Review ArticleClinical Review

Reducing the environmental impact of medications and improving patient outcomes using the ECO-Rx framework

Ilona Hale, Samantha Green, Jessica Nowlan and Ivy Lam
Canadian Family Physician April 2026; 72 (4) 233-238; DOI: https://doi.org/10.46747/cfp.7204233

Abstract

Objective To raise awareness about the environmental impact of medications and provide practical opportunities to reduce this effect.

Sources of information The Planetary Health for Primary Care resource.

Main message Environmental harms and climate change are threats to human health, yet the health care system is responsible for 4.6% of greenhouse gas (GHG) pollution in Canada. Most of this pollution is generated upstream in the supply chain where products, including medications, are produced. In primary care, medications account for 61% of GHG pollution. Medications also have other impacts on the environment including contamination of air, water, and soil. The Evidence, Collaboration, Options, Review Rx (ECO-Rx) framework was designed to support appropriate use of medications through the following: Evidence—use high-quality evidence to guide diagnosis and treatment; collaboration—involve patients in all treatment decisions; options—always consider nonpharmacologic or more sustainable pharmacologic options; and review Rx—regularly review existing prescriptions and deprescribe appropriately.

Conclusion By applying these principles to an entire patient roster, 1 family physician can have a large environmental impact while also improving patient outcomes, minimizing costs for patients and the health care system, and reducing provider workload through fewer refill visits, less monitoring, and fewer complications.

Case description

Laura, a 34-year-old small business owner, presents to the clinic to refill her medications, which include 20 mg of fluoxetine (taken daily), 40 mg of rabeprazole (taken twice daily), a combination oral contraceptive, 50 mg of levothyroxine (taken daily), and a salbutamol metered-dose inhaler (MDI), which she uses before exercise. She is generally well, but is often stressed from the pressures of work and caring for her 2 young children.

Sources of information

This review is based on the authors’ experience developing the Planetary Health for Primary Care resource,1 which involved a pan-Canadian multidisciplinary working group of health care professionals and patient partners who reviewed and compiled existing literature on environmentally sustainable clinical practice. The Evidence, Collaboration, Options, Review Rx (ECO-Rx) framework was developed by reviewing existing appropriate prescribing frameworks and identifying common key elements relevant to environmentally sustainable prescribing.

Main message

Medications have a substantial environmental impact. There is growing awareness that environmental harms, including climate change, are threats to human health.2 Family physicians may be thinking about how to reduce their personal environmental footprint but may not be aware of the ways to reduce environmental impacts at work.

The health care system contributes to environmental harms and is responsible for 4.6% of greenhouse gas (GHG) pollution in Canada.2 Interestingly, most of this pollution is generated not within facilities, but upstream in the supply chain.3 Pharmaceutical manufacturing, for example, is highly energy intensive4 and resources are used at every stage of production, packaging, transportation, and disposal. In an analysis from the United Kingdom, medications accounted for 61% of the environmental footprint (Figure 1)3 in primary care, far exceeding other traditional targets for environmental action such as personal travel or building energy.3 Since many pharmaceutical ingredients remain active after disposal or metabolism and excretion by the body, medications also lead to contamination of air, water, and soil.5 Antibiotics released into the environment contribute to antimicrobial resistance, which is predicted to cause 10 million deaths per year by 2050.6 For family physicians, appropriate use of medications is an important way to reduce the environmental impacts of clinical practice.

Figure 1.
Figure 1.

Greenhouse gas pollution from primary care

Approach to reducing environmental impacts of medications—ECO-Rx framework. There are opportunities for family physicians to optimize outcomes for patients and the planet by applying principles of sustainable health care to prescribing practices, such as reducing unnecessary care, empowering patients, shifting to prevention, and choosing environmental alternatives.7 These principles can be incorporated into practice using the simple mnemonic “ECO-Rx” (Box 1).

Box 1.

Evidence, Collaboration, Options, Review Rx framework

Evidence: Use high-quality evidence to guide diagnosis and treatment

Collaboration: Involve patients in all treatment decisions

Options: Always consider nonpharmacologic or more sustainable pharmacologic options

Review Rx: Regularly review existing prescriptions and deprescribe appropriately

Remember the mnemonic “ECO-Rx”.

Evidence—use high-quality evidence to guide diagnosis and treatment. It is important to ensure patients meet evidence-based diagnostic and therapeutic criteria before initiating treatment. Overdiagnosis and misdiagnosis are important causes of overtreatment. Overdiagnosis can result from inappropriate use of screening tests (eg, lipid, thyroid, or bone-density testing), which can medicalize normal human experiences, or from lowering diagnostic thresholds to include conditions like prediabetes and borderline hypertension.8 For example, if new diagnostic criteria for dementia are adopted, up to 65% of people older than 80 years would be diagnosed with dementia and potentially treated without evidence of improved outcomes.9 Similarly, approximately one-third of Canadians with a diagnosis of asthma and chronic obstructive pulmonary disease have not had this diagnosis confirmed with objective testing.10 Studies have found that between 40% and 55% of proton pump inhibitor (PPI) prescriptions11 and at least 39% of antibiotic prescriptions12 in community-based practice are written without a suitable diagnosis. Choosing Wisely Canada offers evidence-based recommendations related to commonly overprescribed medications (Box 2).13

Box 2.

Choosing Wisely Canada prescribing recommendations relevant to primary care

  • Do not routinely prescribe antibiotics for exacerbations of COPD unless there is clear increase in sputum purulence with either increase in sputum volume and-or increased dyspnea. Antibiotics only prevent complications in select COPD exacerbations populations, with the greatest benefits in ICU-admitted patients. In most cases, short courses (5 days) of oral corticosteroids are beneficial whether the patient meets criteria for antibiotics

  • Do not prescribe IV antibiotics for patients who can safely be treated with an oral option, given that IV antibiotics have a higher carbon footprint. There is emerging evidence that osteomyelitis or infective endocarditis can safely be treated with PO antibiotics after a lead-in period of IV therapy. A 1-week course of oral ciprofloxacin is associated with 1.4 kg CO2e (6.8 km by car) of emissions versus 100.1 kg CO2e (485.9 km by car) for IV ciprofloxacin

  • Do not prescribe antibiotics for upper respiratory infection or influenza unless there is clear evidence of secondary bacterial infection. See criteria below for otitis media, strep throat, sinusitis, and pneumonia

  • Do not prescribe antibiotics in vaccinated children more than 6 months old and adults in whom you suspect acute otitis media, unless there is either a perforated tympanic membrane with purulent discharge or a bulging tympanic membrane with 1 of the 3 following criteria: Fever (≥39°C), moderately or severely ill, or significant symptoms lasting >48 h. In cases that do not fit these criteria, consider either no prescription or a delayed prescription

  • Do not routinely prescribe antibiotics unless the patient’s modified Centor score is >2 and throat swab culture (or rapid antigen test if available) confirms presence of group A Streptococcus. Do not perform throat swabs at all for patients with Centor score ≤1 or if there are symptoms of a viral infection such as rhinorrhea, oral ulcers, or hoarseness

  • Do not prescribe antibiotics for uncomplicated sinusitis unless symptoms have persisted for greater than 7-10 days without improvement. Antibiotics should only be considered if the patient has at least 2 of the following symptoms: P—facial pain or pressure or fullness, O—nasal obstruction, D—purulent or discoloured discharge, S—hyposmia or anosmia (smell); and 1 of those being O or D; and the patient meets 1 of the following criteria: the symptoms are severe or they are not responding to a 72-h trial of nasal corticosteroids

  • Do not prescribe antibiotics for pneumonia unless there is objective evidence (chest x-ray scan). Physical examination alone, demonstrating respiratory crackles, is not sufficient to establish a diagnosis of pneumonia and initiate antibiotics in the majority of situations. Patients with no vital sign abnormalities and a normal respiratory examination are unlikely to have pneumonia and most likely do not need a chest x-ray scan

  • Do not prescribe antibiotics for bronchitis or asthma or bronchiolitis exacerbations. Prolonged cough or greenish sputum are not indications for antibiotics

  • Do not test urine in older patients with a change in mental status unless there is clear evidence of infection.* Treatment of asymptomatic bacteriuria is not recommended

  • Do not order DEXA screening for osteoporosis in low-risk patients. Use “risk-assessment first” screening before ordering DEXA*

  • Do not screen for thyroid dysfunction in asymptomatic nonpregnant adults. Treating subclinical hypothyroidism (TSH level about 4-10 IU/L and normal T3 or T4 hormone levels) showed no benefits in patient-oriented outcomes

  • Do not continue opioid analgesia beyond the immediate postoperative period (3-7 days) or other episode of acute, severe pain

  • Do not initiate opioids long-term for chronic pain. Recommend and help support physical activity as the foundation for managing osteoarthritis and chronic low back pain. Opioid use in osteoarthritis and low back pain beyond 4 weeks’ duration did not show statistically significantly more responders than placebo and demonstrated the highest risk of adverse effects

  • Do not maintain long-term PPI therapy for gastrointestinal symptoms without an attempt to stop or reduce at least once per year in most patients. Indications for long-term PPI use are Barrett esophagus, Los Angeles Grade D esophagitis, and gastrointestinal bleeding

  • Do not initiate long-term maintenance treatments in adult patients with suspected COPD or asthma without confirming a diagnosis with objective testing such as spirometry or methacholine challenge. Many individuals are erroneously assigned a diagnosis of COPD or asthma, exposing them to risks of side effects, cost, and missing other diagnoses

  • Do not prescribe greenhouse gas-intensive MDIs where a lower carbon alternative with comparable efficacy is available (eg, dried-powder inhaler, soft-mist inhaler, or low-propellant MDI) in situations where technique is adequate and where patient preference has been considered

  • Do not routinely use antidepressants as first-line treatment for mild or subsyndromal depressive symptoms in adults

  • Do not use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia. Risk of motor vehicle accidents, falls and hip fractures, and death can more than double in older adults taking benzodiazepines and other sedative-hypnotics. Nonpharmacologic interventions have proven benefit

  • Question the use of antipsychotics to treat insomnia in any age group. Between 2005 and 2012, there has been a 300% increase in off-label use of antipsychotics for insomnia despite a lack of evidence of benefit and the possibility of adverse effects, including weight gain, fall risk, and metabolic disorders

  • Do not use antipsychotics as first choice to treat behavioural and psychological symptoms of dementia. Antipsychotic medicines are often prescribed for people with dementia exhibiting aggression, resistance to care, and other challenging behaviour but they provide limited benefit and can cause serious harm, including premature death

  • Do not recommend or order investigations or interventions before discussing patients’ expected trajectory of health and life expectancy, and exploring their preferences, values, and goals of care

  • Do not continue medications without confirming appropriate clinical indications, with particular attention paid to sedative medications, PPIs, and inhalers

  • Do not prescribe a medication without conducting a medication reconciliation review, and consider opportunities for deprescribing at interfaces of care

  • Do not use a medication to treat the side effects of another medication unless absolutely necessary

CO2e—carbon dioxide equivalent, COPD—chronic obstructive pulmonary disease, DEXA—dual-energy x-ray absorptiometry, ICU—intensive care unit, IV—intravenous, MDI—metered-dose inhaler, PO—by mouth, PPI—proton pump inhibitor, T3—triiodothyronine, T4—thyroxine, TSH—thyroid-stimulating hormone.

*Inappropriate screening can lead to inappropriate treatment.

Recommendations from Choosing Wisely Canada.13

Duration of treatment is another important consideration. It is recommended that pharmaceutical treatment of depression, for example, be continued for only 6 months after remission of symptoms (typically 12 to 18 months of treatment), yet patients in 1 Canadian study continued medication use for an average of 4.8 years.14 Research on PPI prescribing found that nearly half of patients remained on PPIs for almost 5 years despite the recommended duration of 8 to 12 weeks.14 Moreover, new evidence is finding that much shorter courses of antibiotics are as effective as longer courses and actually reduce antimicrobial resistance15 for infections such as cellulitis (5 days), uncomplicated female urinary tract infections (3 to 5 days), and community-acquired pneumonia (3 days).

Collaboration—involve patients in all treatment decisions. Encouraging patients to be active participants in the management of their health conditions can improve patient outcomes, reduce unwanted care, and help patients be more independent.16,17 When patients are well informed about the true risks and benefits of treatments, they often choose less treatment or none at all.17 Primary care studies show that almost 3 in 4 patients (73%) want to be involved in the decision-making process about their medications18 but only 50% felt they were.17 A recent study of 222 elderly patients in New Zealand found that 1 in 2 patients reported feeling they were taking too many medications and 1 in 5 reported that their medications were burdensome.18 Without good information, patients often overestimate the benefits and underestimate the risks of medications.19 For example, in primary prevention of cardiovascular disease, many patients choose not to start statin therapy when fully informed through shared decision making.20 Prescribers often assume that patients expect prescriptions, but this is not necessarily the case17,18; often they are only seeking reassurance and access to follow-up if needed.13 Patients may not be aware that many minor infections such as otitis externa,21 conjunctivitis,22 gastroenteritis, and urinary tract infections23 can be self-limiting and do not always require antibiotics. Although antibiotics may shorten the duration of illness, they can also be associated with adverse effects ranging from mild (diarrhea, yeast vaginitis) to life-threatening (anaphylaxis, Stevens-Johnson syndrome) and patients should be given information that allows them to make decisions based on their own priorities (eg, faster return to work versus avoiding cost of medication). Providers should inquire about and respect patient preferences, especially in serious illness or near the end of life, and should discontinue medications when they no longer align with the patient’s goals of care.24

Options—always consider nonpharmacologic or more sustainable pharmacologic options. For many conditions, a nonpharmacologic approach is the recommended first-line treatment. Nonpharmacological options include exercise and diet, physical therapies, mental health counselling, and nature or social prescribing.25 These alternatives often better address the underlying cause of illness25 and can have longer-lasting benefits, fewer complications, lower cost, and a lower carbon footprint than medications. Watchful waiting for benign self-limiting illnesses is another important option. Delayed prescriptions can be used for some conditions. In 1 study, when patients were given a delayed prescription for otitis media, 62% of these were never filled and no adverse effects were reported.26

Many available pharmaceutical products such as topical triple antibiotics for minor traumatic or surgical wounds27 offer no benefit versus placebo. In other conditions, simple home remedies may be adequate, such as using diluted vinegar for otitis externa, which demonstrates similar effectiveness to antibiotic or steroid preparations.21

In cases where medications are indicated, there are often more sustainable options that offer similar or superior patient outcomes. Long-acting reversible contraceptives (LARCs), for example, have patient and environmental benefits compared with combined oral contraceptives (COCs). LARCs are safer, more effective, economical, and convenient for patients, and they can reduce refill visits for providers and some can reduce menstrual flow and the need for sanitary supplies. Oral medications typically have a lower environmental impact than parenteral medications28 and avoid the need for extra supplies and visits. The use of insulin to manage diabetes, for example, causes substantially more environmental pollution than oral medication.28 As discussed in a previous article in this series, dry-powder inhalers have a much lower environmental impact than MDIs.10

Review Rx—regularly review existing prescriptions and deprescribe whenever appropriate. Regularly reviewing current medications is essential to reducing unnecessary prescriptions. In a study by Mohammed et al, 84% of elderly patients were willing to stop 1 or more of their medications if their prescriber said it was possible.18 When reviewing medications, prescribers should look for legacy medications that were prescribed appropriately initially but then continued longer than necessary. When initiating medications that are not intended to be taken long term, it is important to set this expectation at the outset, re-evaluate regularly, and use electronic medical record reminders for medication reviews.14 In a 2010 study of older adults, prescribers were able to successfully discontinue 58% of patient medications, and 88% of the study participants reported global improvement in health.29 The Canadian Medication Appropriateness and Deprescribing Network30 and Choosing Wisely Canada13 provide other valuable prescribing resources.

Reviewing existing medications is also important when patients present with new symptoms, since many common symptoms in primary care—such as falls, dyspepsia, insomnia, fatigue, and depression—are also common medication side effects. Failure to recognize this can lead to a prescribing cascade, whereby a second drug is prescribed to manage an unrecognized side effect of an existing medication.31 Low mood, for example, can be caused by β-blockers, COCs, PPIs, histamine-2 receptor antagonists, angiotensin-converting enzyme inhibitors, anxiolytics, opioids, and anticonvulsants; and there is an increasing association with a clinical diagnosis of depression as the number of these drugs taken increases, which is not seen in patients taking similar numbers of other medications.32

Other tips for lower environmental impact prescribing. To avoid large volumes of unused medications, consider short trials of new prescriptions. Promote pill splitting when feasible since the environmental cost of producing, packaging, and shipping an 80 mg tablet is similar to a 20 mg tablet, and this offers the additional benefit of reducing costs for patients. Consider ways to minimize packaging by avoiding overpackaged promotional samples and, when feasible for patients, encouraging reusable compliance packs and reduced frequency of dispensing. Educate patients about proper disposal of medication at pharmacies. Encourage patients to think critically about the use of non-prescription products such as supplements and vitamins that often have limited evidence of safety or efficacy yet still require energy and resources to produce.33

Case resolution

Upon further discussion, Laura reports that her depression symptoms began after starting the oral contraceptive following the birth of her last child 4 years ago. The thyroid medication was started at the same time when her thyroid test result was reported as abnormal, although she had no specific thyroid symptoms. Shortly after starting the antidepressant, she was prescribed a PPI due to gastrointestinal complaints. Although she has been asymptomatic, she attributes this to the medications. You explain that some of her medications may no longer be necessary (levothyroxine for subclinical hypothyroidism, prolonged treatment of an episode of depression) or might have been part of a prescribing cascade (low mood from a contraceptive, PPI for gastrointestinal symptoms of the selective serotonin reuptake inhibitor [SSRI]). You explain that most patients treated for depression are able to successfully discontinue SSRIs without recurrence.34 Over the next few visits, you share relevant Choosing Wisely guidelines (Box 2)13 and mention the possible benefits of gradually discontinuing some of the medications or switching to alternatives such as a LARC instead of the COC. You suggest switching to a terbutaline dry-powder inhaler and then order pulmonary function tests to clarify whether she has asthma. While emphasizing that the main objective of deprescribing is to improve her health by reducing the risk of harms from unnecessary medications, you also mention the environmental benefits. The changes to Laura’s medications would eliminate the environmental impact of the production, packaging, and transport of 1825 pills per year plus (assuming she exercises every day) the carbon dioxide equivalent of driving 511 to 1059 km from her MDI each year.10 Laura is delighted that she may be able to take fewer medications, save money, feel better, and also help the environment.

Conclusion

By applying these principles to an entire patient roster, 1 family physician can have a large environmental impact. Avoiding unnecessary medications by adhering to evidence-based, patient-centred prescribing practices represents an important opportunity for family physicians to reduce the environmental impacts of practice while improving patient outcomes, minimizing costs for patients and the health care system, and reducing provider workload through fewer refill visits, less monitoring, and fewer complications.

Notes

Editor’s key points

  • ▸ The health care system is responsible for 4.6% of greenhouse gas emissions in Canada. Family physicians are well positioned to reduce environmental impacts at work.

  • ▸ Medications account for 61% of primary care’s carbon footprint owing to the energy intensity of manufacturing, packaging, shipping, and disposal; and also contribute to air, water, and soil pollution.

  • ▸ The Evidence, Collaboration, Options, Review Rx (ECO-Rx) framework was designed to support appropriate use of medications. Family physicians can optimize outcomes for patients and the planet by applying these principles of sustainable health care to prescribing practices by reducing unnecessary care, empowering patients, shifting to prevention, and choosing environmental alternatives.

Footnotes

  • Acknowledgment

    The original Planetary Health for Primary Care guide was supported by an innovation grant from the East Kootenay Division of Family Practice in Cranbrook, BC.

  • Contributors

    All authors contributed to conducting the literature review and to preparing the manuscript for submission.

  • Competing interests

    Dr Ilona Hale reports that sessional funding was provided for the development of the original Planetary Health for Primary Care document and was supported by an innovation grant from the East Kootenay Division of Family Practice. Jessica Nowlan was employed as an Innovation lead during the development and writing of this manuscript. CASACADES is funded by Environment and Climate Change Canada. Dr Samantha Green has received honoraria from the Ontario College of Family Physicians and held a role with the Canadian Association of Physicians for the Environment. Ivy Lam has received an honorarium for presented education on sustainability opportunities in hospital pharmacies and also reports a grant paid by Environment and Climate Change Canada to Unity Health Toronto for education materials to health care providers.

  • This article is eligible for Mainpro+ certified Self-Learning credits. To earn credits, go to https://www.cfp.ca and click on the Mainpro+ link.

  • This article has been peer reviewed.

  • La traduction en français de cet article se trouve à https://www.cfp.ca dans la table des matières du numéro d’avril 2026 à la page e97.

References

  1. 1.↵
    1. Hale I,
    2. Norris J,
    3. Larkin L.
    Planetary health for primary care [Internet]. CASCADES; 2023 [cited 2026 Feb 25]. Available from: https://cascadescanada.ca/resources/sustainable-primary-care-toolkit/.
  2. 2.↵
    1. Eckelman MJ,
    2. Sherman JD,
    3. MacNeill AJ.
    Life cycle environmental emissions and health damages from the Canadian healthcare system: An economic-environmental-epidemiological analysis. PLoS Med. 2018 Jul 31;15(7):e1002623. doi: 10.1371/journal.pmed.1002623.
    OpenUrlCrossRefPubMed
  3. 3.↵
    1. Tennison I,
    2. Roschnik S,
    3. Ashby B,
    4. Boyd R, et al
    . Health care’s response to climate change: a carbon footprint assessment of the NHS in England. Lancet Planet Health. 2021 Feb;5(2):e84-92. doi: 10.1016/S2542-5196(20)30271-0.
    OpenUrlCrossRef
  4. 4.↵
    1. Belkhir L,
    2. Elmeligi A.
    Carbon footprint of the global pharmaceutical industry and relative impact of its major players. J Clean Prod. 2019;214:185-94. doi: 10.1016/j.jclepro.2018.11.204.
    OpenUrlCrossRef
  5. 5.↵
    1. Cussans A,
    2. Harvey G,
    3. Kemple T,
    4. Tomson M.
    Interventions to Reduce the Environmental Impact of Medicines: A UK perspective. J Clim Chang Health. 2021;4:100079. doi: 10.1016/j.joclim.2021.100079.
    OpenUrlCrossRef
  6. 6.↵
    1. Zeeshan Qadar SM,
    2. Thane G,
    3. Haworth-Brockman M.
    A call to action: an evidence review on pharmaceutical disposal in the context of antimicrobial resistance in Canada. National Collaborating Centre for Infectious Disease; 2021 Jan [cited 2026 Feb 26]. Available from: https://nccid.ca/wp-content/uploads/sites/2/2021/03/A-Call-to-Action-An-Evidence-Review-on-Pharmaceutical-Disposal-in-the-Context-of-Antimicrobial-Resistance-in-Canada.pdf.
  7. 7.↵
    1. Mortimer F.
    The sustainable physician. Clin Med (Lond). 2010 Apr;10(2):110-1. doi: 10.7861/clinmedicine.10-2-110.
    OpenUrlFREE Full Text
  8. 8.↵
    1. Brodersen J,
    2. Schwartz LM,
    3. Heneghan C,
    4. O’Sullivan JW, et al
    . Overdiagnosis: what it is and what it isn’t. BMJ Evid Based Med. 2018 Feb;23(1):1-3. doi: 10.1136/ebmed-2017-110886.
    OpenUrlFREE Full Text
  9. 9.↵
    1. Singh H,
    2. Dickinson JA,
    3. Thériault G,
    4. Grad R, et al
    . Overdiagnosis: causes and consequences in primary health care. Can Fam Physician. 2018 Sep;64(9):654-9.
    OpenUrlFREE Full Text
  10. 10.↵
    1. Green S,
    2. Stoynova V,
    3. Culley C,
    4. Kaplan A, et al
    . Climate-conscious inhaler prescribing for family physicians. Can Fam Physician. 2024 Jun;70(6):381-7. doi: 10.46747/cfp.7006381.
    OpenUrlAbstract/FREE Full Text
  11. 11.↵
    1. Farrell B,
    2. Pottie K,
    3. Thompson W,
    4. Boghossian T, et al
    . Deprescribing proton pump inhibitors: Evidence-based clinical practice guideline. Can Fam Physician. 2017 May;63(5):354-64.
    OpenUrlAbstract/FREE Full Text
  12. 12.↵
    1. Leslie M,
    2. Fadaak R,
    3. Lethebe BC,
    4. Szostakiwskyj JH.
    Assessing the appropriateness of community-based antibiotic prescribing in Alberta, Canada, 2017-2020, using ICD-9-CM codes: a cross-sectional study. CMAJ Open. 2023 Jul 4;11(4):E579-86. doi: 10.9778/cmajo.20220114. Erratum in: CMAJ Open. 2023 Aug 15;11(4):E734. doi: 10.9778/cmajo.20230050.
    OpenUrlAbstract/FREE Full Text
  13. 13.↵
    1. Choosing Wisely Canada
    . Choosing Wisely Canada Recommendations [Internet]. Choosing Wisely Canada; 2023 [cited 2026 Feb 26]. Available from: https://choosingwiselycanada.org/recommendations.
  14. 14.↵
    1. Mangin D,
    2. Lawson J,
    3. Cuppage J,
    4. Shaw E, et al
    . Legacy Drug-Prescribing Patterns in Primary Care. Ann Fam Med. 2018 Nov;16(6):515-20. doi: 10.1370/afm.2315.
    OpenUrlAbstract/FREE Full Text
  15. 15.↵
    1. Abdullah Al Mamun A,
    2. Michel D,
    3. Xie M,
    4. Blondel-Hill E, et al
    . Are antibiotic courses for common infections simply too long? BCMJ. 2022;64(2):82-3, 85.
    OpenUrl
  16. 16.↵
    1. Paterick TE,
    2. Patel N,
    3. Tajik AJ,
    4. Chandrasekaran K.
    Improving health outcomes through patient education and partnerships with patients. Proc (Bayl Univ Med Cent). 2017 Jan;30(1):112-3. doi: 10.1080/08998280.2017.11929552.
    OpenUrlCrossRefPubMed
  17. 17.↵
    1. Mulley AG,
    2. Trimble C,
    3. Elwyn G.
    Stop the silent misdiagnosis: patients’ preferences matter. BMJ. 2012 Nov 8;345:e6572. doi: 10.1136/bmj.e6572.
    OpenUrlFREE Full Text
  18. 18.↵
    1. Mohammed MA,
    2. Harrison J,
    3. Milosavljevic A,
    4. Chan AHY.
    Attitude towards deprescribing and its association with frailty and complexity of medication regimen: A survey of older inpatients in a district health board in New Zealand. BMC Geriatr. 2023 Mar 23;23(1):166. doi: 10.1186/s12877-023-03878-2.
    OpenUrlCrossRefPubMed
  19. 19.↵
    1. Hudson B,
    2. Zarifeh A,
    3. Young L,
    4. Wells JE.
    Patients’ expectations of screening and preventive treatments. Ann Fam Med. 2012 Nov-Dec;10(6):495-502. doi: 10.1370/afm.1407.
    OpenUrlAbstract/FREE Full Text
  20. 20.↵
    1. Stacey D,
    2. Légaré F,
    3. Lewis K,
    4. Barry MJ, et al
    . Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2017 Apr 12;4(4):CD001431. doi: 10.1002/14651858.CD001431.pub5. Update in: Cochrane Database Syst Rev. 2024 Jan 29;1:CD001431. doi: 10.1002/14651858.CD001431.pub6.
    OpenUrlCrossRefPubMed
  21. 21.↵
    1. Ellis J,
    2. De La Lis A,
    3. Rosen E,
    4. Simpson MTW, et al
    . Approach to otitis externa. Can Fam Physician. 2024 Oct;70(10):617-23. doi: 10.46747/cfp.7010617.
    OpenUrlAbstract/FREE Full Text
  22. 22.↵
    1. Centers for Disease Control and Prevention
    . Conjunctivitis (Pink Eye): How to Treat Pink Eye [Internet]. Centers for Disease Control and Prevention; 2024 [cited 2026 Feb 26]. Available from: https://www.cdc.gov/conjunctivitis/treatment/index.html.
  23. 23.↵
    1. Kronenberg A,
    2. Bütikofer L,
    3. Odutayo A,
    4. Mühlemann K, et al
    . Symptomatic treatment of uncomplicated lower urinary tract infections in the ambulatory setting: randomised, double blind trial. BMJ. 2017 Nov 7;359:j4784. doi: 10.1136/bmj.j4784. Erratum in: BMJ. 2017 Nov 13;359:j5268. doi: 10.1136/bmj.j5268.
    OpenUrlAbstract/FREE Full Text
  24. 24.↵
    1. You JJ,
    2. Dodek P,
    3. Lamontagne F,
    4. Downar J, et al
    . What really matters in end-of-life discussions? Perspectives of patients in hospital with serious illness and their families. CMAJ. 2014 Dec 9;186(18):E679-87. doi: 10.1503/cmaj.140673. Epub 2014 Nov 3.
    OpenUrlAbstract/FREE Full Text
  25. 25.↵
    1. Nowak DA,
    2. Mulligan K.
    Social prescribing: A call to action. Can Fam Physician. 2021 Feb;67(2):88-91. doi: 10.46747/cfp.670288.
    OpenUrlFREE Full Text
  26. 26.↵
    1. Sisson RB.
    Wait-and-see vs. standard prescriptions for AOM. Am Fam Physician. 2007;75(2):250-251.
    OpenUrl
  27. 27.↵
    1. Saco M,
    2. Howe N,
    3. Nathoo R,
    4. Cherpelis B.
    Topical antibiotic prophylaxis for prevention of surgical wound infections from dermatologic procedures: a systematic review and meta-analysis. J Dermatolog Treat. 2015 Apr;26(2):151-8. doi: 10.3109/09546634.2014.906547. Epub 2014 Apr 8.
    OpenUrlCrossRefPubMed
  28. 28.↵
    1. Marsh K,
    2. Ganz M,
    3. Nørtoft E,
    4. Lund N, et al
    . Incorporating environmental outcomes into a health economic model. Int J Technol Assess Health Care. 2016 Jan;32(6):400-6. doi: 10.1017/S0266462316000581. Epub 2017 Jan 9.
    OpenUrlCrossRefPubMed
  29. 29.↵
    1. Garfinkel D,
    2. Mangin D.
    Feasibility study of a systematic approach for discontinuation of multiple medications in older adults: addressing polypharmacy. Arch Intern Med. 2010 Oct 11;170(18):1648-54. doi: 10.1001/archinternmed.2010.355.
    OpenUrlCrossRefPubMed
  30. 30.↵
    1. Canadian Medication Appropriateness and Deprescribing Network
    . Other resources for clinicians [Internet]. Canadian Medication Appropriateness and Deprescribing Network; 2023 [cited 2026 Feb 26]. Available from: https://www.deprescribingnetwork.ca/other-resources.
  31. 31.↵
    1. Khezrian M,
    2. McNeil CJ,
    3. Myint PK,
    4. Murray AD.
    The association between polypharmacy and late life deficits in cognitive, physical and emotional capability: a cohort study. Int J Clin Pharm. 2019 Feb;41(1):251-7. doi: 10.1007/s11096-018-0761-2. Epub 2018 Nov 29.
    OpenUrlCrossRefPubMed
  32. 32.↵
    1. Qato DM,
    2. Ozenberger K,
    3. Olfson M.
    Prevalence of Prescription Medications With Depression as a Potential Adverse Effect Among Adults in the United States. JAMA. 2018 Jun 12;319(22):2289-98. doi: 10.1001/jama.2018.6741.
    OpenUrlCrossRefPubMed
  33. 33.↵
    1. Hale I,
    2. Cadenhead K,
    3. Hinchliffe M.
    The scoop on supplements for disease prevention. B C Med J. 2016;58(9):502-3.
    OpenUrl
  34. 34.↵
    1. Mangin D,
    2. Dowson C,
    3. Toop L,
    4. Wells E, et al
    . 2015 NAPCRG Annual Meeting CL32: The Effectiveness of Maintenance SSRI Treatment in Primary Care Depression to Prevent Recurrence: Multicentre Double Blinded Placebo Controlled RCT [Internet]. North American Primary Care Research Group; 2015 [cited 2026 Feb 26]. Available from: https://www.napcrg.org/conferences/36/sessions/14867.
Back to top

In this issue

Print
Download PDF
Article Alerts
Email Article
Citation Tools
Respond to this article
Reducing the environmental impact of medications and improving patient outcomes using the ECO-Rx framework
Ilona Hale, Samantha Green, Jessica Nowlan, Ivy Lam
Canadian Family Physician Apr 2026, 72 (4) 233-238; DOI: 10.46747/cfp.7204233
Twitter logo Facebook logo Mendeley logo

Jump to section