Beyond the medicine cabinet: an analysis of where and why medications accumulate

Active pharmaceutical ingredients (APIs) from medications can enter the environment as trace contaminants, at individual concentrations generally below a part per billion (microg/L). APIs enter the environment primarily via the discharge of raw and treated sewage. Residues of unmetabolized APIs from parenteral and enteral drugs are excreted in feces and urine, and topically applied medications are washed from skin during bathing. These trace residues may pose risks for aquatic life and cause concern with regard to subsequent human exposure. APIs also enter the environment from the disposal of unwanted medications directly to sewers and trash. The relative significance of this route compared with excretion and bathing is poorly understood and has been subject to much speculation. Two major aspects of uncertainty exist: the percentage of any particular API in the environment originating from disposal is unknown, and disposal undoubtedly occurs from a variety of dispersed sources. Sources of disposal, along with the types and quantities of APIs resulting from each source, are important to understand so that effective pollution prevention approaches can be designed and implemented. Accumulation of leftover, unwanted drugs poses three major concerns: (i) APIs disposed to sewage or trash compose a diverse source of potential chemical stressors in the environment. (ii) Accumulated drugs represent increased potential for drug diversion, with its attendant risks of unintentional poisonings and abuse. (iii) Leftover drugs represent wasted healthcare resources and lost opportunities for medical treatment. This paper has four major purposes: (1) Define the processes, actions, and behaviors that control and drive the consumption, accumulation, and need for disposal of pharmaceuticals. (2) Provide an overview of the diverse locations where drugs are used and accumulate. (3) Present a summary of the first cataloging of APIs disposed by a defined subpopulation. (4) Identify opportunities for pollution prevention and source reduction.