Some issues impact not only a particular patient in a specific room, but also every human who breathes the air and drinks water that is far too polluted.Staff nurses spend so much time and energy in the moment-to-moment, hands-on care of patients that it may become challenging to step back to get a broader perspective of nursing’s unique position in the larger world around us. Some issues impact not only a particular patient in a specific room, but also every human who breathes the air and drinks water that is far too polluted. Ultimately, there is no way to transfer to another work environment or living situation that will distance health professionals from the cumulating effects of the water pollution we have helped to create.  In this article, we will share nursing’s guiding principles for environmental health; review research related to pharmaceutical pollution of water resources; describe health care treatments derived from marine life; and discuss suggestions for promoting aquatic health. We will conclude that by taking care to preserve aquatic life, we contribute to the quality of our own human lives.

Guiding Principles for Environmental Health

Fortunately, our professional organizations offer some perspectives about how to prevent environmental pollution. The American Nurse Association’s (ANA) Principles of Environmental Health for Nursing Practice with Implementation Strategiesis one relevant document available to guide nurses in promoting the health of our environment (Ballard et al., 2007).

The ANA’s ten principles include the following:

1. Knowledge of environmental health concepts is essential to nursing practice.
2. The Precautionary Principle guides nurses in their practice to use products and practices that do not harm human health or the environment and to take preventive action in the face of uncertainty.
3. Nurses have a right to work in an environment that is safe and healthy.
4. Healthy environments are sustained through multidisciplinary collaboration.
5. Choices of materials, products, technology, and practices in the environment that impact nursing practice are based on the best evidence available.
6. Approaches to promoting a healthy environment respect the diverse values, beliefs, cultures, and circumstances of patient and their families.
7. Nurses participate in assessing the quality of the environment in which they practice and live.
8. Nurses, other health care workers, patients and communities have the right to know relevant and timely information about the potentially harmful products, chemicals, pollutants and hazards to which they are exposed.
9. Nurses participate in research of best practices that promote a safe and healthy environment.
10. Nurses must be supported in advocating for and implementing environmental health principles in nursing practice (Ballard et al., 2007, p. 16-31).

The Precautionary Principle implies that when an activity raises threats of harm to human health or the environment, precautionary measures should be taken... The second principle, the Precautionary Principle, has particular relevance for this discussion. This principle was drafted and finalized by thirty-two environmentally concerned authors at the Wingspread Conference Center in 1998 and is still applicable today. This principle implies that there is an ethical imperative to prevent rather than merely treat disease, even in the face of scientific uncertainty. The Precautionary Principle implies that when an activity raises threats of harm to human health or the environment, precautionary measures should be taken, even if some cause and effect relationships are not full established scientifically (Ashford, 1998).

Also of particular interest is ANA’s fourth principle, which states that we must look not only at the nursing profession, but beyond to other professions concerned with environmental issues, to gain a broader perspective. Principle number nine reminds us of the value of becoming familiar with research that helps define problems, issues, and possible solutions (ANA, 2007).  The following discussion will help nurses act upon these principles.

Research Related to Pharmaceutical Pollution of Water Resources

This section will discuss several relevant research studies addressing the pharmaceutical pollution of water resources. One example is the Baylor University study of the contamination of fish in the Chicago, Illinois (United States) area. The Table below, based on the work of Ramirez et al. (2009), lists human pharmaceuticals that researchers have found in Chicago’s North Shore Channel.

Table. Human Pharmaceuticals in the Chicago Channel
Diltiazem (antihypertensive)	0.13 nanograms per gram of fish weight
Norfluoxetine(antidepressant by-product)	3.2  nanograms per gram of fish weight
Diphenhydramine (antihistamine)	1.4 nanograms per gram of fish weight
Carbamazepine (anti-seizure)	2.3 nanograms per gram of fish weight

In the past, priority attention has been given to pesticides and industrial wastes as environmental water toxins. However, today there is another diverse group of bioactive chemicals that are now known to be pollutants. These newer pollutants are pharmaceuticals and personal care products (PPCPs). Together this group consists of both human and veterinary prescription drugs, diagnostic agents, sunscreens, and other personal care products (Daughton and Ternes, 1999).

Data on environmental levels of chemicals at low concentrations, and the effects of these chemicals, provide evidence that threats may exist for both human and non-human health. Barnes et al. (2008) found a specific endocrine-disrupting pharmaceutical, sulfamethoxazole, to be one of the top organic water contaminants. Other prescription medications, such as antibiotics, hormones, and some pain killers, are also included in the group of substances referred to as endocrine disrupting chemicals (EDCs) (North Carolina Division of Marine Fisheries, 2010). In Barnes’ et al. (2008) study, the samples were collected from forty-seven ground-water sites across eighteen states. The presence of these pharmaceuticals in our waterways has the potential to cause reproductive, behavioral, immune system, and neurological problems, as well as cancerous tumors, not only in fish and shellfish, but also in birds, amphibians, reptiles, and other coastal wildlife (Coastland Times, 2012). Human hormones, as found in birth control pills, can cause crustaceans and fish to have both female and male reproductive traits or to produce an unequal numbers of males and females (North Carolina Division of Marine Fisheries, 2010). DeFur and Foersom (2000) conducted a study in the Chesapeake Bay area that assessed plant and animal populations, as well as physical and chemical conditions in the environment. Data on environmental levels of chemicals at low concentrations, and the effects of these chemicals, provide evidence that threats may exist for both human and non-human health (DeFur and Foersom, 2000).

Data on medication removal by waste water treatment facilities are sparse; findings vary depending on the individual facility. Bound and Voulvoulis (2005) reported that variables, such as temperature and local rain fall amounts, also determine how much medication remains in the treated water. Bound and Voulvoulis (2005) found that the beta blocker, atenolol, passed through the human body, as well as the waste water treatment plants 90% intact. Bound and Voulvoulis (2005) also determined that although only 9% of diclofenac was removed by the biologic filtration method of waste water treatment, 75% was removed by the activated sludge treatment method. It should also be noted, however, that the sludge generated from this process may itself become a landfill or be spread on agricultural land, with the risk of merely moving the location of these hazardous chemicals, rather than removing them completely from our environment.

If preserved by responsible practices, aquatic creatures may be able to enhance human health. If preserved by responsible practices, aquatic creatures may be able to enhance human health. Research is taking place on a wide variety of aquatic creatures, investigating the potential for developing medications from these creatures that can relieve pain (Rauck, Wallace, Burton, Kapural, & North, 2009); boost the immune system (Parodi, de Florentiis, Martini, & Ansaldi, 2011); lower high cholesterol (Charlton-Menys and Durrinton, 2007); preserve eyesight (Connolly, Desai, Garcia, Thomas & Gast, 2006); and cure cancer (Camp-Sorrell, 2003). Additionally, makers of injectable medications now use an extract from an aquatic creature to check the medication for the presence of bacterial endotoxins (Cooper, Latta & Smith, 2012).

Some of the products mentioned above may be classified as complementary and alternative medicine (CAM) therapies. The National Center for Complementary and Alternative Medicine (NCCAM) was established to explore unconventional medical practices, such as the use of these therapies. The NCCAM is one of the sections within the National Institutes of Health (NIHS). As the number and types of CAMs has increased in the United States (US), the U.S. Federal Drug Administration (FDA) has provided guidance as to which ones are subject to regulation under the Federal Food, Drug and Cosmetic Act (referred to as The ACT) or the Public Health Services Act (PHS Act). A product used in CAM therapy may be subject to regulation as a biological product, cosmetic, drug, device, food, food additive, or dietary supplement under The Act or the PHS Act (Federal Drug Administration, 2012).

NCCAM organizes CAM therapies into four domains that include biologically–based practices; energy therapies; manipulative and body-based methods; and mind-body medicine. NCCAM has explained that the domain of biologically-based practices includes botanicals, animal-derived extracts, vitamins, minerals, fatty acids, amino acids, proteins, and probiotics. The intended use of the product determines how the item is regulated. For example, a botanical product or animal-derived extract, intended for use as a disease treatment, is regulated as a drug. The FDA defines ‘drugs’ as articles intended for the diagnosis, cure, mitigation, treatment, or prevention of disease (Federal Drug Administration, 2012). Such is the case for the products that will be discussed in this article. Some of these ‘drugs’ have met the FDA regulatory requirements and others have not yet progressed to this point.

Health Care Treatments Derived From Marine Sources

We will now explore a more detailed account of marine-source medications and health products. This will include testing for medication purity, as well as medications from aquatic sources for pain, hyperlipidemia, macular degeneration, and cancer.

Enhance Medication Safety

Currently, an extract from the Atlantic Horseshoe Crab (Figure 1) is used to detect the presence of endotoxins that may contaminate injectable medications.  Endotoxins are cell-wall components of gram negative bacteria;

Figure 1. Scientific name: Limulus polyphemus Common name: Atlantic Horseshoe Crab© Alice Elaine McKeown 2011

they may be present on non-sterile components used to make the injectable medications. Their presence may produce fever andhypotensive shock when present in unsafe numbers. Therefore, FDA-approved, Limulus Amebocyte Lysate (LAL) testing is required before a product can go on the market. LAL testing is required on all human and animal injectable medications, as well as medical devices that deliver injectable medications (Cooper et al., 2010).

A specific facility that uses the horseshoe crab extract is the Duke Compounding Facility. In 2007, Duke sought to identify a bacterial endotoxin test that was quick, simple, and approved by the FDA. An automated test system was selected that used a LAL cartridge containing a precalibrated amount of dried reagents. These new cartridges require less handing and allow test results to be obtained in fifteen minutes. Endotoxin detection by LAL reagents, which come from the blood of the horseshoe crab, is enabled by an enzymatic cascade similar to human blood coagulation (Cooper et al., 2010).

Relieve Pain

From the ocean comes a powerful, non-opioid analgesic, Ziconotide, a synthetic version of a peptide found in the venom of the Cone Snail (Figure 2). Ziconotide or Prialt, SNX-111, is now approved by the FDA for patients with neuropathic pain that does not respond to conventional treatments. Notably, prolonged use does not lead to addiction or tolerance (McGivern, 2007).

Figure 2- Scientific name: Conus magus Common name: Cone Snail© Alice Elaine McKeown 2011

Evidence suggests that Ziconotide, used either alone or in combination with another drug, is a potential therapeutic option for patients with severe neuropathic pain (Rauck et al., 2009). Ziconotide, an intrathecal-only analgesic, is introduced by hypodermic needle into the subarachnoid space, spreading the Ziconotide throughout the spinal fluid.  Data for double-blind, placebo-controlled trials showed improvement in pain scores from 15.7% to 31.6% with Ziconotide monotherapy, as compared with untreated pain scores. Low starting doses and slow increases in dosage improved the safety profile (Rauck, 2009).

Boost Immune Systems

The product Squalene, from shark livers, is currently an additive in influenza vaccine injections for more vulnerable populations. Older adults, for instance, have less vigorous immune response to vaccination than younger adults. There have been efforts in the last decade to improve immune response in the elderly. One successful adjuvant for this purpose is an oil-in-water emulsion of Squalene called MF 59. MF 59 is able to increase immune response in the elderly while maintaining acceptable safety and tolerability profiles (Parodi et al., 2011).

Lower Cholesterol

In the future, shark liver extracts may be used in the management of hyperlipidemia. New cholesterol-lowering drugs are needed for those patients who do not tolerate standard statin drugs, or whose low density lipoproteins (LDLs) are not adequately reduced by traditional medications. One such new drug class is that of the squalene-synthase inhibitors, which act at the first step of cholesterol biosynthesis, thus reducing the amount of circulating LDLs (Charlton-Menys & Durrinton, 2007).

Retain Vision

Ophthalmology is yet another area in which shark (Figure 3) extracts may make a positive impact. Squalamine lactate studies have looked at the control of exudative macular degeneration. In this condition, macular degeneration is

Figure 3. Scientific name: Squalus acanthus Common name: Shark, Spiney Dogfish© Alice Elaine McKeown 2011

caused by the growth of new yet fragile blood vessels in the macula, or area of central vision of the eye. These new vessels have thin walls and break easily, leaking blood and fluids on to the retina. The mechanism of action of the Squalamine lactate is related to its ability to block angiogenesis. Thus Squalamine is able to prevent new vessel growth, bleeding, and loss of vision (Connolly et al., 2006).

Cure Cancer

Other important research in marine-source medications is in the area of cancer cures. Contributions are being made from sponges, sea mollusks, tunicates, and sharks. Sponge-source, anticancer drugs include C-nucleosides from a Caribbean sea sponge, Cryptotheca crypta. Decades ago, this sponge provided the basis for the synthesis of Cytarabine, which was the first anticancer agent from a marine source to be developed for clinical use. FDA approved Cytarabine is currently used for treatments of leukemia and lymphoma patients under the brand name Cytosar-U.Gemcitabine, also a sponge derivative, has been FDA approved for treatment of bladder, breast, pancreatic, and non-small lung cell cancers. The field of marine-derivative drugs has expanded significantly because of technical improvements in the deep sea collection of specimens and experiments related to large-scale extraction and production agents through aquaculture and synthesis (Schwartsmann, da Rocha, Berlinck, & Jimeno, 2001).

An example of cancer drugs from the mollusk group is the extract Kahalalide F (KF). KF is is a moderately soluable product belonging to the family of peptides derived from the herbivorous marine mollusk, the Hawaiian Sea Slug (Figure 4). Studies showed KF causes strong cytotoxic activity against solid tumors, particurally in patients with squamous cell carcinomas. Almost 40% of the patients treated with KF were still alive one year after being treated. The further development of KF may be halted due to unavailability of the natural product. However, PM02734 is a closely related derivative of KF with very similar characteristices and activity (Provencio, Sanchez, Gasent, Gomex, & Rosell, 2009). Elisidepsin or PM02734 shows a postitive therapeutic index for non-small cell lung cancer cell lines (Ling, Aracil, Jimeno, Perez-Soler, & Yiyu, 2009).

Figure 4. Scientific name: Elysia rufescens Common name: Hawaiian Sea Slug© Alice Elaine McKeown 2011

Yondelis®, Trabectedin, or ET-743, is a marine-derived alkaloid from a tunicate, the Caribbean Sea Squirt (Figure 5). The mode of action involves binding of the drug to target cell DNA, causing conformational change and lethal, double-stranded DNA breaks. A study done by Roylance et al. (2007) on advanced sarcoma cases achieved a 38% durable, stable disease for an average of four and a half months. The disease response and lasting nature of disease stabilization support the continued study of Yondelis® for advanced soft tissue sarcomas (Roylance, et al., 2007).

Figure 5. Scientific name: Ecteinascidia turbinate Common name: Caribbean Sea Squirt (tubular creature front, middle)© Alice Elaine McKeown 2011

Squalamine, from the liver of the shark, is an antiangiogenic agent in the the subcatagory of endothelial inhibitors. Squalamine is in the same categoty as angiostatin, the drug that revolutionized the field of antiangiogenesis in 1994 (Camp-Sorrell, 2003). Squalamine inhibits the angiogenesis needed for growth of the cancer by a long-acting intracellular mechanism. The medication is taken up into activated endothelial cell through small cellular membrane invaginations; it blocks angiogennesis at several levels. Preclinical studies have begun to establish proof of effectiveness and safety for use of squalamine as a treatment for several types of malignancies, as well as for exudative macular degeneration (Connolly et al., 2006).

Suggestions for Promoting Aquatic Health

A consideration of the importance of the links between the health of aquatic creatures and that of humans should motivate all health care providers to change their medication disposal practices, such as flushing medications into the sewer system. Fortunately, some organizations are already modeling safer medication disposal options. Several examples are presented below.

A consideration of the importance of the links between the health of aquatic creatures and that of humans should motivate all health care providers to change their medication disposal practices... Beginning as early as 2005, North Memorial Health Care in Robbinsdale, Minnesota, has been a model for pharmaceutical disposal. North Memorial sends a large portion of its pharmaceutical waste to an incinerator that generates electricity by burning garbage. Simplified waste stream management and ongoing training of staff have improved compliance with safe medication disposal practices and reduced the cost of proper disposal (Blesch, 2010).

The National Community Pharmacists Association has developed a prescription disposal program to help customers to dispose of unused medications in certain drug store locations. Their partner organization, Sharps Compliance Inc., offers discounted containers for collection of medications.  By 2010, the program had approximately 1,000 pharmacies in 47 states taking part in this type of a medication take-back program. Briggs (2010) reported a total of 8,000 pounds of medications were collected and properly disposed of via this program.

Another example of a pharmacist-lead, take-back program took place on Earth Day, April 2009, in the Manchester, Massachusetts area. During the event, participants drove to a managed care facility and handed their unwanted medications through their vehicle windows to pharmacists, health plan employees, and/or the police. Effort for this day alone resulted in the collection of 100 pounds of medication (Pervans, 2010).

State governments, sanitation districts, and marine fisheries have also participated in take-back programs. The state of Maine offers residents free mailing envelopes to send in unwanted drugs for disposal (Tucker, 2011). In Duluth, Minnesota, the Western Lake Superior Sanitary District holds events four times a year, at which residents can bring in their drugs for proper disposal (Tucker, 2011). In Dare County, North Carolina, The County Sheriff’s Office, in partnership with the North Carolina Division of Marine Fisheries, and the North Carolina Aquarium on Roanoke Island, held a community medicine drop off in 2012 (Coastland Times, 2012).

Throughout the life cycle of pharmaceuticals... nurses can play important roles in eliminating pharmaceutical waste and improving public safety. Nurses will do well to participate with other concerned professions to help prevent medication pollution from reaching the water supply. Throughout the life cycle of pharmaceuticals, including design, regulation, production, use, and disposal, nurses can play important roles in eliminating pharmaceutical waste and improving public safety. Nurses are among the most trusted of professionals and their roles in health care are ever expanding. Important work can be done by nurses as drug researchers; educators to raise public awareness; advocates for improved hospital or government policy on drug disposal; and clinicians to prevent wasted medications and improper disposal at the bedside (Becker, Mendex-Quigley, & Phillips, 2010). For example, the first author of this article, who is currently an educational docent at the North Carolina Aquarium on Roanoke Island, created, with help from aquarium staff, a unique, hands-on, public education display on ‘Marine Medical Marvels,’ showing the human health benefits of preserving aquatic life. Adults and children alike are attracted to touching the aquatic animal artifacts, such as shark jaw and horseshoe crab exoskeletons, exhibited at the aquarium. Visitors can inspect each item and learn about its usefulness for human health. Additionally, visitors leave the aquarium with information on the North Carolina mail-back, drug disposal programs.

There are several simple practices each clinical nurse can develop that would help eliminate wasted medications. Nurses can check to make sure there are no reasons to hold a medication and confirm the patient is present and consenting to take medication, before opening the package. In most cases, an unopened medication can be returned to the drawer or dispenser.

Clinicians can also encourage fellow nurses to take part in setting hospital or unit policy to further reduce waste and pollution. For example, use of bar-coded and individually wrapped medications can help reduce waste. The bar code system has several advantages. First the system is so efficient as to be almost error free. The computer scans the medication and confirms it is the correct medication before the nurse opens the package. This eliminates opening the wrong package and needing to waste the medication. Also, this system wraps each individual pill separately, so that if it must be wasted, only one pill is discarded.

Use of secure medication drug and sharp disposal containers, along with reverse distribution medication services, can reduce medication waste. If a medication must be wasted, as in the case of the patient spitting a pill on the floor, the pill would be place in the biohazard sharps container and taken away from the institution to a location equipped to dispose of hazardous waste. More information on environmentally safe disposal of pharmaceuticals can be seen at the Illinois Environmental Protection Agency's website (Illinois EPA, 2012).

All of these practices can help eliminate the dangers of introducing unwanted medications into the water supply. By avoiding the pollution of our environment; teaching others to do so; and supporting the work of environmental (especially ocean-related) organizations, nurses can support a sustainable environment and offer increased hope to a number of our patients.

Conclusion

We can all help eliminate the threats to human and aquatic life by keeping wasted pharmaceuticals out of the water supply.This article illustrates how the flushing of drugs into sewer or septic tank systems becomes an ecological issue in nursing practice. We can all help eliminate the threats to human and aquatic life by keeping wasted pharmaceuticals out of the water supply. If we can preserve aquatic life, these creatures, in turn, can contribute to the quality of our lives as humans.

Special Note on Illustrations: The first author of this article, Ms. McKeown, has had a life-long interest in fine art. She entered college as an art major before switching to nursing. Throughout her thirty-year nursing career she has maintained her interest in art. She also works at the North Carolina Aquarium on Roanoke Island, where she has made live observations of some of the animals discussed in this article. To insure accuracy of the drawings she has also reviewed photos from several sources. After learning the anatomical facts of these animals, she designed a new art work of each animal showing the creature in an environment of her artistic imagination. Compositions were created using graphite and Derwent Coloursoft® art pencils on Stonehenge Rising®, cotton vellum finish art paper in 2011. Layout elements and overall workmanship is unique and published for the first time in this article.

Author

Elaine McKeown MSN, RN
E-mail: EMcKns@comcast.net

Ms. McKeown is a registered nurse with a baccalaureate degree in nursing from William Jewell College in Liberty, Missouri, and a master’s degree in nursing from the University of Michigan, Ann Arbor, Michigan.  Her nursing career, which has spanned over thirty years, includes working in emergency, cardiac care, and community health nursing, and teaching medical-surgical nursing at Washtenaw Community College in Ann Arbor, Michigan. She is currently an educational docent at the North Carolina Aquarium on Roanoke Island, where she has created a unique, hands-on, public education display on “Marine Medical Marvels” showing the human health benefits of preserving aquatic life. Ms. McKeown is also a member of the Marine Mammal Standing Network and the Network for Endangered Sea Turtles (NEST). She participates in the rehabilitation of injured sea turtle, responds to marine mammal standings, and assists with autopsies on non-viable aquatic creatures.

Judith Pawloski MNS, RN
E-mail: judip@wccnet.edu

Ms. Pawloski received her BSN and MSN from Wayne State University in Detroit, Michigan. Her nursing career has spanned over forty years and has included experience in physical rehabilitation, home care, and teaching in various nursing programs, including Washtenaw Community College in Ann Arbor, Michigan, where she continues to teach part-time as Emeritus Faculty.  Ms. Pawloski is a member of various environmental organizations and continues her interest and involvement in environmental issues.

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© 2012 OJIN: The Online Journal of Issues in Nursing
Article published December 18, 2012