Currently, there is uncertainty about emissions of pharmaceuticals into larger closed ecosystems that are at risk such as the Baltic Sea. There is an increasing need for selecting the right strategies on advanced wastewater treatment. This study analysed 35 pharmaceuticals and iodinated X-ray contrast media in effluents from 82 Wastewater Treatment Plants (WWTPs) across Denmark, Estonia, Finland, Germany, Latvia, Lithuania, Poland and Sweden. Measured concentrations from Finland and Denmark were compared to predicted effluent concentrations using different levels of refinement. The concentrations predicted by the Total Residue Approach, as proposed by the European Medicines Agency, correlated with R(2) of 0.18 and 0.031 to measured ones for Denmark and Finland, respectively and the predicted data were significantly higher than the measured ones. These correlations improved substantially to R(2) of 0.72 and 0.74 after adjusting for estimated human excretion rates and further to R(2) = 0.91 and 0.78 with the inclusion of removal rates in WWTPs. Temporal analysis of compound variations in a closely monitored WWTP showed minimal fluctuation over days and weeks for most compounds but revealed weekly shifts in iodinated X-ray contrast media due to emergency-only operations at X-ray clinics during weekends and an abrupt seasonal change for gabapentin. The findings underscore the limitations of current predictive models and findings (...) demonstrate how these methodologies can be refined by incorporating human pharmaceutical excretion/metabolization as well as removal in wastewater treatment plants to more accurately forecast pharmaceutical levels in aquatic environments.

Appropriate collection and disposal of medicine-related waste has been identified as one of the main ways to decrease the emission of active pharmaceutical ingredients (APIs) into the environment. Improvement to the take-back and treatment of collected pharmaceutical waste may be considered lowhanging fruit when one is considering measures to reduce API emissions. However, comparable information that would enable estimating the potential impact of these efforts has not been available. Directive 2004/27/EC, related to medicinal products for human use, mandates that EU member states implement appropriate collection schemes for unused or expired human-use medicinal products. However, it does not provide any guidelines on practical implementation of these schemes. Several studies have pointed out significant differences among Member States in this regard. In March 2019, the European Commission published the European Union Strategic Approach to Pharmaceuticals in the Environment. The actions specified therein cover all stages of the pharmaceutical life cycle, from design and production to disposal and waste management. It emphasizes such elements as sharing good practices, co-operating at international level, and improving understanding of the risks. This report is aimed at filling knowledge gaps and proposing good practices for take-back and disposal of unused human and veterinary medicines and other pharmaceutical waste. The report is targeted to e.g. ministries, environment and medicines agencies, supervisory authorities, municipalities, hospitals, NGOs, pharmacists, doctors, and veterinarians. For the report, current national practices for take-back and disposal of unused medicines and other pharmaceutical waste in Denmark, Estonia, Finland, Germany, Latvia, Lithuania, Poland, Russia, and Sweden were evaluated. The pharmaceutical waste originating from households, hospitals and other health care institutions, the pharmaceutical industry, and veterinary use was considered. The proportion of citizens who return unused pharmaceuticals via designated collection points varies greatly between Baltic Sea countries, from about 10% to 70%, with 16–80% disposing of them of as mixed household waste and 3–30% flushing them down the drain. The most commonly cited reason for improper disposal of medicines on households’ part is lack of information about their environmental impacts and how to get rid of them in an environmentally sound manner. Separate collection of unused household pharmaceuticals does not exist in Russia, and the collection mechanism functions poorly in Latvia, Lithuania and Poland. Information on the take-back schemes for unused human medicines is more readily available than is corresponding information on veterinary medicines. We identified, all told, 21 good practices and recommendations for take-back and disposal of unused pharmaceuticals and other pharmaceutical waste and for promoting the rational use of pharmaceuticals in the Baltic Sea region. Nevertheless, implementing them at national level requires particular consideration due to differences in national legislation and other characteristics of the EU Baltic Sea countries and Russia. The good practices identified in this report answer the call issued in the EU strategic approach for an efficient risk-reduction strategy.

This report describes the contamination by pharmaceuticals and the environmental risks associated with their environmental levels in the Baltic Sea Region. Data were collected within the three-year project Clear Waters from Pharmaceuticals (CWPharma) funded by the EU’s Interreg Baltic Sea Region Programme. Sampling was performed in the river basin districts of Vantaanjoki in Finland, Pärnu in Estonia, Lielupe and Daugava in Latvia, Vistula in Poland, Warnow-Peene in Germany and Motala ström in Sweden. Analyses were performed on surface water, coastal water, sediment and soil that was fertilized with sewage sludge or manure. Analyses were also performed on emissions from municipal wastewater treatment plants, hospitals, pharmaceutical manufacturing facilities, landfills, and fish and livestock farms. In total, the study covered 13 365 data points from 226 samples as well as collection of human and veterinary consumption data of selected active pharmaceutical ingredients (APIs). Samples were screened for up to 80 APIs, representing antibiotics, antiepileptics, antihypertensives, asthma and allergy medications, gastrointestinal disease medications, hormones, metabolic disease medications, non-steroidal anti-inflammatory drugs (NSAIDs) and analgesics, other cardiovascular medicines, psychopharmaceuticals, veterinary medicines and caffeine. The measured APIs were selected based on analytical capacity, consumption rates, identified data gaps and potential environmental risks. Literature and databases were screened for ecotoxicological information. Acute toxicity tests were performed for two APIs, nebivolol and cetirizine, for which ecotoxicological data were lacking. Measured environmental concentrations were compared with predicted no-effect concentrations (PNEC) to assess environmental risks of the selected APIs.

During the last decades, it has become evident that some active pharmaceutical ingredients (API) have harmful environmental impacts on aquatic ecosystems. Therefore, there is a need to decrease the amount of pharmaceutical residues that end up in the environment. Information gaps related to increased awareness of the environmental impacts of pharmaceuticals in the health care sector and the promotion of sustainable consumption of pharmaceuticals have been identified in the Status Report on Pharmaceuticals in the aquatic environment of the Baltic Sea Region (BSR) published by UNESCO and HELCOM in 2017. The aim of the current report is to fill in some of the identified knowledge gaps identified in the HELCOM report, specifically increasing awareness about the environmental impacts of pharmaceuticals. In Sweden, there are good practices for healthcare professionals about how to consider the environmental impacts of medications already at the prescription phase, as well as guidelines for how to make the environmental information available and accessible to healthcare professionals and the public. The Swedish practices are described and evaluated, and the measures that can be implemented in the other BSR countries are formulated as recommendations. Eight recommendations were formulated through dialogues with stakeholders in Sweden. The recommendations are divided into four main areas i.e. education, databases and guidelines, dissemination of information to public, and collaboration among stakeholders. Some recommendations might be implemented without any large challenges or financial costs while other recommendations require large changes such as economic investments and changes in legislation. This report also contains information about existing practices in other countries in the Baltic Sea region (BSR), provided by the project partners in the CWPharma project. The countries in the BSR are currently at different levels when it comes to management of pharmaceuticals and their residues in the environment. Public awareness of the environmental impacts of pharmaceuticals differs, as do the systems for returning leftover medications. Basic education for health care personnel regarding the environmental consequences of different medications and pharmaceutical compounds exists in most of the BSR countries but the scope and content differs. One recommendation in the report is that environmental impacts of APIs should be compiled in a national, or ideally an EU level, database. As a first step, the Baltic Sea countries could investigate the possibility to establish national interfaces to the Swedish databases “Pharmaceutical and environment” (Janusinfo) or FASS. Although the data in “Pharmaceutical and environment” and FASS are not complete, they are existing platforms which provide valuable information and gather criteria important for classification. In Sweden, there are several channels for the dissemination of information about the environmental consequences of pharmaceuticals with the aim to raise public awareness regarding this subject. Examples of actions to be considered by other countries are information campaigns driven by pharmacies for returning unused and left over medications (Germany and Finland have similar campaigns), and distribution of leaflets with information about the environmental impacts of pharmaceuticals, which have proven to be efficient in raising awareness among pharmacists, doctors and the public. The collaboration of different stakeholders is one of the foremost reasons for the progress that has been made regarding pharmaceuticals in the environment in Sweden. The Swedish Medical Production Agency has set up a Knowledge Centre for Pharmaceuticals in the Environment, providing a platform for different actors to discuss environmental issues connected to pharmaceuticals. Among these actors there is a sense of a shared environmental vision with common goals. Hence, one recommendation for the BSR countries is to investigate the possibilities of establishing similar national knowledge centers within medicine agencies, or to use existing networks as a starting point to also involve other environmental issues related to pharmaceuticals and to find new collaboration possibilities. Finally, collaboration between the EU countries is crucial to successfully implement environmental aspects in the lifecycle of the pharmaceuticals.