LAUSR

This paper reviews options for reducing harm from pharmaceuticals that are known to cause adverse impacts by their presence in the environment. It reviews recent global and EU policy development, which could go further in recognising and addressing the issue in a global context. It considers green chemistry, which can help clean up production processes, but holds only long-term promise for creating 'green' alternatives. It explores the potential of health promotion and disease prevention, which can contribute significantly to a reduction of the disease burden and thus the need for medicines, both for infectious and for non-communicable disease. Eco-directed sustainable prescribing practices are reviewed, which have been adopted successfully to reduce the use of harmful pharmaceuticals. We note recent developments in medicines optimisation and precision medicine, which hold promise for improving patient outcomes, saving costs and reducing pharmaceutical use, through individually tailored prescribing whereby the patient co-decides their therapy. Waste prevention through re-use or redistribution is beginning to find public support, whilst 'take-back' waste disposal schemes set up via extended producer responsibility systems have achieved high returns. Finally, the paper summarises preferred advanced wastewater technologies, including also innovative low-cost, low-energy options. In summary, whilst end-of-pipe options have a role to play, particularly for highly-concentrated wastewaters, solutions further up the medicinal chain and disease prevention interventions, informed by a broad view of health and health care, are needed in order to pursue a much greater potential reduction of pharmaceuticals in the environment than can be achieved by end-of-pipe solutions alone. This article is protected by copyright. All rights reserved. Environ Toxicol Chem 2023;00:0-0. © 2023 SETAC.