Anaesthesia – is it really pain free for the environment?
Asbestos was finally banned in the UK in 1999, 102 years after the first health related issues were
detected. It was linked to mesothelioma as far back as the 1930s. In fact, if you’ve just recovered
from your annual Christmas ‘Wizard of Oz’, you might be surprised to learn that the snow used in
the 1939 film was pure asbestos, used because it was fire retardant. Despite the obvious health
risks, it took decades for asbestos to be regulated and removed from use. As a result, we are still
seeing asbestos-related disease deaths today, with over 5000 reported in 2021 .
Fast forward a century and we are in a similar position with
the issue of pharmaceutical pollution of the environment. In
Anaesthesia News last year Allen et al. asked “But what about
the fish?”, introducing the topic of ecotoxicology and the
provision of sustainable healthcare to anaesthetic practice .
The discharge of pharmaceuticals into the aquatic environment
by wastewater treatment plants across the UK and globally has
been well documented [3, 4]. Most wastewater treatment plants
were not designed to remove the increasing variety of novel and
often complex organic pollutants efficiently, and many medicines
undergo limited degradation and/ or transformation during
treatment [5, 6].
Science drives policy, but despite science, policy development and regulation can take more than a generation to have an impact.
Reports of harm from pharmaceuticals in the environment have
been around since the 1960s. Despite rapid advancement in
research techniques and knowledge since the late 1990s, the
fate of pharmaceuticals, their metabolites and transformation
products once introduced into the aquatic environment remains
relatively unclear and means that we still cannot definitively state
an impact on human or environmental health. In addition much
of the research is performed on individual compounds, and of
course our rivers and oceans contain a cocktail of drugs that may
be reacting with each other and other contaminants. They also
bond onto microplastic particles, which can concentrate their
effect and deliver a bigger dose when eaten by aquatic life.
The pharmaceuticals used in anaesthesia and across healthcare
have a clear potential to harm the environment in terms of
toxicity, persistence and bio-accumulation. Of specific interest to
anaesthetists may be:
- Propofol is an environmental hazard because it does not
degrade, has the potential for significant bioaccumulation
and persistence, and is toxic to aquatic life .
- Lidocaine has a short half-life in the environment, but its
regular use and constant excretion results in pseudo-persistence
- Diclofenac is suspected of causing damage to the inner
organs in rainbow trout , and has led to the near-extinction
of vultures on the Indian subcontinent, caused
by birds feeding on the carcasses of cattle treated with the
- Pyridostigmine and neostigmine are potentially toxic to
Daphnia magna at concentrations in the order of μ.l
- Ketamine has been widely detected in surface waters. It is
absorbed by shallow water fish, and marked changes were
seen in the bacterial community in aquatic sediment .
- Recent work examining the practice of anaesthesia has
resulted in dramatic reductions in carbon emissions
from anaesthetic gases as well as improvements in
the solid waste stream; however the potential aquatic
impacts remain relatively unexplored. Given the beneﬁts
that pharmaceuticals confer in anaesthesia, potential
strategies to mitigate their environmental impact must be
directed to prevent, reduce, and manage their use without
compromising patient care.
During the pandemic we have repeatedly heard the phrase
“We will be led by the science”. Science drives policy, but despite
science, policy development and regulation can take more than
a generation to have an impact. So what are we to do in the
meantime to reduce risk for human and environmental health
from our clinical practice? The current year-on-year increase in
the use of medicines means that while we are trying our best
to make our patients healthier, we are potentially making our
planet sicker. The NHS across the UK has committed to net zero
healthcare with respect to carbon emissions – but shouldn’t we
also be committing to net zero pollution and net zero harm to
This is the vision of the One Health Breakthrough Partnership,
a unique collaboration between Scottish Water, the Scottish
Environment Protection Agency, the Environmental Research
Institute of the University of the Highlands and Islands and
NHS Highland . Together, we have a vision for a Highlands
where non-toxic and sustainable healthcare is delivered. We
are working together, sharing skills, data and perspectives, to
reduce the impact of pharmaceuticals in the environment and
slow the rise of antimicrobial resistance. While the evidence
grows we are working using a precautionary principle, taking
a public health upstream approach and using this as an
opportunity to improve healthcare while reducing the load of
pharmaceuticals on the environment. We are taking a ‘realistic
medicine’ approach to the use of medicines, asking the patient
“What matters to you?” (it may not always be that they want
a medicine), and educating the public on the environmental
effects of medicines and how to dispose of medicines waste.
We are also educating clinicians across all professions, and
‘greening’ our formulary to offer prescribers less toxic choices
that work for patients and the environment.
Of course, in anaesthesia, the perfect future would be one
where much of the need for anaesthetic agents and surgery was
reduced secondary to improved health of our population. In the
meantime, being aware of the potential for environmental harm
from the medicines we use should help us balance the priorities
of clinical effectiveness and patient need versus protecting and
restoring nature as the foundation of health. What will you do in
your own life and practice?
Professor Sharon Pfleger
Consultant in Pharmaceutical Public Health
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