Our addiction to cheap generic drugs pokes fun at NHS green ambitions

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To coincide with the 2021 United Nations Climate Change Conference, also known as COP26, which took place in Glasgow from October 31 to November 13, 2021, the Royal Pharmaceutical Society launched its Sustainable Development Policies.Have[1]Have.

Policies are to be commended and I am particularly impressed with the call for the environmental risk of drugs to be factored into NHS prescribing guidelines and forms.

It comes as the four UK countries have pledged their health systems to achieve net zero carbon emissions in the years to come, as part of the global effort to tackle climate change.Have[2]Have.

In England, the NHS has two main goals: to achieve net zero by 2040 for the emissions it directly controls (the ‘NHS carbon footprint’) and to achieve net zero by 2045 for emissions that it influences but does not directly control (the “NHS plus carbon footprint”)Have[3]Have.

Estimates indicate that drugs account for 25% of total carbon emissions in the NHS, and the health service has chosen to focus on two groups: anesthetic gases, which account for 2% of these emissions, and inhalers, which represent 3%..

There are similar targets in other decentralized nations.

However, there appears to be a blind spot in the environmental ambitions of health services – generic drugs.

The NHS benefits tremendously from low cost generic drugs. In England 81% of all medicines in primary care are already prescribed in generic form, generating significant savings for the NHSHave[4]Have. In 2015, the King’s Fund estimated that – all other things being equal – the increase in the prescription of generics has saved the NHS around £ 7.1bn since 1976 and has allowed the prescription of 490m. ‘additional items with no increase in total expenditure.Have[5]Have. The British Generic Manufacturers Association has estimated that the NHS now saves £ 13 billion a year in England and Wales through the use of generic drugs.Have[6]Have.

This is a fantastic achievement for the NHS, but it has come at a cost, not to us, but to other nations.

Offshore sources

The NHS ‘reliance on cheap generic drugs and the commoditization of the generic drug supply chain are leading to a race to the bottom. Offshoring has been the default approach to reducing manufacturing costs. It is estimated that 70-90% of all generic medicines supplied to the UK come, at least in part, from India and ChinaHave[7,8]Have.

Ministry of IndiaEnvironment, Forests and Climate Change has classified pharmaceutical manufacturing in the “red” category, indicating that it produces the highest levels of pollution. Indeed, successive studies have shown that the air, water and soil of Telangana State, a pharmaceutical manufacturing center, are highly contaminated with toxic chemicals and heavy metals, such as copper, lead, mercury and arsenic.Have[9]Have.

In the United Nations (UN) Environment Program report “Frontiers 2017 – Emerging Issues of Environmental Concern”, the UN identifies increasing antimicrobial resistance (AMR), linked to the release of particular drugs and chemicals in the environment, as one of the most worrying issues. health threatsHave[10]Have. At the launch of the report, Erik Solheim, executive director of the environment for the UN, drew particular attention to a pharmaceutical facility in Hyderabad, India, where tests on discharged water found that the concentration in The treated wastewater of ciprofloxacin was strong enough to treat 44,000 people.Have[11]Have.

In January 2020, India’s Ministry of Environment, Forestry and Climate Change released a bill to introduce limits on the concentrations of antibiotics allowed in wastewater discharged from pharmaceutical factories. Unfortunately, in April 2021, The new Indian express reported that a year after the bill’s publication, the ministry was unable to propose standards to limit antibiotics rejected by industry, due to a lack of available research on the subject, and the bill was droppedHave[12]Have.

The Yangtze and Pearl Rivers have been shown to contain significant levels of antibiotics, with levels as high as 1,080 ng / L

The situation is similar in China, which is home to the largest concentration of manufacturers of active pharmaceutical ingredients (bulk drugs). China has extensive environmental protection laws and a history of enforcement, but despite this, antibiotics have been detected in studies of residents’ tap water and in major Chinese rivers. For example, in Nanjing, China’s Jiangsu Province, two antibiotics (amoxicillin [8ng/L] and 6-aminopenicillanic acid [19ng/L]) were found in tap water. More antibiotics have been found in tap water in cities of Anhui province, and the Yangtze and Pearl rivers have been shown to contain significant levels of antibiotics, with levels reaching 1,080 ng / L, which could cause bacterial resistance in humans and produce many drugs. ineffective. In the United States, France and the United Kingdom, this level is generally below 20ng / L in riversHave[13]Have.

The NHS in Scotland is testing ways to remove traces of pharmaceuticals from hospital wastewater, but what about the manufacturing process? And what about other countries? Are we happy that our drugs are produced at the expense of the environment, as long as it is someone else’s environment?

It’s time to take responsibility

For too long, we have overlooked the cost of our drugs in the name of ever lower prices. The focus on sustainability and the NHS ‘drive to achieve net zero emissions is a great opportunity to change direction and stop pharmaceutical pollution of our environment.

Effective regulation and a new approach to drug synthesis can together stem the tide of environmental pollution from drug production. Green chemistry is “the design of chemicals and processes that reduce or eliminate the generation of hazardous substances”Have[14]Have. The 12 principles of green chemistry focus on developing more energy efficient manufacturing processes, using less of the earth’s resources, generating less waste and reducing the environmental impact of drug manufacturing. The concept serves as a roadmap for developing sustainable manufacturing processes for drugs. A good example is the synthesis of the therapeutic peptide etelcalcetide, the active ingredient in Parsabiv, a calcium inhibitor to help control overactive thyroid gland in patients with kidney disease. The new process produces more peptides in less time, while dramatically reducing solvent and water use and lowering production costs. Despite the strong business case for green chemistry, scaling up adoption has stalledHave[15]Have.

Green chemistry has the potential to eliminate the release of harmful chemicals into the environment

There is also the problem of existing drugs. Thousands of generic drugs were designed, developed and launched before the emergence of green chemistry. Most of these drugs could be made using processes that produce a fraction of the waste they presently produce if they were rearranged using green chemistry principles. Additionally, green chemistry has the potential to eliminate the release of harmful chemicals into the environment. The development of new manufacturing processes will reduce the cost of manufacturing in the long run, but it has an initial cost and industry must be encouraged to make this initial investment. The NHS must break its addiction to buying the cheapest generic drugs for this to happen.

If the NHS is serious in its desire to be net zero and protect the environment, then it needs to fundamentally review the way generics are bought. The price should not be the only determinant. Environmental impact and sustainability must play an equal role in purchasing decisions. This means moving from low cost shopping to long term sourcing based on a balanced economic and environmental scorecard.

Currently, there is no way for a pharmacist to know if the drug they have purchased has been produced to the detriment of the environment, if it has contributed to the growth of AMR, or if it is poisoning populations. premises of the manufacturing plant.

We need to integrate sustainability into the purchasing decision. A radical overhaul of community pharmacy reimbursement is long overdue, and the abandonment of a model that requires the endless search for the cheapest generic drugs is a great opportunity to transform the way community pharmacy is commissioned and rewarded. NHS procurement could centralize the procurement and distribution of essential generic drugs to pharmacies from suppliers audited for their environmental performance, or our post-Brexit regulatory framework could introduce an environmental requirement at the authorization stage which is also filed. high as safety, quality and efficiency.

A new approach that ensures the highest environmental performance from all of our drugmakers is absolutely essential if the NHS is to have any chance of beating its ambitious emissions targets.

Hopefully, the increased focus on sustainability and net zero emissions will measure the impact beyond our shores and seek to ensure that we consider the full cost, not just the price, of our medicines.

  1. 11

    Larsson DGJ. Pollution due to the manufacture of drugs: results and perspectives. Phil. Trans. R. Soc. B. 2014;369: 20130571. doi: 10.1098 / rstb.2013.0571
  2. 13

    Huang R, Ding P, Huang D, et al. Antibiotic pollution threatens public health in China. The Lancet. 2015 ;385: 773–4. doi: 10.1016 / s0140-6736 (15) 60437-8
  3. 15

    Zhang W, Cue BW, editors. Green techniques for organic synthesis and medicinal chemistry. John Wiley & Sons, Ltd 2018. doi: 10.1002 / 9781119288152


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