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</o:shapelayout></xml><![endif]--></head><body lang=EN-US link=blue vlink=purple><div class=WordSection1><p class=MsoNormal><span style='font-family:"Arial","sans-serif";color:#1F497D'>Sorry if this has been cross-posted, but find a very interesting manuscript attached. <o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial","sans-serif";color:#1F497D'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial","sans-serif";color:#1F497D'>(With no offense intended to the authors) Quite a leap relying on our physicians to use P2 in “Personalized adjustment of drug dose…”, but a very plausible (partial) solution. <o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial","sans-serif";color:#1F497D'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial","sans-serif";color:#1F497D'>“To accomplish this, greatly improved promulgation to clinicians of data from emerging low-dose efficacy studies will be required.”<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial","sans-serif";color:#1F497D'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial","sans-serif";color:#1F497D'>Most of our Dr’s are on a completely different planet when it comes to understanding their environmental impact. <o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial","sans-serif";color:#1F497D'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial","sans-serif";color:#1F497D'>Allen Gilliam<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial","sans-serif";color:#1F497D'>ADEQ State Pretreatment Coordinator<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial","sans-serif";color:#1F497D'>501.682.0625<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial","sans-serif";color:#1F497D'><o:p> </o:p></span></p><div><div style='border:none;border-top:solid #B5C4DF 1.0pt;padding:3.0pt 0in 0in 0in'><p class=MsoNormal><b><span style='font-size:10.0pt;font-family:"Tahoma","sans-serif"'>From:</span></b><span style='font-size:10.0pt;font-family:"Tahoma","sans-serif"'> Daughton.Christian@epamail.epa.gov [mailto:Daughton.Christian@epamail.epa.gov] <br><b>Sent:</b> Monday, December 03, 2012 10:44 AM<br><b>To:</b> Daughton.Christian@epamail.epa.gov<br><b>Subject:</b> "Lower-Dose Prescribing: Minimizing 'Side Effects' of Pharmaceuticals on Society and the Environment" <o:p></o:p></span></p></div></div><p>You may be interested in a manuscript just published that proposes a new approach for reducing contamination of the environment by active pharmaceutical ingredients (APIs) released primarily via excretion and secondarily by disposal. For the first time, changes to the practice of medication prescribing are proposed as a sustainable solution for proactively reducing environmental contamination by APIs. The approach is based on pollution prevention rather than on the more costly conventional downstream approaches using waste treatment or programs that target the collection of unwanted, leftover drugs.<br><br>Daughton CG and Ruhoy IS. "Lower-Dose Prescribing: Minimizing 'Side Effects' of Pharmaceuticals on Society and the Environment." <i>Science of the Total Environment </i><b>2013, </b><i>443:</i>324-337; doi:10.1016/j.scitotenv.2012.10.092 (including supplementary materials) [OpenAccess].<br><br>[Note: the publisher has not yet activated on-line OpenAccess, but it should be active within a month; in the mean time, feel free to share the attached reprint]<br><br>Specifically, the role of reducing medication dose had never been comprehensively examined with respect to its potential for reducing the loadings or levels of drug residues in the environment. To the contrary, the possibility of reducing the dose of medications to reduce environmental API contamination has always been actively discounted in the environmental literature as a possibility. This misconception may even have led to disproportionate investment of resources in research and infrastructure directed at end-of-pipe treatment solutions (such as waste treatment) rather than more effective and sustainable pollution prevention solutions (such as modifying prescribing practices involving dose reduction).<br><br>Many of the drugs amenable to lower doses and which are also known to occur as environmental contaminants are among the top 200 prescribed in the US. This shows the feasibility of dose reduction as a pollution prevention measure. Although one of the paper's objectives has been to show that the practice of health care is responsible for driving contamination of the environment by APIs, perhaps more important is that modifications to the practice of medicine (primarily prescribing) can be used to reduce this contamination while at the same time maintain or improve the quality of medical care.<br><br>A major objective of the paper is to highlight what we maintain is the incorrect assumption that the otherwise obvious approach of reducing dose is NOT a viable option for reducing environmental contamination by APIs. This misguided assertion has been counterproductive in advancing the more effective option involving pollution prevention. To do this, we show how drug dose can be controlled in the medical setting (via clinical evidence established by the emerging practice of "conservative prescribing") and that published data exist to support the proposal that reducing dose could have dramatic effects not just on reducing environmental burdens of excreted drug residues, but also on improving the quality of health care and the therapeutic outcomes sought by medication treatment.<br><br>Important to keep in mind is that the occurrence, distribution, and levels of drug residues in the environment have been documented in thousands of published articles. But the role of dose in reducing these levels has never been comprehensively discussed in a single article. We find this quite remarkable. For this reason, the manuscript covers a disparate mixture of published literature ranging from clinical medicine to environmental monitoring. <br><br>This manuscript resulted from work performed under an EPA internal research grant awarded under the second year of ORD's Pathfinder Innovation Program.<br><br><i>(See attached file: 2013 - STOTEN - Low-Dose Prescribing - reprint with supplementary material.pdf)</i><br><br><span style='font-size:10.0pt;font-family:"Arial","sans-serif"'>====================<br>Christian Daughton, Ph.D.<br>Environmental Chemistry Branch<br>Environmental Sciences Division<br>National Exposure Research Laboratory<br>U.S. Environmental Protection Agency<br>944 East Harmon<br>Las Vegas, NV 89119<br>702-798-2207<br><a href="mailto:daughton.christian@epa.gov">daughton.christian@epa.gov</a><br><br>CV: <a href="http://epa.gov/nerlesd1/bios/daughton.htm">http://epa.gov/nerlesd1/bios/daughton.htm</a><br>PPCPs Literature Database: <a href="http://epa.gov/ppcp/lit.html">http://epa.gov/ppcp/lit.html</a><br>Drug Disposal: <a href="http://epa.gov/ppcp/projects/disposal.html">http://epa.gov/ppcp/projects/disposal.html</a></span><o:p></o:p></p></div></body></html>