Human Pharmaceutical Marine Micro-pollution in Nouvelle Aquitaine, France

Submitted in 2024 in fulfilment of the requirements of the Masters of Science (Global Environment & Sustainability) at Birkbeck, University of London.

9/3/20241 min read

assorted medication tables and capsules
assorted medication tables and capsules

I. INTRODUCTION

This essay describes the causes, impacts, and suggested mitigatory strategies in relation to human pharmaceutical marine micropollutants and related micro-pollution (“HPMM”) in the Région of Nouvelle-Aquitaine in France. Section II describes the significance of HPMM, and Section III analyses its primary social and environmental impacts. Section IV addresses certain sustainability interventions and the effectiveness of implemented policies. Section V concludes with implications for research, policy, and practice.

II. THE ISSUE

Pharmaceuticals have been categorised as a contaminant of emerging concern (“CEC”), being substances “which have now been discovered or are suspected present in various environmental compartments and whose toxicity or persistence are likely to significantly alter the metabolism of a living being” (Sauvé and Desrosiers 2014:6) .

France is one of Europe’s top consumers of medicine and particularly antibiotics (Goossens et al. 2005; Haenni et al. 2022). The low or zero cost of French healthcare, including a general lack of requirement for advance payments, may contribute to high medication consumption (Cazals et al. 2023). Higher consumption creates more opportunities for entry into the environment, such as via wastewater, solid waste, human excretion, and sub-standard disposal practices (UNEP 2020). The presence of pharmaceutical elements in the water, particularly in high volumes and when components are persistent, may result in negative environmental impacts on land and at sea.

In 2016, thresholds were exceeded for amiodarone in France’s rivers and lakes and for ketoprofen and paracetamol in groundwater, which is to say that those pharmaceuticals could be considered toxic or ecotoxic (EauFrance 2016). As at 2019, less than 50% of the Région’s surface water bodies, and about a third of its groundwater, were in good ecological condition as defined by the Water Framework Directive (2000/60/EC) (ARB 2021) (see Section III). Additionally, as of 2017, none of the Région’s wastewater treatment (“WWT”) plants were capable of degrading pharmaceutical micropollutants (CESER 2017). The marine environment is crucial for health, recreation, industry, and sustenance in Nouvelle-Aquitaine, occupying a key historic, social, and cultural position in public life (OECD). It is therefore necessary to consider HPMM’s impacts and possible next steps in mitigation.

III. PART 1: IMPACTS

Environment

After discharge into the environment, pharmaceutical micropollutants are further dispersed through the water and trophic networks (Fent et al. 2006). The prevalence of pharmaceutical elements has been demonstrated by their detection at high volumes in surface waters and at trace levels in drinking water (Sauvé and Desrosiers 2014).

In Nouvelle-Aquitaine, data concerning CECs and other micropollutants has up to 2021 been insufficient to facilitate a holistic understanding of regional water quality (ARB 2021). Indeed, a Portuguese study concluded that, subject to knowledge gaps, no significant health risks were associated with contact with trace HPMM levels based on pharmaceutical consumption at current levels (de Jesus Gaffney 2015).

Marine organisms are most vulnerable in relation to HPMM. Unlike humans, who may be able to avoid exposure to marine pollution by relocation, marine organisms do not have the luxury of escaping aquatic pollution including that caused by pharmaceutical ecotoxicology (Fent et al. 2006). This can result in inadvertent ingestion and propagation of HPMM. Several marine organisms have experienced abnormalities in reproductivity, sexual maturity, renal and respiratory activity, and hormonal balance even after short-term low-concentration exposure to certain common pharmaceuticals (Fent et al. 2006), in addition to modifications in growth, metabolic processes, immunology, feeding, and movement (Branchet et al 2021).

Society

Given the essential role of water in human survival, activities, and livelihoods, HPMM’s effects on human life is of grave concern. However, such impacts are not yet comprehensively understood due to knowledge and technological gaps. While HPMM exposure has also been linked to risks of pancreatic and breast cancer (Chen and Chen 2013) and endocrine or hormonal dysregulation (Fent et al. 2006), the severity of these effects is currently unclear.

The social impacts of HPMM affect primarily individuals whose jobs and lifestyles rely on the marine environment, and those who are immunodeficient or similarly vulnerable.

Individuals who are dependent on water quality for subsistence and livelihoods could be deeply affected by HPMM. This could be the case for a notable proportion of the Région’s residents. Its 970km coastline, stretching over 30km along the Atlantic Ocean, is home to more than 1 million residents (OCP). Effectively, around 16% of Nouvelle-Aquitaine residents live on the coast; further, water-related tourism represents approximately 9% of regional gross domestic product. (OECD). Recreational beaches in urban coasts are especially susceptible to HPMM due to inter alia the frequency of human presence and activity in these areas (Baek et al. 2022). Arguable, damage to the marine environment could interfere with the quality of life and work opportunities for the Région’s coast-dwellers and as well as other individuals indirectly.

HPMM may also affect immunodeficient individuals disproportionately. Researchers have observed the presence of anti-infection drugs in HPMM at quantities capable of provoking resistance to antibiotics (Sauvé and Desrosiers 2014). As the body builds antibiotic or even antimicrobial resistance, it may be that recovery or improvement can only be achieved by consumption of ever greater quantities, potentially increasing exposure to side effects, augmenting healthcare costs, as well as vulnerability to infection and preventable deaths (Haenni et al. 2022).

Since the 1990s, the Internet has increased access to direct-to-consumer human pharmaceuticals and the rise of lifestyle or health-adjacent drugs (Fox and Ward 2008). This quasi-liberalisation could be associated with greater patient autonomy but also less regulated consumption levels. Self-medication has also become more common with the advent of teleconsultations and the spread of information on social media (Cazals et al. 2023). This may influence HPMM since, when self-medicating, one may not always be sensitive to the dosage and units appropriate to one’s particular condition and physiology and may prioritise time, convenience, and economy. In a 2022 study in Arcachon Bay, Nouvelle-Aquitaine, 86% of respondents admitted to practising self-medication, with self-medication being particularly prevalent amongst students, stay-at-home parents, and individuals from lower-income groups (Cazals et al. 2023).

Stakeholders at all stages of the pharmaceutical life cycle (“PLC”) could contribute to eliminating the issue of HPMM.

Individuals: Unused prescribed medication accumulates when patients do not comply with prescriptions, when treatments cease or are altered, or when medication deteriorates due to inappropriate storage conditions (Cazals et al. 2023). Individuals whose conditions improve mid-prescription, and proceed to cease consumption, appear to be the most instrumental in HPMM (Cazals et al. 2023) in terms of excess medications disposed of inappropriately. This group could assuage HPMM by adhering more closely to prescribed courses and/or by ensuring safe return of medications, for example, under the French Cyclamed program (see Section IV). Individuals who consume the highest quantities of medications whether prescribed or self-medicated could assist in ameliorating HPMM by regulating their consumption and therefore metabolisation.

Physicians are another key stakeholder in this issue. In the institutional French healthcare system, the types and quantities of medicines prescribed are determined by the extent to which the physician and patient share in the decision-making process (Cazals et al. 2023). In cultures where physicians lead the prescription process, they could also play an integral part in determining the quantities and dosages of medications entering the patient’s possession and bodies.

Pharmaceutical manufacturers could contribute to reducing the environmental impacts of HPMM by improving the degradability of the elements in their products and by administering the return, collection, and safe treatment and disposal of surplus medication.

Legislators have the prerogative of establishing frameworks governing all stages of the PLC including the permitted levels of ecotoxicology of pharmaceutical ingredients, the labelling and disclosure requirements, patient-physician prescription discussions, and medication return and disposal options.

Law and Policy

Some key applicable policies, practices, and legislation are:-

1. The European Union Strategic Approach to Pharmaceuticals in the Environment (COM/2019/128)

Its ambit includes all stages of the PLC from design to disposal, with clear action points in six main strategic prongs, i.e. awareness, training and risk assessment, greener design (see Section V), waste reduction, and improving WWT (EC1; EC2).

2. The Convention for the Protection of Marine Environment of the North-East Atlantic 1992

The Convention, which monitors regional marine contamination, highlights 22 pharmaceuticals as being ‘of possible concern’ (Branchet et al 2021; OSPAR Commission 1992). While OSPAR’s 2002 List of Chemicals for Priority Action includes the pharmaceutical compound clotrimazole (OSPAR 2002), it was determined in 2013 based on current evidence no risk existed to the marine environment, and that further local data was needed (OSPAR 2013). The 2013 update was the most recent, which may suggest that one of the complications in addressing HPMMs could be the time-intensive nature of monitoring and analysis.

3. The Water Framework Directive (2000/60/EC) (“WFD”)

The crux of the WFD comprises the reduction and eradication of pollutants in European waters, securing sufficient water supply for human and non-human life, and regulating pollutants (WFD; EC3). As of 2018, 8 pharmaceuticals have been included in the WFD Watch List (WFD).

4. France: The National Plan against Micropollutants 2016-2021

This non-binding document focuses on analysis and data-sharing, and includes incentives for the development of innovations targeting HPMM at its source (OECD 2019; République Française 2020). 4 years after launching of the National Plan, the French government considered that it had improved its understanding of inter alia the HPMM issue and impacts, by virtue especially of national cross-department exploratory campaigns as well as new reference laboratory analysis techniques (République Française 2020).

In addition to the above, as seen in Appendix “2”, French manufacturers are subject to environmental risk assessments prior to applying for marketing authorisations, with publicised assessment reports on approved medicines; and France is obliged to offer collection services for unused or expired medication.

IV. PART 2: INTERVENTIONS

In 2015, the United Nations (“UN”) set out 17 sustainable development goals (“SDGs”) by way of the 2030 Agenda for Sustainable Development, which goals were adopted by the French Republic in its capacity as a UN member state (UNDESA).

In Nouvelle-Aquitaine, the Regional Directorate for the Environment, Planning, and Housing (“DREAL”) is responsible for inter alia protecting water, air quality, biodiversity, and ground resources (DREAL 2017). In 2019, the Région adopted the Néo Terra energy and ecological roadmap to transition, which supports progress in energy, ecology, and agriculture by 2030 (Néo Terra); in other words, aligning with the 2030 SDG agenda. Responding to SDG6 and SDG14, ‘Water development and management schemes’ (“SAGE”) provide for the management of water quality and ecological conditions in aquatic environments (DREAL 2020a). SAGE covers 78% of the Région (DREAL 2020b).

Sustainability in the developmental context is widely understood to be the balancing of meeting present needs “without compromising the ability of future generations to meet their own needs” by, amongst others, imposing limits on the use of natural resources and managing stresses on biosphere absorption capacities (Brundtland 1987). Broadly, sustainable waste management must produce desired environmental effects, be financially viable, and above all involve the public in the decision-making process (Morrissey and Browne 2004). A sustainable intervention should therefore make prudent use of current resources, be proactive to future issues and needs, and be the product of consultation with and/or receive acceptance at all strata of society.

Cyclamed

Pursuant to Law No. 2007–248 of 26 February 2007, French pharmacies must accept patients’ unwanted medications. In 2022, 87% of French people reported returning unused medications to pharmacies under the Cyclamed initiative, which organises nationwide sorting and recovery of medications (Cyclamed 1) and in which wholesale distributors deliver empty containers to pharmacies and collect filled containers (Rogowska and Zimmermann 2022). Nouvelle-Aquitaine surpassed the national average in terms of grams per capita returned under Cyclamed in 2018, and was the third best performing region in the country (Cyclamed 2). Cyclamed could be described as a successful initiative in terms of enhancing opportunities for safe disposal. The combination of the two forms of end-of-pipe waste reduction (i.e. pharmaceutical waste and plastic packaging waste) could be a good synergy of both goals in the immediate and long term, while avoiding the need for substantial technological or financial investment. The high rate of return could signify widespread public acceptance and thus qualify this initiative as a highly sustainable and effective intervention. Collection rates of surplus medication could be aided by the provision of additional collection bins at areas frequented by people aged 60 and above, such as supermarkets, community clubs and the like, places of worship, and parks.

WWT and Neutralisation

Ingested pharmaceutical substances including hormones and steroids are often not completely eradicated in the usual course of WWT (Larsen et al. 2004). In 2015, EPPPs were designated as pharmaceuticals intended to degrade slowly and/or with difficulty, if at all; however, irreversible effects may also result from non-degradable or partially degradable pharmaceuticals as well as those which, while degradable, nonetheless remain in the environment by reason of frequent emission (UNEP 2020; SAICM 2015). In Europe, WWT generally destroys micropollutants by way of biological degradation; however, some pharmaceuticals are not expunged partially or at all while others merely reduce in size to the level of undetectability (Larsen et al. 2004). As noted in Section II, there has been room for improvement in Nouvelle-Aquitaine’s WWT in terms of pharmaceutical degradation.

Hospitals and other medical and care facilities produce wastewater with the highest concentrations of pharmaceutical micropollutants (Gavrilescu et al. 2015). It is therefore imperative to address effluence from these point sources of HPMM. With that in mind, PILLS - a group of 6 European industry and academic partners – is concerned with WWT from high point-sources of pharmaceutical waste, such as hospitals and hospices, and some PILLS pilot installations have the objective of eradicating persistent drug residues (PILLS 2010). This is achieved largely through mechanical filtration, biological treatment, and further clarification and post-processing with activated carbon (PILLS 2010). While arguably effective at restraining HPMM release into the environment, the high level of financial investment required under this technological intervention could be an impediment to its public acceptance and legitimacy.

Engineered constructed wetlands, comprising cells hosting passive substrates which could be natural (e.g. sand or peat) or engineered, could assist in obliterating intransigent pharmaceutical elements whether alone or in conjunction with conventional WWT (Rossi et al. 2013). By tackling both HPMM and potential climate impacts from sea level rise, this intervention synergises climate and biodiversity goals and mitigating their related impacts and could be considered a fairly sustainable and future-forward intervention, especially if public awareness and support could be enhanced through education and outreach.

Photocatalysis, in which semiconductors are illuminated and generate charges which react with and ease the decomposition of pharmaceutical compounds, could be an option for neutralising pharmaceutical waste, and has been found effective as against diclofenac and fluoxetine (Marquez Brazon et al. 2016). Biomediation - the use of microorganisms such as microalgae - is a financially and environmentally sustainable technique for neutralising or degrading HPMM, and combined with biochar, could be a highly cost-effective and reliable intervention (Mojiri et al. 2021). The energy-intensive nature of these technological interventions, as well as present lack of clarity on effects on surrounding marine organisms, may be an area for further research and consideration in order to improve public reception and therefore their long-term sustainability.

V. CONCLUSION

Sustainable Design: Green chemistry and green/sustainable pharmacy may be useful frameworks for achieving sustainability and reducing environmental injustices. Green chemistry – which emphasises reducing or avoiding use of toxic solvents, restricting or ceasing the production of residues during chemical processes, or treating such residues prior to release into the broader environment (de Marco et al. 2019) – could be valuable in addressing HPMM early in the PLC. Green/sustainable pharmacy, on the other hand, refers to pharmaceutical design which generates little or no hazardous waste (including swift and complete degradability after use), prevents health environment and safety consequences from the outset, and does not compete significantly with other socioeconomic, environmental or biodiversity goals (Kümmerer 2010). For example, there have been suggestions that greener pharmaceuticals should not contain fluorine so as to reduce resistance and bioavailability and/or promote degradability (Sumpter 2010), and that there is a need to balance the compounds’ necessary presence in the body against their desired rate(s) of deterioration in the environment (Clark et al. 2010).

Separation At Source: Waste design could be implemented in households, by way of separation at source and storage of urine in the home, for onward conveyance to nutrient treatment plants (Larsen et al. 2004; Larsen and Gujer 1996). This could involve the redesigning of WCs to divert urine away from the sewage system (Borsuk et al. 2008), thus reducing influx into waterbodies. Since urine carries the vast proportion of wastewater nutrients and metabolised pharmaceuticals and hormones – despite representing a minor percentage of total wastewater by volume – separation at source could be the most sustainable solution in terms of metabolised pharmaceuticals (Larsen et al. 2004).

Consumer Needs and Decisions:

  • A ‘green medicine’ label, classifying medications according to manufacturer sensitivity to environmental risk, and stipulating extended producer responsibility for the recovery of unused medications (Cazals et al. 2023) could be useful in mitigating pharmaceutical waste.

  • A 2017 study of University of Vermont students revealed high retention rates of medication purchased in the next year and relatively low insight into drug take-back programs (Vatovec et al. 2017). This age group is particularly important given that habits and lifestyle choices formed now may shape future practices and needs. It could therefore be worth exploring outreach to young French adults highlighting the existence of the Cyclamed program, as well as encouraging them to choose or request lower volumes and dosages of medications, as suggested by Vatovec et al. (2017) in the Vermont study.

  • Medicine consumption could be constrained at its root by disease prevention, including by promoting public awareness and engagement in healthy diets and lifestyles, and by promoting and integrating alternative and complementary healthcare and remedies, including mental and physical therapeutic practices (Cazals et al. 2023).

Citizen Science: Nouvelle-Aquitaine residents could be involved in community volunteer events to administer tests in local waterbodies to ascertain the contamination levels of certain common drugs, and/or to collect samples for testing. Such forms of citizen science have been cited as a useful multifaceted tool for widening geographical and quantitative range of data while simultaneously raising public awareness and drive toward change (Vasantha Raman et al. 2023).

Commitment to Monitoring: The French government has stated in the National Plan that monitoring is more cost-effective than restoration and purification of water bodies (République Française 2020). It could be therefore beneficial to establish ongoing evaluation of marine water according to the Marine Strategy Framework Directive 2008/56/EC, and include pharmaceutical elements in existing long-term routine programs which monitor aquatic contamination (Branchet et al 2021).

Multi-stakeholder Cooperation: A viable balanced relationship between pollution, economy, and sustainable development could be achieved by improving communication and collaboration between industry, governments, and the public. For instance, there have been calls for increased cooperation with pharmaceutical manufacturers and for improved understanding of pharmaceuticals which are already on the market (UNEP 2020). In 2016, Pharmaceuticals and Environment, a free web database, was launched in Stockholm county, Sweden, to inform consumers of the environmental contents and impact of various pharmaceutical substances (Ramström et al. 2020).

While it is important to treat waste that has been generated, and to ensure user and producer accountability for such waste, waste management commences the moment the idea for a product is formed. HPMM can be mitigated in degradability design and environmentally conscious manufacturing, when it is disposed of and treated appropriately, with strong central and local oversight. Ultimately, a concerted approach is required from all stakeholders at all stages of the PLC.

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