Researchers led by Neele Puhlmann and Oliver Olsson of the Institute of Sustainable Chemistry at Leuphana University of Lüneburg, together with colleagues from the Ecologic Institute in Berlin, the Dutch National Institute for Public Health and the Environment (RIVM), and the University of Helsinki, set out to gauge how prepared Europe’s healthcare sector is to embrace so-called “greener” active pharmaceutical ingredients, or APIs. These are drug molecules deliberately designed at the molecular level to combine therapeutic efficacy with inherently lower environmental risk — for instance, by degrading more readily after excretion or by binding less persistently in sediments. The work, published in BMC Health Services Research, forms part of the wider PREMIER initiative, a public-private project funded through the Innovative Medicines Initiative that examines the environmental and health impacts of medicines across their life cycle.

The team conducted semi-structured interviews with 16 healthcare professionals working across Europe between February and April 2024. The deliberately diverse group included three doctors, three pharmacists, three procurement experts, and specialists in reimbursement, market authorisation, healthcare provision and industry sustainability reporting, as well as one professional from an environmental non-governmental organisation. This breadth was central to the study’s design: pharmaceuticals pass through many hands before reaching a patient, and each actor along that chain — from the regulator who approves a drug to the hospital manager who signs a purchasing contract — holds some influence over which molecules ultimately enter the environment. The researchers analysed the transcripts using qualitative content analysis, a systematic method for identifying recurring themes, opportunities and obstacles within unstructured interview data.

The central message emerging from the interviews was one of cautious but genuine enthusiasm. According to the study, there is clear interest among healthcare professionals in minimising the environmental impacts of the medicines they prescribe and purchase. Crucially, this is not merely an abstract sentiment. Some practical strategies already exist, the interviewees noted, such as incorporating environmental criteria into the public tenders issued by procurement agencies. In several European healthcare systems, hospitals and regional authorities purchase medicines through competitive tendering, and adding environmental specifications to those tenders is one of the few immediate levers available without new legislation. The participants expected that environmental properties of APIs will play a more significant role in healthcare decision-making in the future, moving from a niche concern to a standard consideration alongside efficacy, safety and cost.

Yet the study also makes clear that good intentions collide with hard practical constraints. The most frequently voiced obstacle was a lack of reliable scientific data. Healthcare professionals cannot weigh the environmental footprint of one drug against another if manufacturers do not disclose ecotoxicity profiles, persistence and bioaccumulation data in a comparable, accessible form. The interviewees said that access to robust evidence on the environmental impacts of APIs is a prerequisite for any systematic consideration of greenness in prescribing or purchasing decisions. Without such data, environmental criteria risk remaining vague aspirations rather than measurable benchmarks.

A second, equally fundamental barrier is conceptual: how does one balance a molecule’s benefits and risks for patients against its properties in the environment? The researchers found that interviewees considered this balancing act inherently product-specific. A life-saving cancer therapy with few alternatives may justify a heavier environmental burden than, say, a widely prescribed medicine for which greener substitutes exist. This means that a simple “green score” for all pharmaceuticals is unlikely to be appropriate. Instead, the weighing of patient benefit against environmental risk must be embedded in structured, centralised frameworks — something individual prescribers and pharmacists cannot and should not do alone at the bedside or in the pharmacy.

That observation points to the study’s most consequential finding: the marketing authorisation process is viewed as the main intervention point in the pharmaceutical life cycle for strengthening environmental risk considerations. Every medicine sold in Europe must pass through regulatory assessment before it reaches the market, making this the single checkpoint where all stakeholders converge. The interviewees called for legislative and regulatory frameworks, and practical guidance documents, to ensure that environmental properties are assessed and weighed in a centralised and harmonised manner across Europe. A patchwork of national rules, they suggested, would fragment the market and dilute incentives for manufacturers to invest in greener molecular design. The timing is notable, as the European Union’s pharmaceutical legislation is currently undergoing its most substantial revision in two decades, and environmental considerations have featured prominently in the debate.

The authors also identified a plausible pathway from awareness to action. The evident interest among healthcare professionals, they conclude, may stimulate data sharing by pharmaceutical companies in the short term. If procurement agencies, hospital pharmacies and prescribers begin explicitly requesting environmental information, manufacturers will face commercial pressure to publish it. In the long term, this demand signal could cascade upstream into research and development, encouraging medicinal chemists to design APIs that retain their clinical potency while breaking down more readily in wastewater treatment plants or natural waters. This is the essence of sustainable chemistry thinking, championed in the study by co-author Klaus Kümmerer: environmental benignity should be an intrinsic design property of a molecule, not an afterthought remediated at the end of the pipe.

The technical challenges involved should not be understated. Designing a greener API requires balancing multiple molecular properties that often pull in opposite directions. A compound must be stable enough to survive storage, gastric acid and plasma circulation, yet labile enough to degrade once excreted. It must be potent at low doses, which reduces the mass released into the environment, but selective enough to avoid harming non-target organisms. Degradation products themselves must be benign, since transformation in the environment does not guarantee detoxification. Quantitative frameworks for evaluating such trade-offs — combining predictive toxicology, biodegradability screening and environmental fate modelling with traditional pharmacological assessment — are still maturing, which is precisely why the study’s participants emphasised the need for shared evidence and harmonised guidance.

The study’s methodology has clear boundaries that the authors themselves acknowledge. Sixteen interviews cannot capture the full diversity of European healthcare systems, and qualitative content analysis identifies themes rather than measuring their statistical prevalence. The participants were also, by definition, professionals interested enough in the topic to discuss it, which may inflate the apparent enthusiasm. Nevertheless, the qualitative approach is well suited to mapping the decision landscape: it reveals how actors reason, where they feel empowered or blocked, and which interventions they consider legitimate. The authors explicitly conclude that future research should target the barriers identified and their potential solutions, translating the expressed willingness into concrete instruments — validated environmental criteria for tenders, standardised data formats from industry, and regulatory guidance for market authorisation.

What makes the study resonate beyond academic circles is its reframing of responsibility. Pharmaceutical pollution has often been portrayed as a problem of individual behaviour — patients flushing unused medicines — or of inadequate wastewater technology. This research shifts the focus to the professionals and institutions that decide which medicines enter the market and the clinic. Doctors, pharmacists, procurement officers and regulators collectively wield enormous leverage, and the study suggests they are prepared to use it. The transition to greener APIs will ultimately be won or lost in the chemistry itself, but the demand side, this research shows, is no longer waiting passively. If Europe’s regulatory reform aligns with the appetite its healthcare professionals have expressed, the next generation of medicines may be designed not only to heal patients, but to spare the environment that receives them.

The study focuses on Drug and Therapeutics Committees, or DTCs, multidisciplinary groups typically made up of physicians, pharmacists, nurses and healthcare administrators. Their traditional role is to promote the “rational use” of medicines: giving patients drugs appropriate to their medical needs, at individually suitable doses, for long enough to work, and at the lowest reasonable cost. In Sweden, every one of the country’s 21 regions is required to have at least one such committee. These bodies develop formularies, advise policymakers and clinicians, analyze prescribing data and organize professional education across hospitals and primary-care centers. The new analysis argues that rational prescribing must now include a further consideration: the connection between human health, animals, plants and the shared environment.

That connection is increasingly difficult to ignore. Many active pharmaceutical ingredients are biologically potent by design, and some remain chemically stable after excretion. Conventional wastewater treatment can remove a proportion of these compounds, but not all of them. Residues may therefore reach aquatic ecosystems at concentrations capable of affecting sensitive organisms, particularly when exposure is continuous. Diclofenac, a widely used nonsteroidal anti-inflammatory drug, has become an emblematic example. The drug caused catastrophic declines in vulture populations in South Asia when birds fed on the carcasses of treated livestock and developed fatal kidney failure. Laboratory and field studies have also linked diclofenac exposure to damage in fish tissues, including the liver, kidneys and gills. Swedish authorities classify diclofenac and ciprofloxacin as river-basin-specific pollutants, while several hormones, including estradiol and ethinylestradiol, are also recognized as water contaminants.

The second environmental threat examined in the study comes from fluoroquinolone antibiotics, particularly ciprofloxacin and norfloxacin. These drugs can be persistent in aquatic environments and may exert antibacterial effects far below the concentrations used to treat patients. That matters because low-level antibiotic exposure can create evolutionary pressure favoring resistant bacteria. In effect, wastewater containing pharmaceutical residues may act as a diffuse training ground for microbes, selecting genetic variants able to survive future treatments. Fluoroquinolones also carry important clinical warnings. European regulators have restricted their use because of potentially disabling and long-lasting effects involving connective tissue, including tendon damage and increased risks associated with aortic complications. Unlike diclofenac, however, ciprofloxacin remains essential for some serious infections, including certain upper urinary-tract infections accompanied by fever. The goal is therefore not simple elimination, but precise, evidence-based use.

Researchers conducted an observational case study using official reports, regional and national agency websites, educational materials, communications, presentations and other documents published between 1988 and 2024. They reconstructed how the two DTCs developed environmental policies and compared those activities with sales data for diclofenac, ciprofloxacin and norfloxacin. Prescription and over-the-counter sales were obtained from the Swedish eHealth Agency and converted into kilograms of active substance per year. For systemic diclofenac, the analysis included tablets and capsules; topical products such as gels were assessed separately. Fluoroquinolone calculations covered the two products that were available in Sweden during the period. Measuring mass rather than simply counting prescriptions provides a closer approximation of the amount of pharmaceutical material entering the environment, although it still does not reveal how much was actually consumed or improperly discarded.

Gävleborg began considering the environmental consequences of medicines after a regional political decision in 2002. Over time, the policy became embedded in the region’s formulary, the list of medicines recommended to prescribers. Since 2019, the formulary has included environmental information for every listed drug when such information is available, and medicines with lower environmental impact may be favored when effectiveness, safety and cost-effectiveness are otherwise comparable. The guidance also identifies situations in which non-drug approaches could replace medication. Diclofenac received an explicit “anti-recommendation” in 2018, reflecting both its cardiovascular risks and its ecological effects. The committee also monitored prescribing by individual healthcare centers and hospital clinics, returned the results to clinicians and managers, and used comparisons between providers to encourage improvement.

Västernorrland took a similarly broad approach, beginning environmental work when its DTC was formed in 1997 and creating a dedicated “Pharmaceuticals and Environment” task force in 2021. Its measures included encouraging smaller starter packs for long-term therapies, reassessing treatments when benefits no longer outweighed risks, conducting medication reviews for older patients and promoting the return of unused medicines to pharmacies rather than flushing them into wastewater or placing them in household waste. The regional formulary emphasizes non-pharmacological alternatives such as cognitive behavioral therapy for some mental-health conditions and physiotherapy for some forms of pain. Environmental requirements have also been incorporated into medicine procurement, and the committee works with pharmacies, water and wastewater organizations and healthcare payers. Environmental representatives at healthcare providers receive specialized training, supported by a digital education course.

The prescribing data reveal substantial changes over the 25-year period. Systemic diclofenac sales rose during the first two decades and reached approximately 127 kilograms in Gävleborg and 137 kilograms in Västernorrland in 2011. They then declined rapidly. Over-the-counter systemic sales remained near 20 kilograms per year until 2020, when oral diclofenac was reclassified as prescription-only in Sweden because of cardiovascular concerns. The change did not produce a marked compensatory surge in topical diclofenac sales in either region. Topical products, introduced in 2005, increased for several years, particularly through over-the-counter channels, but their use also began to fall after 2016. The researchers caution that the trends cannot be attributed to the DTCs alone: national regulation, professional campaigns and changes in public awareness also influenced prescribing.

Fluoroquinolone use followed a different trajectory. In 2000, roughly 37 to 50 kilograms each of ciprofloxacin and norfloxacin were sold in each region. Norfloxacin use declined steadily until the product was removed from the Swedish market in 2020. Ciprofloxacin use initially increased as norfloxacin declined, then began falling after 2012, with an especially low level during the COVID-19 pandemic. Gävleborg introduced a fluoroquinolone prescribing target in 2003, while Västernorrland followed in 2005. The latter eventually specified that no more than 10 percent of urinary-tract-infection antibiotic prescriptions for women in primary care should be fluoroquinolones. Gävleborg set a target of fewer than five defined daily doses per 1,000 listed patients per day in primary care. These targets do not prohibit clinically justified treatment; they are intended to make unnecessary prescribing visible and reduce it.

The researchers say the Swedish experience offers a template for healthcare systems facing the same dilemma: how to preserve access to effective medicines while limiting their unintended ecological consequences. The approach begins with a technical challenge that remains unresolved—environmental information is missing for many active pharmaceutical ingredients. Reliable data on persistence, toxicity, bioaccumulation and effects on aquatic species are needed before committees can compare drugs meaningfully, and information about pollution from manufacturing is often absent even when risks from use have been assessed. Better environmental data could allow regulators and DTCs to distinguish drugs that are readily degraded from those that persist, accumulate or disrupt biological processes. Upstream decisions are especially important because wastewater treatment improvements, although necessary, cannot fully compensate for excessive or inappropriate use. The study does not prove that regional policies caused every observed decline, and sales do not equal consumption: medicines may remain unused in homes or be discarded incorrectly. Even so, it demonstrates how environmental stewardship can become part of everyday clinical decision-making, turning a prescription from a purely medical transaction into a One Health decision with consequences beyond the patient.