The more things change, the more they stay the same

The German-born American physician and writer Martin Fisher, famous in his day for his aphorisms, is credited with saying half of the modern drugs could well be thrown out of the window, except that the birds might eat them. It sounds like he was an environmentalist physician well ahead of his time.

It is surprising how little we physicians sometimes know about the medications we prescribe, even those prescribed routinely. It is also surprising that even when we know about the substantial harms of medications, whether to our patients or the environment (thereby contributing to climate breakdown), we continue to prescribe them. Drugs, climate breakdown, and changing physician behaviour; these are the interwoven themes of this month’s issue of Canadian Family Physician.

One of the first research studies I conducted with my colleagues in the Department of Family and Community Medicine at the University of Toronto in Ontario almost 25 years ago was a randomized controlled trial of education and individualized feedback to family physicians aimed at helping reduce benzodiazepine prescribing to elderly patients.¹ Even back then, the harms to older patients (eg, cognitive impairment, increased risk of falls) were well known.

At the time, our intervention was innovative in giving family physicians direct visual feedback on prescribing behaviour compared with what we considered optimal. We had a minimal impact, likely in part because only the better prescribers consented to participate in the study. Sadly, a study from the United States using National Ambulatory Medical Care Survey data from 2003 to 2019 that was published just before the pandemic revealed outpatient prescribing and use of benzodiazepines increased substantially over the past 2 decades,² as have harms.

In their own innovative research article, “Journey of a pill” (page 263), Harjas Kaur and colleagues from McMaster University in Hamilton, Ont, highlight another set of problems with a commonly prescribed benzodiazepine—how the surprisingly many steps in their manufacture, distribution, and prescribing harm the planet and its inhabitants by contributing to global heating.³

The commentary, “The environmental elephant in the office: medications” (page 233), provides information and education about the environmental impacts of both prescription and over-the-counter medications in primary care. Authors Dr Emma McDermott and colleagues advocate for more sustainable prescribing on multiple fronts, including medication optimization, reviewing and discontinuing legacy medications, and deprescribing. They also show how these measures align with CanMEDS roles for experienced family physicians and those in training.⁴

Educating physicians about the various harms of prescribing behaviour and providing them with feedback in various forms, from the randomized controlled trial my colleagues and I carried out, to the research and commentary articles mentioned above, is crucial, but more may be needed to meaningfully change our behaviour than education and even feedback.

Over and above education, McDermott and colleagues offer tools for readers such as the Options for the Sustainable Prescriber guide⁵ that helps family physicians prescribe in ways that prevent adverse medication effects, reduce costs to patients, and decrease environmental harms associated with unnecessary medications.

But more will be needed than individual physician change to make a noticeable impact. Structural and systemic changes (eg, manufacturers discontinuing the production of harmful medications like hydrofluoroalkane metered-dose inhalers, or regulatory agencies withdrawing approval of such products) will likely be necessary, as well.

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