Climate-Conscious Medication Therapy Management: Perspectives of Canadian Primary Care Pharmacists

Abstract

(1) Background: The climate impact of health care work has raised interest in climate-conscious health care practice. Medications contribute significantly to the carbon footprint; there has been insufficient work describing climate-conscious medication therapy management practices that could be useful to address climate change caused by health care work. (2) Methods: This exploratory qualitative research study focused on climate-conscious medication therapy management practices. A semi-structured interview protocol was used. A total of 17 primary care pharmacists were interviewed (following informed consent) to the point of thematic saturation. A constant-comparative analysis was undertaken to identify and categorize themes. The research was undertaken based on a protocol approved by the University of Toronto Research Ethics Board. (3) Result: Three main themes emerged: (a) There is insufficient evidence currently available to guide climate conscious medication therapy management; (b) seven specific climate-conscious medication therapy management strategies were identified as being most likely to be acceptable by primary care pharmacists; (c) medication therapy management services focused on climate adaptation strategies for patients should be expanded; (4) Conclusions: As medications become the primary intervention used in health care, climate-conscious medication therapy management becomes more essential than ever. Further work in providing evidence to guide climate-conscious prescribing decisions is needed.

1. Introduction

The climate impacts of health care work are becoming an increasing concern to both climate scientists and health care professionals [1,2,3]. Climate impacts range from unnecessary waste disposal due to excess packaging or clinically questionable “hygiene theatre” (procedures that give the illusion of cleanliness and sterility) to ground water and soil contamination caused by medical supplies polluting the ecosystem [4,5]. By one estimate, health care work contributes over 5% of global greenhouse gas (GHG) emissions annually [1]. Paradoxically, health care professionals—who are ethically bound to heal the unwell—are actually contributing to and exacerbating illness through the polluting effects of the work they do [6].

In many health professions, this has led to the development of a concept referred to as “climate-conscious practice” [7,8]. Climate-conscious practice is a general term that is used to describe the clinical, patient-focused activities undertaken by front-line health care professionals in a manner that is sensitive to and aware of the climate impacts of everyday clinical decisions and actions [9]. Climate-conscious practice recognizes and respects that the prime directive of every health care professional is to help and heal patients: for example, in an emergency situation where a patient is bleeding, the focus must always be on saving the patient and stopping the injury—not on counting the number of gauze bandages consumed in a specific procedure. While this prime directive of health care work can never be compromised nor forgotten, climate-conscious practice aims to support climate change goals and targets by reorienting everyday clinical practice towards more sustainable choices and decisions [9].

This is a complex and nuanced process, particularly given the extraordinary demands on front-line health professionals to make life-and-death decisions in resource-constrained and time-pressured clinical environments. Layering additional cognitive burdens onto overtaxed physicians, nurses, pharmacists, paramedics, and other professionals must be carefully managed, and the priority of climate-related impacts on clinical decision-making must be realistically assessed.

Still, given the known and significant climate impacts associated with health care professionals’ work, it is essential to consider how climate-conscious practice can be responsibly, proportionately, and sustainably infused into daily clinical work [10]. While each profession (e.g., medicine, nursing, dentistry, pharmacy, etc.) has its own unique opportunities to support climate-conscious practice, there are certain aspects of health care work that transcend professional boundaries and are broadly applicable to all practitioners [11]. For example, medications and medication use are one of the most important aspects of health care work with some of the most polluting impacts on the climate [9,10,11]. Medication use in health care is ubiquitous and growing in importance: where, in the past, other interventions were more frequently used (such as surgery, psychotherapy, etc.), the modern health system has grown increasingly reliant on prescription and non-prescription medication use as a mainstay of therapeutic intervention. It is estimated that upwards of 75% of visits to a family doctor end with a new or renewed prescription [12]. More than 2/3 of American adults take one or more prescription medications [13]. While each individual medication may appear innocuous enough (due to the small size of an individual tablet or capsule), the sum of all these medications used across society has a significant effect on climate and health and represents a significant opportunity for climate-conscious practice.

Medication therapy management (MTM) is the collaborative and intentional process of reviewing and assessing medications used by patients to ensure safety, efficacy, and necessity [14]. Any professional (e.g., physician, nurse, dentist, paramedic, etc.) involved in the prescribing, dispensing, or administering of medications is engaged in some form of MTM [15]. As prescription and non-prescription medication use has expanded in society, the importance of MTM has become greater [16]. Traditionally led or facilitated by pharmacists, MTM consists of a variety of different techniques designed to optimize patient health and outcomes through more rational use of medications [14,16]. As the health professional with the most in-depth knowledge and skills related to pharmaceuticals and medications, the pharmacist’s role in MTM has grown in prominence within interprofessional collaborative care settings [17]. Activities such as medication reviews (in which an individual’s medications are carefully assessed to ensure safety and efficacy) or academic detailing (in which unbiased pharmacists provide impartial education and evidence to physicians, dentists, and other prescribers regarding safe and effective medication prescribing instead of relying on pharmaceutical company staff) are part of the continuum of medication therapy management [14,15,16].

Reframing current MTM practices and objectives with climate objectives in mind has not been formally undertaken or researched. Current MTM explicitly integrates certain socio-political and economic concepts (e.g., cost of medications) with pharmacological and therapeutic considerations (e.g., possibility of side effects or adverse medication interactions with other medications) [14]. As currently practiced, MTM is not a purely clinical or pharmacological exercise but is rooted in issues such as patient preferences (e.g., some patients dislike using suppositories even if they are (pharmacologically) the best option) or dietary/religious issues (e.g., avoiding use of certain medications not considered kosher or halal or advising Muslim patients on how to manage medication use during fasting periods such as Ramadan) [14]. Integrating climate consciousness into MTM processes and medication-related decision-making adds additional complexity to this work but also has the opportunity to yield valuable climate benefits, particularly given how ubiquitous medication use is in society and its known negative climate impacts.

The objective of this study was to examine climate-conscious medication therapy management—a multi-professional, collaborative activity—from the perspective of pharmacists in order to begin to develop models and approaches to better integrate climate objectives into clinical/therapeutic decision-making.

2. Materials and Methods

The potential value and impact of medication therapy management in reducing climate impacts have not been widely reported. Since there is little literature or evidence in this topic area, an exploratory, qualitative research method for this study was selected as being most appropriate [18]. Semi-structured interviews with pharmacists were identified as a useful initial research approach, given the pharmacist’s role and scope of practice in MTM and primary health care delivery [19]. Semi-structured interviews have been used previously to support authentic engagement with research participants while still maintaining a focus on a central research theme or objective [19].

In undertaking exploratory qualitative research of this sort, research rigour and quality are essential in order to ensure findings are relevant and acceptable [18]. The indicativeness and trustworthiness of both the research method and the interpretation of data must be ensured. The consolidated criteria for reporting quality research (COREQ) checklist is a widely used method in qualitative research to ensure adherence to high-quality methods throughout the research process [20]. For this study, the COREQ was used to guide research design, research conduct, data collection, data storage and management, data analysis, analysis and synthesis of findings, and reporting of outcomes.

For this research, pharmacists working in primary health care team settings were the focus of the study. Inclusion criteria for this study were (i) licenced/registered practicing pharmacist; (ii) working in an interprofessional, collaborative, primary health care team setting for a minimum of 3 years; and (iii) English-speaking.

In Canada’s universally accessible health care system, primary health care is a government-funded initiative [21]. Primary health care teams maintain a visible web presence in order to engage with their communities; through these websites, it was possible to identify primary health care team pharmacists and to contact them directly via email to participate in this study. Ontario is the largest of Canada’s provinces, with a census population of over 15 million people. As of June 2025, there were 330 interprofessional, team-based primary health care practices in the province [21]. Five cohort groupings were identified for this study based on catchment: large urban area (population > 1,000,000), suburban/adjacent large urban area, mid-size community (population between 50,000 and 1,000,000), small town (population less than 50,000), and Aboriginal/Indigenous catchment (community with >50% first nation, aboriginal, or indigenous population) [21]. The 330 identified primary health care team practices were allocated to one of these five groups to ensure adequate sampling of different kinds of primary care practices across the province. Emails were sent to the pharmacists identified at each of the 330 practices. These emails included an explanation of the rationale for the study and an invitation to contact the researchers to learn more and to participate.

Individuals who agreed to participate were required to complete informed consent pursuant to a research protocol approved by the University of Toronto. A semi-structured interview protocol was developed and pilot-tested (see Appendix A). Three individuals participated in the pilot testing process and provided their feedback to ensure the protocol was clear, concise, and on-topic. Modifications to the initial protocol were made iteratively during the pilot testing process.

Consistent with exploratory qualitative research processes, interviews with participants were undertaken to the point of thematic saturation. Saturation is a theoretical construct describing the point in a qualitative research project where the research team believed no new, meaningful, or important additional information that would result in new codes, categories, or themes being identified during data analysis would be derived from conducting additional interviews [18].

All interviews were undertaken virtually using the Zoom platform. With informed consent from the participant, interviews were recorded and verbatim transcripts generated using Zoom’s automatic transcript function. Subsequent review and “cleaning” of these automatically generated transcripts by the interviewer were required to ensure accuracy and clarity and to help adjudicate discrepancies between verbal comments and non-verbal cues of participants during the interview. Pursuant to the approved research protocol, each participant was offered the opportunity to review their individual transcript, once cleaned, if they wished to do so.

All transcripts were reviewed by two researchers who undertook independent coding and categorization of data using the constant comparative data analysis method. Data was managed and analyzed using nVivo v15.3, a widely used qualitative data management package. This version of the software included an artificial intelligence (AI) assistant. The AI assistant could be set to varying levels of sophistication with respect to data collection, analysis, and interpretation. For this study, AI functions were used only in order to summarize documents, suggest codes, and provide initial summaries for analytical frameworks and coding structures. These functions were used by the researchers during initial data management and analysis, but all final decisions regarding interpretation, coding, categorizing, and theming were made by the research team itself. As a result, while AI was used to support the research and to enhance operational efficiency, human-in-the-loop AI methods were relied upon to ensure all final decisions were made by human researchers. Throughout this process, specific transcript data were referred to in order to ensure a clear evidentiary basis for the identified codes, categories, and themes. The 32-item COREQ checklist was used to ensure all research processes and methods conformed to quality expectations for this kind of participant-focused, interview-based, qualitative research study.

The researchers involved in this study have extensive experience in health services and pharmacy practice research, with a combined experience of over 40 years and over 100 published manuscripts. The research team has no particular expertise with respect to climate science, but both researchers have strong personal interests in advancing climate-conscious professional practice in health care.

This study received ethics board approval from the University of Toronto, Canada. It was deemed low-risk research given the relatively low threat of vulnerability faced by participants, all of whom were highly educated, autonomous health care professionals. No patient-identifying data or disclosure of details related to vulnerable individuals was included in the study protocol or in the study itself. This manuscript reporting findings of the study was entirely generated by human researchers with no assistance from AI, other than superficial text editing for grammar, spelling, punctuation, and formatting.

3. Results

After two rounds of email invitations to prospective participants (spaced 4 weeks apart), a total of 40 individuals contacted the research team to gain further understanding about the study and what it entailed. Of these 40 individuals, 37 met the inclusion criteria. Of the 37 who met the inclusion criteria, a total of 20 agreed to continue with the study and complete informed consent. Of these 20 participants, 3 dropped out due to personal or professional life change circumstances. Ultimately, a total of 17 primary care pharmacists were recruited to participate in individual interviews in this study following completion of informed consent procedures. Approximately 60% of participants in this study were female; the average age was 40.2 years (range: 23–61 years), with an average of approximately 10 years of experience in primary care practice. Demographic characteristics of these participants are noted in Appendix B All participants fully participated in semi-structured recorded interviews. Three participants accepted the offer to review their transcripts prior to inclusion in the data set for analysis; none of these participants indicated concerns with their transcripts or requested modifications/changes. Analysis of transcript data was undertaken using the constant-comparative method involving two researchers independently reviewing each transcript, developing codes and themes, then conferring with one another to confirm and refine the final coding structure and themes. Based on this independent dual-coding, researchers reached consensus that thematic saturation had been achieved at the 15th interview; two subsequent interviews were undertaken, and transcript data were analyzed to confirm that saturation had indeed been achieved. Thematic saturation was assessed at the point where neither independent reviewer was able to identify any new, different, or additional information, code, or theme from analysis of the transcript data. For interviews 16 and 17, all analyzed data confirmed pre-existing codes and themes from the previous 15 interviews. During the constant-comparative data analysis process, each researcher independently reviewed, coded, and generated themes based on the transcript data. Both coders used AI tools in NVivo to support initial summarizing of transcript data and to provide initial framing of potential codes and themes. Both coders also exercised reflexivity in analyzing AI summaries and recommendations prior to finalizing their own summaries, codes, and themes. Comparisons between independent coders were undertaken following interviews 3, 6, 9, 12, 15, and 17. Where discrepancies and disagreements in understanding, coding, analysis, or theming arose between the researchers, a collaborative conversational approach was undertaken to allow each coder to better understand the other’s perspective with the objective of achieving consensus. Had consensus not been achieved, a third coder was available to provide additional perspective. However, in this study, consensus was achieved between the two coders, and recourse to the third coder was not required.

Based on this analysis, three key themes were identified. For each of these three themes, indicative transcript excerpts are presented to illustrate the diverse ways in which participants described the theme and its importance.

• There is insufficient evidence currently available to guide climate-conscious medication therapy management.

“It’s really frustrating actually. You want to do the right thing, to minimize the carbon footprint, the environmental impact, of medications and medication use, but there’s no real place to go to find out information to do this. Except for, well famous examples like inhalers [used to treat asthma], it’s virtually impossible to determine what the carbon impact of individual medications actually are. So this makes it hard to be climate conscious.”

“I wish there was a reference—you know, some place where you could simply look up and compare—what’s the climate impact of this drug vs. that drug, then you could make a prescribing decision based on that. But this doesn’t exist. I sometimes wonder if this is deliberate, like a strategy from the [pharmaceutical industry] to keep us in the dark. It can’t be that hard to calculate the climate impact and make it available to [health care professionals].”

“The single biggest limitation we have is that we just don’t have the information we need to make climate conscious MTM a reality. The climate impact of a tiny white pill we prescribe and dispense is enormous—think of the raw materials sourced in China, the manufacturing occurring in India, the packaging occurring somewhere else. Then it all needs to be shipped or flown or somehow get here. Then it goes on trucks and comes into the pharmacy and is stored. And then the packaging, layers and layers of packaging, it’s ridiculous. What the patient ultimately takes home is a tiny white tablet or whatever, but the climate impacts of getting from there to here are massive—and we have no way of knowing what the carbon load really is so we can’t make informed climate conscious decisions.”

All participants in this study agreed that information with respect to the climate impacts of medications is insufficient to make evidence-based medication therapy management decisions that focus on climate goals. This considerably limits their ability to engage in climate-conscious MTM. Participants noted that calculating the environmental impacts of medications is incredibly complicated, as it encompasses a global research, development, manufacturing, packaging, storage, shipping, procurement, distribution, and dispensing chain involving literally thousands or tens of thousands of kilometres. Further, understanding the impacts associated with the disposal of medication or contamination of sewage through excretion of metabolic by-products of medications consumed by patients is not easily accessible. Participants noted that this current information void is due, in large part, to the highly globalized, highly disaggregated nature of the pharmaceutical manufacturing system. Even attempts to procure, prescribe, and dispense medications made locally (to minimize greenhouse gas emissions associated with shipping medications across the globe) are next to impossible since so many raw materials for medications are sourced in distant countries such as India and China. Participants expressed their frustration in attempting to enact climate-conscious MTM in a context where limited or no evidence, information, or data is available to guide decision-making.

Several participants noted that current regulatory processes that are used to licence or allow medications to be used in Canada could be modified, so manufacturers are required to declare the carbon impacts of the products they are selling. They also noted that regulatory processes could be used to require disclosure of environmental contamination issues associated with medications consumed by patients. In many cases, medications taken by individuals will result in metabolic by-products that are then excreted in the urine or feces and end up in sewage. It is unclear if sewage treatment processes are capable of managing metabolic by-products, and thus there is a risk that these by-products will end up in ground water and soil, leading to ecosystem impacts. The absence of regulatory requirements that mandate research and reporting on this issue was identified as a significant problem and cause for the information void that currently exists.

All participants in this study endorsed the notion that an evidence-based, data-driven approach to climate-conscious MTM is necessary in order to be helpful and impactful on climate goals. They also supported the notion that regulation that requires manufacturers to provide information regarding carbon impacts of medications sold in Canada should be part of the review and approval process. This information should include data regarding manufacturing, packaging, storage, and shipping of medications to pharmacies prior to dispensing to patients, as well as data regarding metabolic by-products and their environmental/ecosystem impacts. In the absence of this kind of information, participants expressed pessimism that significant advances in climate-conscious MTM would be possible.

2.

Seven specific climate-conscious medication therapy management strategies were identified as being most likely to be acceptable and actionable by primary care pharmacists, physicians, nurses, and other health professionals.

“Even without the information we need, I think there’s still an opportunity, actually a responsibility—I mean there’s still things we can and should do to minimize climate impacts of medication use just using the tools we do have available…things like deprescribing for example, or better formulary management to minimize inventories.”

“I really pay attention to packaging. It’s absurd—I mean you know how many layers of cardboard and foil and cellophane you need to wade through before you get to the bloody capsule you want to dispense? As a profession, we should really be putting pressure on manufacturers—I mean they do this with toys and food now, right? So they could reduce the packaging and that would be a big help I think in terms of what just goes into the garbage.”

“We really need to focus more on using what we already can do. Okay, so for example, when a patient starts a new prescription let’s say for (high blood pressure). Because of the drug benefits plans, they often want us to dispense three months supply at a time to minimize costs. But a lot of times—let’s say a side effect or nausea or something happens after the first few doses, then the drug has to be changed and boom! You have a couple of hundred pills that are now waste. We can’t recycle or reuse medications once they’ve left the pharmacy—I get that, that’s reasonable. Most patients just flush them down the toilet and there you go—into the sewage system, and then god knows where it ends up contaminating. If pharmacists use their prescribing power better to dispense a week supply of meds, see how the patient tolerates, adjust accordingly, we could really reduce the wastage that just ends up down the toilet.”

Despite the lack of data or evidence around the carbon impacts of individual medications, participants in this study indicated there were a variety of different strategies that could be used immediately to advance climate-conscious MTM in primary care. Seven specific strategies were highlighted by most participants as being potentially both impactful and reasonable to implement in a busy clinician’s day-to-day work. These strategies included the following:

(A)

Deprescribing: Deprescribing is the process of removing unnecessary medications in a systematic and safe way. In many cases, patients are started on a medication to help manage a short-term issue (for example, insomnia or acute pain) [14,22]. Over time, there are a few systems in primary care that are available to monitor patients closely enough in order to declare medication treatment a success and therefore discontinue the medication. Instead, patients end up continuing to receive medications long after the initial need no longer exists. In many cases, patients themselves may be reluctant to discontinue the medication, as it has become part of their routine. Further, prescribers may be reluctant to stop a medication for fear that the original problem may return. As a result, patients may end up taking unnecessary medications for years longer than they need to. This not only represents an unnecessary expense, but it also exposes patients to unnecessary side effects, medication interactions, or other problems, including heightened risks of addiction. Deprescribing involves active monitoring of a patient’s medications with a specific view to discontinuing medications after they are no longer needed. Deprescribing is emerging as a unique and important role for primary care pharmacists who are most closely connected to the monthly or periodic dispensing of medications to patients [14]. All participants in this study noted that deprescribing is valuable for patients and their health but that it also has coincidental benefits for the climate and the ecosystem. Reducing the number of unnecessary medications used by patients is good clinical practice; it also reduces carbon and ecosystem impacts. Importantly, deprescribing is part of the job of primary care pharmacists, so it does not represent additional time or workload burden. As a result, it is the kind of medication therapy management activity that should not be simply acceptable but actually embraced by pharmacists, physicians, nurses, and others. For all participants in this study, this was a particularly salient point: deprescribing is not a make-work project or additional labour; it is central to providing good quality care to patients…with the added dividend of being a climate-conscious practice.

(B)

Trial Prescription Services: The process of calibrating prescription medications for individual patients is complex and time-consuming. Based on a diagnosis, a prescriber (physician, nurse, pharmacist, etc.) uses clinical guidelines to identify an appropriate medication to treat the patient. For any given medical condition, there are often many different medications that could be used. Each patient responds differently to a medication in terms of side effects, tolerance, response, etc. As a result, the first medication that is prescribed—based on clinical guidelines—may not be the best option for an individual patient, resulting in the prescribing of a second, third, or fourth option until the best medication is found. This trial-and-error process for prescribing is common—but also generates incredibly large amounts of medication waste. Typically, drug insurance (benefits) supports dispensing 1–3 month supplies of medications. If, after 1–2 days of use, a medication is found to be suboptimal, the remainder of the dispensed supply is wasted. No jurisdiction in Canada allows unused medications to be returned and reused by pharmacies out of concern for safety and hygiene. In many cases, where patients have unused medication at home, they may not bother to return these to a pharmacy for safe disposal and instead simply flush them down the toilet, where they then enter the sewage processing system and may end up contaminating ground water and soil. In an effort to address this climate and ecosystem impact, all participants in this study highlighted the potential value of trial prescription services as a medication therapy management intervention. In such a service, the pharmacist dispenses a small (e.g., 3–5 day) supply of an initial medication to assess whether it is optimal for patients [23]. If it is, a three-month supply can then be dispensed with no risk of wastage. If the initial medication is suboptimal, the pharmacist can use their scope of practice to modify dosages, adapt the prescription, or change to another medication that may be more effective for that specific patient and issue another 3–5 day trial prescription. While this represents additional workload for the pharmacist, it is safer and more effective for the patient and more likely to result in optimal medication therapy more quickly. Further, it reduces the risk of medication wastage and unsafe disposal. Like deprescribing, trial prescription services are well aligned with pharmacists’ scope of practice and clinical roles and therefore should be embraced…but also have, as a dividend, environmental benefits that support climate-conscious MTM.

(C)

Reducing Hygiene Theatre: The term “hygiene theatre” refers to the elaborate rituals undertaken by health professionals to demonstrate their commitment to sterility, cleanliness, and minimization of risk of transmitting infectious diseases [24]. These rituals range from the use of alcohol swabs prior to administering vaccines to the significant amount of packaging around individual medications that sends a signal that individual capsules or tablets are sterile and uncontaminated. In most cases, the elements of hygiene theatre (e.g., gloves, masks, personal protective equipment, packaging, needles, syringes, etc.) are not recyclable and end up in landfills or are incinerated. While the objective of cleanliness is, of course, essential, the actual value of hygiene theatre in reducing the risk of transmission of infections is increasingly being questioned, particularly in the context of environmental impacts associated with all the waste that such rituals generate. Participants in this study noted that there was poor or no evidence available to guide decision-making in this area. While some may question whether alcohol swabbing every arm prior to administering a vaccine is really necessary or helpful, most of them continued to do so simply because that is the way they have always administered vaccines in the past. When one considers the millions or billions of alcohol swabs used in vaccinations every year—and the reality that all of this ends up as garbage, not recycled—the environmental impacts are significant. As a climate-conscious MTM practice, critical analysis of hygiene theatre rituals was identified as an important and underutilized strategy, one that would benefit from better research evidence and clearer guidance from public health authorities. At the individual level, participants in this research noted that pharmacists have significant opportunities to reduce packaging waste by sourcing medications that are not overpackaged. Leveraging their role in purchasing and procuring medications and intentionally selecting vendors who have responsible packaging practices was identified as a straightforward and actionable climate-conscious MTM practice by participants in this study—a strategy that could potentially have significant climate-positive impacts.

(D)

Formulary Management: Within health care, a “formulary” describes a listing of medications that are approved for prescribing and dispensing within a specific clinical setting. Formularies emerged decades ago as an essential tool for cost containment in health care. For any given medical condition, there are sometimes dozens of similar medications offered for sale by different pharmaceutical manufacturers. Allowing physicians to prescribe any or all of these dozens of options creates a significant financial burden in terms of inventory issues; by reducing the number of acceptable prescribing options through a formulary, significant cost savings will result, with minimal impacts on patient care and outcomes. Participants in this study noted that a formulary system could also be used, focused on the climate impacts of medications. All participants in this study cited the example of inhalers used to treat asthma and other respiratory conditions. For the past decade, there have been dozens of different kinds of inhaler devices available, some of which contained CFCs, which are known to deplete ozone and contribute to global warming. One of the great successes of climate-conscious MTM has been to use formularies to shift prescribing behaviours away from CFC-containing inhalers to other, more climate-friendly options. Formularies force pharmacists, physicians, and nurses to select from a narrower menu of options; in this case, those options were derived based on safety and efficacy for patients as well as environmental and climate impacts. Expanding this formulary approach to other carbon-negative medications (e.g., anesthetic gases used by dentists and others) could represent an important step forward in climate-conscious MTM. Pharmacists have a particularly important role to play in formulary management, given their role as stewards of medications and medical supplies in the primary care system.

(E)

Academic Detailing: The business of medications is both complex and lucrative. An enormous, wealthy, and powerful pharmaceutical industry sector has arisen. From this sector have come numerous life-saving innovations and breakthroughs. However, this sector is, by definition, focused on profit maximization, and as a result, concerns have been expressed regarding the objectivity of the pharmaceutical sales force that provides information to physicians, nurses, pharmacists, dentists, and others regarding the products produced and sold by manufacturers. To address these concerns regarding corporate bias, the concept of ‘academic detailing’ has evolved [25]. Pharmacists, as the health care professional group with the most in-depth training in and understanding of medications, serve as honest brokers of impartial information regarding optimal prescribing of medications [25]. These pharmacists are not employed by pharmaceutical manufacturers and are therefore less likely to exhibit profit-motivated bias in the education they provide. Continuous professional development in health care is essential: each year, dozens or hundreds of new medications and treatments are introduced, and it is essential that health professionals have a process for keeping up to date on these new developments. Systems that rely on for-profit companies to provide this education may not be as impartial as hoped; academic detailing focused on evidence and data rather than for-profit motivations is thought to enhance high-quality, unbiased education. Incorporating climate-conscious MTM into the academic detailing process was identified by participants in this study as a significant but currently underutilized opportunity to enhance awareness of the climate impacts of medication use.

(F)

Patient education: Most participants in this study noted that an increasing number of their patients are asking critical questions regarding the climate impacts of medications they are prescribed and are using. Public interest in and awareness of the polluting effects of medications are increasing, and with it, the public is starting to demand climate-conscious MTM as never before. This public drive for more responsible prescribing is shaping health professionals’ behaviours as well. Participants in this study noted and described personal experiences of helping patients educate themselves on the climate impacts of health care. They noted that—similar to the experience of health professionals—there are very limited high-quality, data-driven sources of evidence the public can access to better understand the climate impacts of medications they are using. Several participants noted that this sometimes means patients refuse to take necessary medications out of a misguided belief that environmental impacts outweigh personal health benefits. The role of the primary care pharmacist in providing education and information to patients about the risks and benefits of medications in general and the specific climate impacts associated with individual prescriptions was highlighted as an essential component of climate-conscious MTM. Most participants also highlighted an important sub-element of this: the importance of educating patients regarding the impacts of climate change itself on their personal health and medication use. For example, some medications used to treat high blood pressure and other conditions may predispose patients to some dehydration. This situation can become a medical emergency during a climate-change-induced heat wave, where excess perspiration further dehydrates a patient. Educating patients about the medications they are taking and how to manage climate-change-related environmental issues like heatwaves is becoming more important than ever as a way to protect patients from potential harm.

(G)

Operational waste: All participants in this study highlighted everyday opportunities to support climate-conscious MTM by simply looking around the offices and spaces within which they work. Identifying opportunities to reduce, reuse, and recycle within an office/clinical environment may seem trivial in the context of climate-conscious MTM, but it still could have significant benefits. For example, switching to LED lightbulbs, ensuring recycling bins are available and clearly labelled, and examining workflow to reduce the amount of paper generated were all cited as examples of the ways in which unnecessary operational waste could be reduced. Several participants in this study noted that there continues to be controversy regarding the shift away from paper-based prescription and record management towards electronic health records (EHRs), as well as the rapid proliferation of artificial intelligence (AI) technologies in health care. They noted that both of these consume large amounts of electricity that must be generated and transmitted in order for these systems to function. They described the illusion that EHRs or AI are clean and unpolluting when in reality it is not clear how polluting the electricity required to run such systems may actually be.

3.

Medication therapy management services focused on climate adaptation strategies for patients should be expanded.

“I guess you’d say I’m a pessimist now. We’ve blown it in terms of trying to prevent climate change so as a [primary health care provider] we really need to shift our focus to help patients figure out how to deal with climate change now that it’s a reality and won’t get better any time soon.”

“Patients ask me this all the time. What do I do if there’s an extended power failure and my [medication that needs to be stored in the freezer] starts to warm up. Educating people on how to adapt to climate change and its realities on their health and medication—that’s a huge new job.”

“Dehydration is one of the biggest problems. You see those statistics in the paper how thousands of elderly people die every year in heat waves. It’s not simply the lack of air conditioning, though that’s an issue. It’s likely because, well, they’re on [certain medications] and that makes them prone to dehydration. In a heat wave, everything amplifies and before you know it, it’s too late. It’s completely preventable though, if we incorporate this into our education of patients on their meds and make a point of reaching out during a heat wave to remind them.”

Participants in this study described their understanding of the distinction between “climate mitigation” and “climate adaptation”. Many of the strategies highlighted above represent attempts to reduce carbon outputs and therefore mitigate, or reduce the risk of, further human-driven climate change. Currently, there is general pessimism that carbon reduction targets will be achieved in a way that will actually mitigate climate breakdown processes. As a result, there is increasing attention now being paid to climate adaptation strategies. From this perspective, human-driven climate change is assumed to be a foregone conclusion that is no longer stoppable or addressable; instead, time, energy, and resources are dedicated towards supporting meaningful strategies that allow human beings to live with the consequences of climate change as best as possible. Importantly, climate mitigation and adaptation strategies can and often do coexist and are simultaneously applied, both in health care practice and in other sectors.

Within primary care, climate adaptation strategies have become a more common topic of conversation and focus of climate-conscious MTM practice. Depending on geographic location, the specific climate change impacts experienced by patients will vary. In the jurisdiction that was the focus of this study (Ontario, Canada), the climate change issue that was most prominent for participants related to lengthy heat waves and, in particular, the impact these have on medications. Northern climates have experienced longer and more intense heat waves than in the past, and in many cases, individual patients may not have air conditioning or other supports to manage this change in climate. As noted in the illustrative transcript quotations above, this is emerging as an important point of patient education and as a form of climate-conscious MTM since it involves actively reconnecting with vulnerable patients during heat waves to confirm their ability to rehydrate to protect themselves from medication-related harms. Since most clinical offices and pharmacies are now air-conditioned, the idea that such health care facilities could also serve as community cooling centres during exceptional circumstances was also raised. Most participants also indicated the importance of connecting with other community and social support systems and developing inventories or listings that could be shared with patients so they had other resources and places to go during heat emergencies. This form of “social prescribing”—leveraging existing community/social supports in order to enhance health and well-being—is becoming particularly important in the context of climate change and climate adaptation, particularly for vulnerable people, the elderly, and those on certain high-risk medications.

4. Discussion

This study was among the first identifiable attempts to enumerate and describe climate-conscious MTM strategies from the perspective of primary care pharmacists. Medication therapy management is not the unique purview or role of pharmacists: physicians, nurses, dentists, and any health professional who is involved in the prescribing, dispensing, or monitoring of patients receiving medications have a role to contribute in MTM. As the health care professionals with the most advanced training in and understanding of medications, pharmacists are uniquely placed to lead climate-conscious MTM as well as educate other professionals and patients to expand its impact.

A common theme in this study is the absence of data and information to guide evidence-based clinical decision-making that is climate-conscious but also supports optimal patient care. Participants in this study expressed their frustration that regulators who allow medications to be sold are not taking a more active role in generating or requiring evidence regarding climate impacts that could be useful in clinical decision-making. Nonetheless, these participants also noted that there are still many opportunities to implement climate-conscious MTM in the absence of this kind of centralized repository of data. It also highlights potential opportunities for the pharmaceutical industry to cooperate in developing such repositories or the development of mandatory environmental disclosure systems as part of the drug approval process.

These opportunities focus on the notion that climate-conscious MTM should not be additional work or a burden on already overburdened primary care professionals. Layering on additional work or responsibility would be unlikely to succeed or be sustainable. Instead, the strategies supported by participants in this research all have a common theme of simply being good and effective patient care. Techniques such as deprescribing, trial prescription services, formulary management, etc., are all in the clinical best interest of patients but have, as an additional benefit, climate-positive potential impacts. Participants in this study stressed that this dual-purpose approach would be essential for success. First and foremost, all health professionals have ethical obligations to do what is in the best interests of their patients. In a health care context, emergency medical priorities must always take precedence over longer-term environmental concerns. Optimal patient care is the prime directive for health professionals. As noted by participants in this study, it is both possible and feasible to integrate optimal patient care with climate-conscious practice, but this requires intentionality and planning.

The strategies discussed by participants in this study are neither revolutionary nor unique to a climate-conscious variant of MTM. They are not the purview of one specific profession, like pharmacy. Instead, they are broadly applicable to diverse professions and practice contexts because, ultimately, they are about delivering the best possible patient care to patients. This virtuous alignment between patient objectives and climate goals is essential to emphasize to gain buy-in and acceptance from busy clinicians. Importantly, participants in this study also noted that, in their experience, the vast majority of health professionals accept and are concerned about the realities of climate change. As scientifically trained and educated people, most professionals recognize and take personal responsibility for helping to address climate breakdown in both their personal and professional lives. This means that there is a pre-existing foundation of interest and goodwill already available upon which climate-conscious MTM can be established—provided it is presented in the context of being an effective way to improve the quality of patient care itself.

As one of the first studies of its kind to explore this issue, this research has helped advance thinking and discussion of an urgent issue in health care and society. The qualitative research method that was utilized allows those closest to the work to articulate their perspectives and to be heard. The use of the COREQ approach to ensure rigour and quality in qualitative research enhances the trustworthiness and indicativeness of findings. There are, of course, limitations that must be considered. As a small, exploratory study of a large and complex issue, findings from this research should not be considered final nor generalizable. The limited geographical context for this study (Ontario, Canada) means that some findings may not be applicable in other jurisdictions due to different regulatory, scope of practice, and cultural dissimilarities. The focus on pharmacists in this study means that additional work to examine perspectives of other professional groups (e.g., physicians and nurses) is necessary to confirm and enrich our understanding of this topic.

As noted by the participants in this study, further work exploring climate-conscious MTM is required. System-wide initiatives that will allow for the generation of evidence-based repositories to guide clinical decision-making are needed to allow front-line professionals to more effectively integrate climate awareness into their practice. Further work across different health systems and geographical jurisdictions is needed so that learning can be shared and promising practices disseminated. Perhaps most importantly, continued and sustained interest and attention in the role of health professionals in mitigating and adapting to climate breakdown realities is essential.

5. Conclusions

The climate impacts of health care professionals’ work are significant. Equally, there is growing momentum among health professionals to address this reality in a way that is supportive of optimal patient care. This study has helped identify strategies that may be useful to support climate-conscious medication therapy management. Given the significant role medications play in the delivery of modern health care, this represents a potential contribution to both optimal patient care and mitigation/adaptation to climate change. Medication therapy management is of interest to diverse health professionals, including physicians, nurses, pharmacists, dentists, and others who prescribe, dispense, or administer medications. This study has provided an opportunity to reflect upon climate-conscious practices that may be applicable in day-to-day practice.