for easy recall of measures that can improve the sustainability of your chronic pain practice. Disclosure: AMN receives research funding from Veoneer to investigate a biomarker for cannabis intoxication in roadside testing. Other authors have no disclosures.

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