Prescribing a Greener Future: Evaluating the Sustainable Revolution in Pharmacy Packaging
TL;DR:
Medications present a sizable global waste problem due to the production, packaging, and dispensing of medications to patients.
Several companies seek to resolve this waste issue, including new means of packaging and dispensing medications, such as cardboard and glass-based pill bottles.
Issues will be how to integrate these changes into the current pharmacy workflow and drug-supply chain.
In 2019, nearly 3.8 billion prescriptions were processed in the United States. It is likely at least half that much is being thrown away as plastic pill bottles by patients. Considering that Americans also purchase a large amount of OTC and supplemental health products and that most of the medications shipped to pharmacies to dispense come in bottles, we can probably agree there's a sizable amount of medication waste being used and thrown away. Taking this on a global scale, and it's a sheer deluge.
As the world becomes more concerned about carbon emissions and waste, a growing concern is building regarding the potential of health-related waste and mechanisms to reduce the carbon footprint of medications. This can span multiple issues, such as waste generated from the production of medications, the packaging of medications, and leftover dispensed products. In the end, this is a problem that the pharmaceutical industry, medical device companies, and those in the pharmacy supply chain (including the pharmacy) will have to take on.
Looking at the history of packaging, it's not hard to see why some products today are prepared and packaged the way they are, which generally comes down to costs. However, how do we reduce such waste while maintaining the level of convenience and cost mechanics that are now default?
Now consider how these medications are packaged and dispensed:
Pill Bottles - Generally in an amber plastic bottle that varies by dram (size) to hold the suitable number of tablets/capsules based on size. Also, the general format for most OTC and supplements in a large quantity. The advantages are that they can help block light that may degrade the medication, prevent moisture accumulation, and help provide child safety measures.
Unit-Dose Packaging - Several formats exist here, such as those that come in individual foil-sealed packages common to some OTC products and those that are separately prepared by the pharmacy. Those include blister packaging (hot and cold) and strip packaging. These are predominately plastic and paper-based.
Inhalers - Primarily used for pulmonary conditions (COPD & Asthma), these come in multiple formats (MDI, DPI, mist) that, upon actuation, allow a patient to inhale a dose of treatment. These tend to use a plastic shell with medications kept internally via a metallic strip or in a pressurized container.
Injectables - Needles, syringes, pens, autoinjectors, these formats are commonly used for insulin products, vaccinations, and the growing biologic classes. As we see an increasing use of GLP-1A and related grow in use, these injectables will also rise in prominence.
Other - Aside from the above, we have topicals (ointments, creams), patches, suppositories, and others that come in varying materials.
One last item that should be addressed is the other accouterments that accompany medications. As we see the rise of mail-order production, shipping materials also become an issue. This includes boxes, internal packaging, and cold-chain materials (e.g., ice packs and related). Lastly, instructional materials are another commonly included item, such as instructions for use (IFU) and medication guides for patients on how to use their medication and what to keep an eye out for. For many of you, this can be regarded as the information often attached to your bag of medication (that, more often than not, gets thrown out).
So, at this point, with all of this material that has entered the environment, how do we handle it? What do we do with all of this plastic, paper, and related material? Can we make it sustainable, cut waste, or help reuse or recycle it?
Lately, I think there has been a growing concern related to this topic. I've seen some push from pharma and health-related startups trying to address this, so I thought it'd be nice to do a recap on current advancements I am seeing, which I'll discuss here.
How do we reduce pill bottle waste?
Let's start with the beloved amber vial. Introduced in the 1950s post-WWII with the advancement in plastic development, the amber vial has many positive facets surrounding it. It helps prevent light from getting to the tablets/capsules, reduces moisture, and has child protection features (required by default due to the Poison Prevention Packaging Act of 1970).
Originally, pill containers were paper-based and came in a circular cardboard pack that was placed together or just a cardboard box that a label is written upon, such as what's seen in Its a Wonderful Life (see the scene). These were often then tossed or burned. In addition, glass bottles were also used and evolved during the 1800s-1900s but fell out of favor due to the cost of production and issues (e.g., breakage and weight of transport) compared to plastic. By the mid-1970s, glass packaging would widely be phased out in favor of plastic bottles, which most Americans are familiar with getting their medications from the pharmacy.
Taking into consideration that most medications are oral format, these pill bottles likely make up the largest pharmacy-related waste out there. Looking into it, I was curious about what tactics exist to help reduce this waste.
The first obvious question is, why not just recycle? The answer is complicated, I am realizing. It appears that the traditional orange plastic used won't be recycled easily if you are just putting it with your other recyclable material by the curb on trash day. Instead, it would have to go to a specific center to be recycled. And, based on my personal experience and talking with colleagues, all those plastic bottles that our drugs come in to be dispensed in the pharmacy from our wholesalers ends up on the general trash as well. So recycling is theoretically possible, but the feasibility or enforcement level is lacking, I'd say.
Ok, how about ditching the pill bottle in favor of something else? Are there alternatives? Interestingly, I've come across several startups trying to address this, including:
Parcel Health - Led by pharmacy student innovators now turned entrepreneurs, this company has created cardboard boxes that can be used in place of a pill bottle to package and dispense medications.
Cabinet Health - Instead of using plastic or paper, this company has gone back to glass. Patients get their medications stored in a glass bottle that they can refill and use .
Interestingly, I came across some other pitches for recyclable cardboard pill boxes, such as this one from Tikkun Olam Makers, or a metal pill bottle from the pharmacy that could be reused multiple times. In addition, there seems to be a push to help make pill bottles from recycled plastic.
Personally, I have several thoughts on the hurdles trying to get rid of the plastic pill bottle will come across, including:
Scalability Issues: As the majority of large pharmacy businesses are aiming to engage upon central distribution centers to fullfill chronic medication filling and support for local pharmacies, a focus on automation to conduct such business will be a focus. However, most of that automation are meant for pill bottles, and that will likely be a barrier for acceptance over time.
Mail Order: Plastic survives the USPS. Can cardboard and glass do the same, without adding on more packaging to keep them safe and then negating the whole mission? This will become a greater issue over time I think that will be considered.
Workflow Speed: Similar to the automation level, but prepping any new mechanism to package medications should be simple. Looking at how long it took us to get from using a typewriter to write a label and then affixing it to a bottle with a self-adhesive label from a printer, I think any step back is going to be a barrier. I still hate prepping those Target pill bottles from the pre-CVS acquisition. They were a pain and really limited how fast you could get medications ready.
Despite these concerns, I do hope that something gets done to reevaluate our reliance on current pill bottle formats. Do we return to what we did 100 years ago with cardboard? Do we help reduce the waste and better recycle? Is there another way forward? I hope we figure something out, as this area is ripe for change I think. The only advice I'd give is to consider how pharamceutical products will be dispensed to patients in the next decade to have a firm business case.
How about other Pharmaceutical Products?
Aside from the iconic pill bottle, we face the issue of other packaged pharmaceuticals. Many of these come in plastic formats as well, which aid in containing and aiding the delivery of the medication through a specific route (e.g., SubQ, IM, inhaled).
Looking through current media, it is difficult to say if there is any specific company targetting this field, though there seems to be attention across the industry to help reduce related waste. This waste will accumulate due to the rising role of self-injectable biologics (syringes, autoinjectors) and the current insulin market. Some innovations to tackle these issues that stood out to me include:
Reusable Autoinjectors - Some medical device companies are attempting to create autoinjectors with refillable cartridges that can be used multiple times. This would help cut down some of the waste without throwing out the whole injector system.
Reducing Carbon Emission - Autoinjectors with zero emission for production are coming to fruition, which may spur some pharma companies to engage with, aiming to reduce waste.
Takeback Programs - Eli Lilly, Sanofi, and Novo Nordisk are launching programs to help reduce waste by offering programs that can take back insulin pens and devices. Other programs are being launched around the world as well, though how large or central of an attempt to do this will vary.
Cardboard Inhalers - Some are looking into redoing the inhaler similar to the pill bottle by creating single-use inhalers that can be tossed out after use. This may have some role in some markets or products but will likely be difficult.
Overall, I would say this side of the pharmaceutical market is ripe for advancement, and I expect more focus to develop over time. Especially if we see a rise in connected or smart drugs and sensors, such as the CGM space that will tie into insulin use. In addition, as the GLP-1A market grows, I anticipate that concerns related to device waste will become a topic of concern.
Can we reduce ancillary pharmacy waste?
The last hurdle, aside from the pharmaceutical production of medications (a whole other conversation), is the ancillary waste associated with dispensing medications. Take, for instance, the years-long running joke of how long a CVS receipt is and the associated waste it brings. Now, with digital coupons, it has been somewhat relieved through virtual mechanics, but it's an example of the problem we face.
Other issues include package handouts, bags, and patient education guides that come with medications. Can we just go digital with them or offer a digital version for patients to cut down on the physical waste?
The mailing of medications and packaging is also an issue, with many coming in boxes and cold-supply devices (e.g., foam, ice packs) to help preserve some medications during shipment. Could alternative delivery services cut down on the waste associated with traditional delivery mechanics (e.g., drones)?
Overall, this will be an area I think will adjust as we see the pharmacy business advance with how patients get their medications. If mail order grows over time, then I anticipate more focus. Other issues will be regulatory-related, such as rethinking patient medication guides or handouts.
Conclusion
Overcoming the waste associated with the preparation and dispensing of medications will be a burden that will take many different interventions to overcome. This will include from the start of medication creation to the final dispensing to patients. Key stakeholders will come from pharma, regulators, med device companies, and the pharmacy itself to innovate and solve these problems while preventing any disruption to current patient expectations of receiving and using their medications.