Exploring Sustainable Pharmacy Practices

Automatically transcribed

Aaron Hill: Welcome to the Real Research Podcast. I'm Aaron Milad Hill, and I'll be your host for this episode. In the virtual studio with me, today's practicing pharmacist scholar, environmental warrior, economic sage, PhD candidate, and all around good guy Milad Sadreghaemy.

Milad is a pharmacist by trade and PhD, candidate at Ure University in the Netherlands. Together with his research team at URE University, Milot is studying the fascinating intersection between healthcare, environmental sustainability, and economically sound production methods for pharmaceuticals.

Milad, welcome to the show.

Milad Sadreghaemy: Thank you for having me on the podcast.

Aaron Hill: we appreciate you taking the time.

Milad Sadreghaemy: conversation.

Aaron Hill: Ah, we're glad to have you on here. So Mila, tell me a little bit about your background. How did you become a pharmacist and what are you doing now?

Milad Sadreghaemy: Yeah, I started pharmacy, education in 2013 and graduated in 2020 during the COVID, lockdown, I. in, different public pharmacies, near Amsterdam. at the same time I started, doing research within Sustainable medicine utilization. I do this, research together with three dedicated researchers, professor Wan Berts, Dr.

Rob Herding and Dr. Lawrence Bloom. our research focuses on sustainable drug use. As well as, environmentally sustainable, and cost effective, production methods of medicines.

Aaron Hill: so you started out as a pharmacist. what got you into the environmental production side of things?

Milad Sadreghaemy: Yeah, it started when I was, still a pharmacy student. I worked, in a public pharmacy, within the town that I live. and I worked there weekends. I saw every day that patients came. With a full of unused medicine to the pharmacy for proper disposal. we had a special barrel in our pharmacy, and that barrel was about a hundred liters, I think it's about 30 gallons. we put those unused medicines, in that barrel. from time to time. Special chemical company came and collected these barrels, and incinerated those medicines. every two weeks we had to replace that barrel with an empty one. that was, huge numbers of unused medicines that patients brought back to the pharmacy I ask the patients, that switch to another, medicine due to side effects, what they do with their medicines that, are left over and they say, sometimes we bring them back to pharmacy for disposal, but sometimes we throw 'em away, with household waste or we even flush them into the sewage and. that was quite interesting. But also, um, yeah, quite shocking because flushing medicine into sewage can, causes serious health problems. For example, if you flush antibiotics into sewage. They can affect the bacterial metabolism and eventually cause antibiotic resistance.

And then on the long term, they can make the effectiveness of our current antibiotics much less so. I was quite fascinated with this, things that I saw in the pharmacy and I started to research this, for myself. I couldn't find a clear picture of the magnitude of pharmaceutical waste, within the Netherlands and also globally,

I found two interesting articles, that I want to share with you. One article was from the DEA, in 2016, they reported that they collected about. 700,000 pounds of unused medicine. And another article that I read was the, unused medicine, that Economical damage that. the used medicine to, the economy is about $5 billion each year. Only in us.

It's, it was for me, quite shocking to read those articles and what I saw that kept me busy.

So I decided, That not only as a pharmacist, but also as a researcher, that I wanted to do something about this. I wanted to, contribute and make a solution for this problem. So I decided to join this wonderful research group that I'm currently, involved with.

Aaron Hill: Oh, that's great. Yeah, I know in the United States, one of the problems that we have is that, you know, we always hear the messages about, getting rid of opioids and, clearing out your cabinet and making sure that they're not available for your children or whatever. Right. but the programs differ city to city, state to state. And so what's legal in one state may be not legal in another state. and so I think a lot of times there's just a lot of confusion about what to do. I would bet anyway, that a very small fraction of the prescription drugs make it back to any sort of, responsible, waste disposal type.

Milad Sadreghaemy: Exactly, If another example is, chemotherapy medicine, that if they come into the environment, they can affect, metabolism of animals as well. And they can also accumulate throughout the food chain. And on the long term, they potentially can have, negative influence on pregnant women and children.

So this, uh. With, with all kind of different, medicine group, they can cause specific problem, not only for the environment, but also for the human health in the long term.

Aaron Hill: Mm-hmm.

Milad Sadreghaemy: So I think that's also one of the reasons that fascinated me and I wanted to do something about it.

Aaron Hill: That was awesome. so you, recognize this need and you did some research and there's not a lot of academic research out there on the topic. so what came next for you?

Milad Sadreghaemy: Yeah. I joined, this research group and, we wanted to explore the amount of value that patient gave to the environmental impact of their medicine. And a specific method, a good method to use is, To use conjoint analysis because we can match attribute to another attributes of medicine.

So, we can, relate this, to other, important things like the environmentally sustainable daily habits. The knowledge of the patients about pharmaceutical waste and their effects and their environmentally responsible medicine use,

Aaron Hill: So you guys put together a questionnaire. So you asked questions about how they were using the medication, what types of behaviors they had with other environmental issues, and then you did a con analysis. To measure how they valued the pieces of the environmental picture.

Milad Sadreghaemy: Exactly. Yeah. We thought, if we want to. use conjoint analysis. Then Sawtooth has the strongest software. So we, applied for a grant and, we were very glad that, our grant was, accepted. we used Discover application for our research and we designed, A survey that existed from, five parts.

The part one was we wanted to know the patient, the environmental attitude within their daily lives. So we asked, for example, do you prefer to use, Products with plastic or not, or, how do you travel to your work or, do you purchase locally produced products that were environmentally, sustainable, the attitudes within the daily life that we wanted to know. And then we ask also, what is the reason that you choose for these. attitudes, within your life, are they environmentally, based, concerns, personal health concerns, cost? What is the reason? So we wanted to know the patients, and then the next step was

Aaron Hill: how did you analyze that data? did you do any sort of like key driver analysis or anything like that? Or is just looking at the descriptive?

Milad Sadreghaemy: we made that, as a questionnaire in Discover application.

Aaron Hill: Okay.

Milad Sadreghaemy: the second part was to. identified, environmentally responsible medicine use. So we ask patients, would you like to see, for example, a label that describe on your medicine, how can this medicine affect the environment when they are, for example, flushed through the sewage? Or would you return your leftover medicine to pharmacy? how do you do that in your daily life? A third part was the conjoint analysis. So we, made the patient choose eight times between two different medicine that have three different. Attribute with each two level. The first attribute was the medicine that is harmful or not harmful to the environment.

The second was easy or not easy to use, and the third attribute was the cost. Do you prefer a medicine that is 10 euros or five euros, cheap or expensive?

Aaron Hill: Mm-hmm.

Milad Sadreghaemy: And, the fourth part was how they see their, sustainable healthcare. are those patients, open for example, to use, quality assured return medicines that people. Have brought back to the pharmacy that is quality checked. is a good medicine.

Aaron Hill: Okay, so you're talking about recycling medicine. So taking medicine that somebody had been prescribed, but then perhaps had not used all of it. 'cause they switched to a different medication or course of treatment ended and they bring it back to a recycling center and they put that back into the medicine supply.

Milad Sadreghaemy: Exactly, but the difference is, that is quality checked. we discussed that previously about the Tylenol, incident in the US that is not the Tylenol incident. those are quality checked medicine that are sealed and, the temperature is checked.

Aaron Hill: that was my big question back when I was a kid, I remember, in elementary school, they handed out notices to all of us and there was a big scare because somebody had opened up capsule bottles of Tylenol and put cyanide in it, and several people had died.

and so it made everybody question the whole medicine delivery system. that's why in the United States, all of the medicines have. seals around the caps and, there are multiple seals on the bottles the boxes and the caps, to make sure that the medicine is safe.

the first thing I thought was, oh man, if somebody brings back medicine, how do you make sure that that's safe? So what you're suggesting is that it would go through a quality check to make sure that the medicine was safe and effective, and hadn't been stored improperly or whatever. Yeah.

Milad Sadreghaemy: Exactly, but safety is first within the healthcare. So the drug, the medicine that are brought back to the pharmacy must be saved or else, No one is allowed to use them. And the last part was the demographic characteristics. What is the gender?

What is the age, et cetera, of the patients. we centered these, questions to, a nationwide panel in the Netherlands. 25,000 patients, received this questionnaire, and we had about 6,000 responses. Okay?

Aaron Hill: Okay, so how did you choose which respondents to send it to? I mean, did you pick a specific profile? How did you screen your respondents?

Milad Sadreghaemy: that is, a panel that is a special, the name of that panel is, pharmacy Monitoring Panel and they have 25,000 members. each time a researcher wants to investigate, some topic, they can contact this company, that panel, and they're allowed to, to send them questionnaire.

So the, these participants were members of a,

Aaron Hill: and they all, were people that had used pharmaceuticals.

Milad Sadreghaemy: Yes, these 25,000 members are all chronic medicine users that use one or more medicine longer than three months.

Aaron Hill: Okay. So regular users of prescription

Milad Sadreghaemy: Yes. And we receive. About 6,000, responses and after quality check, and performing, root likelihood from the Sawtooth, we, included 4,000, respondents within our survey and based on the responses on. Part three of our questionnaire. So based on the conjoint analysis responses, we performed latent class analysis to identify different groups based on latent class analysis, we identified four different groups, which we named, based on their preferences.

Aaron Hill: Okay.

Milad Sadreghaemy: the first group was the greatest group. we call that eco focus group that is about 56% of our population,

Aaron Hill: Mm-hmm.

Milad Sadreghaemy: and that eco focus group had the highest preference for environmentally friendly medicine. They, had the highest, Environmental sustainable, daily life attitude. and they had also the highest knowledge about the pharmaceutical pollution, pharmaceutical waste. The second largest, we called it cost focus group.

Aaron Hill: Mm-hmm.

Milad Sadreghaemy: And that was the 20% of our study population. And the, interestingly, they prefer. Mainly cost. they wanted the cheapest medicine.

Their concerns about, daily life cost based. Everything was cost within this group. that's fascinating.

Aaron Hill: And did you see that in their other answers as well?

Milad Sadreghaemy: that was so surprisingly they preferred at least the cheapest medicine and based on cost. interestingly, they had the least knowledge about the pharmaceutical waste and the effect of pharmaceutical waste. the third group that we identified was the indifferent group, and that was about 16% of our, study population. They had a mixed preference. they had not a high preference for, a, for a attribute. And they had balanced concerns about, environmental impacts and the answers that they gave, that's why we call them indifferent group.

Aaron Hill: Mm-hmm.

Milad Sadreghaemy: The last group, what I personally find most interestingly fascinating was, we called it the Eco Skeptical Group. And that is about 8% of our study population. what is fascinating, about this group is they didn't prefer an environmental friendly medicine at all. but at the same time, they had a very high, eco based lifestyle.

So they purchased at least, plastic, products. They purchased a lot of, locally produced, Products, and they traveled, very, environmentally sustainable to their work. that was more paradoxical thing that we saw. And, when we dig in into their answers, we saw that there is something like balanced, concern. About environment as well as personal health. So they preferred living environmental sustainability during their daily life and the choices that they make within the life. But the healthcare and personal. health concerns, are high within their choices.

And they don't prefer environmental friendly medicine at all.

Aaron Hill: Mm-hmm.

Milad Sadreghaemy: And well, if we dig further, we cannot explain this more because that's one limitation of Our survey that, yeah, we had a limited amount of questions,

Aaron Hill: Yeah. I think there is some research out there with environmental causes, a lot of times people will do some e even though they know that they should be doing A, B, C, D, and E, they'll do A, B, and C feel good enough about what they're doing and then not do d and e, right?

So if I'm recycling my plastic bottles and I'm driving a hybrid car, then I don't feel as guilty. taking my flight to my luxury travel destination and using the throwaway shampoo bottles at the hotel. Right? so maybe that's something that's playing in where it's like, Hey, I'm making my ecologically sound choices in these other areas, and I'm not going to consider it for healthcare because I want to focus on other things.

Milad Sadreghaemy: Exactly, and maybe what I was thinking about lastly, it has something to do with a sense of stewardship. we didn't ask about, religious beliefs of the participants. But maybe If you're a religious person, you have a sense of responsibility for the environment you live.

But the healthcare medicine is something that is further from your view and from your daily life. So maybe it's something. with sense of stewardship. something that I was, lastly think about,

Aaron Hill: Yeah. It's all interesting questions.

Milad Sadreghaemy: That's,

Aaron Hill: one of the things you measured putting information or making people aware of the environmental impact of the medicines they take?

Milad Sadreghaemy: mm-hmm.

Aaron Hill: Would there be a concern that if you put that information on and you've shown that it changes people's behavior, that people might not take medicines they should be taking because of their environmental issue?

Milad Sadreghaemy: That's a very good question. one of the things that we discussed based on the result of this When we see those different groups, they have all different concerns and different views of medicine and environmental sustainability, they have also different, style within their daily lives.

So if we want to educate a large group of people, we have to. Make some kind of tailored approach preferences, based on their lifestyles, based on their concerns. For example, the cost focus group that a cost concern. If we want to educate these people and make them more aware about pharmaceutical pollution. We have to approach them, with a cost based education. If we want to approach the eco focus group, we have to environmental based, approach or eco skeptical. We to approach them with personal maybe that, explanation about antibiotics is more tailored, for the eco skeptical group because they have a lot of, concerns about personal health. So that's a very good question, and I think, if we want to educate them, we have to tailor a different approach There is no one size fits all for pharmaceutical waste education.

Aaron Hill: Yeah. Yeah, and I think that's one of the interesting things about your research is that I've seen over the years, a lot of studies where people have done environmental projects looking at how much value people put on green space and things like that. And a lot of the studies tend to be kind of one dimensional where it's like, we just want to justify, these environmental changes that we wanna make.

Yours is interesting though, because you're looking at it from multiple perspectives. So you're a pharmacist, you want to help people improve their health quality. Right. So you're looking at it from a health perspective. How do I get people to take drugs that are better for them, better for the environment, better for us all in the long run, but also, how do I make it cheaper for people to get drugs?

And I think that's a fascinating aspect of your research the economic impact, you gave a number earlier, that $5 billion worth of drugs a year. In one estimate in the United States alone, you know that's $5 billion that we could drop prescription prices by if we recycled stuff.

Milad Sadreghaemy: Absolutely. all those, spillage, the cost spillage that now focusing on cost spillage. You can help a lot of people. You can reduce the cost, within the healthcare system or, reduce the Medicaid cost. Not only you throw Valuable resources, valuable medicine. Away you throw valuable money away. that's how I see.

Aaron Hill: Yeah. Yeah. So tell me what's next? what's up next for your research team? what's the next steps in your quest to, save the world and to reduce our drug prices?

Milad Sadreghaemy: the next step is, we have started, a research recently about the production methods, of syringes that are used within the, intensive care units. we look to. Different methods that these syringes are made. when you have a medicine that is resistant to heat, you can produce that syringe, with two different techniques.

One is, you can produce it by sterilization. you can compound it and sterilize it, within, pressure cooker or auto claf. Uh, and another method is that you can produce it, uh, we call it septically. within a highly clean area, the highly, clean room and. You are compounding this syringe, very cleanly.

Aaron Hill: Mm-hmm.

Milad Sadreghaemy: And the question is, which method is the most environmentally sustainable as well as cost effective? Because they have both their benefits and they have both their drawbacks that, we have to look at and then we can say, well, this method is, the cleanest method as well as cost effective Or maybe we can look further around tailoring these methods. Making different methods to, make those syringes more cleanly. So that's a project that we have started, recently. we work, with different parties. so we work, with, university Medical Center, and also with a compounding pharmacy that is connected with us. Uh, yeah. maybe it is, interesting for the listeners, the findings of research that we have done recently and published a year ago. it is about the antibiotic use, specifically amoxicillin use. amoxicillin is a widely used antibiotic, that, children can use in liquid form, the problem with that is the dosage for every child is based on the weight of that child, and the duration of the therapy is indicated. every child uses another amount, another dosage. So if, you have a child that has a certain amount of weight, it has a different dosage than his brother or sister that has other weight.

And the problem with that is that the manufacturers of amoxicillin. Liquid produce that product with a certain amount, of, volume. So we have in the Netherlands only a volume of a hundred milliliter. I dunno what is in the us but that's.

Aaron Hill: Actually, it's, it's. One of the weird things where we actually use milliliters, so Yeah,

Milad Sadreghaemy: Oh, wow, I didn't know that.

Aaron Hill: yeah. We don't use metric except for weird one off, things like that.

Milad Sadreghaemy: Well, interestingly, that's why I look for the barrel, the a hundred liter gallon, the 30 gallon.

Aaron Hill: yeah.

Milad Sadreghaemy: use milliliter.

Aaron Hill: Yeah.

Milad Sadreghaemy: the manufacturers produce only bottle size of a hundred milliliter in the Netherlands. Maybe it is the same in the us. So every time that a child,

start with an antibiotic and finish it. There is always something left over and we wanted to invest become leftover? We calculated this for 62,000 children that use as one or more, time. Amoxicillin during three years, and we found that average, 27% of each time that a child use amoxicillin, 27% of that amount becomes leftover, is not used.

It's thrown away

Aaron Hill: Yeah. So that's if they took the dose as prescribed all the way through. They'd still waste 27% or they'd, they'd take it longer than they were supposed to or misuse it in other ways. Yeah.

Milad Sadreghaemy: And we calculated how much pure amoxicillin, pure, uh, raw material. That is about 600 kilogram each year. is wasted. That is not used that is worth about half millions of euros every year.

Aaron Hill: That's a

Milad Sadreghaemy: It's ridiculous

Aaron Hill: And where does that all go?

Milad Sadreghaemy: whether they, yeah, I think, that's the answer that patient gave me sometimes. They bring it back to the pharmacy and sometimes they throw it away in household waste or flush it into the sewage.

Aaron Hill: Mm-hmm.

Milad Sadreghaemy: And then we have, at long term, the bacterial residency problem.

Aaron Hill: Mm-hmm.

Milad Sadreghaemy: Our antibiotics doesn't work properly because of that.

That's something that, I want in the future, to go to the future perspective of this research. I would like to contribute to. Less pharmaceutical wastage so that we have less environmental effects of pharmaceutical waste and also make medicine cheaper by reducing the wastage of leftover drug that's something that, I would like to contribute. To it. Uh, and that's why I also joined this research group.

Aaron Hill: Oh, that's great. So what happens next with this research project? So you did the research, is it being published? how are you using it to move the,

Milad Sadreghaemy: we would like to publish this, we have not submitted yet. I hope that I can submit it, next week. We have also, invited to, present this at a convention in Sweden, Euro Dark Convention that's in Sala Sweden.

I have the honor to present this research to greater audience. I really look forward to it.

Aaron Hill: Oh, that's great. I hope it gets a great reception. So if people are interested in talking to you about this subject or. Following your research, how do they get ahold of you? how can they track what you're working on?

Milad Sadreghaemy: I have a, page on URAC University that I. not yet, finished I would like to make that page the results of our research group, and projects are we involved, with make a webpage within the URAC University, website.

If people are interested, they can read our work,

Aaron Hill: Okay. Well great. Thank you so much for taking the time. Any last thoughts?

Milad Sadreghaemy: Yeah. for me I also believe that, it is important, to Not only Clean but affordable drug production and make them locally. we have a huge amount of drug shortages in the Netherlands, and I think we're, if we force to switch to produce, medicines locally more clean and more affordable, we can help to reduce this drug shortage problem. I dunno how that is in the us but that's a huge problem in the Netherlands.

And together with that, sustainability means also creating a resilient and reliable, drug supply. And I hope my work can contribute this, in the future.

Aaron Hill: That's great. Well, we wish you the best of, success with your research and with your, doctoral program.

Milad Sadreghaemy: Thank you so much.

Aaron Hill: thank you so much for sharing your research with us and taking the time to meet with us today. I wanted to talk just a second about the grant program.

If you are a student working on a PhD or a master's program and you want to do, a conjoint analysis or use any of the tools that Sawtooth software has available, you can apply for the grant program. the grant program will give you free licenses to the software to use for research projects.

For more on that, you can go up to the sawtooth software website, www.sawtooth.com, and, look for the grant program and, apply up there. And with that, thank you so much again for coming on the show. Thank you listeners for, listening in and, taking the time to, listen to our story today.